ACUTE OTITIS MEDIA 315
presence of headache, especially frontal headache, may indicate intracranial
invasion. Facial paralysis may occur in the suppurative stage if there is a
dehiscence in the bony wall of the facial nerve canal.
CLINICAL FEATURES. In the early stage there is retraction of the drumhead
and possibly an effusion which may not be visible because of slight thickening
of the drumhead. The next stage of progressive hyperaemia shows injection
of vessels along the long process of the malleus and the appearance of fine
vessels between the umbo and the periphery, resembling the spokes of a
wheel (see Plate X, 4). If the infection is arrested at this stage the
tympanic membrane will return to normal. If the condition progresses, the
hyperaemia becomes general and the membrane bulges (see Plate X, 6),
at first in its posterior half; later the whole membrane becomes very
red and convex and the handle of the malleus can no longer be seen. Per-
foration is now almost inevitable and is preceded by the appearance of a
small yellow pulsating spot frequently in the posterior half of the membrane.
Sometimes a nipple-shaped projection surmounted by a yellow spot develops
on the membrane.
After rupture of the membrane there is a discharge of pus with relief of
tension and a marked improvement in the patient's condition. Pain is relieved
and sleep follows. Temperature becomes normal and resolution of the infec-
Accumulation of pus and desquamated epithelium may obscure the
drumhead so that cleansing of the meatus by gentle syringeing or mopping
is necessary. At this stage the perforation may appear as a pulsating bead
of pus which reappears after mopping.
PROGNOSIS. In the large majority of cases the prognosis is good as regards
healing of the drumhead and the return of hearing provided that adequate
treatment and supervision are maintained until resolution is complete.
Discharge should cease within a few days and the drumhead should gradually
assume a normal appearance. In some cases a small scar may be seen at
the site of the previous perforation, in others there is no sign of the infection
remaining. A persisting dry perforation is associated with some loss of
hearing and further treatment will be required to obtain complete healing.
TREATMENT. This is directed locally to: (a) relief of pain, (b) the main-
tenance of the patency of the Eustachian tube, (c) neutralization of the infec-
tion and (d) restoration of normal hearing. In mild cases the patient should
be confined to the house and, if a child, should be kept in bed. The diet
should be light and the patient encouraged to drink freely.
Relief of pain is best achieved by the use of analgesics and the early ad-
ministration of penicillin. For children paracetampl_ elixir paediatric in
doses of 5-10 ml is preferable to the routine use of soluble aspirin. Intense
pain may require the use ofjnorphine in adults^ The application of dry
heat, e.g. a half-filled covered hot-water bottle or an electrically heated
pad, may be useful.
The instillation of nasal decongestants, such as ephedrine hydrochloride
cent in normal saline, is indicated~T6f ~the relief of
tubal obstruction. Drops should be instilled into the nostril on the side of
the affected ear with the patient recumbent, the head extended and rotated
slightly to the affected side. The patient is encouraged to sniff gently, but
forceful inflation of the tube should be discouraged. Medicated (menthol