64

T h e Journal of Laryngology,

[February, 1903.

OTOMYCOSIS OF THE MALAY ARCHIPELAGO.

BY DAVID

J.

GALLOWAY,

M.D., M.R.C.P., Edin. (Singapore).

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THE prevalence of fungous disease of the ear in the countries comprised under the term " t h e Malay Archipelago " is very great, so much so that in a series of some hundreds of cases of ear disease of all kinds it formed 70 per cent, of the whole. It affects mostly Europeans, next persons of mixed parentage; Arabs and Malays suffer but rarely, Chinese scarcely at all. This latter fact is probably explained by the manner in which the meatus in the Chinese is shaved, scraped, and brushed out as part of the daily toilet, the wide, straight meatus of that race lending itself to such treatment. Among modern writers it is usual to class parasitic ear disease as either an acute or a chronic meatitis (otitis externa dijf'usa), some even denying the existence of an otomycosis as a separate entity i.e., apart from inflammatory complication. This dictum it is impossible to accept, as, though undoubtedly the greater number of cases are driven to seek advice by the pain of an acute meatitis, associated with the presence of the parasite, a not inconsiderable proportion complain only of a discomfort and itching of the meatus, the anatomical changes in which are proliferative, but not inflammatory. Politzer's experiment shows the true relation of these classes. In a meatus in which he found an accumulation of aspergillus without trace of inflammation, he made a small incision. An inflammatory infiltration followed, which took a fortnight to resolve. It is thus evident that a breach of surface is necessary to convert a pure otomycosis into a diffuse meatitis, and in practice this receives the fullest and most constant confirmation. The primary cause of the disease is a fungus. In most specimens the occurrence of long unbranched, unsegmented fibres, and, more rarely, the presence of a basket-shaped sporangium, is characteristic of Mucor mucedo, while in a small proportion of cases the parasite was the Aspergillus Jiacearens. Aspergillus niger was found in one case only, and that an imported one. Mixed thallogenic infections are rare. This marked preponderance of mucor as the cause of an otomycosis seems to be a local peculiarity. Eeliable observers in China, Siam, and the Dutch East Indies describe other species as occurring either alone or in conjunction with mucor, while in

February, 1903.]

Rhinology, and Otology.

65

Europe, according to Bezold, the Aspeiyillus fumUjatus is most commonmucor least so. Given thus a causal element of universal distribution, the etiology of the disease is not far to seek. Among the many things which may act as excitants, the chief place may be given to bathing, especially sea-bathing, and some of the bathing resorts have, in relation to this disease, acquired an unenviable reputation. Per contra, there is rarely found any trace of parasite in a meatus constantly bathed in pus, but the statement, so very frequently made, that a meatus with a healthy secretion of wax is also an unfavourable nidus for the development of the parasite requires to be taken with many grains of salt. A healthy secretion of cerumen argues a healthy meatus, and, beyond the resistance offered by a healthy tissue to extraneous invasion, nothing further can be argued. It seems to be an inversion of the proper statement, which is that in a meatus invaded by the parasite no healthy secretion of wax will be found, nor will it be found so long as any trace of parasite remains. Without invalidating in any degree this statement, it h a s occurred to me on more than one occasion to find both parasite and healthy secretion in one m e a t u s ; in other words, to have been so fortunate as to make an inspection during the process of invasion. It is also not an infrequent occurrence to find a film of parasite overlying masses of old hard wax, giving a most puzzling presentment. Diathetic conditions play little part in an otomycosis, though, as is to be expe6ted, the strumous, debilitated, and tuberculous suffer more intensely in the inflammatory conditions, perichondritis and mastoid tenderness being common in them. The pathology of otomycosis varies only with the deptli of tissue involved. In pure uncomplicated cases a thin pellicle of the parasite is closely adherent to part or to the whole of the meatus and tympanic membrane. But such a condition must, of necessity, be but a transitory one, as, by the presence of a living organism in process of active growth and closely applied to the epidermis, certain changes of necessity occur. The mildest form is that in which the irritation affects only the sebaceous glands, the increased secretion from which forms, with the mycelium, a thin pellicle limited to the cartilaginous meatus. The next is that in which there is a hyperactivity of the superficial layers of the entire meatus and even of the tympanic membrane. A further irritation induces an infiltration of the deeper layers of integument, a sodden condition of the horny layers, and

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66
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T h e Journal of Laryngology,

[February, 1903.

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some serous exudation. In all the varieties there is a great exfoliation of the pavement cells, and in the moist variety a condition of denudation resembling red eczema is found on detaching the covering membrane of combined parasite, epithelium, and fatty matter. But, following some trauma providing a portal of entrance to the deeper layers, the usual acute diffuse meatitis occurs, with all the concomitant features of a true inflammation. There is great tumefaction of the meatus, more in the cartilaginous than the osseous p a r t ; there may be a perichondritis. The membrana tympani participates presumably throughout its whole thickness, and a certain amount of hyperaemia of the middle ear must occur, it being an almost constant feature to find a quantity of fluid in the middle ear after all inflammation has subsided. Pus formation does not enter into the process in any part or at any time, the inflammatory process subsiding by resolution, aided, perhaps, ^y the extrusion of a few scanty drops of serum. This serum always contains a short streptococcus along with fragments of mycelium. It is not quite easy of demonstration as to whether the .trauma provides an entrance to the deeper meatal layers for the parasite or for an infection of a secondary nature. Bo far as my observations go, it would seem to be the latter. The objective signs of an otomycosis are very distinctive and interestingin fact, beautiful. In the dry variety the first feature which strikes the examiner is the abnormal cleanness of the meatus, no trace of cerumen being visible, its place being taken by a few yellow scales, dry and easily detachable from the cartilaginous meatus. The distinctive appearance is seen in the deeper parts as a beautiful light, almost luminous, mother-of-pearl coloured pellicle, spreading over the tympanic membrane and outwards along the canal. It brings to mind the appearance of frost upon a window-pane, with its delicate tracery and feathery prolongations over the drumhead. Wreden, who first described the fungi, was of opinion that they were limited to the membrane, but it is capable of everyday demonstration that they spread outwards throughout the entire canal. In the second variety the walls of the canal are covered by a dense, lustreless membrane of a yellowish-white colour, with large flakes detached, or in process of detachment, occupying the lumen of the canal. This membrane can be removed by the syringe as a hollow cast of the meatus, like the finger-tip of a glove. It frequently leaves a red, raw, oozing surface. In the moist variety the ear is filled by a grayish-white mass

February, 1903]

Rhinology, and Otology.

67

resembling dirty-white blotting-paper. It also may readily be removed by the syringe as a solid cast of the meatus, and a view of the drumhead obtained. On it, as also over the deeper parts of the canal, may be seen the pearly-gray luminous appearance already described, though usually only in patches. Further syringing will remove these, and it can then be seen that the surface is slightly inflamed, the tympanic membrane is dulled red in the vicinity of the handle of the malleus, and the bright spot is lost. The meatal walls are congested and somewhat shiny from an exudation of sticky fluid, which, if plentiful, collects on the floor of the canal, or, if scanty, dries as brown scales. The power of regeneration of these " blotting-paper " masses is remarkable. I removed a specimen which entirely filled the meatus just three weeks after removing an exactly similar one from the same ear. Two rare cases came under observation, in which the yellow glare of pus was got in the position of the drumhead, resembling closely a middle-ear suppuration on the point of bursting through the membrane. It lacked, however, the markings as well as the subjective sensations of such a condition, and a cautious application of a cotton-wool probe proved it to be a thin layer of pus lying between a pellicle, composed of parasite and flat epithelial cells, and the tympanic membrane itself. The appearances in the* acute diffuse inflammation of the external sac, so common as a complication or as a sequel of otomycosis, differ in no way from those due to inflammation from other causes. There is the same tumefaction of the walls, occlusion of the lumen, serous discharge, and, perhaps, perichondritis, the only superaddition being the parasitic association. The symptoms of mycotic ear disease, pure and simple, are, briefly, four: Pruritus, deafness, sense of moisture, extrusion of parasitic masses. Pruritus, deep-seated and persistent, is by far the most important symptom. It is a valuable guide to the surgeon, as it is invariably present; it is the first to appear, and does not disappear so long as any trace of parasite remains. It is the precursor, often the indirect cause, of that diffuse inflammation so often confused with parasitic disease, in so far that it is for its relief that some instrument (usually a hairpin) is used, not wisely, but too well, thus repeating clinically Politzer's experiment. Deafness varies in quality with the type of the disease. In the dry varieties the thin pellicular formation interferes little, if at all, with the conduction of sound ; while in that with a firm, fairly t k membrane covering the deeper meatus and drumhead the

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68

T h e Journal of L a r y n g o l o g y ,

[February, 1903

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deafness may be considerable. In the moist variety the " blottingp a p e r " deposit may pack the canal tightly, and produce a high degree of deafnessmore so than impacted wax. The cause of this is the rapidity of generation of the mycotic element, its production from all parts of the meatus, and its close apposition to the walls. The sense of moisture in the meatus is very probably a wrong interpretation of a slight degree of pruritus, as the amount of fluid is rarely sufficient to account for such a sensation. It is, however, a frequent complaint on the part of the patient, and as such is tabulated here. The extrusion of particles from the meatus during movements of the head or jaws is due to the nature of the material which fills the meatus. Unlike wax, the different kinds of parasitic growth already described have little cohesiveness, they are readily detached, and drop into the concha. The material thus extruded may be either scaly, membranous, or soapy, according to the type of the disease. But in the diffuse inflammation produced by wounding of the meatus by a hairpin or other instrument which may have been used to alleviate the pruritus there is a very different train of symptoms. Pain is the symptom which overshadows all others, its severity depending on the site of the trauma and the intensity of the inflammation. When it affects the drumhead and tympanic ring it is intense and deep-seatedthe pain of a myringitis, and is scarcely to be distinguished from disease of the middle ear. If it affects the bony canal the pain is still very great, the lining of the canal being also the periosteum. In the cartilaginous portion the potentialities of expansion, and thus diminished tension, render the pain more bearable. It is as a result of inflammation of this part of the canal that cases are seen with the concha standing out from the head at almost a right angle, with great turgescence of the surrounding partsa perichondritis, in fact. The sequelae of the disease are not manj^. In the inflammatory type just described, fluid in the tympanum is an almost invariable one. It is usually absorbed within a week or two, and rarely requires relief by puncture. But the most annoying sequel to this disease, whether of the inflammatory or non-inflammatory kind, is the drying up of all ceruminous secretion. Its place is taken by a whitish-yellow material, with a greasy feel and little cohesiveness. The treatment of uncomplicated otomycosis is simple. If the auroscope shows no breach of epidermic surface strong remedies

February, 1903.]

Rhinology, and Otology.

G9

may be used. The most effective are bichloride of mercury (4 grains in an ounce of rectified spirit), silver nitrate (20 grains in an ounce of spir. ether nit.), or a saturated solution of boric acid in spirit. After two or three days' use of these the parasite may be syringed out, and a less stringent use of the remedies for a week longer will lead to a return of the part to health. But where any breach of surface exists these preparations must be used in a greatly attenuated form, and their action carefully watched. Should stiffness on moving the jaws be complained of, or any tumefaction of the bare areas be visible on inspection, then the case must be treated as of the acute inflammatory variety. Dench and other American otologists advise strongly a thorough removal of all parasitic membrane by curettage. This is obviously unnecessary, as, after a few days' treatment with any of the solutions mentioned above, the syringe will remove most, if not all, of the intruding material. If not, the ear forceps, carefully manipulated under good illumination, will detach what remains. If still obstinate, the use of a glycerine preparation is indicated. The use of the curette is not without danger, as, even in the most careful and experienced hands, abrasion of the meatal wall is inevitableenough to turn the scale and to convert a simple parasitic infection of the meatus into an acute diffuse inflammation. The treatment of parasitic disease complicated with trauma is more difficult. Should it be seen early, an attempt may be made to abort it. The canal should be irrigated with an antiseptic lotion, as hot as can be borne, then filled with glycerine of carbolic acid (o per cent.), and plugged with cotton-wool. A leech is now applied in front of the tragus, and one over the mastoid, and the bleeding sncouraged. In four hours the irrigation and filling the canal with the carbolized glycerine must be repeated. Probably it may require three or four such treatments to cut the process short, but daily irrigations and the use of one of the alcoholic preparations will be necessary for probably- a week. It is usual, however, for the case to come into your hands with the meatus quite occluded by the turgidity "of its walls, and the passage of a speculum impossible. The condition of the deeper parts has then to be taken on trust, and it must not be forgotten that there may be a mass of combined parasite and cerumen (the " blotting-paper " masses I have spoken of) lying in the bony canal, and being pressed by the growing turgescence firmly against the tympanic membrane. If, from a consideration of the subjective symptoms, you are satisfied that such a condition exists, 6

70

T h e Journal of Laryngology,

[February, 1903.

it is well not to temporize, but by a free incision under chloroform to establish a free exit for the retained matters. But in many instances leeches or incision are vetoed, and some other means must be found of attempting to mitigate the pain and to relieve the intrameatal tension. A strip of gauze of very small dimensions is soaked in carbolized glycerine and carried by a probe along the floor of the meatus until it is judged to be very near the membrane. This is covered by a few layers of dry gauze, and over this is put a small Japanese lire-box, a contrivance at once inexpensive and efficient. Entrance to the deeper meatus having been obtained by any of these measures, a thorough syringing of the canal is made with a small nozzled syringe and very hot water. Quite a quantity of milky-looking fluid containing many pieces of membrane may thus be got rid of with great relief to the symptoms. Glycerine pledgets, medicated with any convenient parasiticide, now find their use, and ought to be continued as long as there is pain. Exuberant granulations springing from the incisions may require treatment. The after-treatment must be prolonged and thorough, and is best carried out by the daily use of some of the alcoholic preparations of sublimate, chinosol, or boric acid, as are found to suit. The dry, scaly condition of the meatus, with thickening, is best treated by an ointment of white precipitate of mercury in vaseline, applied freely with a camel-hair brush. Such, then, are the chief symptoms of this disease and their broad Iine3 of treatment, but its great tendency to become chronic and its still greater tendency to recur give opportunity for refinements in treatment which leaves an ample field for individual ingenuity.

A CASE OF CANCER OF THE LARYNX CURED BY THE X RAYS.1

BY W. SCHEPPEGEELL, A.M., M.I).,
2

Ex-Vice-Fresiik'iit of the American Laryngological, Rhinologieal, and Otologieul Association ; Ex-President of the Western Ophthalmolouic and Oto-Laryngologies Association, etc., Xew Orleans, La.

THE efficacy of the X rays in the treatment of malignant disease, when located on the surface so as to be directly intluenced by the rays, has been so often attested that its benefit is no longer
1

We are indebted to the author for the manuscript of this paper, which has also been
Yuri: Ma!leal J<>urn<~tl. E D I T O R S ,

sent to the Xrir

-Annual meeting of the American Electro-Therapeutic Association, September 2-i, 1902.

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