Inflations of the tympana are n.ot only valueless, but often injurious, as they but tend to force pathogenic germs into the middle ear, and shock the auditory nerve by impact upon the fenestrfe of the internal ear.
The condition of the nares being im proved, gentle pnertmomassage of the membrana t3,,mpani and (mediately) of the ossicles, will be beneficial. This is best accomplished by the Siegle pneu matic speculum, applied under direct in spection of the membrana by the sur geon. There are other forms, but they are likely to be too rough.
Excellent results are often produced by gentle treatment of chronic catarrhal otitis media as outlined above, continued 2 or 3 times weekly for several months, whereas under vigorous treatment by strong. sprays, phonomassage, and nu merous inflations of and local applica tions to the naso-pharynx and middle ear, all the symptoms—tinnitus, deaf ness, and vertiao—increase. In no case will applications to the external ear and membrana do anything but harm.
If, in spite of rational, conservative, non-irritant treatment of the naso pharynx, and gentle pneumomassage of the membrana, the ear-symptoms grow worse, resort may be had to removal of the incus. The resultant overcoming of the retraction of the chain of ossicles, and consequent liberation of the stapes, will be followed by diminution and final cessation of the tinnitus and vertigo, and in some eases, by improved hearing.
The instruments required for perform ing tympanotomy and ossiculectomy are an electric head-lamp, held on the head by- means of a band similar to that of the ordinary forehead-mirror, as shown in Fig. 3 and by a set of instruments similar to those Shown in their natural ,size in Figs. 4 and 5.
In performing removal of only the incus the patient must be etherized, the membrana and auditory canal sterilized, and, by means of a knife shown in Fig. 4, B, an incision made in the upper posterior quadrant of the membrana, and the incus-stapes joint exposed. The in cus must then be detached from the stapes by means of traction outward and downward with the incus hook-knife (Fig. 4, D). The descending ramus of the incus must then be seized with for ceps (Fig. 5) and gently pulled down ward and outward through the perfora , tion of the membrana into the auditory canal and removed from the ear. The meatus should then be stopped with a loose tampon of sterilized gauze and let alone for twenty-four hours. Healing
by first intention usually' occurs, if the ear is protected with dry sterilized gauze and let alone. Removal of the incus is never followed by inflammatory reaction if the above-named conservative treat ment is carried out. If anything is ap plied to the wound in the drum-mem brane or to the middle ear, inflammatory reaction will surely occur.
Chronic ear-vertigo is ehronologically the latest symptom or lesion of chronic catarrhal otitis media, being always pre ceded by profound deafness and tinnitus. It is due to undue impaction of the Fig. 4.—A, Blunt-pointed knife. B, Knife for initial incision. C, Curved knife for te notomy of tensor tympani; two-edged. D, Incus hook-knife.
stapes in the oval window, as well as to stifTening of the round-window mem brane, from the catarrhal condition of the drum-eavity. In a normal ear any inward pressure of the stapes upon the labyrinth fluid is compensated by a cor responding outward movement of the membrane of the round window toward tlw mpanie N .kny undue pres sure 11'0111 N\ it hill the laby: huh by influx t.f mph or endolymph from the t F.1111.11 Cal e0111liellIS:1 ted by a cor responding out N\ Ora 1110Velllent Of t NN ell :11, Of t he l'01111(1-Will(lOW ilihralle toward the drum-eavity. .111 at] of these compensations being in terfel ed with. intralab rinthine pressure cs increased. the ampulla]. nerves unduly t our-es-ed. nd reflex phenomena eVOked NN 1111211 are termed ear-verti!ro. ..1s these altered condition, of intntiabyrintiline pre--11n. are not constant. but vary with the health of the patient and the state of the drum-cavity. chronic ear-vertio is paroxysmal in natnre. As retraction of the chain of ossieles and consequent impaction of the stapes in the oval win dow in ehronie catarrh of the middle ear play the greatest part in the production of these vertiginous phenomena. the in dieat ion therefore is to liberate the stapes from the superposed hums by removal of the latter, thrott.rdi an incision in the lipper posterior quadrant of the mem 1rana tyinpani of the etherized patient. Tbis procedure resorted to in twenty -even ea,e, giving entire relief from vertigo in every instance. C. H. Bur nett (Laryngoscope, July, 1900).