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External Ear. The external ear may be involved by lupus vulgaris, but this
is now rare. For details of treatment, reference should be made to the stan-
dard textbooks on dermatology.

Middle Ear. Tuberculous otitis media is now a rare condition in Great
Britain. Cases of tuberculous otitis media may be divided into two groups:

(1) In infants and very young children who are fed, in whole or in part, on
unsterilized cow's milk which contains the bovine type of tubercle bacillus.
Suppurative otitis media in an infant, which is not responding to treatment,
should make one think of tuberculous middle ear disease. (2) In the advanced
stages of pulmonary tuberculous disease of the middle ear cleft sometimes


Infection by Way of the Eustachlan Tube. (1) Tuberculous infiltration of
the mucous membrane spreads up the tube to the tympanic cavity, or

(2)  Infectious particles may be insufflated up the Eustachian tube during
the acts of coughing and sneezing. Invasion of the labyrinth occurs first of
all through the oval and round windows. In advanced cases there is caries
and necrosis of the bony labyrinth capsule. In rare cases there is a tendency
to spontaneous cure of the tuberculous labyrinthitis.

Infection by the Blood Stream. If the Eustachian tube and tympanum
appear to be healthy, while the mastoid process alone is diseased, the prob-
ability is that infection has occurred by way of the blood stream.

SYMPTOMS. The onset appears to be painless, in marked contrast to the
early stages of pyogenic otitis media. The lymph glands surrounding the
ear are often enlarged. In the early stage the discharge is watery, and later
it may be flocculent: in the advanced stages, where mixed infection is present,
it is offensive and purulent. Pale granulations may be seen and these recur
rapidly after removal. Paralysis of the facial nerve may occur and multiple
perforations in the tympanic membrane (Plate X, 8), may sometimes be seen in
adults. Involvement of the labyrinth is of frequent occurrence, and takes place
at a comparatively early stage of the disease. Tuberculous labyrinthitis, like
tuberculous otitis media, appears to have a quiet onset, in marked contrast
to the violent symptoms produced by an attack of acute purulent labyrinthitis.

COMPLICATIONS. Tuberculous otitis media and interna do not, as a rule,
give rise to intracranial complications, although tuberculous granulation
tissue on the dura mater is frequently met with at operation. A number of
cases, however, have been reported where a tuberculoma of the brain has
occurred, the cerebellum being the most likely site.