What Shall a General Practitioner Do for 
an Acute Otitis? 
BY 
EDWARD B. DENCH, M.D., 
Professor of Otology in the Bellevue Hospital and Medical College. 
Surgeon New York Eye and Ear Infirmary. 
New York. 
FROM 
ARCHIVES OF PEDIATRICS, 
May, 1895. WHAT SHALL A GENERAL PRACTITIONER 
DO FOR AN ACUTE OTITIS? 
BY EDWARD B. DENCH, M.D. 
Professor of Otology in the Bellevue Hospital Medical College. 
Surgeon New York Eye and Ear Infirmary. 
New York. 
A more intelligent understanding of those measures 
which lie at the command of a general practitioner in 
dealing with the disease in question, can perhaps be ar- 
rived at by considering just those resources which are to 
be adopted for the relief of the symptoms which the dis- 
ease causes. The symptoms which most prominently 
present are first, pain in the ear ; and second, discharge 
from the ear. A word of caution here may not be out of 
place from the fact that children occasionally complain 
of aural pain when the ear is perfectly normal, the pain 
being neuralgic in character and due to dental caries. It 
is to be suggested therefore, that in children over two 
years of age, that the practitioner first examine the mouth 
to see if any carious teeth are present, unless he is suffi- 
ciently versed in otoscopy to determine the aural condi- 
tion directly. 
When the pain is due to inflammation either of the ex- 
ternal auditory meatus, or of the middle ear, and the pa- 
tient is seen in the early stages of the attack, the physician 
should attempt to abort the inflammation as well as to 
relieve the symptoms. The most efficient measure for 
aborting the attack is undoubtedly the local abstraction 
of blood. In very young children either wet cupping or 
the use of natural leeches is difficult, although the cup 
can be applied if the child is firmly held, and if the phy- 
sician does not possess enough confidence in himself to 
manipulate instruments in the external auditory canal, it 
is certainly wise to employ local depletion. The region 
selected for the application either of the wet cup or of 2 
Dench : Acute Otitis. 
leeches, is that lying close to and immediately in front of 
the tragus. From half an ounce to one and a half ounces 
of blood may be withdrawn in this region, and in many 
cases the measure is beneficial. The patient should be 
kept in bed and a free catharsis instituted. If the case is 
seen very early, it is frequently wise to follow the abstrac- 
tion of blood by the administration of an opiate sufficiently 
powerful to quiet the patient for five or six hours, in the 
hope that depletion and absolute rest for several hours 
may abort the attack. For the further relief of pain the 
use of heat about the ear is a means at the disposal of all, 
and is certainly valuable, either after local depletion, or 
where this measure is not deemed advisable. The most 
convenient method of employing dry heat is by means of 
the Japanese pocket stove ; the hot water bag, although 
less convenient is equally efficacious. Where these are 
not available, a stove lid, a flat-iron or a brick previously 
heated, wrapped in a piece of flannel and placed under 
the pillow will supply the place of the more convenient 
apparatus above described. In order that the heat may 
be applied more directly, I occasionally recommend that 
a small hot salt bag be introduced into the meatus, heat 
being applied externally by means of the hot water bag 
or other device as stated before. These salt bags are 
conveniently made by cutting off the finger tips of a kid 
glove, filling the tips with salt and placing them upon a 
hot plate until they are thorougly heated, after which 
they are placed just within the meatus and heat is applied 
externally as already described. 
If there is one point we should emphasize more than 
another, it is that under no circumstances is any oily sub- 
stance to be introduced into the meatus. The old practice 
of dropping warm sweet oil, or a mixture of sweet oil and 
laudanum into the external auditory canal for the relief 
of otalgia, is a relic of barbarism that deserves no place in 
modern medicine. 
I am not inclined to favor the use of moist heat in the 
early stages of an acute otitis, consequently the irrigation 
of the canal with warm water, or the application of pouF Dench : Acute Otitis. 
3 
tices to the ear, the canal being previously filled with 
water, are not, I think, measures to be advised. Moist 
heat softens the tissues and encourages their disintegra- 
tion, while our efforts in the early stages should be directed 
towards aborting the inflammation. Heat is employed 
in the early stages simply for the relief of pain, and dry 
heat does not encourage suppuration, while moist heat 
certainly favors it. 
If after the effects of the opiate have disappeared the 
pain reappears, it is unwise to administer a second dose, 
as it will only mask the symptoms. The local abstrac- 
tion of blood and the application of dry heat are then the 
only resources at the command of the physician, previous 
to the appearance of discharge from the ear, unless he is 
able to use the head mirror and inspect the parts 
affected. 
After discharge has made its appearance frequent irri- 
gation of the external meatus by means of a weak anti- 
septic solution, such as a solution of the bichloride of 
mercury I to 5000, or of carbolic acid 1 to 100, or a sat- 
urated solution of boracic acid, is the best measure for 
combatting the inflammatory process, and for preventing 
its extension to the neighboring bony parts. In many of 
these cases the discharge is serous in character and will 
continue so unless it is infected as it lies in the external 
auditory canal. All that is needed is to keep the meatus 
perfectly clean and prevent infection of the discharge. It 
is unwise to stop the meatus with cotton, or to keep the 
ear covered, as in this way local infection of the canal is 
liable to occur, causing either circumscribed or diffuse in- 
flammation. While the ear is discharging, considerable 
relief may sometimes be obtained by filling the meatus 
with warm water and applying heat ex.ternally; a poultice 
covering the auricle, however,is not necessary and causes 
so much maceration of the integument as to constitute a 
disadvantage; if the canal is filled with water and dry 
heat is applied externally, we have the beneficial action 
of the heat and moisture upon the parts affected without 
inflicting any injury upon the auricle. 4 
Dench : Acute Otitis. 
.After the acute symptoms have subsided certain meas- 
ures directed towards checking the discharge may seem 
necessary. It must be remembered that under no condi- 
tion should any attempt be made to diminish the quantity 
of the discharge until the temperature becomes normal 
and all pain has disappeared. In the large proportion of 
cases where spontaneous rupture of the drum membrane 
has taken place, if the parts are kept carefully cleansed 
in the manner previously described, the discharge will 
cease spontaneously ; in a small proportion of cases it 
continues. The use of astringent instillations cannot, I 
think, be commended. In cases where the discharge 
persists, it is perfectly safe to use a saturated solution of 
boric acid in alcohol, as an instillation after syringing. A 
few drops of this solution introduced into the meatus by 
means of the medicine dropper, after previous careful 
syringeing, may be employed with perfect safety and is 
usually sufficient to stop the discharge. The objection 
to solutions of sulphate of zinc and other kindred instilla- 
tions, is that they form an excellent nidus for the devel- 
opment of vegetable parasites, and unless the physician 
can inspect the parts and watch the effect of the applica- 
tion intelligently, they possess no advantage over the 
alcoholic solution of boric acid. The insufflation of 
powders into the meatus should only be employed by 
those thoroughly trained in otoscopy ; the advice some- 
times given to fill the canal with boric acid powder can- 
not be too strongly condemned. 
To recapitulate then, the measures at the service of 
one who is unwilling to trust to his skill in otoscopic ex- 
amination, will be comprised under local depletion and dry 
heat before the appearance of discharge; and local deple- 
tion and moist heat with frequent irrigation, after the ap- 
pearance of discharge. Extension to the bony parts, as 
indicated by tenderness upon pressure behind the ear, is 
to be combatted by the use of the ice coil or the ice bag 
to the mastoid process, the frequent irrigation of the canal 
being continued. The cold applications should not be 
used for longer than forty-eight hours-after this they 
simply mask the symptoms. Dench : Acute Otitis. 
5 
Where an otoscopic examination has been made, the 
appearance of the parts involved frequently causes us to 
modify our treatment, and at the present day very few 
practitioners are incompetent to make such an examina- 
tion and to be guided by it. The local depletion and dry 
heat are always perfectly safe in the early stages. If these 
fail to relieve the pain, it is wise under all circumstances 
to evacuate any collection of fluid which may have 
formed, or to still further deplete the parts by incision if 
inflammatory effusion has not yet taken place. It is much 
better to do this than to wait for spontaneous perforation 
of the drum membrane. 
* 
As the present remarks have to do particularly with 
otitis in young children, a few remarks concerning the 
technique of otoscopy in infants will not be out of place. 
It is to be remembered that in the infant at birth the su- 
perior and inferior walls of the meatus are in contact, 
that the superior wall lies immediately upon the external 
surface of the squamous portion of the temporal bone, and 
that the membrana tympani constitutes a prolongation or 
extension of this superior wall. As development advances 
the bony meatus is formed, during which process the in- 
ferior wall becomes separated from the superior in the 
deeper portion of the meatus. In infants therefore, in 
order to expose the membrana tympani it is necessary to 
draw the auricle downward, backward and outward be- 
fore inserting the speculum, and after this instrument is 
in position, to direct the eye upward to the superior wall 
of the meatus and follow this to its inner extremity, in 
order to inspect the membrana tympani. Such an inspec- 
tion is not difficult, and a little practice enables anyone to 
make it. 
Any tumefaction within the external canal whether it 
constitutes an external otitis limited to the canal wall, or 
is caused by an accumulation of fluid behind the drum 
membrane, or by swelling of the tissue in the vault of the 
tympanum, demands incision, if previous depletion and 
dry heat have not relieved the pain. I am strongly in 
favor of an early incision in acute otitis media in order to 
cut short the inflammatory process and to prevent the 6 
Dench : Acute Otitis. 
formation of pus. Such an incision can be easily made if 
done carefully, even by one not particularly expert in 
manipulating aural instruments. Such an incision should 
be free, should lie in the posterior portion of the mem- 
brana tympani, and may well be carried for some distance 
upon the postero-superior wall of the canal. If a delicate 
and very sharp knife is carried directly through the tume- 
faction until the point of the knife impinges upon the 
bony wall of the middle ear and is made to cut its way up- 
ward, backward and outward, the rich vascular plexus 
which lies in this region is opened, and direct deple- 
tion is the result. Such an incision seldom fails to 
stop the inflammatory process, if the measure is insti- 
tuted before effusion has taken place; while it is a 
matter of necessity after pus formation, in order to 
evacuate the secretion and to prevent either extension 
or septic infection. After such an incision has been made 
the rules previously laid down in regard to frequent irri- 
gation of the canal are to be followed. As regards the 
frequency with which irrigation is to be repeated, this 
must depend upon the amount of discharge. This dis- 
charge in young children is frequently very profuse, espe- 
cially after spontaneous perforation, and for the first 
few days it may be necessary to irrigate the ear as fre- 
quently as every two hours during the day time, and once 
or twice during the night. In syringeing the ear in an 
infant the auricle should be drawn downward and back- 
ward, and the tip of the instrument should be introduced 
well into the meatus. The instrument most easily mani- 
pulated where we have to do with very young children, 
is the soft rubber ear syringe. In this instrument both 
the receiver and the delivery tube are of soft rubber, and 
it is impossible to inflict any injury by introducing it into 
the meatus. In older children an ordinary piston syringe 
of hard rubber is preferable, as the bony meatus is already 
developed. The instrument is best provided with an 
olive tip to prevent too deep introduction into the meatus. 
The attendant is instructed simply to introduce the sy- 
ringe as far as possible into the canal and to inject the Dench : Acute Otitis. 
7 
fluid with moderate force. In this way no harm can be 
done, while the perfect cleansing of the canal is 
insured. 
Where early incision has been resorted to, the dis- 
charge seldom lasts more than five or six days, and if 
the case has been one of a circumscribed external otitis 
the discharge does not last as long as this, the edges of 
the wound approximating and uniting in a very short time. 
If there has been an acute catarrhal otitis media involving 
the lower portion of the cavity alone, or if we have had the 
more severe form of acute purulent otitis involving the 
structures within the tympanic vault, the incision through 
the membrana tympani heals perfectly in a very short 
time. Herein lies the advantage of surgical interference 
as compared with spontaneous perforation of the drum 
membrane. Where this latter occurs it must be the re- 
sult of a local necrosis and actual tissue destruction, and 
considerable time is required to repair the parts ; it should 
be remembered that when a wound in the membrana 
tympani cicatrizes the fibrous layers are not reproduced, 
and the cicatrized portion possesses less resistance than 
the normal membrana tympani, and in later life is fre- 
quently the cause of a tension anomaly with consequent 
disturbances of audition. No such cicatricial tissue is 
formed in the healing of an incised wound, and a few 
months after the operation it is frequently impossible to 
recognize the line of incision. 
I do not think that we can too strongly urge the ad- 
vantage, or indeed the necessity, of early and free incision 
through the inflamed tissue in all cases of acute otitis 
which do not yield to the abstraction of blood and to the 
application of dry heat. The disappearance of all symp- 
toms upon incision is usually immediate, although occa- 
sionally the temperature remains slightly elevated for 
twenty-four to forty-eight hours in spite of the fact that 
drainage is perfectly free. A sudden rise of temperature, 
either after incision or after spontaneous perforation, is 
usually an evidence that the irrigation has been imper- 
fectly performed, and the temperature frequently falls im- 8 
Dench: An Acute Otitis. 
mediately after thorough cleansing of the canal. A con- 
tinuous high temperature after free discharge, following 
either spontaneous perforation or surgical interference 
should always lead to a careful examination of the mastoid 
process. Where early incision is adopted extension in that 
direction rarely takes place, as when the knife is carried 
well up into the tympanic vault it passes through the 
upper and posterior part' of the membrana tympani and 
from thence to the canal wall, and the incision serves the 
same purpose as the Wilde incision behind the auricle; 
with the exception that it is much more efficient. In 
the infant the mastoid process is rudimentary, while 
the tympanic vault is of about the same dimensions as 
in adult life, and division of the tense fibrous bands 
lying in the upper portion of the tympanic cavity is 
therefore more efficacious than an incision through the 
periosteum covering the external surface of the mastoid. Archives of Pediatrics 
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