Treatment. Treatment is directed toward cleaning the back of the nose and reducing swelling at the openings of the Eustachian tubes in this locality, and inflating the tubes with air. A spray of Seiler’s solution[3] is thrown from an atomizer through the nostrils, with the head tipped backward, until it is felt in the back of the throat, and after the water has drained away the process is repeated a number of times. This treatment is pursued twice daily, and one hour after the fluid in the nose is well cleared away the Eustachian tubes may be inflated by the patient. To accomplish this the lips are closed tightly, and the nostrils also, by holding the nose; then an effort is made to blow the cheeks out till air is forced into the tubes and is felt entering both ears. This act is attended with danger of carrying up fluid into the tubes and greatly aggravating the condition, unless the water from the spray has had time to drain away.

Blowing the nose, as has been pointed out, is unwise, but the water may be removed to some extent by “clearing the throat.” The reduction of swelling at the entrance of the Eustachian tube in the back of the nose can be properly treated only by an expert, as some astringent (glycerite of tannin) must be applied on cotton wound on a curved applicator, and the instrument passed above and behind the roof of the mouth into the region back of the nose.

Rubbing the parts just in front of the external opening into the ear with the tip of one finger for a period of a few minutes several times a day will also favor recovery in this trouble.

Water in the ears is sometimes removed by jumping about on one foot with the troublesome ear held downward, and if it is in the external canal it may be wiped out gently with cotton on the end of a match, as recommended in the article on treating wax in the ear (see p. 35). In the treatment of catarrh in the nose or throat only a spray from an atomizer should be used, as Dobell’s or Seiler’s solutions followed by menthol and camphor, twenty grains of each to the ounce of alboline or liquid vaseline.

Exposure to cold and the common eruptive diseases of children, as scarlet fever, measles, and also diphtheria, are common causes of middle ear inflammation. In the latter disorders the protection afforded by a nightcap which comes down over the ears, and worn constantly during the illness, is frequently sufficient to ward off ear complications.

Although earache or middle ear inflammation is common, its dangers are not fully appreciated, since the various complications are likely to arise, and the result is not rarely serious. Extension of the inflammation to the bone behind the ear may necessitate chiseling away a part of the skull to liberate pus or dead bone in this locality, and the occurrence of abscess of the brain will necessitate operation.

The use of leeches in the beginning of the attack is of great value, and though unpleasant are not difficult or painful in their application. One should be applied just in front of the opening into the ear (which should be previously closed with cotton to prevent the entrance of the leech), and the other behind the ear in the crease where it joins the side of the head and at a point a little below the level of the external opening into the ear. A drop of milk on these spots will often start the leeches immediately at work, or a drop of blood obtained with a pin prick. When the leeches are gorged with blood and cease to suck, they should be removed and bleeding encouraged for half an hour with applications of absorbent cotton dipped in hot water. Then clean, dry absorbent cotton is applied, and pressure made on the wounds if bleeding does not soon stop or is excessive.

The after treatment of the bites consists in cleanliness and the use of vaseline. The patient must stay in bed, and the hot water bag be constantly kept on the ear till all pain ceases. If the drum perforates, a discharge will usually appear from the external ear. Then the canal must be cleansed, once or more daily, by injecting very gently into the ear a solution of boric acid (as much of boric acid as the water will dissolve), following this by wiping the water out of the canal with sterilized cotton, as directed for the treatment of wax in the ear.

The syringing is permissible only once daily, unless the discharge is copious, but the canal may be wiped out in this manner several times a day with dry cotton. It is well to keep the opening into the ear greased with vaseline, and a plug of clean absorbent cotton loosely packed into the canal to keep out the cold. Excessive or too forcible syringing may bring about that complication most to be feared, although it may appear through no fault in care, i. e., an implication of the cavity in the bone back of the ear (mastoid disease). Germs find their way through the connecting passage by which this cavity is in touch with the middle ear, or may be forced in by violent syringing. When this happens, earache, or pain just back of the ear, commonly returns during the first or second week after the first attack, and tenderness may be observed on pressing on the bone just back of the ear close to the canal. Fever, and local redness and swelling of the parts over the bone in this region may also occur. Confinement to bed, and constant application of a rubber bag containing cracked ice, to the painful parts must be enforced. If the tenderness on pressure over the bone and pain do not subside within twenty four to forty eight hours, surgical assistance must be obtained at any cost, or a fatal result may ensue. The opening in the drum membrane, caused by escape of discharge in the course of middle ear inflammation, usually closes, but even if it does not deafness is not a necessary sequence.

The eardrum is not absolutely essential to hearing, but it is of great importance to exclude sources of irritation, dust, water, and germs which are likely to set up middle ear trouble. More ordinary after effects are chronic discharge from the ear following acute inflammation and perforation of the eardrum, which may mean at any time a sudden return of pain with the occurrence of the more dangerous conditions just recited, together with deafness. Bearing all this in mind it is advisable never to neglect a severe or persistent earache, but to call in expert attention. When this is not obtainable the treatment outlined below should be carefully followed.

Symptoms. Pain is severe and often excruciating in adults. It may be felt over the temple, side and back of the head and neck, and even in the lower teeth, as well as in the ear itself. The pain is increased by blowing the nose, sneezing, coughing, and stooping. There is considerable tenderness usually on pressing on the skin in front of the ear passage. In infants there may be little evidence of pain in the ear. They are apt to be very fretful, refuse food, cry out in sleep, often lie with the affected ear resting on the hand, and show tenderness on pressure immediately in front or behind the ear passage.

Dullness, fever, chills, and convulsions are not uncommon in children, but, on the other hand, after some slight illness it is not infrequent for discharge from the ear to be the first sign which calls the attention of parent or medical attendant to the source of the trouble. For this reason the careful physician always examines the ear in doubtful cases of children’s diseases. Unless the inflammation subsides with treatment, either a thin, watery fluid (serum) is formed in the middle ear, or pus, when we have an “abscess of the ear.” The drum if left to itself breaks down in three to five days, or much sooner in children who possess a thinner membrane. A discharge then appears in the canal of the external ear, and the pain is relieved. It may occasionally happen that the Eustachian tube drains away the discharge, or that the discharge from the drum is so slight that it is not perceived, and recovery ensues. Discharge from the ear continues for a few weeks, and then the hole in the drum closes and the trouble ceases. This is the history in favorable cases, but unfortunately, as we have indicated, the opposite state of affairs results not infrequently, especially in neglected patients.

Treatment. The patient with severe earache should go to bed and take a cathartic to move the bowels. He should lie all the time with the painful ear on a rubber bag containing water as hot as can be comfortably borne. Every two hours a jet of hot water, which has been boiled and cooled just sufficiently to permit of its use, is allowed to flow gently from a fountain syringe into the ear for ten minutes, and then the ear is dried with cotton, as described under the treatment of wax in the ear. No other “drops” of any kind are admissible for use in the ear, and even this treatment is of less importance than the dry heat from the hot water bag, and may be omitted altogether if the appliances and skill to dry the ear are lacking. Ten drops of laudanum for an adult, or a teaspoonful of paregoric for a child six years old, may be given by the mouth to relieve the pain. The temperature of the room should be even and the food soft.

If the pain continues it is wiser to have an aurist lance the drum, to avoid complications, than to wait for the drum membrane to break open spontaneously in his absence. Loss or damage of the eardrums may call for “artificial eardrums.” They do not act at all like the drumhead of the musical instrument by their vibrations, but only are of service in putting on the stretch the little bones in the middle ear which convey sound. Some of those advertised do harm by setting up a mechanical irritation in the ear after a time, and a better result is often obtained with a ball of cotton or a paper disc introduced into the ear by an aurist.

To remove solid bodies, turn the ear containing the body, downward, pull it outward and backward, and rub the skin just in front of the opening into the ear with the other hand, and the object may fall out.

Failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. The essentials of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. If beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. To obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed.

In the middle ear we have an air space connected with the throat by the Eustachian tube, a tube about an inch long running downward and forward to join the upper air passage at the junction of the back of the nose and upper part of the throat. If one should run the finger along the roof of the mouth and then hook it up behind and above the soft palate one could feel the openings of these tubes (one for each ear) on either side of the top of the throat or back of the nose, according to the view we take of it.

Then the middle ear is also connected with a cavity in the bone back of the ear (mastoid cavity or cells), and the outer and lower wall is formed by the drum membrane. Vibrations started by sound waves which strike the ear are connected by means of a chain of three little bones from the drum through the middle ear to the nervous apparatus in the internal ear. The head of one of these little bones may be seen by an expert, looking into the ear, pressing against the inside of the drum membrane. Stiffening or immovability of the joints between these little bones, from catarrh of the middle ear, is most important in producing permanent deafness. The middle ear space is lined with mucous membrane continuous with that of the throat through the Eustachian tube. This serves to drain mucus from the middle ear, and also to equalize the air pressure on the eardrum so that the pressure within the middle ear shall be the same as that without.

When there is catarrh or inflammation of the throat or nose it is apt to extend up the Eustachian tubes and involve the middle ear. In this way the tubes become choked and obstructed with the oversecretion or by swelling. The air in the middle ear then becomes absorbed in part, and a species of vacuum is produced with increased pressure from without on the eardrum. The drum membrane will be pressed in, and through the little bones pressure will be made against the sensitive nervous apparatus, irritating it and giving rise to deafness, dizziness, and the sensation of noises in the ear. Noises from without will also be intensified in passing through the middle ear when it is converted into a closed cavity through the blocking of the Eustachian tube.

A very important feature following obstruction of the Eustachian tubes, and rarefaction of the air in the middle ear, is that congestion of the blood vessels ensues and increased secretion, because the usual pressure of the air on the blood vessels within the middle ear is taken away.

This then is the cause of most permanent deafness, to which is given the name catarrhal deafness, because every fresh cold in the head, or sore throat, tends to start up trouble in the ear such as we have just described. Repeated attacks leave vestiges behind until permanent deafness remains. In normal conditions every act of swallowing opens the apertures of the Eustachian tubes in the throat, and allows of equalization of the air pressure within and without the eardrum, but if the nose is stopped up by a cold in the head, or enlargement of the tonsil at the back of the nose (as from adenoids), the process is reversed and air is exhausted from the Eustachian tubes with each swallowing motion.

The moral to be drawn from all the foregoing is to treat colds properly when they are present, keeping the nose and throat clean and clear of mucus, and to have any abnormal obstruction in the nose or throat and source of chronic catarrh removed, as enlarged tonsils, adenoids, and nasal outgrowths.

The deafness is sudden because, owing to the accidental entrance of water, the wax quickly swells and chokes the canal; or, in attempts to relieve irritation in the ear, the finger or some other object is thrust into the opening in the ear (auditory canal) and presses the wax down on the ear drum. The obstruction in the ear is usually a mixture of waxy secretion from the canal, and little scales of dead skin which become matted together in unwise efforts at cleansing the ear by introducing a twisted towel or some other object into the ear passage and there turning it about; or it may occur owing to disease of the ear altering the character of the natural secretion. In the normal state, the purpose of the wax is, apparently, to repel insects and to glue together the little flakes of cast off skin in the auditory canal, and these, catching on the hairs lining the canal, are thrown out of the ears upon the shoulders by the motion of the jaws in eating.

Nothing should be introduced into the ear with the idea of cleansing it, as the skin growing more rapidly from within tends naturally to push the dead portions out as required, and so the canal is self cleansing.

Symptoms. Sudden deafness in one ear usually calls the attention of the patient to an accumulation of wax. There is apt to be more or less wax in the other ear as well. Noises in the deaf ear and a feeling of pressure are also common. Among rarer symptoms are nausea and dizziness. But the only way to be sure that deafness is due to choking of the ear passage with wax is to see it. This is usually accomplished by a physician in the following way: he throws a good light from a mirror into a small tube introduced into the ear passage. This is, of course, impossible for laymen to do, but if the ear is drawn upward, backward, and outward, so as to straighten the canal, it may be possible for anyone to see a mass of yellowish brown or blackish material filling the passage. And in any event, if the wax cannot be seen, one is justified in treating the case as if it were present, if sudden deafness has occurred and competent medical aid is unobtainable, since no harm will be done if wax is absent, and, if it is present, the escape of wax will usually give immediate relief from the deafness and other symptoms.

Treatment. The wax is to be removed with a syringe and water as hot as can be comfortably borne. A hard rubber syringe having a piston, and holding from two teaspoonfuls to two tablespoonfuls, is to be employed the larger ones are better. The clothing should be protected from water by towels placed over the shoulder, and a basin is held under the ear to catch the water flowing out of the canal. The tip of the syringe is introduced just within the entrance of the ear, which is to be pulled backward and upward, and the stream of water directed with some force against the upper and back wall of the passage rather than directly down upon the wax. The water which is first returned is discolored, and then, on repeated syringing, little flakes of dry skin, with perhaps some wax adhering, may be seen floating on the top of the water which flows from the ear, and finally, after a longer or shorter period, a plug of wax becomes dislodged, and the whole trouble is over.

This is the rule, but sometimes the process is very long and tedious, only a little coming away at a time, and, rarely, dizziness and faintness will require the patient to lie down for a while. The water should always be removed from the ear after syringing by twisting a small wisp of absorbent cotton about the end of a small stick, as a toothpick, which has been dipped into water to make the cotton adhere. The tip of the toothpick, thus being thoroughly protected by dry cotton applied so tightly that there is no danger of it slipping off, while the ear is pulled backward and upward to straighten the canal, is gently pushed into the bottom of the canal and removed, and the process repeated with fresh cotton until it no longer returns moist. Finally a pledget of dry cotton should be loosely packed into the ear passage, and worn by the patient for twelve or twenty four hours.