Thedistributionofthemastoidcellsisofthegreatestclinicalimportanceasitgovernstheextentanddirectionofaninflammatoryprocessspreadingfromthemiddleear2NoncellulartypeofmastoidprocessOnsectionthemastoid ID: 942695
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ACUTEMASTOIDITISByJ.DOUGLASMcLAGGAN,M.A.,F.R.C.S.(Surgeon-in-chargeEar,NoseandThroatDepartment,RoyalFreeHospital;Surgeon,CentralLondonThroat,NoseandEarHospital.)AnatomyoftheMastoidProcess.Themastoidprocessisshapedlikeaconewiththebaseuppermost.Above,itisseparatedfromthetemporalfossabythesupra-mastoidcrestwhichiscontinuedforwardsovertheexternalauditorymeatusastheposteriorrootofthezygoma.Posteriorly,themastoidprocessarticulateswiththeoccipitalboneandabovethiswiththemastoidangleoftheparietalbone.Anteriorly,theprocessformstheposteriorwalloftheexternalauditorymeatus.Thetipisfreeanddirecteddownwards.Onitsoutersurfacethetendinousfibresofthesterno-mastoidmuscleareattachedandonitsmedialsideisagroovewhichlodgestheposteriorbellyofthediagastricmuscle.Immediatelyaboveandbehindthepostero-superiorcurveoftheexternalauditorymeatusthereisatriangularcribiformarea,whichmarksthesiteoftheunderlyingmastoidantrum.Onornearthemasto-occipitalsutureisanopeningwhichtransmitsthemastoidemissaryvein:theveinlinksupthetransversesinuswiththeoccipitalvein.Onitscranialsurfacethemastoidprocesshasabroadshallowgroovewhichlodgesthetransversesinusanditscontinuationthesigmoidsinus.Onsection,twomaintypesofmastoidprocessaredifferentiated,cellularandnon-cellular.I.Cellulartypeofmastoidprocess.Themastoidantrumissituatedintheupperandanteriorpartoftheprocess.Continuouswiththeantrumthereisahoney-combnetworkofcellswhichspreadsthroughthemastoidprocess.Thecellsareveryvariablebothintheirsizeandintheirdistribution.Frequentlytheyextendthroughouttheprocesswithlargercellsatthetipandbehindthegrooveofthesigmoidsinus.Cellsmayextendbackwardsbeyondthemasto-occipitalsutureintotheocci-pitalbone.Theymayinvadethesupra-mastoidcrestandcontinueupwardsintothesquamoustemporal,orforwardsalongtheposteriorrootofthezygomaroofingovertheexternalauditorymeatusandreachingthezygomaticprocessitself.CellsmaysurroundtheexternalauditorymeatusandtheEustachiantube.Theymayinvadethepetrousportionofthetemporalbone,surroundingthebonycapsulewhichenclosestheinternalearandreachingasfarasthetipofthepetrousbonewhereitarticulateswiththesphenoid.Themastoidcellsareseparatedfromthesurfaceandfromtheduramaterofthemiddleandposteriorfossaebythinplatesofbone.Allcellsarelinedwithmucousmembranewhichisdirectlycontinuouswiththemucousmembraneofthemastoidantrumandofthemiddleear.September,1939ACUTEMASTOIDITIS335 Thedistributionofthemastoidcellsisofthegreatestclinicalimportanceasitgovernstheextentanddirectionofaninflammatoryprocessspreadingfromthemiddleear.2.Non-cellulartypeofmastoidprocess.Onsectionthemastoidprocessisseentoconsistofivorydenseboneorofdiploeticbone.Theonl
ycellularspacesarethemastoidantrumandoneortwosmallaircellsimmediatelysurroundingtheantrum.Thistypeofmastoidprocessisprobablyduetoafailureofthenormalprocessofpneumatisationandisnottheresultofapreviousinflammatoryprocessinacellularmastoid.Bothmastoidprocessesareusuallyroughlysymmetrical.Bothareusuallycellularorbothnon-cellular-inthecellulartypesthereiscommonlyafairlycloseresemblanceinthedistributionofthecellsonbothsides,butexceptionstothisruleoccurandonemastoidprocessmaybecellularwhiletheotherisnon-cellular.Themastoidprocessininfancy.Ininfantsthemastoidprocessisnotdevelopedbutthemastoidantrumispresentatbirthandisaslargerelativelyastheantrumintheadult.Ininfancytheantrumliessuperficially,separatedfromthesubcutaneoustissuesonlybyathinplateofbone.Cellsbegintoappearsoonafterbirthandbythetimethechildisfourtofiveyearsoldtheprocessiswelldeveloped.Oneimportantresultoftheabsenceofamastoidprocessintheyounginfantisthatthefacialnerve,asitemergesfromthestylo-mastoidforamen,isunpro-tectedbyanyoverlyingboneandmaybeinjuredbyaskinincisionextendingintotheneck.Themiddleearcleft.Themastoidantrumcommunicateswiththeupperpartofthemiddleearcavitythroughashortwidepassage-theaditus.Initsturnthemiddleearcavitycommunicateswiththenaso-pharynxthroughtheEustachiantube.Thisseriesofcavitiesandcommunicatingpassagesmaybecalledthemiddleearcleft.Thecleftfromthenaso-pharyngealorificeoftheEustachiantubetothemostdistalmastoidaircellislinedthroughoutbyacontinuousmucousmembrane.Aninflammatoryprocessofthenaso-pharynxpassestothemiddleearcavitybywayoftheEustachiantube.Whenasuppurativeotitismediahasdeveloped,thecloseproximityofthemastoidantrumandaircellsandthecontinuityofthemucousmembraneensuresomedegreeofinflammationinthesecavities.Thisismostclearlyevidentinchildrenorinadultswithextensivepneumatisationofthemastoidprocess,andisshownbytendernessonpressureoverthemastoidprocess.Thetendernessismostmarkedonpressureappliedimmediatelyoverthemastoidantrumandlessensprogressivelyoverthemastoidprocess.Thetendernessisgreatestbeforethetympanicmembranehasrupturedandbecomesprogressivelylessasdrainagethroughaperforationbecomesestablished,butitmaytakeseveraldaystodisappearcompletely.Thetendernessindicatesanearlystageofmastoiditisbutdoesnotcallforamastoidoperation,providedthatitcontinuestodiminish,thereisnopainandthegeneralconditionimprovesprogressively.IfanX-rayofthemastoidprocessistakenatthisstagethemastoidcellswillappearhazy,owingtothickeningoftheirmucousmembraneliningand,perhaps,tothepresenceofexudate.336POST-GRADUATEMEDICALJOURNALSeptember,1939 Courseofamastoiditisafterruptureofthetympanicmembrane.Therearethreepossibili
ties:I.Mostcommonlyacureresults.Theperforationinthemembraneissuffi-cienttoensuredrainage.Thepatient'sresistanceovercomesthevirulenceoftheinfectingorganism,allacutesignsdisappear,thedischargebecomesprogressivelylessandultimatelyceases.Theperforationinthetympanicmembraneheals.2.Achronicorlatentmastoiditisdevelops.Theperforationinthemembranegivessufficientdrainagetorelievethepatientofallacutesignsofmastoidinfection.Themastoidtendernessslowlylessensandultimatelydisappearsentirely:con-valescenceisprotracted,eveningtemperatureremainshighforsomedaysaftertheappearanceofthedischarge,andpainpersists,butgraduallylessens,untilfinallytheonlyindicationofmastoidinfectionisapersistentdischargefromtheear.Thisdischargeispurulentincharacterandisoftenprofuse.Itmaypersistwithoutsymptomsformonths,butthereisatendencyforacuteexacerbationstooccur.Anexacerbationisoftenheraldedbyadisappearanceorlesseningofthedischargeandthisisfollowedbyarenewalofpain,mastoidtendernessandpyrexiaoverafewdays.AnX-rayofthemastoidprocessestakenatanytimeduringthecourseofthedischargewillshowthatthemastoidcellsontheaffectedsidearecloudyandblurred.Achronicmastoiditisofthisnaturecallsfordrainageoftheinfectedmastoidprocess.Operationisbestundertakenduringaquiescentperiod.3.Anacutemastoiditisdevelops.Thedrainagesuppliedbytheperforationinthemembraneortheresistanceofthepatientisnotsufficienttoovercometheinfection.Theoedematousmucousmembraneoftheantrumandmastoidcellsbecomesulcerated.Theunderlyingboneisdeprivedofitsbloodsupplyandbecomesinfectedinitsturn,withdestructionofthebonycellwalls.Theacutesymptomsandsignsoftheotitismediabecomeintensifiedanditisnownecessarytodraintheinfectedmastoidprocess.Thesymptomsandsignsofthisstagevaryenormously,accordingtothetypeofmastoidprocess,andtheywillbediscussedastheyoccur(a)inacellularand(b)inanon-cellularmastoidprocess.SignsofAcuteMastoiditisinaCellularMastoid.Pain.Theseverepainofanacuteotitismediaisrelievedbytheperforationofthetympanicmembrane.Asanacutemastoiditisdevelops,painreturnsbutisrarelysosevereasduringtheinitialstages.Itisthrobbingorboringincharacter,deeply-seatedandissituatedratheroverthemastoidprocessthanintheearitself.Itisusuallyworstatnightsothatsleepisinterrupted.Thepainisoftengreatlyrelievedbytheapplicationofwarmdressingsorbytheadministrationofaspirin.Therecurrenceofpainistheusualbutnotinvariableaccompanimentofanacutemastoiditis.InfectionwithapneumococcustypeIIIorganism(streptococcusmucosus)mayrunapainlesscourse.Temperature.Duringtheonsetoftheinfection,inthestageofacutenaso-pharyngitisandotitismedia,thetemperatureispersistentlyhigh.Afterdrainageofthemiddleearhasbeenesta
blishedthroughaperforationinthetympanicmembranethetemperaturetendstodropsteadilytonormal,inthecourseoftwoorthreedays.As'anacutemastoiditisdevelopspyrexiarecursbutrarelytoalevelsohighasduringtheinitialstages.ThissecondonsetoftemperatureisSeptember,1939ACUTEMASTOIDITIS337 rarelyapersistenttemperaturebutshowsadailyswing,lowinthemorningandprogressivelyhigherintheevening.Itisoftheutmostimportance,therefore,duringthefewdayswhichfollowtheonsetofthedischargetokeeparegulardailychartshowingmorningandeveningtemperature,andgreatsignificancemustbeattachedtoit,particularlyintheabsenceofothercomplicationssuchascervicaladenitis.Tenderness.Therearenomoremisleadingsignsinacutemastoiditisthanthepresenceorabsenceoftenderness.Itspresencedependsonthedegreeofpneumatisationofthemastoidprocessandthedegreeofthicknessoftheboneformingthecortexofthemastoidprocessandseparatingtheinfectedcellsfromthesurface.Wherecellsarenumerousandlargeandthecorticalboneisthin,tendernessisanearlysign.Whencellsarefewandthecorticalbonethick,tendernesswillbelateinitsappearanceormayneverbepresent.Atfirsttendernessinawellpneumatisedprocessismostmarkedatthreepoints-overthemastoidantrum,overthetipandoverthepostero-inferiorborderoftheprocess.Astheinfectiondevelopstendernessbecomesgeneralisedoverthemastoidprocess.Ifoperationisdelayedtendernessmayagainbecomemorelocalised,eitheroveragroupofparticularlylargecellsnearthesurface,oratapointwhereper-forationofthecorticalboneisimpending.Truemastoidtendernessisadeep-seatedtendernesselicitedonlybyfirmpressureonthebone.Asuperficialtenderness,duetoaninfectionofsmalllymphglandsoverthemastoidprocess,mustnotbemistakenfortruemastoidtenderness.Mastoidtendernessmustnotbeconfusedwiththetendernesscausedbyafuruncleoftheexternalmeatus.Thelatteriselicitedbydisplacementoftheauricleandiscommonlymostsevereonpressureoverthetragus.(Edemaoftheperiosteumandofthecellulartissuesoverlyingthemastoidprocess.Inaverycellularprocesswiththincorticalbonethiscedemamaybeanearlysign,presentformanydaysbeforeperforationofthecortexoccursandasubperiostealabscessisformed.Itisdetectedbygentlepalpationandcomparisonwiththehealthymastoid.Theskinoverthemastoidprocessmaybeslightlyreddened.Ifthemastoidprocessesareviewedfrombehind,theauricleontheaffectedsidewillappearslightlymoreprominent.Formationofasubperiostealabscess.Asubperiostealabscessisformedbyperforationofthecorticalbonefromaninfectionofacloselyunderlyingcell.Itisaveryfrequentandcomparativelyearlycomplicationintheveryyoung.Theformationoftheabscessisshownbyagreatincreaseintheperiostealoedemaandanobviousswellingoverthemastoidprocesswhichdisplacestheauricle.Usuall
ytheperforationoccursintheboneimmediatelyoverlyingthemastoidantrumandtheresultantswellingdisplacestheauricledownwardsandforwards.Thisswellingisnotpathognomonicofacutemastoiditisasitdevelopssimilarlyinmanycasesoffuruncleoftheexternalmeatus.Infurunculosisthereisalocalisedswellingintheouterhalfoftheexternalauditorymeatnsandthetympanicmembraneisintactandnotbulging.338POST-GRADUATEMEDICALJOURNALSeptember,1939 Sometimes,unfortunately,furunculosiscoincideswithanotitismedia.Thedifferentialdiagnosisofthemastoidswellingmaythenbecomeverydifficult.HelpmaybeobtainedbyX-rays,whichwillshowthedisintegrationofcellwallsinacutemastoiditis,butifthisisnotavailableexplorationmayberequired,andshouldbeundertakenincasesofrealdifficulty.Iftheconditionisnotrelievedbyoperationtheskinovertheabscessmayultimatelyreddenandbreakdownwiththeformationofasinusthroughwhichbarebonecanbeprobed.Rarersitesfortheformationofasubperiostealabscess.(a)Belowthetipofthemastoidprocessundercoveroftheattachedsterno-mastoidmuscle.(b)Abovetheauricleoverthezygomaticprocessorsquamoustemporal.(c)Alongtheposterio-inferiorborderofthemastoidprocess.Thesesitesaredeterminedbythepresenceoflargeinfectedcells,eitheratthetipoftheprocessorextendingforwardsalongtheposteriorrootofthezygoma,orupwardsintothesquamoustemporal,or,finally,behindthegrooveforthesigmoidsinus.(a)ThistypeiscalledaBezold'smastoiditis.Theperforationtakesplacethroughthemedialsurfaceofthemastoidprocessandtheabscessextendsalongtheposteriorbellyofthedigastricorundercoverofthesternomastoidmuscleandtendstotrackdowntheneckinthelineofthegreatvessels.Thereisusuallygreattendernessonpressureoverthetipofthemastoid.Thisswellingmustnotbeconfusedwiththeswellingwhichistheresultofaninflammationintheuppermostglandsoftheanteriortriangleoftheneck,secondarytotheinitialnasopharyngitisandotitismedia.Theswellingduetoanadenitisissituatedbelowthetipofthemastoidprocess,whichcanbeseparatedfromitbycarefulpalpationandwhichisnottenderondeeppressure.TheswellingofaBezold'smastoiditisisdirectlycontinuouswiththetipofthemastoidprocess.(b)Zygomaticmastoiditisisthetermappliedtotheformationofasubperiostealabscessoverthezygomaorinthetemporalfossa.Theswellingisvisibleaboveandinfrontoftheauricleandinvadestheupperandlowereyelidsonthesameside.Inthecellulartissuesoftheeyelidsthecedemaismostevidentandwilloftenbethefirstindicationofthistypeofmastoiditis.(c)Asubperiostealabscessmayformonthepostero-inferioraspectofthemastoidprocess,duetoanescapeofpusfromcellswhichextendbackwardsanddownwardsbeyondthecurveofthesigmoidsinus.Themastoidemissaryveinpiercesthecortexatthissiteandpusmayescapethroughtheperforation
whichtransmitsthevein,eitherfrominfectedcellsinthevicinityorfromaperisinousabscess.Theremaybeanaccompanyingthrombosisoftheveinorofthesinus,orofboth.OtoscopicExamination.Thetympanicmembraneiscongested,oedematousandbulginginitspostero-superiorquadrant.Thebulgemaytaketheformofanipple-shapedprojection,pointingdownwardsandforwards,perforatedatthetip.Thedischargefromtheperforationispurulent,pulsatingandprofuse,sothatitwellsintotheexternalSeptember,1939ACUTEMASTOIDITIS339 meatusinquantitysogreatthatitobviouslycomesfromawiderareathanthesmalltympaniccavityitself.Co-extensivewiththecedemaofthemembranethereisasaggingofthepostero-superiormeatalwall.AprofusedischargeisalsoseeninsevereEustachianinfectionsbutitismoremuco-purulentincharacter,stringyandsticky,andifcarefullywipedaway,itcanbeseenwellingupfromananteriorperforationoppositethemouthoftheEustachiantube.ItisessentialindifficultcasestotakegreatcarewiththeotoscopicexaminationtodifferentiatethedischargewhichiscomingfromaninfectedmastoidprocessfromthedischargeofapersistentEustachianinfection.Theessentialpointsare:I.Thesaggingandcedemaofthepostero-superiordeepmeatalwallinacutemastoiditis.2.Thesiteofthebulgeinthetympanicmembrane-abulgefromaboveandbehind,downwardsandforwardsinacutemastoiditis.3.Thenatureratherthanthequantityofthedischarge.Thick,creamyandpurulentinacutemastoiditis--notmuco-purulent.Constitutionalsymptoms.Theseareprominentinacutemastoiditis.Head-ache,lossofappetiteand,aboveall,sleepdisturbedbyboutsofpain.X-ray:diagnosis.ThediagnosisshouldbemadebyphysicalsymptomsandsignsandnotbyX-ray,exceptinafewdifficultcases.X-rayscanbemostmis-leadingbecauseinallcasesofacuteotitismedia,evenwhenthereisnotsufficientinfectioninthemastoidprocesstowarrantoperation,themastoidcellswillappearcloudy.Atruemastoiditiswillbeshownbysofteningandbreakingdownofthecellwallswithabscessformation.Inspiteofthesedifficulties,anX-rayofthemastoidprocessshouldbetakenbeforeoperationasitgivesanaccuratepictureofcelldistributionandofthespreadofthediseaseandenablesthesurgeontoplanthescopeofhisoperation.AcuteMastoiditisinaNon-cellularMastoid.Ifthemastoidprocessisnotcellularbutofthediploetictype,anacutemastoiditistakestheformofaspreadingosteomyelitiswhichinvolvestheplatesofbonecoveringduramaterbeforeitreachesthesurfacethroughadensecortex.Thediseaseinthiscaseisthereforeparticularlydangerousandisapttoleadtointra-cranialcomplications.Ifthemastoidprocessissclerosed,anacutemastoiditisisunlikelytodevelop-itisinthistypethatachronicsuppurativeotitismediaoftenfollows.Acutemastoiditisinadiploeticmastoidisaparticularlydangeroustypeofmastoiditisandallthemoresobecaused
iagnosisisdifficultandoperationtendstobedelayed.I.Theusualphysicalsignsofmastoiditisareabsent.Owingtothedensecortexthereisnomastoidtenderness.Thereisnocedemaoftheperiosteum,nodisplacementoftheauricle.Asubperiostealabscesswillnotformtilllongaftertheinfectionhasreachedtheduramater.Itisimportantthenthatthefewsignsthatpersistshouldnotbemissed.'340POST-GRADUATEMEDICALJOURNALSeptember,1939 2.Onotoscopicexaminationthereissaggingofthedeepmeatalwallbecausethemastoidantrumliesincloseproximitybeneathit.Thereisbulgingofthetympanicmembranewiththenippleshapedtypeofperforation,asinacellularmastoid.Thereisaprofusepulsatingpurulentdischarge.Toomuchstresscanscarcelybelaidontheseveryvitalsigns.3.Thegeneralconditionofthepatient.Thereispersistentpainintheearanddeepseatedheadacheafterthedischargehasbeenfullyestablished.Thepatientshowssignsofmarkedtoxaemia,withlossofappetite,constipationandsleeplessness.Thetemperatureremainshighandtendstobeoftheswingingsepticvariety.Tosumup,inthismostdangeroustypeofacutemastoiditisthereisnotender-ness,nomastoidoedema,nodisplacementoftheauricle.Thediagnosismustthereforebemadebyotoscopicexaminationandconsiderationofthepatient'sgeneralcondition.AtypicalFormsofAcuteMastoiditis.I.Petrositis.-Acutemastoiditiscomplicatedbythespreadofinfectionintothepetrouspartofthetemporalbone.Thisismostlikelytooccurwhenthereisanextensionofcellsintothepetrousbone.Thesecellssurroundthedensebonycapsuleofthelabyrinthandextendtothetipofthepetrous.Thesignsandsymptomsusuallyappearafteranacutemastoiditishasbeenfullyestablishedandoftenduringtheconvalescencefollowingamastoidoperation.Theymay,however,appearatthebeginningofanacutemastoiditis.Themostprominentsymptomisneunalgicpainoverthetemporalregiononthesameside,radiatingdownwardsoverthecheekandintotheteeth,oradeep-seatedboringfrontalheadache,roundandbehindtheeyeball.ThispainismostlikelycausedbyirritationoftheGasserianganglionofthefifthnerveasitliesontheapexofthepetrousbone.Thesixthnervealsocrossesthetipofthepetrousboneandmaybeinvolved.Asaresultthereisparalysisoftheexternalrectusmuscleonthesamesidewitharesultantsquintanddiplopia.Theinfectionroundthelabyrinthmaycausesymptomsofvertigowithspon-taneousnystagmus.Thereisacontinuedpyrexiaoftheswingingseptictype,andalsopersistent,copious,purulentdischargefromthemeatus.Asuppurativeprocessofthepetrousboneuntreatedisexceedinglydangerous,astheinfectionreadilyextendsintothecranialcavitywitharesultantmeningitiseitherlocalisedandserousor,morefatally,spreadingandsuppurative.Alternatively,thepusmayrupturethroughthefloorofthetipofthepetrousboneandcausealateralpharyngealabscess.Inthiscasethereisbulgi
nginwardsofthetonsilandofthewholelateralpharyngealwallwithtrismus.Itismostimportanttorecognisethatthesymptomsofpost-operativetrigeminalpainandparalysisoftheexternalrectusmayarisewithoutasuppurativeprocessinthepetrousbone.Thesymptomsarethenmostprobablytoxicinoriginandoperationonthepetrousboneshouldbeavoided.IncasesofdoubtanX-rayviewofthepetrousboneitselfisinvaluablefordiagnosis.September,1939ACUTEMASTOIDITIS341 2.Mastoiditisduetoinfectionwiththestreptococcusmucosus(pneumococcustypem).Infectionbythisorganismhasasinisterreputationbecauseitleadstoawidespreaddestructionofbonewithfewsymptomsbeyondapurulenteardischarge.Thereislittleornopainortendernessandanintracranialcomplicationmaybethefirstserioussignoftrouble.Theinfectioniscommonerintheoldandthosesufferingfromdebilitatingdiseases,suchasdiabetes.3.Theacutemastoiditisofmeasles.Intheyoungchildanacuteotitismediaisoftenthoughttobepainless.Thisinmanycasesisprobablyduetothefailuretointerpretthesignsofdistressinatoxicchildduringtheshortintervalwhichelapsesbetweentheonsetoftheinfectionandtheperforationofthemembranewiththeappearanceofdischarge.Theinfectionisalmostalwaysduetoanhamolyticstreptococcusand,inachildoflowresistance,thereisarapiddestruc-tionofthetympanicmembranewithulcerationofthemucosaofthetympanum,antrumandmastoidcellsandspreadingosteitis.Asaresult,complicationsarerelativelyfrequentorachronicsuppurativeotitismediaisestablishedwhichdoesnotyieldtotreatment.4.Acutemastoiditiswithanormaltympanicmembrane.Itisnotuncommontogetafullydevelopedmastoiditiswithanintacttympanicmembrane.Themiddleearaswellasthemastoidprocessisinfectedandcontainspus.Thetympanicmembraneisinjectedandbulging.Aparacentesisofthemembraneshouldbedoneatthesametimeasthemastoidoperation.Itisverymuchlesscommontogetanacutemastoiditiswithanormaltympanicmembrane.Itistheoreticallypossibleforthistooccurwhentheinfectionhasreachedthemastoidprocessbywayofthebloodstream,insteadofbytheusualroutethroughthemiddleear.Itismuchmorelikelythattherehasbeenatransientotitismediawhichhasresolvedwithoutperforationofthemembrane,leavingbehinditalocalisedabscessinagroupofmastoidcells.Ahistoryisthenobtainedofaprecedingattackofpainintheear,followed-afteranintervalofsomedaysorevenweeks-bytendernessinastrictlylocalisedareaoverthemastoidprocessorevenbytheformationofalocalisedsubperiostealabscess.Operationwillrevealpusinanoutlyinggroupofmastoidcells-theremainderofthemastoidprocessandthemiddleearbeinguninfected.Itisdifficulttobelieveinageneralisedinfectionofthemastoidantrumandaircellswithoutsomechangesinthetympanicmembranebeingvisibletoacarefulobserver.5.Acuteosteomyelitisoftemporalbon
e.Thisisararebutveryserioustypeofinfectionwithahighmortality.Theinfectionmayspreadtothetemporalbonedirectlyfromneighbouringbonesofthecranialvault.Theinfectionmayreachthetemporalbonebywayofthebloodstreamfromadistantfocus.Theosteomyelitismaybeduetoadirectspreadfromamastoidinfection.Thereiscedemaoverthemastoidandinthetemporalfossa,greatpain,highfeverandprostration.Intra-cranialcomplicationsandmetastaticabscessesarecommonsequelae.IndicationsforOperation.Therearefewphysicalsignswhichareabsoluteindicationsforoperation.Persistentoedemaoverthemastoidprocess,formationofasubperiostealabscess,342POST-GRADUATEMEDICALJOURNALSeptember,1939 orpersistentsaggingofthepostero-superiordeepmeatalwallaretheprincipaldefiniteindications.Failingthese,carefulconsiderationhastobegiventoacombinationofmanyminorpoints.Thegeneralconditionofthepatientshouldsteadilyimproveaftertheappear-anceofthedischarge.Appetiteshouldreturnandsleepbeundisturbedbyattacksofpain.Thetemperatureshouldgraduallyreturntonormalandnottendtoswingupwardsintheevening.Tendernessshouldgrowprogressivelyless.Thedis-chargemayremaincopiousbutshouldnotbecomepurulent.Whileitisagoodthingtooperatewhentheinfectionhasbecomelocalisedasmuchaspossible,itisexceedinglydangeroustowaitforlocalisationtotakeplaceinfaceofaprogressivedeteriorationinthegeneralconditionofthepatient.Scopeoftheoperation.Theoperationaimsatopeningandgivingfreedrain-agetotheinfectedmastoidantrumandtoalltheinfectedmastoidcells.Thiswillentailacarefulsearchforcells.Failuretofindanddraininfectedcellsmayhaveseriousconsequences.AnX-raywillaffordanexcellentguide,butcarefuloperativetechniqueisbetterstill.Itisnotnecessarytoremovetheplatesofbonecoveringtheduramaterandlateralsinusasaroutine,butitisbettertoexposeduramaterunnecessarilythantoleaveanextra-duralcollectionofpusundrained.Complications.I.Extraduralabscessusuallygivesrisetonosymptomsandisfoundatoperationbyacarefulfollowingupofinfectedcells.Itrequiresnotreatmentbeyondfreedrainage.2.ThrombosisofthelateralsinuswillbeimmediatelysuspectedifthepatienthasabruptrisesoftemperaturetoIo3F.orhigher,accompaniedbyarigorandfollowedbysweatingandanabruptfalloftemperature.3.Abscessofthetemporallobeorabscessofthecerebellumwillgiverisetosignsofincreasedintra-cranialtensionwithlocalisingsignsvaryingwiththesiteoftheabscessandthedegreeofsurroundingencephalitis.4.Infectivemeningitiswillbediagnosedbysevereheadache,neckstiffnessandheadretraction,hightemperatureandchangesinthecerebro-spinalfluid,obtainedbylumbarpuncture.5.Labyrinthitiswillgiverisetoprofounddeafness,severevertigoandtheonsetofspontaneousnystagmus.September,1939A·CUTEMASTOIDITIS34