MASTOID ABSCESS. 
BY 
S. P. SCHROEDER, M.D., 
OF HOyleton, ill. 
EROM 
THE MEDICAL NEWS, 
February 25, 1893. [Reprinted from The Medical News, February 25, 1893.] 
MASTOID ABSCESS. 
By S. P. SCHROEDER, M.D., 
of hoVTETon, ill. 
Mastoid inflammation is a complication of sup- 
purative inflammation of the middle ear, but of such 
gravity and so serious that it might be called a 
separate disease. 
Anatomically the mastoid process lies posterior 
and external to the petrous portion of the temporal 
bone. It is composed of cavities, in the healthy 
state intersected and subdivided by partitions. 
These cavities open into the tympanic cavity. In 
suppurative inflammation of the tympanic cavity 
the inflammatory process may extend into these 
cells, and once the pyogenic cocci have found 
entrance and lodgment in these caves, it is easily 
understood that it will be a hard fight on the part 
of the physician to get them out of their fortifica- 
tions. On the inner and posterior side of the mas- 
toid process is found the sigmoid groove, the 
continuation of the lateral sinus. This groove 
stands in danger of being injured when the mastoid 
process is opened. 
The causes of suppurative inflammation of the 
middle ear may be summarized as follows: i. Cold. 
2. Injuries-(a) The forcible removal of foreign 
bodies, chief of which is impacted cerumen. 2 
The forcible injection of fluids. 3. The infectious 
diseases, among which scarlet fever takes first 
rank. The pathology of mastoid abscess is that of 
other bone-inflammation. There may be softening, 
sclerosis, caries, or necrosis. 
The accidents, as they may be called, consist in 
the extension of the inflammatory process to neigh- 
boring parts, which occurs in two ways: («) By 
extension along the vessels and natural openings, 
and (<5) by forming a fistulous opening by caries 
through its bony walls. The inflammation may 
extend outward, inward, upward, downward, or 
forward. 
When the inflammation extends outward it will 
show itself by edema, redness, and deep tenderness 
over the mastoid process, and the ear will stand 
farther from the head than its fellow. If left to 
open itself, the abscess is slow in its progress, and 
when it opens the pus is offensive in odor. If the 
inflammation extends inward it will be recognized 
by symptoms caused by phlebitis, thrombosis, and 
embolism of that portion of the cranial cavity that 
is drained by the lateral sinus and the superior and 
inferior petrosal sinuses. Hence there would be 
edema of the corresponding side of the face, mas- 
toid prominence, and head, due to the obstructed 
return-circulation. There may be high fever and 
vomiting. 
If the inflammation extend upward there will be 
symptoms due to meningitis, as for example, severe 
headache, not localized, restlessness, fever, vomit- 
ing, irregularity of pulse, coma, and death ; while, 
if cerebral abscess should form, I take it the symp- 3 
toms would be so obscure that they could not be 
differentiated from those of meningitis, and the 
diagnosis could only be positively made in the post- 
mortem room. 
If the inflammation extend downward, the pus 
would gravitate into the retro-maxillary fossa, and 
from there downward along the cellular plains in 
connection with the great bloodvessels of the neck. 
If the inflammation extend forward, an abscess is 
formed on the posterior wall of the external auditory 
canal, which, after it opens, leaves a sinus, and from 
its external opening large granulations spring up 
resembling polypi. 
I shall give the history of a case that had three 
of these accidents: Periosteal mastoid abscess, 
extension of the inflammation into the external 
auditory canal, and very probably cerebral abscess. 
It also shows the ravages of this affection : 
Case I.-In March, 1889, I was called to see 
J. McCairy, a farmer, and a native of Ireland, aged 
seventy years, remarkably stout for his age, who com- 
plained of pain in the left ear, which radiated over 
the corresponding side of the head and face. He 
had suffered from pain about five days. There was 
slight fever. Otoscopic inspection revealed a red 
zone around the attachment of the tympanic mem- 
brane, and a red line where the handle of the 
malleus was located. The membrane was bulging 
outward, and had lost its luster. There was deep 
tenderness of the mastoid process. I recommended 
paracentesis of the tympanic cavity. This he ob- 
jected to. Two days afterward, however, the 
patient permitted me to incise the membrane. At 
this time, however, the external auditory canal was so 4 
swollen that it was well-nigh impossible to get a 
clear view of the membrana tympani. There was 
some edema over the mastoid prominence, and the 
ear stood farther from the head than its fellow. I 
warned him of the gravity of the case, which scared 
him, and the next I knew he was attended by 
another physician. After four weeks I was called 
to take charge of the case again. As soon as I 
entered the sick-room I observed that the left side 
of his face was completely paralyzed. The eye of the 
corresponding side was kept constantly open, even 
during sleep, contrasting strongly with the facial 
paralysis due to a central lesion of the cerebrum, in 
which the upper fibers of the facial nerve are not 
implicated. The paralysis affected his speech so 
that it was almost impossible to understand him. 
It seemed as though the tongue was too large and 
thick. The soft palate was drawn over to the 
opposite side ; he had difficulty in swallowing, and 
taste on the corresponding side was deficient. 
There was a large periosteal abscess over the mastoid 
eminence, which fluctuated. I opened it, and con- 
siderable offensive smelling pus passed out. On 
probing I found a fistulous opening in the mastoid 
process. There was discharge of pus from the ear. 
After syringing the ear I found large granulations 
present. On using an angularly bent probe I dis- 
covered a fistulous opening on the posterior wall of 
the external auditory canal, extending into the 
mastoid process. The late Dr. Henry, of this 
place, was called in consultation, and with him I 
saw the case a number of times. The patient grew 
gradually worse, suffering almost constantly from 
excruciating pain, except when relieved by large 
doses of anodynes. He became more paralytic, had 
more difficulty in swallowing and in speech, and 
suffered from subjective sensation of heat and cold, 5 
till death finally relieved him, six months after the 
inception of the malady. 
Symptoms. When in the course of a suppurative 
inflammation of the middle ear there is constant 
tenderness on pressure over the mastoid process, 
edema and swelling, with the ear pushed out from 
the head or not, we may suspect mastoid abscess. 
The treatment may be divided into general and 
local. The general treatment includes laxatives and 
anodynes. Locally may be applied the rubber coil 
or bags of ice. When heat is desired, a rubber bag 
filled with hot water may be placed behind the ear, 
or small sacks filled with heated bran or salt may be 
used. I would warn against the too common use 
of injecting hot water into the external auditory 
canal, or the application of poultices over the ear, 
as the moisture and heat increase the pus-formation, 
and this, as will be readily seen, is dangerous in a 
closed cavity like the mastoid process. Another 
mistake often made by general practitioners is the 
habit of filling the external auditory canal with 
powdered boric acid when there is discharge from 
the ear; this will close the fistulous opening or the 
ruptured drum-membrane, and thereby prevent free 
drainage. The injection of H2O2 has a tendency to 
thicken the pus and thereby prevent its free exit. 
The surgeon or specialist will open the cavity or 
enlarge the already existing fistulous opening which 
is too small for free drainage. 
Two methods of opening the mastoid antrum are 
in use : One by boring with a drill ; the other by 
chiselling into the cavity with chisel and hammer. 6 
In young children, and in those cases in which the 
bone is softened, the operator may often open into 
the cavity by pressing well down with a strong knife. 
The chief landmarks for the surgeon are the tem- 
poral ridge and the external auditory canal. The 
opening should be made one-half inch below the 
temporal ridge and one-half inch posteriorly to and 
parallel with the external auditory canal. The chief 
risk lies in the danger of injuring the lateral sinus, 
which may easily occur to a careless operator, but 
if the foregoing precautions are observed there is 
little danger. 
I will cite here another case in which the cavity 
was opened, and the case terminated favorably in a 
very short time. 
Case II.-R. A. C., American, aged fifty years; 
a saloon-keeper, healthy, living only a block from 
my office; came for me to examine his ear the ist 
of April, 1892, when he complained of severe pain 
on the right side of the head, radiating from the ear 
in all directions. There was partial deafness and 
tinnitus. On inspecting the affected ear, I found 
all the symptoms of suppurative inflammation of the 
middle ear. He was treated in the usual way. The 
case progressed rather slowly, but I hoped for a 
favorable termination. He was never confined to 
his bed. He had greatly improved three weeks 
after the first treatment. About this time he went 
to Centralia, exposing himself, and on his way 
home he got wet in a cold April shower. After 
he came home he suffered with a chill, and in a few 
days all the ear-symptoms took on an acute exacer- 
bation. The pain was very severe, deep tenderness 
over the mastoid process developed simultaneously, 
and a day later there was swelling and edema of the 7 
mastoid prominence. I recommended opening of 
the abscess, to which the patient consented. On 
the 24th of April, with the assistance of Drs. Carter, 
of Nashville, and Beckmeyer, of Addieville, we 
proceded to open the abscess. The head for a 
short distance aroYind th-e process was shaved and 
thoroughly cleansed with soap and water, and then 
with an antiseptic solution. A crescent-shaped in- 
cision, posterior to the ear and with its concavity 
toward the ear, was made, and then a cross incision 
at right angles from the first was made, extending 
backward. The pericranium was pushed back and 
the bone examined to see whether or not a softened 
place could be found. As we could not discover 
this, an opening was bored with the triangular center- 
piece of a three-quarter-inch Galt trephine. Great 
care was taken in directing the trephine-point, so 
that it was parallel with the external auditory canal 
and one-half inch below the temporal ridge. After 
boring down fully three-eighths of an inch, dark 
blood oozed out, and it was thought best not to 
bore any deeper. 
This patient expressed himself perfectly free from 
pain after he recovered from the anesthetic, and 
made a very rapid and uninterrupted recovery. 
The wound was not closed, but dressed and treated 
open, in order that drainage might be free. The 
objection to the boring is, that the operator has 
to work in the dark and does not know when he 
has entered the mastoid antrum; for this reason 
I think that the chiselling procedure will supersede 
the boring. The Medical News. 
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