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Full text of "Diseases Of The Nose Throat And Ear"

CHRONIC SUPPURATIVE OTITIS MEDIA                325

The appearance of an accumulation of white epithelial debris also in associa-
tion with attic or marginal perforations must suggest the presence of chole-
steatoma which is very commonly present in the dangerous or unsafe ear.

SYMPTOMS. Chronic purulent discharge from the ear, perforation of the
tympanic membrane and deafness are the principal symptoms and signs of
chronic middle ear suppuration. Discharge may be profuse and muco-
purulent, especially in cases in which the Eustachian tube and anterior
part of the tympanum are affected (tubotympanic infection). The discharge
is also usually odourless and the hearing impairment may be slight. On the
other hand, in attico-antral disease (the unsafe ear) the discharge may be
very scanty, perhaps represented by a small crust of dried pus on the posterior
margin of the membrane or overlying the membrana flaccida. After removal
of the crust a perforation is usually evident and the purulent discharge has
a characteristic foetid smell. Impairment of hearing is more severe since
destructive disease in the middle ear has caused an interruption of ossicular
continuity, the loss exceeding 50 dB. Tinnitus is an occasional symptom,
particularly hi the older patient with a healed ear.

Pain is uncommon and should be regarded as a warning symptom denoting
an acute exacerbation of infection and inadequate drainage from the middle
ear. Other symptoms and signs such as headache, vertigo, sickness or rigors
indicate a spread of infection beyond the confines of the middle ear.

DIAGNOSIS. Whilst the diagnosis of chronic suppurative otitis is readily
made in the large majority of cases from the history of chronic otorrhoea,
from the accompanying symptoms and signs, and from the appearances
of the drumhead, it is important that the stage of the disease should be noted
and every effort made to determine whether the ear belongs to the safe or
unsafe category. Routine clinical examination requires to be supplemented
by bacteriological studies, by audiometry, by mastoid radiography and in
many cases by examination with the operating miscroscope with or without
general anaesthesia.

TREATMENT. The aims of treatment are to render the ear safe by over-
coming infection so that the ear is dry and inactive, to remove disease and
prevent extension beyond the middle ear and to promote recovery of func-
tion. Whether treatment is medical or surgical depends upon the result of
the clinical examination of the ear, the degree of activity of the infection,
the situation of the disease, the nature of the discharge and the location
and size of perforation. The presence of granulations, polypi and chole-
steatoma prevent the effective application of local medical treatment.

Routine aural toilet is necessary for the success of medical measures in
chronic middle ear suppuration. CleanHness of the ear can be obtained by
suction, by dry mopping or by J^tl^JsyrSigeihg so tEat the prescribed
topical application may come into contact wittftKe diseased tissues. Further
discharge may be aspirated using Siegle's pneumatic speculum and by
Eustachian inflation. A high degree of cleanliness can be obtained using the
technique of suction clearance with the operating microscope. When the
ear is clean and no further discharge appears, drops are instilled or powder
insufflated.

Whilst the parenteral administration of antibiotics has proved of little
value in the treatment of chronic otitis media owing to the difficulty of
obtaining a sufficient concentration and maintaining it in the diseased middle