PARTIAL MYRINGECTOMY AND REMOVAL OF THE INCUS AND STAPES For the Relief of the Lesions of Chronic Catarrhal Otitis Media. BY CHARLES H. BURNETT, M.D., AURAL SURGEON, PRESBYTERIAN HOSPITAL, ETC., PHILADELPHIA. FROM THE MEDICAL NEWS, May 13, 1893. [Reprinted from The Medical News, May 13, 1893.] PARTIAL MYRINGECTOMY AND REMOVAL OF THE INCUS AND STAPES FOR THE RELIEF OF THE LESIONS OF CHRONIC CATARRHAL OTITIS MEDIA. By CHARLES H. BURNETT, M.D., AURAL SURGEON, PRESBYTERIAN HOSPITAL, ETC., PHILADELPHIA. There are numerous cases of chronic catarrhal otitis media-with its attendants, tinnitus, deafness, and aural vertigo-which continue to suffer and per- plex their physicians, even after the nares, naso- pharynx, and fauces are rendered normal, or nearly so. Therefore, after bringing the nose, naso- pharynx, Eustachian tube, and throat into a normal condition, but still finding the aural symptoms little or no better, the aurist is confronted with the very important question as to what shall be done to improve the hearing, reduce the tinnitus, and abolish the vertiginous tendency. Many methods of treating the ear at this point of its history have been suggested, chiefly for the relief of the one prominent symptom-deafness. These range from simple puncture to total excision of the tympanic membrane, and the removal of one or more of the ossicula. Without stopping in this short article to discuss the merits and demerits of these various methods of 2 surgical treatment, I shall present briefly the notes of some cases in which I have performed a modified operation, the form of which is indicated in the title of this paper. In all of the following opera- tions, the patients were etherized and the ear illu- minated by an electric forehead-lamp. Case I.-Mrs. T. H., of Connecticut, fifty-nine years old, has been deaf in the left ear for twenty- five years, after typhoid fever. She can hear some words in her left ear with the otophone; there is con- stant tinnitus; she hears loud words close to the ear. The tuning-fork is heard well per ossa. There is a large bulbous cicatrix-comprising the entire pos- terior superior quadrant of the membrana. The incus-stapes joint is plainly visible through the thin cicatrix, when it is pushed inward by the pneumatic speculum. The malleus is shown by the pneu- matic speculum to be adherent to the promontory. On October 31, 1892, the patient being etherized, the thin cicatrix described was excised, and the incus-stapes articulation, with the stapedius tendon, was exposed to view. The stapedius tendon was severed ; the incus was separated from the stapes by the incus hook-knife, and easily removed. The blunt stapes-hook was passed, from below, under the head of the stapes between the crura. The stapes was found to be firmly ankylosed in the oval window. Gentle traction upon the stapes brought away the head and crura only. The rest of the membrana and the malleus were left in situ. On November 1st there was no reaction, no im- provement in hearing, and no change in the tinnitus. On November 2d there was no reaction. The oval window was plainly visible; the foot-plate of the stapes was touched with a probe and found to be firmly attached to the oval window. The hearing this morn- 3 ing was better, being equal to six inches for isolated words, low tone, near the ear. The tinnitus was not lessened. On November 4th there was no reaction, though the patient had some coryza. Hearing was the same as at the last visit, viz., six inches for the voice. Tinnitus was less. On November nth the hearing was eight inches for the voice. There was no reac- tion, and no signs of closure of the opening made by excision in the membrana. The patient returned to her home and I have not seen her since, though I have heard from her that the slight improvement in the hearing has been maintained, a d that there has been no reaction in the ear operated upon. Case II.-Miss E , of Virginia, thirty years of age, was first examined in June, 1892. The patient has had nasal polypi removed; she has also had typhoid fever, and finally nervous prostration, with uterine disease, for which she has been treated. All of these maladies cover a period of the last six years. The hearing began to fail about two years previous to the time of first consulting me. There was then some slight hypertrophic nasal catarrh, for which the patient was ordered to use a spray of Dobell's solution two or three times a week. In November, 1892, when I saw the patient again, I made the following notes: The right membrana tympani is retracted, opaque, bluish-pearl color; the incus-stapes articulation is not visible through the membrana; there is constant tinnitus ; the hear- ing for all sounds per aer = o ; the tuning-fork is heard per ossa. The external auditory canal is very narrow. On November 21st the patient was etherized, and the upper posterior quadrant of the membrana tym- pani was cut away and the incus revealed; the incus was detached from the stapes and removed from the tympanic cavity. The stapes was high- placed and not seen. Had I made the incision a 4 little higher the stapes might have been seen, and an endeavor made to remove it. On November 22d no reaction had taken place, and the patient volunteered the statement that the tinnitus was decidedly less, and that she could hear a little. On November 23d she heard a little better; no reaction was present, and the tinnitus was decreasing. On November 25th there was a little more tinnitus than on the 24th, but not as much as before the operation. On November 26th the patient could hear loud vocal sounds, per oto- phone, that were inaudible before. No tinnitus existed. On November 29th the same report was made as on the 26th instant. The patient now re- turned to her home. After her return home she exercised this ear, according to my directions, by having some one read to her through the oto- phone once or twice daily, for fifteen minutes at a time. In December, 1892, she reported that she could hear better with the otophone, but not without it. In January, 1893, her father wrote me that his daughter could now hear reading near the right ear, unaided by the otophone, and with the voice slightly elevated. There has never been any reaction. I am unable to say whether the perforation in the membrana has been maintained. A letter in April informs me that still further improvement in hear- ing has occurred. Case III.-Mrs. S., of Connecticut, aged forty- seven years, now at the menopause, has had chronic sclerotic otitis media in both ears for twenty years, beginning first in the left ear. At the time of examination hearing in R. E. = o; in the left ear, the voice close to the ear was heard. On December 13th the patient was etherized and ex- cision of the upper posterior quadrant of the left membrana was performed. The membrane, being 5 exceedingly thick and integumentary, bled profusely, and the operation was, in consequence, greatly de- layed. The incus was seen with difficulty, but finally dislodged. Thq stapes was not seen at the time of the operation. The incus was accidentally dropped from the forceps into the tympanic cavity, but was finally hooked into view and removed. I now endeavored to convert the upper posterior quadrant of the membrana into a flap, and push it inward against the promontory to act as a preven- tive against a detached ossicle from falling into the tympanic cavity. On December 17th the patient heard the voice several inches away from ear. She had some fugitive pains in the ear, but no discharge of any kind. On December 19th there was some pain reported in the ear on the night of the 17th, and some bloody muco- purulent matter ran from it, probably due to the grappling for the incus when it fell to the bottom of tympanic cavity. However, at this date, there was no pain and the improved hearing was maintained. Case IV.-This was the right ear of the same patient as reported in Case III. It had been my intention to operate on both ears in this case at the same etheriza- tion, but the delay caused by the hemorrhage, drop- ping the incus, and finally the breaking of a " lug " in my storage battery, forced me to postpone the operation on the right ear until December 19, when the patient being again under ether, I excised the upper posterior quadrant of the membrana tympani and exposed the incus and the stapes. The chorda tympani prolapsed into the auditory canal after the removal of the incus, which was easily accomplished. I made traction with the blunt hook on the stapes and brought away the head and crura. On December 20th the patient could hear at a distance of several inches in this ear, in which she had not heard for years. There was no reaction. On December 23d * 6 she heard better in the right than in the left ear. On December 24th the patient went home pleased with the result of the operations. Case V.-Mr. J. H. P., twenty-three years old, has had chronic hypertrophic aural catarrh-ambi- lateral-for several years. The left ear was formerly better than the right ear. The latter has improved under treatment of the naso-pharynx, but the left ear has not improved. The hearing-distance in the left ear for the voice was one foot, and there was annoy- ing tinnitus. The membrana tympani was opaque. The incus-stapes articulation was not visible through the membrana. On December 15th the patient was etherized and the posterior superior quadrant of the membrana was excised. The incus, stapes, stapedius pyramid, and the tendon inserted into the stapes were plainly visible. The tendon of the stapedius was first severed ; then the incus was separated from the stapes and removed from the tympanic cavity. The blunt stapes-hook was passed beneath the head of the stapes and traction was made. The bonelet was found to be most firmly imbedded in the oval window. Traction upon the bonelet by the stapes- hook brought away the head and crura. The oper- ation was bloodless. On December 16th no reaction had taken place and there was much less tinnitus. The hearing-dis- tance was not noted, as I failed to see the patient. On December 17th no reaction had occurred and there was marked diminution of the tinnitus; the hearing-distance for voice, low tones, was from four to six feet. On March 28, 1893, the perforation in the membrana had been maintained. • A little tinnitus is perceived in this ear, if the patient takes cold in his head; otherwise he does not observe it. He volunteers the statement that the operation was worth the relief from the tinnitus, regardless of the improved hearing. The hearing-distance at the pres- 7 ent time is from eight to ten feet for isolated words. Case VI.-B. B., a girl, twelve years old, had been known to have dulness of hearing in the left ear for two years. The right ear is entirely normal. Hearing in the left ear, o; tinnitus, and vertigo at times, are annoying; the tuning-fork is heard per ossa. On December 16, 1892, the patient was etherized and excision of the upper posterior quadrant of the left membrana was performed; no bleeding followed. The incus, stapes, and stapedius pyramid, with ten- don, were distinctly seen. The stapedius-tendon was seveied first; then the incus was detached from the stapes; the.stapes was then removed entire, with the greatest ease, from the oval window. There was no escape of labyrinth-fluid. Finally the incus, which seemed unusually adherent in the attic, was removed. The operation was bloodless. On the next day there was no reaction, no vertigo, and the patient felt well and lively; she heard isolated words in the left ear at a distance of from eight to ten inches; there was no tinnitus. On December 22d there was no reaction and no regeneration of the membrana; voice was heard in whisper at a distance of from six to eight inches; louder tones from two to three feet. There was no regeneration a month later. On April 1, 1893, regeneration of the membrana was found. The hearing was not improved, but there has been entire relief from tinnitus and vertigo, which symptoms had been ascribed to other causes before the ear was examined by me and finally operated upon. Case VII.-H. W., a cook, twenty-six years old, of English parentage, had been deaf for many years. In the right ear she hears the tuning-fork per aer at a distance of one inch; in the left ear at two inches. She has marked symptoms of sclerotic otitis media. On January 13, 1893, patient 8 was etherized and the posterior superior quadrant of the right membrana was excised. 1 he incus, stapes, and stapedius tendon were exposed, the last cut, and the incus detached from the stapes and pushed aside to be left in the tympanic cavity in this instance. The stapes head and crura were then removed with- out the foot-plate, the latter being firmly fixed in the oval window ; no bleeding ensued. On January 14th, there had been no reaction, but considerable bloody serum had run from the ear, and the patient now left the hospital, in very cold weather. She heard isolated words at several inches' distance in the right ear. On January 16th, the patient reported that she had had a little pain in this ear ; the bleeding from it still continued. This patient has very bad teeth, and at times, toothache. The atmospheric tem- perature was at o° at this time. On January 17th, pain still continued in this ear and there was a dis- charge of bloody serum. The mucous membrane of the tympanum was congested and secretory ; there was marked tinnitus. From January 18th to 25th, there was more or less constant and severe pain in this ear, with swelling of the meatus, tenderness, and a discharge of considerable pus. Loss of sleep from ear-pain was complained of. On January 31st, the ear was entirely well; the perforation in the mem- brana had healed and the patient heard no better than before the operation. The incus should not have been left in the tym- panum after its detachment, and the patient should not have left the hospital the day after the opera- tion, in such very cold weather as was then pre- vailing. Case VIII.-H. S., a girl, twelve years old, said that about two or three years ago hardness of hearing was noticed in the right ear. No cause was assigned 9 for such a failure in function. Hearing was perfect in the other ear. Voice, close and loud, could be heard in the right ear. The patient had some sclerotic catarrh of the nares and naso-pharynx. The latter was treated for some weeks, with benefit, but without improving the hearing. On March 3, 1893, myringotomy was performed in the posterior superior quadrant, and the incus and stapes ex- posed. The incus was detached from the stapes and removed. The stapes was pulled upon by the blunt hook and the head and crura detached from the foot-plate, but they were drawn off the hook by the tendon of the stapedius and dropped out of sight behind the membrana. On March 4th, no reaction had ensued and no improvement in hearing. On March 28th, there had been no reaction and no irri- tation in the ear at any time. The membrana is entirely healed and rises and falls normally under Siegle's speculum. There has been no improvement in hearing. Case IX.-Mrs. W. G. P., forty-one years old, of New York, came under observation December 7, 1892. The patient stated that she began to grow deaf at the age of sixteen years ; tinnitus existed in both ears of equal intensity and of a pulsating variety. Hearing in each ear, for the voice, was at about six inches, perhaps less acute in the left ear. The tuning-fork was not perceived per aer. Bone- conduction was normal. A nasal polypus was re- moved from the right naris; otherwise there was no disease of nose or naso-pharynx. The membranse tympanorum were slightly opaque. On March 16, 1893, the patient was etherized and myringectomy at the posterior superior quadrant of the left membrana revealed simply the extreme lower curved end of the incus. The incus was de- tached by the blunt hook and removed from the drum- cavity. The stapes was not seen, and hence was left 10 undisturbed. The round window was placed very- high and its plane turned farther forward and outward than any I have ever observed. The operation was nearly a bloodless one. On March 17th, no reaction had followed and no improvement in any of the symp- toms. On March 18th, there had been no reaction, and the hearing was a little better, the tinnitus being less than in the other ear. In fact, the patient felt so much relief in the left ear as to express a desire to have the operation performed on the other ear. On March 19th, there was still no reaction, and the patient went to church. On March 20th, it was decided to operate on the right ear, as the left ear felt so much better than the right ear, which had been considered the better ear. Case X.-On March 20, 1893, operation was performed on the right ear of the patient in the preceding case. Excision of the upper posterior quadrant was effected. The membrana was found thicker and more retracted than that of the left, and there was a little more bleeding than from the left. No cocaine was used, as I am convinced that it is an irritant to the mucous membrane of the drum. The incus was detached in the same manner as was the left incus, and was removed from the tympanum. On March 21st no reaction had followed. The patient felt very well, and could hear isolated words spoken eight feet off, and she also heard her com- panion singing some distance from her, which she had never heard before. The tinnitus, however, was not materially relieved. The patient also heard sounds in the house and street she had never heard before from her room. On March 23d the patient returned to her home, and on March 28th I heard from her that the improvement had continued. 11 Conclusions.-i. The operation of partial ex- cision of the membrana tympani (myringectomy of the posterior superior quadrant) is practically unat- tended by reaction. 2. Reaction not attending this modification of excision of the membrana, regeneration of the membrane is less likely to occur than when total excision of the membrana is performed. 3. Removal of the malleus is not necessary for relief in cases of simple chronic catarrhal otitis media. 4. The removal of the incus alone, or of the incus and the head and crura of the stapes, is fol- lowed by results as good as when the incus and the entire stapes are removed. 5. Displacement of the incus and leaving it in the drum-cavity, where the stapes is removed in part or in whole, is likely to be followed by inflammation of the middle ear, as shown in Case VII. 6. Removal of the incus alone, the membrana, malleus, and stapes being left in situ, gives more space in the drum-cavity, increases its resonance, and permits freer access of sound waves to the stapes, thereby improving the hearing. 7. The relief of tinnitus and aural vertigo is very probably due to the liberation of the stapes from the impacting weight of the incus, forced in- ward and held so by the retractive power of the indrawn membrana tympani and malleus, as I sug- gested over four years ago.1 1 The Polyclinic, Philadelphia, August, 1888. The Medical Neues. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $750 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.