Mastoiditis with Spontaneous Perfora tion of the Medial Plate of the Process. —In some instances of mastoid em pytina spontaneous perforation of the midial plate of the process occurs, and pus is poured into the digastric furrow of the bone beneath the insertion of the sterno-mastoid muscle. The pus thus liberated from the mastoid cells may find its way, either forward along the tract of the cligastric muscle, and point in the pharynx, or backward, toward the nucha,—but beneath the deep fascia of the neck in both instances. This form of acute mastoiditis with spontaneous per foration of the medial plate of the proc ess when it takes place usually occurs in connection with an acute otitis of the middle ear. and has been termed 'Be.zold's mastoiditis," because Bezold, of Munich, recently recalled professional attcntion to it.
Symptoms.—After pain has lasted for several days or even weeks, in a case of acute otitis media. the pain in the ear alid mastoid may suddenly diminish or ecase entirely, the otorrhoea continu inz nevertheless. The mastoid process may or may not haye been entirely free from external symptoms; usually, how ever, it is free from objective symptoms in this form of mastoiditis and remains so. Within twenty-four bolus of the cessation of pain in the ear and in the mastoid there will be noticed a brawny swelling beneath the mastoid process, extending sometimes both behind and in front of the insertion of the sterno mastoid muscle, but generally only be hind and below the process with a tend ency to extend below and backward toward the region of the splenius mus cle. Pressure upon these brawny swell ings beneath the mastoid may not be very painful, but by such pressure pus can be forced upward, through the spon taneous opening in the mastoid process, through the mastoid cells, antrum, and middle ear, and out into the external auditory canal. A patient in this condi tion usually shows pymmic symptoms, and will require an operation for the free escape of the pus now burrowing in the deep, soft tissues of the neck.
The main features regarding, the diag nosis of mastohliti.; may bo summarized as follows: 1. Mastoiditis is always sub sequent to purulent inflammation of the middie ear. 2. Tenderness of the bone is an important symptop when present, hilt the mastoid may be full of pus with absolutely no tenderness. 3. Bulging of the eanal-wall is a most important symptom. 4. The absenee of tempera ture is no guide whatever. 5. Improve ment in the hearing is usually indicative of subsiding inflammation in the middle ear. 6. The operation is safe; delay
may be dangerous. Philip Hammond (Amer. Medicine. April 12. 1002).
Treatment.—The mastoid process is laid open and a counter-opening is made in the neck at the most prominent part of the inframastoid tumefaction, where upon recovery will ensue. In some cases only the counter-opening in the retro mastoid swelling, without opening the mastoid bone, already spontaneously perforated, will be required and speedy cessation of all the aural and nuehal symptoms, with recovery of the hearing, will take place, just as it occurs after prompt incision into an extramastoid suppuration consecutive to spontaneous opening of the mastoid cortex behind the ear and over the outer mastoid surface.
In some cases of Bezold's mastoiditis in which general mastoid symptoms—as pain, tenderness, swelling, redness, etc. —demand it, before the counter-opening is made in the neck to relieve the gravi tation-abscess, the outer mastoid cortex is to be opened, the cavity exposed, and the passageway of the pus, through the medial plate of the process, and the di rection of the sinus into the neck are to be sought with a probe, and a counter opening in the neck made accordingly. If the counter-ope.ning in the neck is made promptly,—i.e., as soon as any symptoms of burrowing of pus in the neck-tissues show themselves,—quick re covery ensiles. But delay in operating in such cases is generally followed by septicmmia, and sometimes death.
The after-treatment of the wound cavities in an uncomplicated case of Bezold's mastoiditis with burrowing into the neck is to be conducted on general antiseptic surgical principles.
I have found that, in all cases of spon taneous perforation of the mastoid with discharge of pus beneath the soft tissues, whether the simple form or the Bezold form of mastoiditis, after free incision in the soft parts and escape of pus, espe cially if fluid syringed either through the ear or through the wound escapes at the opposite end of the suppurating tract, healing takes place promptly un der one daily syringing of the tract with a solution of bichloride (1 to 6000) with out any trepanation of the mastoid.
Chronic Catarrhal Otitis Media. — Acute catarrhal otitis media, instead of undergoing resolution or resulting in acute suppuration, may pass into a chrcnic, hypertrophic, catarrhal otitis media. In such cases it will be found that the naso-pharynx has become the seat of hypertrophic catarrh.