A System of Operative Surgery Part 53

Before considering the question of removal of foreign bodies, the following points cannot be emphasized too forcibly:--(1) No attempt should be made to remove a foreign body until it is certain that one really exists. (2) Provided there is no middle-ear suppuration, a foreign body left in the ear will very rarely cause any immediate harm.

(3) The most serious complications are due almost invariably to ill-advised haphazard attempts to remove the foreign body; as a rule from working blindly in the dark without making use of reflected light.

If a foreign body be suspected, the surgeon should first carefully examine the auditory ca.n.a.l in order to determine its character and position and the condition of its walls. On this will depend the treatment to be employed.

If the object be a living insect it should be killed at once by the instillation of warm oil, rectified spirit, or chloroform. This will cause immediate relief of the intense pain and tinnitus which may have been set up by its movements against the sensitive tympanic membrane.

The methods employed for the removal of a foreign body are syringing, extraction by instruments through the external meatus, and removal by operation by making a post-auricular incision and reflecting forward the auricle.

=By syringing.= In the vast majority of cases syringing is successful, and therefore should always be tried except under the following conditions:--(_a_) If the foreign body be of such a nature that it may be driven inwards; for example, a percussion cap for a toy pistol, lying with its concavity outwards.

(_b_) If there be much inflammation and swelling of the walls of the external meatus, unfortunately frequently due to previous unsuccessful attempts at extraction by instruments. In such cases forcible syringing may cause considerable pain, and in addition immediate removal of the foreign body may be impossible owing to the temporary occlusion of the meatus.

Unless urgent symptoms of retention of pus behind the foreign body are present, it is wiser to wait for a few days until the inflammation has subsided, in order that the ca.n.a.l may become more patent and permit of a more favourable opportunity for removal of the foreign body. The auditory ca.n.a.l, in the meanwhile, may be mopped out two or three times a day with pledgets of cotton-wool, and a 1 in 5,000 alcoholic solution of biniodide of mercury afterwards instilled into the ear.

The method of syringing has already been described (see p. 308). The syringe should be a large one with its tip protected by some india-rubber tubing. The point is inserted within the meatus up against the foreign body and the stream of lotion is directed towards any c.h.i.n.k which may exist between it and the auditory ca.n.a.l. It may be necessary to use many syringefuls with considerable force before the foreign body can be expelled, but the syringing should be stopped if pain or giddiness are caused.

If the foreign body cannot be removed at the first attempt, drops of rectified spirit may be instilled into the ear several times a day, provided there are no urgent symptoms. This will tend to diminish any swelling of the soft tissues of the external meatus and of the foreign body if it is a vegetable substance. The ear should again be syringed after two or three days. In many cases this will now be successful; if not, the foreign body may be moved gently with a probe (using a speculum and reflected light), great care being taken not to push it further into the auditory ca.n.a.l, and another attempt may be made to remove it by prolonged syringing. If this fails it may be left _in situ_ for a still longer period, provided there are still no symptoms requiring its immediate removal. In some cases, instead of the instillation of alcohol, a 5% solution of carbolic acid in glycerine or olive oil proves more effectual.

In the case of a hard substance, repeated attempts may be made to dislodge it before resorting to further measures; but in the case of a soft vegetable substance like a pea, it must not be forgotten that moisture tends to make it swell and perhaps will necessitate almost immediate extraction by instruments.

Extraction by instruments.

=Indications.= (i) If inspection shows that the foreign body can at once be removed by a suitable instrument: for example, a percussion cap the edge of which may be grasped by a pair of forceps (Figs. 179 and 193); or a small boot b.u.t.ton whose shank, if it faces outwards, may be caught by a small hook.

(ii) If repeated attempts have failed to remove the foreign body by syringing.

(iii) If previous attempts by others have failed, and the foreign body has been pushed in beyond the isthmus, and cannot be removed after prolonged syringing.

(iv) If syringing produces violent giddiness, showing the probable presence of a perforation of the tympanic membrane.

(v) If there be symptoms of acute inflammation of the middle ear or of pus being pent up behind the foreign body.

[Ill.u.s.tration: FIG. 179. CROCODILE FORCEPS. Two-thirds size.

A, Points of crocodile forceps, full size.

B and C, Aural punch-forceps.

D, Aural scissors.

=Operation.= An anaesthetic may not be necessary in adults if the foreign body is not too deeply placed within the ear, if its removal appears to be a simple matter, and if the patient is of a placid temperament.

Otherwise, unless contra-indicated for some special reason, a general anaesthetic should always be given in children, and it is also preferable in adults for the following reasons:--(1) Inability to remove the foreign body after repeated attempts by syringing usually means that its extraction by instruments will be a somewhat difficult matter. (2) The risk of injury to the meatal walls or tympanic membrane from involuntary movements of the patient during the operation is far greater than the risk of the anaesthetic. (3) If the foreign body cannot be removed through the meatus by means of instruments, the post-meatal operation is indicated. This, if necessary, can be done at once if the patient is under a general anaesthetic.

If no anaesthetic is given the patient may sit up in a chair; otherwise, the rec.u.mbent position is advised.

It is usually necessary to use an aural speculum, but if the foreign body be situated near the entrance of the meatus a sufficient view may be obtained by pulling the tragus forward and the auricle backward. Good illumination is essential.

(i) _If the body be a soft substance_, such as a pea, the core of an onion, or a fragment of wood, it is best removed by fixing into it some form of sharp hook (Fig. 178, D). These hooks vary in shape. They may be curved, or shaped like a crochet-hook, or have the sharp point placed at right angles to the shaft of the instrument.

In the case of a round substance like a pea, especially if it is tightly impacted within the meatus, its removal is sometimes facilitated by first slicing it into pieces by means of a small bistoury.

As a rule, the foreign body is impacted at the junction of the cartilaginous and bony portion of the auditory ca.n.a.l; sometimes, however, it is more deeply situated within the osseous meatus, usually the result of previous attempts to extract it.

[Ill.u.s.tration: FIG. 180. IMRAY'S SCOOP FOR EXTRACTING A FOREIGN BODY.]

In the former case, the instrument is pa.s.sed along the upper posterior wall of the ca.n.a.l between it and the foreign body, the point of the hook being kept upwards or downwards so as not to project into the auditory ca.n.a.l. The instrument is first pa.s.sed well beyond the foreign body, and then the shaft is twisted round so that the hook projects into the auditory ca.n.a.l. With a quick movement it is drawn outwards a short distance so that the point of the hook pierces the impacted substance.

Gentle traction is now used and in the majority of cases the foreign body can be extracted.

If this fails, a slightly curved fenestrated scoop (Fig. 180) or curette should be pa.s.sed, if possible, between the foreign body and the anterior wall of the auditory ca.n.a.l. The hook already fixed into the foreign body prevents it from being driven further within the meatus, whilst the scoop, if it can be got beyond the foreign body, can usually lever it out.

If the foreign body has been pushed in beyond the isthmus and lies deeply within the osseous ca.n.a.l, it is better to pa.s.s the hook along the anterior inferior wall of the meatus, because owing to the inclination of the tympanic membrane its anterior inferior margin is much more deeply placed than its upper posterior part.

(ii) _In the case of a hard substance_, such as a piece of stone, coal, or a bead, blunt hooks may be used instead of sharp ones. They should be pa.s.sed into the meatus _beyond_ the foreign body in the manner already described.

(iii) _In other cases_, depending on its shape and position, the foreign body is better removed by means of a snare, the loop of which is manipulated round it and then drawn tight in the same manner as in the extraction of a polypus.

The chief points to observe in these manipulations are (_a_) not to push the foreign body farther in and (_b_) not to injure the walls of the meatus or the tympanic membrane.

=Other methods of extraction= are--(1) _Drilling through the foreign body_, if it is a hard substance, and then inserting a fine hook into the opening so made. (2) _The agglutinative method_, which consists in dipping a small paint-brush into a concentrated solution of seccotine or glue and then inserting it into the meatus until it comes in contact with the foreign body. The brush is left in this position for several hours in the hope that it may become adherent to the foreign body; if so, on withdrawing the brush from the ear, the foreign body should be extracted with it. This method can only be used provided the ear is kept dry.

These procedures, although said to be successful in a few cases, are not recommended.

=After-treatment.= If the tympanic membrane and auditory ca.n.a.l have not been injured, it is sufficient to dry the meatus and puff in a little boracic powder. If there be abrasions of the ca.n.a.l, a small strip of gauze should be inserted and changed as frequently as it becomes moist with secretion, the meatus, if necessary, being also syringed out with an aseptic lotion. If there be acute inflammation of the walls of the ca.n.a.l, accompanied by much swelling and purulent discharge, drops of glycerine of carbolic (1 in 10) may be instilled frequently. After the inflammation has subsided, an alcoholic solution of 1 in 3,000 biniodide of mercury may be employed. If the tympanic membrane has been injured, either from the presence of the foreign body itself or from the attempts at extracting it, the treatment is similar to that for an ordinary middle-ear suppuration.

=Removal by operation.= This may be done in the following ways:--

=By means of a post-aural incision.=

=Indications.= (i) If prolonged attempts to remove the foreign body by instruments have failed. This operation becomes imperative if there are signs of retention of pus within the middle ear.

(ii) If the foreign body has been pushed into the tympanic cavity and cannot be removed otherwise. In such cases, if the perforation is large and the foreign body is small, an attempt may first be made to dislodge the substance by injecting fluid into the middle ear through the Eustachian tube by means of the catheter and syringe (see p. 372). This method, however, is rarely successful.

=Operation.= The procedure is the same as for the removal of exostoses (see p. 318). After separating the fibrous from the bony portion of the ca.n.a.l, an incision is made through it and the cut edges are held aside with forceps. Usually the foreign body can now be seen lying within the ca.n.a.l. It is best removed by pa.s.sing a small fenestrated curette beyond it and levering it out. In some cases one of the hooks already mentioned will be found to be more suitable. Forceps should not be used, as they may inadvertently push the foreign body farther in. If the foreign body be very deeply placed, removal of the upper posterior portion of the bony meatus may be necessary. The subsequent steps of the operation and its after-treatment are similar to that already described in the case of an exostosis.

=By means of an operation upon the mastoid.=

=Indications.= (i) If the above measures fail to remove the foreign body.

(ii) If there be symptoms of inflammation of the mastoid process, or of internal-ear or of intracranial suppuration.

(iii) If there be facial nerve paralysis the result of pressure from the foreign body.

=Operation.= The operation performed depends on the condition found.

Simple opening of the mastoid antrum may be sufficient in a case of recent middle-ear suppuration, although it is usually necessary also to remove a considerable portion of the posterior wall of the auditory ca.n.a.l before the foreign body can be extracted. If these measures fail, an attempt may be made to dislodge the foreign body by forcibly syringing through the aditus, or by the insertion of a probe through it, into the tympanic cavity. If this likewise ends in failure, it will then be necessary to perform the complete operation. These cases fortunately are rare.

If it be certain that chronic middle-ear suppuration already exists, the complete mastoid operation is indicated.

If it becomes necessary to operate on the mastoid process, owing to other means having failed to dislodge the foreign body, it is wiser, as a rule, to perform the complete operation at once, because, under these circ.u.mstances, irreparable destruction must have taken place within the tympanic cavity.

The technique of these operations and their after-treatment are described in the chapter on operations upon the mastoid process (see p.