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Tuberculosis of the Ear
544
TUBERCLE
TUBERCLE. SEPTEMBER, 1931.
Tuberculosis of the Ear. Most tuberculosis authorities are agreed as to the comparative rarity of tuberculosis of the middle ear ~s a complication of pulmonary tuberculosis, ~he percentages given by various observers ranging from 8"5 in Italy [1] to 1 per cent. at Brompton [2]. Sir StClair Thomson [3], speaking at the Royal Society of Medicine recently, discussed the subject of tuberculous otitis media as met with in adults in a sanatorium, basing his remarks on 25 9 cases seen at Midhurst during two periods, 1911 to 1921 and 1926 to 1930. In all these 25 eases the most striking point was the absence of pain, fever or free discharge, the patient usually first complaining of a dull sensation in the ear or deafness. The early and rapid onset of deafness is, indeed, very marked. ']2he drum is generally seen, before perforation, to be opaque, thickened, dull and sodden-looking. I t never requires incision since it usually gives way without having given rise to any earache, the opening being usually situated posteriorly in the lower segment. The otorrhoea is never abundant, and, as is well recognised, tubercle bacilli are not easily detected in the discharge. In only 3 out of 14 cases in Sir StCIair Thomson's second series (1926-1930) were bacilli discovered, although in all the 14 cases the sputum was positive. Animal inoculation of the aural discharge yielded no better results. The local treatment adopted at Midhurst consists merely of the application of hydrogenperoxide drops, saline syringing and occasional Politzer inflations. In 9,2 out of the 25 cases the otorrhcea and the deafness persisted during the several months of sanatorium treatment. In S i r StClair Thomson's experience this complication, as in the case of laryngeal tuberculosis, is an indication of a severe infection and justifies a grave prognosis,
[ S e p t e m b e r , 1931
although in a few cases it may heal under simple measures with general sanatorium treatment. In any case, the painless onset of a scanty thick otorrh~a and marked deafness in an adult should suggest a tuberculous origin. Mr. F. G. Ormerod, who opened the discussion on Tuberculosis of the Ear, said that tuberculosis might occur in the ear primarily or secondarily. Most of the primary cases occurred in children and infants, the infection beginning in the middle ear or in the mastoid process with or without involvement of the middle ear. In the adult, in the great majority of cases the condition was secondary to pulmonary phthisis with tubercle bacilli in the sputum, the path of infection being usually the Eustachian tube, although in a certain number the infection was probably blood-borne. With the disappearance of the tympanic membrane by extension of the perforation, the ossicles were attacked by osteoporosis or white caries and disappeared until nothing was to be seen of the long process of the incus and only the smallest remnant of the handle of the malleus. The course of the disease was very chronic, little change taking place over long periods, the tendency being for the inflammation to wear itself out. In adults extensions from the middle ear were rare, and mastoiditis had only been met with rarely at Brompton. Occasionally massive necrosis of the mastoid region or of the internal ear did occur, but Mr. Ormerod had had no personal experience of this in adults. In children, however, the disease presented very distinc~ characteristics, chief among ~hese being the tendency to mastoid involvement. Mastoiditis in children was observed in the very earliest months of life, and resulted in necrosis of bone around the antrum before there was much development of the process. Facial paralysis was much commoner in children than in adults, and appeared to be due to pressure from granulation tissue. In most cases it was necessary to carry out the complete radical operation before healing was attained. Aural tuberculosis in young children took on
September, 1931]
TUBERCULOSIS
a more active form than in adults, the mastoid process being much more commonly affected, and its spread to other parts of the temporal bone and infection of the meninges was a distinct danger in children; whereas in adults the disease was much more likely to be restricted to the middle ear. Mr. A. R. Tweedie, the President of the Section of Otology, commenting on the reference made by Mr. Ormerod as to the complete destruction of the tympanic membrane being one of the end-results of tuberculous lesions of the middle ear, said that if it could be regarded as almost pathognomonic of a pre-existing tuberculous lesion it meant that in many of such cases the patients recovered without the aid of treatment, since it was fairly common to find this appearance, with the exposed middle ear perfectly healthy and tolerant, and the owner having no recollection of any past auralpain or otorrhma. One other important point to which Mr. Tweedie drew attention was the suggestion made by L6wenstein, Cemacb, H. J. Corper, and Sweany and Evanoff, to the effect that cultivation was a much surer diagnostic aid than animal inoculation. Other speakers at this discussion drew attention to possible fallacies, Mr. J . F . O'Malley urging that in every case of middle-ear suppuration, care should be taken to dissociate this from tuberculosis unless there was manifest evidence in proof, and that even when microorganisms of tuberculous type were found, it did not necessarily follow that the lesion in the middle ear was tuberculous. Mr. 3. S. Fraser concurred in this, and said that a distinction should be made between " tuberculous otitis m e d i a " and " otitis media in tuberculous subjects," The occurrence of tuberculous mastoiditis in adults as well as in children was the subject of a French thesis [43 not long ago, the writer, E. Kessis, m~intaining that the disease is more frequent than is generally supposed, and that apart from cases in which the mastoid becomes infected by the bloodstream, tuberculous mastoiditis is almost always secondary to tubercu. lous otitis media. Anatomically the 35
OF T H E E A R
545
affection is characterised by a great variety of lesions, of which the following five types have been described: (1) a progressive infiltrating f o r m ; ('2) a necrosing type with formation of sequestra ; (3) a rarefying and perforating type, in which the destructive process is slower than in the preceding f o r m ; (4) a type characterised by chronic osteitis with hyperostosis of the mastoid: (5) a fungating type characterised by the development of a soft non-fluctuating mass consisting of tuberculous granulation tissue. Kessis states that the diagnosis of tuberculous mastoiditis is often difficult, as its course is insidious, and it should always be confirmed by laboratory tests, especially inoculation of a guinea-pig. The prognosis depends chiefly on the previous health of the patient, being very grave in cases of diabetes, albuminutia, or pulmonary tuberculosis. I n most cases local surgical treatment is required as well as the general measures suitable for all cases of tuberculosis. Dr. G. F. Still [5] has also drawn attention to the frequency of ear infection in cases of pulmonary tuberculosis in young children. In his series of 269 tu0erculous children there were 15 cases in which it seemed most probable that the primary focus of infection was the middle ear. All these 15 cases occurred in children under the age of 5 years, and no less than 13 of them occurred within the first two years of life. Small doses of tuberculin have been found by some workers [6] to be of value in cases of both tuberculous otitis media and tuberculous mastoiditis, especially where these conditions were not yielding to ordinary sanatorium treatment. REFERENCES. [1] SZlNETr, L. Atti d. Clin. Oto-r~n~-Zaryngoiatrica d. R. Univ. di Roma, 1928, ~65. [2] ORMEROD, F. C. P~oc. Roy. Soc. Med., 1931, @-4,953. [3] STCLAIRTHO~,ISON. Ibid., 959. [4] KESSIS, E. Th~se de Paris, 1929, No. :163. [5] STILL, G . F . " Comraon Disorder~ and Diseases of Childhood." 4th eel., 1924. [6] GIBB, J . A . Prec. t~oy. Soc. Med., 1931,
24, 966.
TUBERCLE
TUBERCLE. SEPTEMBER, 1931.
Tuberculosis of the Ear. Most tuberculosis authorities are agreed as to the comparative rarity of tuberculosis of the middle ear ~s a complication of pulmonary tuberculosis, ~he percentages given by various observers ranging from 8"5 in Italy [1] to 1 per cent. at Brompton [2]. Sir StClair Thomson [3], speaking at the Royal Society of Medicine recently, discussed the subject of tuberculous otitis media as met with in adults in a sanatorium, basing his remarks on 25 9 cases seen at Midhurst during two periods, 1911 to 1921 and 1926 to 1930. In all these 25 eases the most striking point was the absence of pain, fever or free discharge, the patient usually first complaining of a dull sensation in the ear or deafness. The early and rapid onset of deafness is, indeed, very marked. ']2he drum is generally seen, before perforation, to be opaque, thickened, dull and sodden-looking. I t never requires incision since it usually gives way without having given rise to any earache, the opening being usually situated posteriorly in the lower segment. The otorrhoea is never abundant, and, as is well recognised, tubercle bacilli are not easily detected in the discharge. In only 3 out of 14 cases in Sir StCIair Thomson's second series (1926-1930) were bacilli discovered, although in all the 14 cases the sputum was positive. Animal inoculation of the aural discharge yielded no better results. The local treatment adopted at Midhurst consists merely of the application of hydrogenperoxide drops, saline syringing and occasional Politzer inflations. In 9,2 out of the 25 cases the otorrhcea and the deafness persisted during the several months of sanatorium treatment. In S i r StClair Thomson's experience this complication, as in the case of laryngeal tuberculosis, is an indication of a severe infection and justifies a grave prognosis,
[ S e p t e m b e r , 1931
although in a few cases it may heal under simple measures with general sanatorium treatment. In any case, the painless onset of a scanty thick otorrh~a and marked deafness in an adult should suggest a tuberculous origin. Mr. F. G. Ormerod, who opened the discussion on Tuberculosis of the Ear, said that tuberculosis might occur in the ear primarily or secondarily. Most of the primary cases occurred in children and infants, the infection beginning in the middle ear or in the mastoid process with or without involvement of the middle ear. In the adult, in the great majority of cases the condition was secondary to pulmonary phthisis with tubercle bacilli in the sputum, the path of infection being usually the Eustachian tube, although in a certain number the infection was probably blood-borne. With the disappearance of the tympanic membrane by extension of the perforation, the ossicles were attacked by osteoporosis or white caries and disappeared until nothing was to be seen of the long process of the incus and only the smallest remnant of the handle of the malleus. The course of the disease was very chronic, little change taking place over long periods, the tendency being for the inflammation to wear itself out. In adults extensions from the middle ear were rare, and mastoiditis had only been met with rarely at Brompton. Occasionally massive necrosis of the mastoid region or of the internal ear did occur, but Mr. Ormerod had had no personal experience of this in adults. In children, however, the disease presented very distinc~ characteristics, chief among ~hese being the tendency to mastoid involvement. Mastoiditis in children was observed in the very earliest months of life, and resulted in necrosis of bone around the antrum before there was much development of the process. Facial paralysis was much commoner in children than in adults, and appeared to be due to pressure from granulation tissue. In most cases it was necessary to carry out the complete radical operation before healing was attained. Aural tuberculosis in young children took on
September, 1931]
TUBERCULOSIS
a more active form than in adults, the mastoid process being much more commonly affected, and its spread to other parts of the temporal bone and infection of the meninges was a distinct danger in children; whereas in adults the disease was much more likely to be restricted to the middle ear. Mr. A. R. Tweedie, the President of the Section of Otology, commenting on the reference made by Mr. Ormerod as to the complete destruction of the tympanic membrane being one of the end-results of tuberculous lesions of the middle ear, said that if it could be regarded as almost pathognomonic of a pre-existing tuberculous lesion it meant that in many of such cases the patients recovered without the aid of treatment, since it was fairly common to find this appearance, with the exposed middle ear perfectly healthy and tolerant, and the owner having no recollection of any past auralpain or otorrhma. One other important point to which Mr. Tweedie drew attention was the suggestion made by L6wenstein, Cemacb, H. J. Corper, and Sweany and Evanoff, to the effect that cultivation was a much surer diagnostic aid than animal inoculation. Other speakers at this discussion drew attention to possible fallacies, Mr. J . F . O'Malley urging that in every case of middle-ear suppuration, care should be taken to dissociate this from tuberculosis unless there was manifest evidence in proof, and that even when microorganisms of tuberculous type were found, it did not necessarily follow that the lesion in the middle ear was tuberculous. Mr. 3. S. Fraser concurred in this, and said that a distinction should be made between " tuberculous otitis m e d i a " and " otitis media in tuberculous subjects," The occurrence of tuberculous mastoiditis in adults as well as in children was the subject of a French thesis [43 not long ago, the writer, E. Kessis, m~intaining that the disease is more frequent than is generally supposed, and that apart from cases in which the mastoid becomes infected by the bloodstream, tuberculous mastoiditis is almost always secondary to tubercu. lous otitis media. Anatomically the 35
OF T H E E A R
545
affection is characterised by a great variety of lesions, of which the following five types have been described: (1) a progressive infiltrating f o r m ; ('2) a necrosing type with formation of sequestra ; (3) a rarefying and perforating type, in which the destructive process is slower than in the preceding f o r m ; (4) a type characterised by chronic osteitis with hyperostosis of the mastoid: (5) a fungating type characterised by the development of a soft non-fluctuating mass consisting of tuberculous granulation tissue. Kessis states that the diagnosis of tuberculous mastoiditis is often difficult, as its course is insidious, and it should always be confirmed by laboratory tests, especially inoculation of a guinea-pig. The prognosis depends chiefly on the previous health of the patient, being very grave in cases of diabetes, albuminutia, or pulmonary tuberculosis. I n most cases local surgical treatment is required as well as the general measures suitable for all cases of tuberculosis. Dr. G. F. Still [5] has also drawn attention to the frequency of ear infection in cases of pulmonary tuberculosis in young children. In his series of 269 tu0erculous children there were 15 cases in which it seemed most probable that the primary focus of infection was the middle ear. All these 15 cases occurred in children under the age of 5 years, and no less than 13 of them occurred within the first two years of life. Small doses of tuberculin have been found by some workers [6] to be of value in cases of both tuberculous otitis media and tuberculous mastoiditis, especially where these conditions were not yielding to ordinary sanatorium treatment. REFERENCES. [1] SZlNETr, L. Atti d. Clin. Oto-r~n~-Zaryngoiatrica d. R. Univ. di Roma, 1928, ~65. [2] ORMEROD, F. C. P~oc. Roy. Soc. Med., 1931, @-4,953. [3] STCLAIRTHO~,ISON. Ibid., 959. [4] KESSIS, E. Th~se de Paris, 1929, No. :163. [5] STILL, G . F . " Comraon Disorder~ and Diseases of Childhood." 4th eel., 1924. [6] GIBB, J . A . Prec. t~oy. Soc. Med., 1931,
24, 966.