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300                                          THE EAR

protect the drumhead and middle ear by supporting the growth on its medial
aspect with a curved dissector. Large osteomata may require a wider expo-
sure by means of an endaural incision or an external retro-auricular approach.
Other benign tumours of epithelial and mesenchymal origin may affect
the external meatus but, apart from papillomata, these are only occasionally

MALIGNANT TUMOURS (see Chapter 71)


Rupture of the drumhead may result from a variety of causes, the com-
monest of which arises from ill-advised attempts at clearing the ear of wax
or relieving irritation by the insertion of a matchstick, hair grip or similar
readily available instrument. The introduction of foreign_ho4Jes in the ear
and unskilled attempts at their removal can also produce rupture. During
syringeing of the ear a stream of lotion directed at the drumhead instead
of along the posterior wall of the meatus has not infrequently been the cause
of perforation, although in many of these cases there has been a pre-existing
thin scar which has ruptured under pressure. The accidental application of
a caustic agent has been reported to produce a perforation, and a sgark
entering the meatus during metal welding has been known to burn through
the membrane. The detonation of high explosives results in the formation
of blast waves of expansion and contraction, which may not only rupture
the drumhead but may seriously injure the inner ear. Blast injuries of the
drumhead generally affect the antero-inferior quadrant although almost
complete destruction of the membrane may occur. Either phase of the
explosion may be responsible for the damage but the view is expressed that
the drumhead which has been displaced inwards by the expansion or positive
wave can less readily respond to the contraction or negative wave and the
membrane ruptures outwards. Comparatively less severe pressure changes
resulting from a blowjpver the external ear by the palm of a hand or a robust
kiss on the ear are potential causes of injury. Bleeding from the ear and a
tear in the drumhead are common complications of skull fracture involving
the tympanic part of the temporal bone.                       "~

SYMFTOMS. Pain of varying intensity occurs at the moment of rupture and
is accompanied by deafness and sometimes by bleeding. Tinnitus may be
severe and there may also be nausea and vertigo. With inner ear involve-
ment deafness may be profound and permanent.

PROGNOSIS. The prognosis regarding hearing depends largely on the extent
of the damage to the cochlea. Many of these cases result in legal proceedings
and therefore audiometric examination should be done and a full description
of the injury noted. Secondary infection of the middle ear may adversely
affect recovery of hearing and the full effect of blast injury on the cochlea
may not be apparent for several years.

TREATMENT. Many small tears will heal without treatment apart from
measures taken to avoid the introduction of infection. Syringeing of the ear
or instillation of ear drops must be strictly avoided. A plug of sterile cotton-
wool should be placed in the meatus and the patient warned against allowing
water to enter the ear. These measures must be scrupulously maintained