CHAPTER XLIV. OTALGIA. 389. The name otalgia is given to the various forms of pain referred to the ear which cannot be traced directly to some aural lesion. It is hence the generic name of pain which may vary much in character and duration. The complaint may be a trivial one; or, in other cases, it may incapacitate the sufferer. It is mostly one-sided. Some instances of otalgia can be definitely traced to a dental origin-sometimes the eruption of a wisdomtooth, oftener caries of a molar tooth, either upper or lower. In the former case the pain ceases when the tooth has made its appearance, unless some soreness of the gum persists. In the case of a carious tooth the pain may persist until the origin is recognized and remedied. There may not be any toothache whatsoever. Sometimes the pain is intermittent. In an extreme instance observed by myself a young child had had daily attacks of earache for some months. After passing through the hands of half a dozen physicians without relief, the child had become accustomed to daily injections of morphin. The attacks ceased at once after extracting a carious tooth. In other instances the pain referred to the ear is of pharyngeal origin. Acute inflammations in the lateral angle of the pharynx, ulcerations of any kind, tonsillar wounds, carcinoma of the faucial or lingual tonsil, are all apt to be accompanied by more or less earache. But when such lesions can be demonstrated, the term otalgia is superfluous. In hysteric subjects painful affections of the throat sometimes leave behind a psychic remembrance of the pain referred to the ear, even long after the heal ing of the original lesion. It is very difficult to relieve such patients. Their pain usually yields to nothing but time, or some strongly impressive suggestive treatment. The use of electricity may come under this head. Severe pain, constant or intermittent, referred to the mastoid region without evidence of existing ear disease, is in rare cases due to a growing cholesteatoma without suppuration, or may even indicate a subdural abscess. The diagnosis is suggested in such cases by the former history of otitic suppuration. There are on record some instances in which persistent pain, uncontrollable by other means, led to an attempt at mastoid operation. The bone was found sclerotic. The antrum was either not reached or found intact, and still the operation, apparently uncalled for, resulted in a permanent cure. In the majority of cases of so-called otalgia no local cause can be found. Sometimes the attacks are typically neuralgic and may yield to antipyrin, quinin, or arsenic. Regular periodicity of the pain has in a few instances been traced to malarial influence and cured by quinin. In other cases again the pain is not typical of neuralgia. It may depend on anemia, and in such instances is benefited by iron. If it is in any way related to rheumatism, large doses of salicylate of sodium may sometimes prove of benefit. One of the rarest forms of otalgia, usually bilateral, is periodic migraine localized in and limited to the region of the ear. Its diagnosis is made by its irregular periodicity and its accompanying symptoms-for instance, the more characteristic sick headache or nausea. 33 CHAPTER XLV. PYOGENIC EXTENSION OF OTITIS. SEROUS AND PURULENT MENINGITIS.-PHLEBITIS AND THROMBOSIS OF THE LATERAL SINUS WITH SEPTICEMIA OR PYEMIA.-SUBDURAL ABSCESS.-ABSCESS OF THE BRAIN. 390. The greatest danger of otitic suppuration, acute or chronic, is the possibility of its extension into the cranial cavity. This may take place through the intact roof of the middle ear or of the mastoid antrum, when the plate of bone is thin or even partially deficient. In children the relatively thick roof of the mastoid antrum diminishes the danger from this locality. Oftener, however, carious spots and fistulæ are found in the roof of tympanum or antrum. In the antrum the inflammatory process may extend through connecting pneumatic cells to the cranial surface. Less common is suppurative extension into the labyrinth, whence it can reach the cranial cavity either through the aqueducts or along the course of the auditory nerve. Quite rare is the propagation of the disease through a thin anterior wall of the tympanic cavity to the carotid canal and thence upward. The diagnosis of intracranial complications may be quite difficult, especially the differential diagnosis between the different lesions. With the exception of meningitis the other complications may sometimes develop so gradually as to mislead any one not thoroughly familiar with the symptomatology of inflammatory ear disease. On the other hand, an otitis may itself provoke symptoms which suggest a cerebral complication. As pointed out in ¶ 358, acute otitis produces occasionally in children-very rarely in adults-symptoms which simulate brain disease-viz., headache, stupor, delirium, or convulsions. The dependence of these symptoms on the inflammation of the middle ear may be shown by their prompt cessation after paracentesis of the drumhead, but such observations are very rare. The persistence of such symptoms, except headache, after free drainage has been established would positively indicate extension beyond the tympanic cavity. In chronic cases with cholesteatoma or caries it may also be difficult to recognize intracranial complications at the beginning. One-sided headache, dizziness, nausea, and vomiting may depend merely on extension of the disease into the labyrinth, or may signal the beginning of an intracranial accident. Fever is a more significant symptom. It is only moderate and transient in uncomplicated acute otitis, except in children. If, therefore, a high fever persists during acute aural disease, or still more significantly, if fever develops in the course of a chronic otitis, it means either meningitis or thrombosis of the lateral sinus. In the former case the fever is more continuous, and chills are not common, while sinus disease is characterized by sharp thermometric fluctuations, often with chills. Yet this rule is not absolute. Abscess, either subdural or intracranial, has but little, if any, fever. When distinctly cerebral symptoms occur,viz., mental alterations, coma, delirium, pareses (more than merely facial),-intracerebral disease is evident, but even then a differential diagnosis may be difficult. Inflammation of the optic nerve (optic neuritis or choked. disc) is rather exceptional in all these affections, but when present, is very significant. All cerebral complications are apt to produce the systemic disturbance common to pyogenic infection-viz., derangement of the appetite and digestion, furred tongue, constipation, and lack of vigor. An important diagnostic method in obscure cases is lumbar puncture-the tapping of the spinal canal below the spinal cord. As the question has lately been raised. regarding the absolute safety of this procedure, it is best to limit its use to those instances in which no diagnosis can be made without it. The technical details of this operation do not require discussion in this place. The information gained by lumbar puncture is positive as to the existence of meningitis, negative regarding the other complications. When the cerebrospinal fluid escapes under abnormal high pressure, but is either perfectly clear or contains only microscopically leukocytes, a serous meningitis is proved. When the fluid, however, is turbid and the microscope reveals the presence of pus-cells as well as bacteria, especially streptococci, it is proof positive of a purulent meningitis. In abscesses within the skull and in sinus phlebitis the evidence by lumbar puncture is negative. The otitic intracranial complications are most common in late childhood and early middle life, are decidedly more frequent in the male than in the female, and occur oftener on the right than on the left side. Of all the lesions, the extradural abscess is the most frequent and often the intermediate step between ear disease and the other complications. In the case of acute otitis the cerebral sequels may not become manifest until quite a time-even weeks-has elapsed after the apparent cure of the ear disease. The liability to cerebral complications is very small in those cases of chronic purulent otitis in which free drainage is indicated by an absence. of fetor. The greatest danger is in the cases with stagnation of fetid pus, especially in the course of subacute exacerbations, particularly when caries or cholesteatoma exist. It is sometimes not possible to recognize with certainty the existence of an intracerebral complication or to diagnose the exact lesion prior to the operative dissection. If in the course of an operation carious fistula or paths of granulations are found, they are to be followed up to wherever they lead. As with rare exceptions these patients are sure to die if not treated surgically, the operation must not stop short of the utmost obtainable |