OPERATIVE MEASURES FOR THE RELIEF OF CHRONIC SUPPURATIVE AND NON-SUPPURA- TIVE INFLAMMATION OF THE TYMPANUM ; THE INDICATIONS FOR 'THE EMPLOYMENT OF SUCH MEASURES, AND THE RESULTS OBTAINED. BY By E. B. DENCH, M.D. AURAL SURGEON, N. Y. EVE AND EAR INFIRMARY. PROFESSOR OF OTOLOGY, N. Y Reprinted from the New York Eye and Ear Infirmary Reports, Vol. I., Part I, January, 1893. OPERATIVE MEASURES FOR THE RELIEF OF CHRONIC SUPPURATIVE AND NON-SUPPURA- TIVE INFLAMMATION OF THE TYMPANUM ; THE INDICATIONS FOR THE EMPLOYMENT OF SUCH MEASURES, AND THE RESULTS OBTAINED. By E. B. DENCH, M.D. AURAL SURGEON, N. Y. EYE AND EAR INFIRMARY. PROFESSOR OF OTOLOGY, N. Y. POLYCLINIC. VER since Kessel in 1877 removed the malleus and incus from a patient suffering from chronic catarrhal inflamma- tion of the tympanum, operations upon the structures within this cavity have been attempted. Within the last few years, however, so much has been written on this subject, that it is apparent that operative otology will, at no distant day, become by no means an insignificant department of special surgery. It is not strange that many surgeons, anxious to keep fully abreast of all advances made in their chosen field, should have been led to undertake operative procedures in a large propor- tion of cases, and perhaps in some instances in which satisfac- tory results might have been obtained without resort to operation. The result has been that, in spite of much testi- mony in favor of intra-tympanic surgery, many prominent otologists have condemned operations of this kind, some after giving them a fair personal trial, others, perhaps, after a hasty judgment, arrived at after seeing a few cases operated upon by others, in which the results were not as brilliant as might have been hoped for. Believing that a decision based upon personal experience is more valuable than one which is the result of collating the labors of others, -I have endeavored during the last eighteen months, to determine the success or failure of operative measures as evidenced by the results obtained in cases Reprinted from the New York Eye and Ear Infirmary Reports, Vol. I., Part i, 1893. 45 OPERATIONS WITHIN THE TYMPANUM. operated upon by myself at the New York Eye and Ear Infirmary. Intra-tympanic operations are undertaken: (i) for the relief of impaired hearing ; (2) for the relief of tinnitus ; (3) for the relief of a persistent discharge from the ear, which has resisted all the gentler methods of treatment. These three conditions may exist together, or any one or two may be met with without the others. The pathological process has been either a suppurative inflammation, resulting in a more or less complete destruction of the membrana tympani and ossicles, and the formation of adhesions within the tympanum, or there may have been no suppuration or destruction of the parts, but by a slow process of inflammation the structures may have been so thickened and bound together as to be unable to perform their functions, or the relations of the various parts may be so dis- turbed that they cannot carry out the work for which they were designed. If suppuration has been the cause of the trouble, the discharge may be constant or intermittent, or it may have ceased entirely, leaving behind it the changes already alluded to. The above statement no doubt seems somewhat unnecessary, but is made to emphasize the fact that it must be fully deter- mined that the seat of the trouble is within the tympanum, before any intra-tympanic operation is done to relieve it. Herein, I believe, lies the reason that so many able otologists have condemned these procedures, having observed the results in cases which a careful examination would have shown to be entirely unfit for operation. An ear may have been the seat of a suppurative process, as a result of which the membrana tympani has been almost completely destroyed and the ossicles bound together. Impaired hearing or tinnitus in such a case might depend upon this condition, or might depend upon some lesion of the auditory nerve, for which operation would avail nothing. A careful determination of the lesion should be made in every case before an operation is suggested, and for this purpose a series of tuning-forks of different pitch, furnishes us the means. In most of my cases such determinations were made with the series of forks devised by Hartmann. The lowest fork is a C fork, registering 128 vibrations per second ; the DENCH. 46 highest, a C fork, four octaves higher, registering 2,048 vibra- tions per second. The intervening forks are also tuned to the note C, and vary from each other by an octave of the scale. All of the tests alluded to in this paper have been made with these forks. I have lately added a much lower fork, one making 32 vibrations per second, although such a fork is of little value in determining the advisability of an operation. In determining the advisability of operative interference for the improvement of hearing with this series of forks, applica- tion is made of the well-known fact that, in lesions of the conducting mechanism, the normal relation between air- and bone-conduction is reversed. While the normal ear perceives the vibrating tuning-fork held in front of the ear for a much longer period of time than when it is placed on the mastoid, when the conducting apparatus is interfered with, the dura- tion of bone-conduction either exceeds that of air-conduction, or approaches more nearly to it. This reversal of the duration of bone-conduction, as compared with that of air-conduction, begins in affections of the conducting apparatus with the lower notes of the scale, and as the pathological process within the tympanum advances, bone-conduction for the higher notes becomes at first more nearly equal to, and then greater than air-conduction. It is this progressive increase in bone- conduction for the higher notes to which special attention should be drawn, as it indicates the degree to which the con- ducting mechanism is involved. If now the degree of involvement is proportionate to the impairment of hearing, we are justified in locating the lesion in the conducting apparatus alone, and to give a favorable prognosis as the result of opera- tive interference, granting, of course, that the ordinary procedures have failed to afford relief. In following this rule I have seldom been disappointed in the ultimate result of an operation, while in cases in which I have operated where this precept was not followed, little or no improvement has been effected. A few cases will make my meaning more clear. Case I.-E. L., set. twenty-two, was referred to me by a physician in this city, with the following history. For five years the hearing had been gradually becoming impaired, the right ear being affected first, the left at a later date. There 47 OPERATIONS WITHIN THE TYMPANUM. was considerable tinnitus in both ears. The patient had been under treatment at various times, and all the ordinary pro- cedures, such as inflation with the catheter and by Politzer's method, attention to the nose and naso-pharynx, etc., had been skilfully carried out, in spite of which the hearing was continually becoming worse. Examination by inspection revealed both tympanic mem- branes thin, retracted, adherent in places to the promontory ; there was beginning calcification about the periphery of the membranae, and at the umbo ; all changes were more marked upon the right side. Both Eustachian tubes were free, and the nose and naso-pharynx were in a fairly normal condition. Functional examination was as follows : W. D. R. : 2", L. 14". Tested with the tuning-forks the right ear showed an increase of bone-conduction over air-conduction for the first three octaves only ; the first two forks were not heard at all through the air, while the two highest forks were not heard at all by bone-conduction. Upon the left side bone-conduction was greater for the first two octaves only. After inflation the whispering distance on the right was 3 ", on the left 24 ", Considering the fact that, although the hearing power of the right ear was very greatly diminished, as evidenced by the whis- pering distance, the exaggeration of bone-conduction as com- pared with air-conduction extended only to the third octave, and was very marked for only the first two, together with the fact that bone-conduction for the two upper forks was entirely absent, I believed that, although there was undoubtedly a pathological condition in the conducting apparatus, the audi- tory nerve was also affected secondarily, and that the amount of relief obtainable from operation would not be very great ; in other words, while the transmitting mechanism was un- doubtedly at fault, the receptive apparatus was far from perfect, having been secondarily involved, and that the con- dition was beyond the reach of operative interference. As the patient was anxious to have anything done which might offer him the least possibility of improvement, and as all other methods of treatment had been of no avail, I consented to operate, after fully explaining the condition to him. The membrana tympani, malleus, and incus were removed, the stapes mobilized, and a thick membrane over the round window was divided with the knife. Very little improvement followed the operation, the whispering distance one week later being only 4", and the tinnitus but little improved,- fully bearing out the opinion that the conducting mechanism DENCH. 48 alone was not at fault. Under the administration of pilo- carpin, the whispering distance in the ear operated upon gradually rose to io" although the membrana tympani was partially reproduced. This case demonstrates fairly how exactly the cause of the impairment of hearing can be decided upon, and also the futility of proposing the operation in all cases in which the conducting mechanism is at fault. The same rules apply to the location of the cause of impair- ment of hearing in suppurative cases with more or less destruc- tion of the membrana tympani. In two cases in which the membrane was almost entirely wanting, and the tuning-fork tests indicated serious involvement of the auditory nerve, the operation was attempted as a forlorn hope, but the results were unsatisfactory. Experiences such as these have led me to depend almost entirely upon the examination with the tuning-forks in determining the propriety of operative inter- ference, and it is rarely that I have been misled. One of the most satisfactory cases is the following : Case II.-P. K., set. sixteen, consulted me some six weeks ago on account of greatly impaired hearing, the result of sup- purative otitis media following scarlet fever at the age of two years. Both ears had been the seat of long-continued suppura- tion, but the discharge had gradually diminished in amount, and for the last two years had practically ceased. Examination revealed extensive destruction of both mem- branae ; the ossicles were present but firmly bound down by adhesions ; there was a small amount of sero-purulent dis- charge in each canal. The functional examination was as follows. Whispering distance : R. E. 8 ", L. E. 8 ft. Tested with tuning-forks upon the right side aerial conduction was poor for the first four octaves, but bone-conduction was excellent and much better than aerial conduction Upon the left side bone-conduction was better than aerial for the first four octaves, but the aerial conduction was much better than upon the opposite side. For the two upper forks the aerial conduction was better than bone-conduction upon both sides. The power of hearing high notes by aerial conduction being preserved, and the exaggeration of bone-conduction for the first four octaves, together with the marked reduction in the distance at which whispered speech was heard, made me believe that the right ear might be improved by freeing the conducting apparatus. The malleus and incus were removed from the right 49 OPERATIONS WITHIN THE TYMPANUM. ear, after which the stapes was also extracted, and the dense mass of cicatricial tissue, found over the round window, was freely incised. The result was most satisfactory, whispered speech being heard now at five feet and the voice at six or eight feet. In this case the conducting mechanism was bound down as the result of a chronic suppurative process. In the two fol- lowing cases there had been no suppuration, the rigidity being the result of a slow inflammatory process within the tympanum, with the formation of new connective tissue. A complicating lesion of the auditory nerve being excluded by means of the tuning-fork tests, operation was advised, the results being excellent, as the histories show. Case III.-Miss. S., set. twenty-four, had been conscious of im- paired hearing for about two years; the left ear was first affected, the right being subsequently attacked. In the early period of the affection there had been considerable tinnitus, but when she presented herself for treatment this did not constitute a distressing symptom. Under inflation with the catheter, first with air, and then with the vapor of iodine, menthol, and camphor, the hearing for the whispered voice improved upon both sides from a few inches to several feet. After this treat- ment had been carried on for some months no further improve- ment resulted, and I advised the patient to submit to the operation of removal of the malleus and incus upon the left side, and the division of any adhesions about the stapes, should such be found, after opening the tympanic cavity. The tuning-fork test revealed increased bone-conduction for the first four forks of the series upon the left side, and for the first three upon the right. Her left ear was operated upon, the two larger ossicles being removed, and adhesions about the stapes and the stapedius muscle were divided. The operation was successful, a permanent central perforation remaining and the whispering distance being increased to about six or eight feet. Some weeks later the right ear was subjected to the same procedure, and the whispering distance increased to fifteen feet. Upon this side the tympanic membrane re-formed, and after this the power of audition became much reduced, whis- pered words being heard at six or seven feet only, a distance greater than before the operation, but not as great as before the reproduction of the membrana tympani. Inspection revealed that the stapes was bound down by the cicatricial membrane, thus impairing the hearing power. After all traces 4 DENCH. 50 of inflammation had disappeared from the re-formed membrana tympani, the cicatricial membrane was easily removed under cocaine anaesthesia, and the stapes liberated from its adhesions. Since the last operation the hearing for whispered words has returned to fifteen feet, and the membrana tympani has not been reproduced. Case IV.-Miss W., aet. eighteen, presented with a very similar history. In this case the left ear was first affected, and the tuning-forks revealed exaggerated bone-conduction upon this side for the first, four octaves. Upon the opposite side bone-conduction was exaggerated for the first two octaves, thus showing clearly that the conducting apparatus was more affected upon the right than upon the left side. Tinnitus was present in both ears-more marked in the right. Under infla- tion, conducted as described in the preceding case, together with the dilatation of the left Eustachian tube by means of the bougie, considerable improvement took place for a time, but finally, the condition remaining stationary, operative procedures were adopted as in the preceding case, the left ear being operated upon first. In this instance the membrana tympani was completely reproduced, yet the hearing distance for whispered words and numbers has steadily increased, until now they are heard at from six to eight feet. The patient is now able to use this ear, which was formerly the poor one, in conversing at the telephone, a purpose for which it was entirely useless. The tinnitus upon this side was permanently relieved, but persisted upon the opposite side, and about six weeks after the above operation the right ear was treated in a similar manner, in the hope that the tinnitus might be improved. Improvement in the hearing was not expected upon this side, but I felt confident that the operation could be safely done without danger to the hearing and with a prospect of relieving the tinnitus. In this instance the tinnitus has remained un- changed since the operation, and the hearing was unaffected also ; the membrana tympani re-formed, binding down the stapes, but section of these adhesions has restored the hearing to the condition present before the operation. One fact has been noticed in certain cases operated upon, and while the number of cases suitable for such an observa- tion has not been large enough to enable me to formulate a general statement, I believe that the phenomenon was more than a coincidence. I refer to an improvement in the hearing, in the ear not operated upon, immediately after operation. It has been my practice in all cases, when the impairment was 51 OPERATIONS WITHIN THE TYMPANUM. bilateral, to operate upon the poorer ear first, and upon test- ing these cases from time to time it has been noticed that the hearing in the better ear has improved in a marked degree after the operation. In one case this was especially marked, the ear operated upon being only slightly improved, while the whispering distance in the other ear became more than double what it had been originally. In the two preceding cases already cited this improvement was also noted to a certain extent, but the subsequent operative measures upon the better ear rendered further observations in these cases of little value. The same observation has been made by Cholewa {Archives of Otology, vol. xix., p. 151) in cases of tenotomy of the tensor tympani upon one side, and he even advises tenotomy of the tensor in the poorer ear, as a means of retarding the progress of the pathological process in the better ear. While the decussation of the fibres of the auditory nerve has been proven, the real reason why an operation upon the conducting apparatus of one side should exert so much influence upon the function of the auditory organ of the opposite side is hard to explain, unless we conceive that it depends upon the same cause which operates in Gelle's experiment {Arch, f Ur Ohren- heilk., vol. xxviii., p. 58). Gelle has found that if the air in one external auditory meatus is compressed, a vibrating tuning- fork held before the other ear will not be heard as long as under normal conditions. Gelle believes that the increased tension upon one side, caused by the compression of the air in the meatus, disturbs the muscular tension in the opposite ear by reflex action. In a like manner it might be supposed that increased tension in the conducting apparatus of one side, due to a pathological process within the tympanum, might re- flexly cause disturbances of tension in the muscular structures of the opposite tympanum. This is, of course, only a sugges- tion as to the cause of the phenomenon, which certainly presents itself in a certain proportion of cases. Where this improvement in the ear not operated upon is observed, one cannot be too cautious in advising operative measures to still further improve the condition. With reference to the effect of the operation upon subjective noises, in but few of my cases were these especially distressing, DENCH. 52 and in those instances when the operation was performed for the relief of this symptom alone, the results have not been as satisfactory as when the object to be attained was an improve- ment in the hearing. I am well aware that other operators have found the relief of tinnitus to be even more certain than an improvement in the hearing, but among my own cases, in which an operation was deemed advisable, this symptom was not marked. I can only explain this in two ways : one being that a certain number were undoubtedly excluded as improper cases, on account of the result of the tuning-fork tests ; another reason is that the cases which ordinarily present themselves at a hospital are not as easily disturbed by subjective symptoms as cases met with in private practice, and are not apt to consult a physician unless their malady interferes with their means of earning a livelihood. I would not be understood as saying that I have seen no relief to tinnitus by operative measures ; on the contrary, in one case there was considerable improve- ment, while in another the tinnitus disappeared, but in two other cases no improvement followed. These four cases were the only ones among those operated upon in which this symptom was especially annoying. I have before stated that it was my purpose to consider the results of operative measures upon the function of the ear, without making the division, so commonly made, into suppura- tive and non-suppurative cases. The problem before the sur- geon in such case is to locate the lesion, either in the conducting or receptive apparatus ; having been located in the former, to determine as exactly as he may be able the special part of the tympanum involved, and then to aim by his operation to once more restore the integrity of the conducting mechanism. It has been shown in the early portion of this article that our tuning-fork tests enable us to locate the lesion in either the middle or internal ear, in the large majority of cases, whether or not there has been previous suppuration. A large number of cases, however, present themselves in which the impairment or perversion of function is not the sole or often the principal cause for seeking advice. I refer to the cases of chronic puru- lent inflammation of the middle ear, in which the patients seek relief on account of the persistent discharge. Here, as in 53 OPERATIONS WITHIN THE TYMPANUM. every other department of medicine, no conscientious surgeon will advise operation until all milder measures have been given a thorough trial in competent hands, and in the lines which follow, such cases alone are referred to. Masterly papers, with the reports of cases, have been contributed on this subject by Kretschmann [Archiv fiir Ohrenheilkunde, vol. xxv., p. 165), Ludewig ^Archiv fiir Ohrenheilkunde, vol. xxix., p. 241, ibid., vol. xxx., p. 263), Reinhardt {Archiv fiir Ohrenheilkunde, vol. xxxiii., p. 94), and Grunert {Archiv fiir Ohrenheilkunde, vol. xxxiii., p. 207) ; the testimony of all being in favor of operative measures. With reference to the probability of completely arresting the discharge in these cases, everything depends upon the parts involved. A long-continued otorrhcea, unchecked by careful treatment, in the large majority of instances depends upon bony necrosis within the tympanum. If this necrosis is con- fined to the ossicles, or to such parts of the tympanic cavity as are accessible to instruments introduced through the meatus, then a complete cure can be effected by means of operations conducted in this manner, the necrotic ossicles being removed and the walls of the tympanum carefully curetted wherever softening is found. As it is frequently impossible to judge of the extent of necrotic process exactly, many surgeons hesitate to advise operative procedures. The cases which form the basis of this paper have taught me, and the observation is cor- roborated by the work of the authors already mentioned, that the greatly improved drainage obtained from the fornix tym- pani, by the removal of the malleus and incus, and a thorough curetting of the cavity of the fornix almost never fails to reduce the amount of discharge greatly, even if it does not effect a complete cessation. Without much doubt the incus is the ossicle most frequently affected ; in all of my 24 cases of suppurative otitis this bone was either carious or completely destroyed. Grunert foe. cit.) found caries of the incus in 25 out of 28 cases, while Ludewig {Archiv fiir Ohrenheilkunde, vol. xxx., p. 276) found this condition present in 64 out of 75 cases. In 21 out of 24 suppurative cases both malleus and incus were diseased, while Grunert found a similar condition in 14 DENCH. 54 of 28 cases. Caries of the walls of the tympanum was found in 7 of my cases. In 2 the stapes was carious. The presence of carious or necrotic bone within the tympanic cavity should always be suspected, when in any case the otor- rhoea has resisted careful treatment. It is not always so easy to demonstrate its presence and to locate its position exactly, although this can in a large proportion of cases be done with a delicate silver probe introduced through the perforation into the tympanic cavity. Instead of the metal probe, a method of much service is that advocated by Dr. Blake, of winding a small amount of cotton upon the end of the probe, and twist- ing the cotton projecting beyond the end of the probe into a slender shaft, which can be given the desired curve and passed into the tympanum. If this cotton comes in contact with roughened bone, some of the fibres will be pulled from the surface, and an examination of the pledget with a glass, after the exploration of the cavity has been effected, will demonstrate this fact. The location of the perforation is, to a certain extent, an indication of the seat of the necrosis. Grunert has made a study of this subject, but his investigations teach us simply that when a perforation is located behind the malleus, near the short process, caries of the incus is most usually present, while with a perforation above or in front of the short process, the head or neck of the malleus is more likely to be the site of the lesion. The appearance of the perforation is frequently very suggestive of dead bone, being more or less filled with exub- erant granulations. When the membrana tympani has been largely destroyed, the presence of a sinus behind the short process of the malleus, leading upward into the fornix tympani, and affording an outlet to the purulent discharge, which is seen, after the ear has been once cleansed, to flow downward along the posterior part of the inner tympanic wall, points to caries of the incus. Unfortunately, although the above appearances teach us that certain of the ossicles are affected, we have no means of determining with certainty that the process has not extended beyond the limits of the ossicles and involved the walls of the tympanic cavity. Involvement of the tympanic ring can be determined in many cases by means of the probe, 55 OPERATIONS WITHIN THE TYMPANUM. and in the same manner we may find evidence of necrosis in the fornix, but of its extent we are often able to judge very little. This uncertainty has led many to consider the removal of the ossicles of doubtful utility in these cases, but to my own mind it should only influence us in regard to the promise of absolute cure. If it is certain that the destructive process is limited to the ossicles or to accessible parts, then it is justifiable to prom- ise a complete cessation of the discharge after operation ; in the doubtful cases, however, while the operation is indicated in order to improve drainage, and we can promise a diminution in the amount of discharge, and freedom from the dangers of retained pus, no conscientious surgeon will, I think, promise a perfect cure unless he is able to define exactly the location of the necrotic area. Preparation for the Operation.-As a general anaesthetic is always necessary for the performance of any intratympanic operation, except the division of adhesions, in cases where a large part of the membrana tympani has been previously destroyed, the physician and patient will be saved much annoy- ance by attention to the condition of the bowels and a restric- tion of the diet upon the day of the operation. The ear, which has, up to the time of operation, been kept as free from secre- tion as possible by frequent syringing, should be thoroughly douched, several hours before operating, with a solution of bichloride of mercury, i to 5000. In cases where no discharge is present such a douche should also be employed. The position of the patient is a matter of no little importance as affecting the result of the procedure. As the operative field is extremely limited, the surgeon should avail himself of every means in his power to have the head in such a position that he can easily see all parts of the tympanic cavity, and conduct his manipulations without the necessity of assuming an uncomfor- table position. To this end, I now always operate with the head and shoulders well elevated, the head being supported upon a rest which admits of motion in all directions. The patient is anaesthetized in the recumbent posture, and, after thorough etherization, is raised to the desired posture upon the rest shown in Fig. 1. Straps passed under each arm prevent the body from sliding downward during the operation DENCH. 56 Elevation of the head and shoulders also diminishes the hemorrhage, and the blood, instead of flowing into the upper and posterior portion of the fundus of the canal, in the region of the incudo-stapedial joint, is directed to the floor of the canal, and hence does not obscure that portion of the operative field which demands our closest attention. Technique of the Operation in Cases where the Membrana Tym- pani is Intact.-An incision is made with a sharp knife, Fig. 2, F, in the posterior superior quadrant beginning just below the membrana flaccida, following the course of the insertion of the membrane, of sufficient extent to bring the incudo-stapedial fig. I.-Head- and Shoulder-rest. articulation into view. If the single incision does not accom- plish this, as often happens when the articulation is situated high up, a horizontal incision may be made from the upper extremity of the first, toward the short process, thus allowing a triangular flap of the drum membrane to be turned down. It is best to avoid incising the membrana flaccida if possible, as the bleeding which is apt to follow an incision into the part obscures the field. Care should also be taken, for the same reason, not to wound the mucous membrane covering the promontory. By cautious manipulation with the fine probe, the head of the stapes can usually be brought into view, o-r, if not, its position can be made out. The tendon of the stapedius muscle should not be divided with the same knife used in making the first incision, and then the incudo-stapedial articulation will be more 57 OPERATIONS WITHIN THE TYMPANUM. plainly seen. Disarticulation at the joint is now effected by means of the triangular bent knife, Fig. 2, C, it being passed in front of the long arm of the incus with the point directed back- ward, and pressed downward through the articulation, any remaining fibres being severed with the point of the knife. With the fine probe, the mobility of the stapes is now deter- mined, as if this is found to be more firmly fixed than normal, steps will be necessary later in the operation to mobilize it. With the sharp knife a horizontal incision is next made at the lowest point of attachment of the membrana tympani to fig. 2.-Middle-Ear Instruments, with Universal Handle. the tympanic ring. A blunt knife, Fig. 2, E, is inserted into them, and the membrana is divided peripherically close to the ring from below upward, at first anteriorly and then posteriorly, to just above the short process. Up to this point there will have been very little hemorrhage, and the section being made from below upward, as first advocated by Schwartze ^Lehrbuch der chirurgischen Krankheiten des O fires, 1884, p. 283), the exact line of incision can be followed. There still remains to be divided that portion of the membrana flaccida above the short DENCH. 58 process. The sharp knife is again used for this incision, being plunged upward and inward above the short process, dividing the ligaments which hold the malleus and the remains of the membrana, by carrying the cutting edge at first forward and then backward ; the bleeding at this stage is more free, and may obscure the field ; usually, however, the sharp process of the malleus can be distinctly seen, and it only remains to grasp FIG. 3.-McKay's Ear Forceps. (For operative work, the proximal segment of the blades should be one half inch longer than represented in the cut.) this with the forceps, Fig. 3, and pressing at first inward, to dislocate the neck of the ossicle from its niche, and then downward, and finally by traction outward this bone with the attached membrana is removed. The next step is the removal of the incus, and is one which may be attended with some little difficulty. By the extraction of the malleus the incus is frequently displaced, and upon 59 OPERATIONS WITHIN THE TYMPANUM. inspecting the cavity the ossicle may not be seen. Some writers, notably Sexton {The Ear and its Diseases, New York, 1884, p. 388), advise removing the incus before the malleus, and if the long process of the ossicle can be easily grasped after the incision of the membrana has been completed, there is no objection to this being done. Of late, however, I have almost invariably extracted the malleus first, and find the procedure ess difficult than the other. If the ossicle has passed beyond the line of vision it can usually be brought into view by the use of an incus hook, Fig. 2, H. These hooks are curved in opposite directions for the right and left ear, and are to be inserted into the handle in such a way that the hollow looks anteriorly ; this hook is inserted into the posterior portion of the tympa- num, and being carried behind the ring, is then swept cautiously forward through the fornix, very little force being used. In executing this manipulation, the hook should be kept in con- tact with the tympanic ring by gentle traction outward. In this manner it is usually possible to bring the long arm of the incus into view, it presenting close to the margin of the ring and being easily recognized ; the difficulty in finding the incus frequently arises from the fact that we are inclined to search for it too high up, and too deeply in the cavity ; the previous removal of the malleus usually loosens the attachments of the incus, and allows the ossicle to fall somewhat backward and downward ; it, moreover, usually hugs the margin of the ring closely, and often at first seems to belong to this structure, but a touch with the probe or hook will push it farther into view and reveal its true nature. When the long process has been clearly exposed, it should be inspected closely, to be sure that no fibres of the incudo-stapedial ligament are undivided, and if such fibres are present, they should be severed. The long process of the incus is then seized, and by gentle traction, at first down- ward and then outward, the ossicle will be easily removed. After the cavity has been thoroughly dried, the stapes should be inspected, and if it is at all rigid, incisions should be made about its base, when by gentle pressure with a cotton-tipped probe applied at first below it, and later to its other aspects, it is rendered more movable. This procedure has been carried out by Boucheron, Miot, and others. Thanks to the investiga- DENCH. 60 tions of Kessel {Archiv filr Ohrenheilkunde, vol. xi., p. 199), and Botey {Am. Jou n of Med. Sciences, vol. ci., p. 632), we know that the removal of the stapes is not attended by any risk, and Blake and Jack {Trans. Amer. Otol. Society, 1892) have demonstrated that its removal is often a benefit to the hearing. If it seems advisable to remove the ossicle, it may be extracted either with the forceps, or better by means of a blunt hook passed between the crura, after dividing the attach- ments about the foot-plate, as already described. In cases where the stapes is concealed behind the margin of the ring, it is occasionally advisable to remove that portion of the osseous canal which hides the stapes from view. Kessel {Archiv fur Ohrenheilkunde, vol. xiii., p. 83) advised the use of a chisel for this purpose ; a cutting forceps, Fig. 4, some- what after the pattern devised by Hartmann, has answered my purpose well. It is better, however, to avoid the removal of a portion of the bony ring if possible, as the reaction which fol- lows favors the reproduction of the membrana tympani. After the stapes has been satisfactorily dealt with, the region of the round window should be examined, and if there is any thickening in this part of the cavity, several incisions may be made in the dense tissue with an angular knife Fig. 2, B, in the hope that upon cicatrization, the tension may be relieved. After the operation, a strip of antiseptic gauze is carried to the bottom of the cavity, and the canal is lightly packed. In this manner the formation of a clot is avoided, the gauze ab- sorbing what little blood may ooze from the wounded parts. In the course of a few hours the gauze is removed and the ear syringed with a weak antiseptic solution, a saturated solution of boric acid or a bichloride solution 1 to 5000 being used, and the gauze is replaced. Upon the following day the gauze is dispensed with, and the patient is ordered to douche the ear with the antiseptic solution twice or three times daily, accord- to the amount of discharge. Too much douching is highly objectionable, the purpose being to keep the parts cleansed only. The ear should be manipulated as little as possible, and in a few days any discharge which may have been present diminishes in quantity ; at this stage it is often well to discon- tinue the douching at the hands of the patient, and leave the 61 OPERATIONS WITHIN THE TYMPANUM. cleansing of the ear to the surgeon, the drop of secretion being removed with a cotton pledget, after which a little boric acid is insufflated. If this is not possible, and the discharge is somewhat free, the use of the douche daily, or upon alternate days, may be advised, a solution of boric acid in alcohol being dropped into the ear after each douching. It sometimes happens FIG. 4.-Cutting Forceps, for Removing Portions of the Tympanic Ring. that a permanent perforation remains, an object to be desired in all cases ; if, however, the membrane re-forms, this may not vitiate the success of the operation, as is shown by some of Lucae's {Archiv fur Ohrenheilkun.de, vol. xxii., p. 238) cases as well as by some of my own. If the membrana is reproduced after the operation, the sur- geon should wait until all traces of inflammation have disap- DENCH. 62 peared, and then, if the hearing is not as good as might have been expected, or as good as before the membrane had com- pletely re-formed, this new membrane should be removed. The membrane which has been reproduced is much less sensitive than the normal membrana tympani, and with the two larger ossicles removed its excision is a very simple matter. General anaesthesia has never been necessary in my cases, and I perform the operation in myelinic or office without special preparation. Sufficient anaesthesia for a large incision is obtained by keeping a pledget of cotton saturated with a io per cent, ointment of cocaine in lanolin in contact with the membrane for a few minutes. Upon entering the tympanic cavity, a drop of a io per cent, solution of cocaine renders all subsequent procedures painless ; in no case have the patients complained of severe pain. The section of the membrane is made first with a sharp- pointed knife, and completed with a blunt knife. When half of the circumference has been divided, the relaxation of the membrane makes the completion of the section difficult. This may be overcome by making a second puncture close to the original starting-point, and completing the section by carrying the knife in the opposite direction. The fragment is then held at two points only, and is easily detached with forceps. If a second removal does not result in a permanent opening, a third or fourth may be done, as each time the membrane re-forms it is less and less dense. In plethoric patients, a restriction of the diet for a few weeks before and after the removal of such a membrane will aid very materially in preventing complete closure of the artificial opening. Practically no reaction follows this procedure, the discharge, if any, being insignificant, and the ear frequently is perfectly dry upon the second day after the operation. A permanent perforation is especially advisable, since it enables us subsequently to divide any adhesions which may have formed after the first operation, and to thus further improve the hearing. For the same reason, I advocate the re- moval of the two larger ossicles, not because they are in all cases the actual cause of the impaired hearing, but because their removal affords us access to the tympanic cavity at any time, without the danger of setting up a serious inflammation, and also enables us to reach structures which, from the limited 63 OPERATIONS WITHIN THE TYMPANUM. size of the field, would be beyond the reach of our instruments, if these parts were present. In the technique of the operation I am aware that I have differed somewhat from other writers. In the division of the incudo-stapedial articulation, I prefer to press the shaft of the knife closely upon the antero-internal aspect of the long pro- cess of the incus and cut downward, completing the division if necessary by cutting from below upward with the point of the instrument, rather than pressing the knife against the pos- terior aspect of the long process of the incus, as is often advised. My reason for this is that the field of operation is in much better view in the former case than in the latter. In removing the incus, the method described is the reverse of that advocated by Kretschmann (Archiv fur Ohrenheilkundey vol. xxv., p. 192), who was the first to formulate this procedure. This surgeon devised an incus hook with a double curve, the distal extremity being cup-shaped. To remove the incus, the bent part of the instrument was carried into the fornix, the distal extremity looking backward. Rotation of the instru- ment backward upon the axis of the shaft, carried the cup- shaped end of the hook over the short process of the incus, thus bringing the ossicle into view. In my hands, this method has not succeeded as well as using the simple hook already men- tioned, and carrying it in the opposite direction. It certainly would seem that backward rotation would be more likely to dislocate the ossicle into the mastoid antrum, than manipula- tion in the opposite direction. Some operators advise against a prolonged search for the incus, on the ground that the prolonged manipulation of the parts interferes with a prompt recovery and successful func- tional result. I cannot agree with this opinion, and I believe that the removal of the incus is of great importance. If the incus cannot be seen, the operator can hardly assure himself that the incudo-stapedial articulation has been entirely di- vided, and in such a manner that the parts cannot reunite. On the other hand, if the stapes can be seen, and the articulation has certainly been divided, the incus must have been displaced and hence act as a foreign body ; for this reason alone it would be proper to remove it. I can conceive of nothing which would DENCH. 64 deter me from removing it, unless I satisfied myself that it had been dislocated far beyond reach into the mastoid antrum, an accident which may occur, but is not common. Prolonged search has not in my hands been attended with any untoward results, either in the way of reaction after the operation, or in the impairment of function after recovery, and I believe that the operator is justified in prolonging the operation in order to remove the ossicle. Technique of the Operation when the Membrana Tympani is Partially Destroyed.-The method of operating, already de- scribed, must be somewhat modified in cases where a more or less complete destruction of the membrana tympani has taken place as the result of a preceding inflammatory process. In such cases, the increased vascularity of the parts to be divided renders the hemorrhage following the incisions more profuse, thus hiding the deeper structures from view quite early in the operation. As the steps of the operation which are of the most moment are those which are executed in the region of the stapes, it is advisable either to free this ossicle from the sur- rounding structures early in the operation, before the more vascular parts are divided, or to remove the malleus as the initial step, and when the hemorrhage has been controlled, to sever the incudo-stapedial articulation and remove the incus. In cases where the partial loss of the membrana enables us to see the incudo-stapedial articulation, or where the parts in this region are not very vascular, the first step should be to divide this articulation, tenotomy of the stapedius having been first per- formed to bring the parts more clearly into view. After this has been effected, the membrana tympani should be separated from the ring by a blunt knife introduced into the existing perforation, and swept around the periphery of the membrane, the first incision being made through the least vascular segment. These peripheral incisions stop just behind and in front of the short process, and the incision through the membrana flaccida above the short process, loosening the strong attachments of the malleus, should be made with the sharp knife, as directed in the technique of the operation when the membrane is intact. Adhesions between the manu- brium and inner tympanic wall seldom require division, but if 65 OPERATIONS WITHIN THE TYMPANUM. they are present and interfere with the removal of the malleus, a blunt knife, curved on the flat (see Fig. 2, D), is to be used in dividing them. The remaining steps are then to be carried out in the manner already described. Frequently, however, the site of the posterior-superior quadrant is covered by a thick vascular fold, the result of a long-continued inflammatory process in the remains of the membrana tympani in this region, and the parts have been so deformed that the location of the incudo-stapedial articulation cannot be defined. In such cases, the smallest incision is followed by a troublesome hemorrhage, which completely obscures the field of operation. In such cases, my best results have been obtained by incising with the sharp knife the structures above the short process of the malleus, freeing this ossicle from its attachments, and rapidly continuing the inci- sions with the same knife, anteriorly and posteriorly, until the remnants of the membrane have been freed from the tympanic ring. Rather sharp bleeding follows this procedure, and can be checked by crowding one or more pledgets of cotton into the fundus of the canal, and allowing this firm packing to remain for a few moments. Upon removing the pledgets, the fundus of the canal will be found to be dry, and the malleus can be grasped close to the short process and removed in the manner already described. It is surprising how quickly the troublesome bleeding ceases after the removal of this ossicle, the divided parts retracting and closing the severed vessels. The posterior-superior segment is then to be explored with a probe or incus-hook, and the incudo-stapedial articulation is to be brought into view and divided, after which the incus is re- moved in the usual way. The stapes, if diseased, should also be removed. After the cavity has been wiped out with cotton pledgets, all suspicious parts should be thoroughly curetted; the fornix usually presents softened areas here and there in its wall, and these may be removed by means of the curettes shown in Fig. 2, G. If the margins of the ring are affected, the curette (Fig. 2, A) should be used freely here, or the cutting forceps may serve a good purpose. The free use of the curette after the removal of the ossicles is quite as important to the success 5 DENCH. 66 of the procedure as the removal of the bones themselves, and should be carried out with scrupulous care. It sometimes happens that, from the long-continued inflam- mation, the ossicles have become ankylosed either to one an- other or to the walls of the tympanum. Remembering how thin the bony roof of the tympanum is, no undue force should be made to extract the ossicles when this condition exists. The proper procedure is then to use the curette cautiously, and remove every trace of softened bone, leaving the anky- losed ossicles in position. In one case of this kind the result was a complete cure. When the ossicles are ankylosed with one another, this rule of course does not hold. I have twice removed the malleus and incus together, so firmly united that separation was impos- sible even after removal. In another case, the incudo-stapedial articulation was ankylosed, and the incus could only be re- moved by fracturing the long process, a procedure which detached the stapes from the oval window. As this ossicle was also carious its removal was indicated, and the patient made a complete recovery with notable improvement in hear- ing. It should also be remembered that, as the result of the preceding inflammatory process, the incus may have been completely destroyed, hence this ossicle may not be found in every purulent case. When operative measures are undertaken in these cases for the improvement of the hearing, the same procedures are to be executed for freeing the stapes, and relieving the tension of the membrane of the round window, as have already been enumerated in treating of non-suppurative cases. The after-treatment of cases in which a purulent discharge was present, previous to operation, differs very little from the after-treatment of non-suppurative cases. Any exuberant granulations which may spring up should be touched either with silver nitrate or chromic acid, and the use of a solution of boric acid in alcohol after each cleansing of the ear should be advocated. If any areas of necrosis have escaped the curette, the application of a strong solution of lactic acid to the part, the medicament being rubbed on rather vigorously by means of a cotton pledget, will often be found of service. 67 OPERATIONS WITHIN THE TYMPANUM. The length of time which must elapse before the complete cessation of the discharge will vary greatly. From three to six weeks can be looked upon as a fair average, but in some cases the time will be less than this, and in others much longer. Even when the period is prolonged, the condition of the ear is such that only occasional inspection on the part of the surgeon is necessary, the patient being able to thoroughly cleanse the ear, and to conduct such local treatment as may seem desi- rable, until the discharge ceases. My own operations at the hospital during the last eighteen months include twenty-four cases of chronic suppurative otitis operated upon. In fourteen the discharge was stopped as the result of the operation, and in eight it was much reduced in amount, an occasional cleansing of the ear being all that was required ; two are still under treatment, the operation having been but recently performed. In fourteen cases the hearing was improved, while in nine it remained the same, and in one was apparently somewhat reduced. In one of these cases the hearing distance was increased at least eightfold, the operation having been performed simply for the improvement of the hearing, the discharge being so insignificant as to require no treatment. In most of the chronic purulent cases operated upon, the arrest of the discharge was the object of operative interference, and the results above given demonstrate clearly that there is no danger of impairing the hearing, this function in all cases, with one exception, either remaining the same or being improved. In the vast majority of instances the impair- ment in hearing was so slight, even before operation, as to cause very little annoyance, and was not sufficient in amount to demand radical measures for its relief. Of the twenty-four cases already spoken of, the malleus alone was removed in six cases, in one of which the incus was found afterward to be present; in the other five, however, it had apparently been destroyed completely, as the result of caries. The malleus and incus were removed in eleven cases, and the malleus, incus, and stapes in three. In two cases the ossicles had been entirely destroyed, and the cavity of the tympanum was thoroughly curetted, one case being cured and the other improved. In another case, only the head and crura DENCH. 68 of the stapes could be seen, and as the parts were carious they were removed and the entire cavity curetted. A complete cure resulted, and the hearing was normal after the operation. In a fourth case, the ossicles were found so firmly adherent to the roof of the tympanum that removal seemed unjustifiable ; the tympanic cavity was thoroughly curetted, and the patient made a complete recovery, the hearing improving greatly and the discharge being completely arrested. Of cases operated upon in which the membrana tympani was intact, nine operations have been performed upon seven patients, both ears having been operated upon in two cases. Of the nine operations, the hearing was greatly improved in four cases, somewhat improved in four, and unimproved in one case. In the instance in which the hearing was unimproved, the operation was done primarily for the relief of tinnitus, whispered words being heard at a distance of eight feet before the operation. The operation did not reduce the hearing, but the tinnitus was not improved. Of the cases slightly improved, in one patient the receptive apparatus was known to^be involved before the operation ; in a second, there was complete cessation of the tinnitus in the ear operated upon, while the hearing upon the opposite side was augmented twofold ; in the third case, the patient was unable to hear at all by air-conduction in the ear previous to the operation, while after the operation loud sounds could be heard. As I was only the operator in this case, and had made no examination as to the condition of the auditory nerve, I am unable to state whether the receptive apparatus was involved or not, but, from the patient's age, I should say that it prob- ably was. In the fourth case, the stapes was so firmly fixed that operative measures failed to render it movable enough to restore useful audition. Of the cases much improved, a permanent perforation re- mained in two instances, while in the other two the membrane completely re-formed, and yet the improvement in hearing remained so great that secondary removal was not thought advisable. Of the cases slightly improved, the membrane re-formed completely in three, but the hearing before the closure of the perforation had not been enough greater than after this 69 OPERATIONS WITHIN THE TYMPANUM. had taken place, to indicate that the secondary removal of the membrane would improve the function of the organ. From what has been shown in the preceding pages, it seems to me that there can be no question that surgical procedures upon the middle ear enable us to benefit a large number of patients who would otherwise be unrelieved. Operative inter- ference in this region must take the same position as in any other : it must not be adopted to the exclusion of all other plans of treatment, nor must it be resorted to in every case in which milder methods have failed to afford relief. Care in the selection of cases, restricting surgical procedures to those only in which a thorough study by all means in our power, indicate that operative treatment will be beneficial, cannot fail to give operative otology a prominent place in the special surgery of to-day. d:e Iknicherbocket press (G. 1'. PUTNAM'S SONS) NEW YORK