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304                                          THE EAR

of the mastoid process. Swelling of the meatus associated with discharge
from the ear may cause difficulty in deciding whether infection is limited
to the outer ear or originates within the middle ear.

In distinguishing between furunculosis of the external meatus with oedema
and acute otitis media with mastoiditis several observations should be noted:
(1) A Jiistpry of recent head cold or influenza is suggestive of middle ear
infection whereas staphylococcal infection in some other area of the body
may point to furunculosis. (2) Careful and gentle otoscopic examination
may reveal a boil and when a normal dmmhead can be seen the diagnosis
is not in doubt. (3) Jleanng in the affected area is better in furunculosis
than in mastoiditis. Insertion of an infant-size aural speculum into the
meatus when possible without causing undue pain will improve the hearing
if no middle ear infection is present. (4) Pair^in furunculosis is of a continuous
dull throbbing character and may last foF^everal days until the boil bursts,
or is incised, when there is a scanty yellow discharge. In acute otitis media
a sharp piercing pain varying in duration and intensity occurs and is relieved
by the appearance of discharge which may be copious. The presence of mucus
in the discharge suggests an otitis media. (5) Movement of the auricle and
pressure on the tragus increase pain in furunculosis but not in otitis media.
(6) In furunculosis maximum tenj|erness is present over the tragus, below
and medial to the lobe of the ear and along the anterior border of the mastoid
process. Tenderness in mastoiditis is more often elicited along the posterior
border of the mastoid and over the mastoid antrum. (7) Obliteration of the
postauricular sulcus with forward displacement of the auricle suggests a
furuncle and this is confirmed if aspiration of a fluctuant swelling yields
pus on piercing skin. If it is caused by a subperiosteal abscess from mastoid
mfection^niisjs not met with until bone is reached. (8) Mastoid radiographs
showing well-developed clear cells on the affected side witt exclude mastoiditis
but a retro-auricular oedema produces some haziness of the cells compared
with those of the normal side. Furunculosis and mastoiditis may occur
together and if the latter cannot be excluded an exploratory operation may
be justified.                                                                           j

TREATMENT. Local and general measures are necessary. Heat applied to
the ear by a covered hot-water bottle, radiant heat or short-wave diathermy
relieves pain especially if combined with the administration of Sedatives.
Meatal packs consisting of narrow (12 mm) ribbon-gauze wicks soaked in
10 per cent ichthammol glycerine B.P.C_spjution, gently inserted, have a
soothing effect. The wicks are changed dally. MdsTfufuncles burst spon-
taneously and the discharge should be removed by dry mopping, the ich-
thammol glycerine wicks being continued until the ear is dry. After-treatment
consists in keeping the external meatus clean and applying a disinfectany'
such as 1 per cent solution of gentian violet in spirit. The majority of boils
are due to Staph. aureus infections and unless there is a previous history of
sensitivity a 5-day course of treatment with penicillin gives a rapid relief
of pain, particularly if given mtramuscularly. Incision of a boil should be
delayed until it is clearly pointing on the skin. Recurring boils are not un-
common. In persistent cases the urine should be tested to exclude diabetes
mellitus. The patient is frequently a scratcher and transfers infection from
the nasal vestibules which are also a source of Staph. aureus infection. In
such cases the application of a chlorhexidine cream (Naseptin) for several