316 THE EAR and benzoin) steam inhalations are helpful in relieving viscid nasal secretion. The finding of an inflamed drumhead is an indication for antibiotic therapy and the antibiotic of first choice, except in cases of known sensi- tivity, is penicillin which should initially be administered parenterally. The first dose should be of 1 million units of benzyl penicillin. Therapy may then be continued, if the initial response is favourable, by an oral penicillin, e.g. phenoxymethylpenicillin, giving 250 mg 4- or 6-hourly to the adult and 125 mg at the same intervals to the child. The duration of treatment is important and should be judged by the clinical and, where there is aural discharge, bacteriological response. If the response is satisfactory treatment should be continued for not less than 5, and preferably 7, days. If there has been no clinical improvement after 48 hours on full penicillin dosage a change to a broad-spectrum antibiotic, Fig, 167. Incision of the drumhead (myringotomy). The small figure shows the extent and direction of the inqision. e.g. ampicillin or the cephalosporins, in suitable dosage must be considered. These should be given for 7 days. Inadequate dosage or the too early with- drawal of an antibiotic increases the risk of persisting infection with the possible production of a masked mastoid infection. In severe cases, where it is believed that perforation is imminent, myringo- tomy may be required (Fig. 167). The decision to operate is made on the appearance of the drumhead and the persistence of pain which robs the patient of a night's sleep. Another indication for myringotomy is a delayed resolution of the drumhead which remains congested and full in spite of adequate antibiotic therapy. The operation is performed under general anaesthesia, the incision being made in the most bulging part of the mem- brane. The membrane is thickened and the incision must be sufficiently deep to enter the middle ear cavity. Pus usually wells out, and a swab should be taken for bacteriological culture and sensitivity tests.