Elevation of temperature, though slight, combined with tenderness on pressure over the mastoid process, in a ease of acute otitis media of ten days' standing, is characteristic of mastoid disease. Pressure should always be made on both mastoids, however, as occasion ally such pressure causes pain in a healthy mastoid. Bulging- of Shrapnell's membrane, with drooping of the posterior and upper cutaneous lining of the exter nal meatus, are absolute symptoms of mastoid involvement, and in such it is always necessary to perforate the mas toid cells. If mastoid symptoms, pain, etc., in connection with chronic purulent otitis media, do not yield to local and general antiphlogistic remedies, there should be no hesitation in making an ex ploratory opening in the mastoid. Bacon (Trans. Amer. Otol. Soc., vol. vi, pt. 4).
Treatment. — The presence of acute empyeina or acute consecutive mastoiditis in a case of acute otitis media being es tablished, the surgeon must proceed to open the antrum. Many such cases go on to spontaneous rupture of the outer bony wall of the mastoid and entirely recover, like any other spontaneously evacuated abscess. But, considering the position of a mastoid enliven-la, so near the cranial cavity, it is not wise to await many days for spontaneous opening, because such an escape of pus from the mastoid may take place on its inner, nearly as probably as on its outer wall. Many cases of mastoid ernpyema are relieved by spontaneous rupture of the outer cortex, and doubt less many such occurrences are antici pated by a hurried mastoid trepanation. But, with the three symptoms—pain, prolapse, and pyrexia — manifesting themselves in a given case, it is impera tive on the surgeon to open the antrum. At such a point in the disease the mas toid skin-surface may present no abnor mal appearance, and the surgeon must operate on the indication of the three symptoms or of the pain only.
If a minute fistula in the mastoid cortex shonld be found after exposure of the surface, this should be followed prefer ably to making the antral opening at once. The patient being etherizal, an in cision should be made, running from just behind the temporal artery, half an inch from the attachment of the auricle, around and behind it to the tip of the mastoid process, and the soft tissues re tracted, backward and forward, so as to expose the mastoid especially at its up per, anterior position where it merges into the bony auditory meatus, at the so-called suprameatal triangle. The sur geon should proceed to make an opening with a grooved chisel and hammer (never with a trephine), working forward and inward and a trifle downward at first, until he is well under the traces of the zygoma. Ordinarily the antrum will be
reached 2 to 3 millimetres beneath the surface of the bone, though at times it has been necessary to penetrate 6 railli metres before reaching the antral cavity. This opening in the bone should be fun nel-shaped, with its mouth outward, and growing narrower as the antrum is ap proached. By making it of such a shape the cranial cavity is avoided above and the facial canal below. The antrum will be found in such cases to contain pus, and there may be also a few granulations found in it. If the case has been op erated upon early in the attack, the quantity of pus will be small; if late in the disease the pus will be found in larger quantity and deeper, often lying aaainst the sinus or over the re,rion of the labyrinth. If the bone over the sinus and over the region of the laby rinth is intact, removal of the pus by crentle lavacre from these localities and from the middle ear will be next in order. Granulations especially on the inner wall of the antrum and mastoid cavities should not be disturbed: currettege of these may excite inflammation of the labyrinth or of the sigmoid sinus. If un disturbed they- will heal rapidly with the rest of the abscess-cavity, as in any other form of abscess. After lavage of the wound-cavity with an antiseptic, an en deavor should be made to promote heal ing by first intention. If this is not at tained, then, under daily syringing the ear and the operation tract with a bi chloride solution (1 to 5000 or 6000), the ear gets entirely well in six weeks at the latest. The ear generally ceases to run before the mastoid wound does, and the hearing begins to improve and is finally often as good as before the ear became inflamed. The mastoid wound in favoralde cases gradually closes from the bottom and is healed, as said already, in a few weeks.
If, before the antrum and mastoid have been opened, their inner walls have become diseased and the cranial cavity imadtd, the surrvon is confronted with the most 51.TiOlIS and often the most pti.,.-„eing of all affections, viz.: intra eranial suppurative lesions of otitic origin. These last-named diseases are more likely to oceur as sequels of chronic purulent otitis media„ but they not in frequently follow close upon acute puru ltnt otitis media. especially when the triatment of the primary otitis has been an irritant one and secondary infection 1 been brought about thereby.