[Reprinted from The Medical News, May 26, 1894.] 
THREE CASES OF ATTIC SUPPURATION IN 
WHICH OPERATION WAS Ffi L LOW ED 
BY FACIAL PARALYSIS (BELL’S 
PALSY.J1 
By L. J. HAMMOND, M.D., 
OF PHILADELPHIA. 
I wish to report three cases of upper tympanic or 
attic suppuration, in which operation was followed by 
facial paralysis, for the purpose of learning from those 
of larger experience in this very important branch of 
surgery, how far it is possible to avoid this complication 
which, owing to the anatomy of these parts, is unques- 
tionably a condition that is likely to occur. By review- 
ing our anatomy of this region of the middle ear we find 
it marked off at about its middle by the bony ridge which 
forms the covering of the facial nerve, or, indeed, the 
nerve may pass through this region entirely devoid of 
any bony covering. It will, therefore, be seen that 
nothing but the greatest care could possibly prevent 
wounding this important structure, or if the bony cover- 
ing be present and carious, its removal cannot be accom- 
plished without seriously interfering with the nerve. 
Another problem which my limited experience has not 
afforded me an opportunity of solving is whether the 
condition would be less likely to occur if the posterior 
operation (of Stacke) be employed instead of the opera- 
tion through the canal, the latter being the method that 
1 Read before the Section of Otology, College of Physicians 
April 3, 1894. 2 
I have employed in each case. The patients were all 
treated by thorough cleansing, both by means of the 
cotton applicator and with the post-tympanic syringe, as 
far as it was possible and as long as I felt it was wise to 
continue it. The results obtained, in so far as the sup- 
puration was concerned in each case, I think justify the 
operative procedure. 
Case I.—Mr. L., thirty-two years of age, first con- 
sulted me April, 1893, when he gave a history of sup- 
puration of the left ear for twenty-two years; suppura- 
tion from the right side had lasted but a few months, 
while on the left side it had been persistent during the 
entire period; he had been treated at intervals, though 
without in any way affecting the condition. The ex- 
amination when I first saw him showed in the right ear 
a depressed cicatrix in the lower anterior portion of the 
membrane and some general thickening; on the left 
side there was a fetid discharge from the canal, which on 
removal showed considerable destruction of the upper 
wall, and the bent probe readily passed into the attic 
region ; the hearing for whisper-sounds was on the left 
side, one foot, on the right, about six feet; the tuning- 
fork gave R. upon both sides; the patient complained 
of a fulness and some aching and tinnitus. The treat- 
ment, which was continued from three times to twice a 
week, from April until September, consisted of thorough 
cleansing, both by means of the cotton-carrier and hy- 
drogen dioxid, and syringing with hot water carried 
well up into the cavity, and then followed by dusting 
the canal with borated powder. The naso-pharynx 
was also treated each time the ear was treated. While 
this treatment served to greatly lessen both the fetor 
and the amount of discharge, the latter at no time en- 
tirely ceased, there being at each visit some suppuration 
from that region. The operation consisted of removing 
what remained of the membrane, malleus, and incus, 
the head of the malleus being lost and also a large part 3 
of the body of the incus ; the cavity was then thoroughly 
curetted and part of the upper, posterior portion of the 
roof of the canal was carefully chiselled away ; the whole 
cavity was then thoroughly washed out with a hot satu- 
rated solution of boric acid, and dusted with aristol, and 
the canal closed with a cotton pledget. Thirty-six hours 
after the operation, a marked paralysis was noted of the 
entire left side of the face, including the eyelids and 
brow, which fortunately subsided in six weeks. The 
suppuration had entirely ceased in eight weeks. The 
patient has reported to me once a month, and I have been 
gratified to find that the good results still continue. 
Case II.—Miss K. McN., twenty years old, has had 
suppuration on the right side for fourteen years; she has 
no recollection of having had suppuration on the left 
side, though a lower, anterior cicatrix clearly proves the 
contrary; the condition followed scarlet fever. When she 
consulted me on June 12, 1893,1 found the canal partially 
filled with desiccated pus, removal of which brought 
to view an attic filled with granulation-tissue, the 
removal of which left the malleus-head bare. This 
case was treated in the routine way described until the 
latter part of September, when the operation was per- 
formed. The membrane, malleus, and incus were re- 
moved ; the malleus was apparently not carious, while 
a large portion of the body of the incus was lost; the 
entire cavity was then thoroughly curetted and treated 
as in the foregoing case ; paralysis here appeared on the 
third day after the operation and continued for about 
seven weeks; the discharge had entirely ceased by the 
end of the tenth week, and the cavity is perfectly well 
at the present time. The examination of the membrane 
within a month past shows a perfectly healthy cicatrix. 
The hearing, which was very deficient, was not in any 
way improved, though she thought the tinnitus, which 
was very marked, was somewhat improved. 
Case III.—Mrs. Le C., thirty-four years of age, has 4 
had suppuration from the left ear for thirteen years. 
When I saw her first, about one and a half years ago, 
there was free fetid discharge, which was more profuse in 
this case than is usually found in cases of attic suppu- 
ration ; the bent probe passed well up into the attic, and 
the cleansing brought down large quantities of necrotic 
tissue, black and very fetid; the tuning-fork gave R.; 
the hearing was very good, a whisper being heard at four 
feet; she complained of vertigo and tinnitus, the former 
being so great that treatment by syringing was extremely 
difficult to carry out. After having treated the woman for a 
year and more without benefiting her to any great extent— 
indeed, if she went longer than a week without cleansing, 
the discharge would become as profuse and fetid as 
when I first saw her; the operation was performed No- 
vember 2, 1893. In addition to removal of the malleus, 
the head of which was almost entirely destroyed, a portion 
of the posterior part of the roof of the canal was chiselled 
away, and what remained of the membrane was excised ; 
theincus could not be found, and was probably destroyed ; 
paralysis was noted in this case before she had recovered 
from the anesthetic ; it was indeed complete. The sup- 
puration had entirely ceased by January, though for a 
month previous to that time it had only been sufficient in 
amount to harden the powder that had been blown into 
the canal. The paralysis in this case has been per- 
sistent, and while it is at present showing evidence of 
subsiding, it will, I fear, be some time before it is com- 
pletely relieved; the vertigo following the operation 
was also a very annoying symptom, and continued for 
two weeks; there was, however, but slight elevation of 
temperature. The case is now under treatment at the 
University Hospital, at the hands of Dr. Potts, the elec- 
trician, who has kindly furnished me notes as to the 
muscular reactions, his opinion being that the nerve was 
not severed, but that it had been greatly irritated, prob- 
ably by the pressure of a spicula of bone against it. 5 
Electrician’s Notes.—The muscles did not respond 
to the faradic current, but did to a moderate galvanic cur- 
rent (about 6 to 8 milliamperes). Qualitative reactions 
were present, the muscles responding in the peculiar slow 
manner characteristic of degenerated muscles and the 
ACC was about equal to K C C. Owing to the fact that 
the muscles exhibited K C C of about equal strength to 
that of A C C six weeks after reception of injury, we were 
led to assume that the nerve had not been seriously in- 
jured and to give a good prognosis. Normal reactions 
have returned in some of the muscles—now something 
over two months since treatment was begun. 
In none of the cases was there any perceptible change 
in the hearing. There was, however, apparently some 
lessening of the tinnitus in Case II, and absolute relief 
from the vertigo in the last case. In all, the discharge 
was stopped, and it is reasonable to believe cured, though 
I am not prepared to claim this latter fact absolutely. 
It is my opinion that the want of proper drainage is the 
sole cause for the persistence in attic suppuration, as 
we know that drainage through the tube is usually cut 
off by the inflammatory adhesions within the middle-ear 
cavity, and thereby leaving the attic region entirely 
without any drainage. It would, therefore, seem to be 
good surgery to remove all obstructions, even though so 
annoying a condition as paralysis may follow.