Furunculosis of the External Auditory Canal

(A
THE
GLASGOW MEDICAL JOURNAL.
No. I. July, 1901.

ORIGINAL ARTICLES.

FURUNCULOSIS OF THE EXTERNAL AUDITORY CANAL.1

By JAMES GALBRAITH CONNAL, M.B., F.F.P.S.G., Lecturer on Aural Surgery, Anderson's College Medical School; Surgeon,
Throat and Nose Department, Glasgow Central Dispensary ; Assistant Surgeon, Glasgow Ear Hospital.

Furuncle in the external auditory canal is one of the less common diseases of the ear. Taking the statistics of the Glasgow Ear Hospital for the last four years, where there
were on an aggregate 5,653 cases, furuncle occurred 136 times, or about 2 J per cent of all cases of ear disease. Last year
there were 41 cases, in the great majority of which the furuncle occurred as the primary and sole lesion; but in a minority (30 per cent) it was associated with other lesions, notably chronic purulent inflammation of the middle ear, less commonly ceruminous collections and eczema of the external auditory canal.
Lowenberg has stated that this disease is due to an invasion of the ceruminous or sebaceous glands of the canal by the staphylococcus aureus or albus; but probably any local abrasion of the epithelial lining of the canal affords a fitting

1 Read before a meeting of the Glasgow Medico-Chirurgical Society-

held on 5th April, 1901.

No. 1.

A

Vol. LVI.

2

Mr. Connal?Furunculosis of the

nidus for the staphylococcus, and in the presence of a suitable constitutional condition of the patient may produce the disease. Hence it is often met with during the course of an eczema of the canal, when the itching impels the patient to scratch the part with a pin or the finger nail, and thus to give rise to an abraded surface. The same reason holds good with regard to
ceruminous masses, the sense of an obstruction in the canal

leading the patient to make efforts to remove it with ear-picks

or pins. There is a peculiar periodicity in the appearance of these
cases, so much so that the term epidemic has been applied to them. Gruber quotes two instances of this?an epidemic in Paris in May and June, 1863, and in Vienna a little later (Text-book, Diseases of the Ear, p. 234). Patients with furuncle present themselves most commonly in the spring and autumn months, when one may see from ten to twelve cases in a

week; on the other-hand, weeks or even months may elapse

and hardly a single patient present himself for treatment.

Though furuncle of the auditory meatus is one of the less

common diseases of the ear, it is still worthy of some

consideration when one realises that it gives rise to severe

pain, much local and constitutional disturbance, and for a

time occasions anxiety to the physician in attendance.

A common history of this affection occurring primarily may

be illustrated by the following case:?

Christina S., 21 years of age, complains of dulness of

hearing, of severe pain in the right ear with tinnitus of a

"
beating"

character,

and

slight

attacks

of

giddiness

of

one

week's duration. She states that the illness came on suddenly,

with severe pain in the right ear, which has continued since.

The tinnitus is described as of a beating or hammering

character. She has never had any ear affection previous to

onset of present illness. On testing the hearing power, it is

found that the dulness of hearing is well marked. A watch

which should be heard at 40 inches is only heard at 1 inch.

The left ear is normal = W.R. TV> W.L.

With tuning-

forks to the right ear, bone conduction is in excess of air

conduction; while with the tuning-fork applied to the fore-

head, the sound is referred to the affected ear (Weber's test).

Examination objectively shows a furuncle on the floor of the

external auditory canal, and extremely sensitive to touch

with the probe.^ The furuncle was incised and iodoform

ointment prescribed. In three or four days the patient

hwaads dbiestatpepreartehde. hearing restored, the tinnitus and giddiness

External A wditory Canal.

3

The clinical history here given in epitome illustrates the leading local symptoms of this affection, namely, pain, dulness of hearing, tinnitus, sometimes giddiness, and occasionally a slight discharge from the ear.
Pain is generally the prominent symptom, and compels the patient to seek relief. It is often described as agonising, shooting from the ear over the side of the head, and preventing

Fig. 1. Boy, 8 years of age. Furuncle in exxtteerrnnaall auditory ccaannaall.. ((EEddeemmaa oovveerr tthhee mmaassttooiidd,,
displacing auricle downwards aanndd ffoorrwwaarrddss..
sleep at nights. Movements of the jaw, as in eating, generally aggravate the pain, while any movement of the auricle, or the introduction of an aural speculum into the external auditory canal for the purpose of examination, can hardly be tolerated. The pain is generally unilateral, but not always so, for rarely
one meets with furuncular inflammation in both ears. It is to be noted, however, that the nearer the furuncle is to
the outlet of the canal the less severe is the pain, so that now

4

Mr. Connal?Furunculosis of the

and again one sees cases with slight oedema over the mastoid and a furuncle near the outlet of the meatus, and yet there has been no complaint of pain. But, as a rule, pain is the prominent symptom.
The dulness of hearing in the affected ear is generally due to the mechanical obstruction in the canal, and disappears on
the removal of the obstruction. Sometimes it is due to a

FiaF.ia.2. 2.
BoyB,oy1,1 1y1eayresarosf oafgea.ge.FurFuunrculneclien ienxteexrtnearlnaaludaiutdoirtyorcyancaaln.al. (E(dEedmeamoaveorvetrhethmeasmtaositdo,id, witwhitdhisdpilsapcleamceenmtenotf otfhethaeuraiucrlieclfeorfwoarrwdasr.ds.
coincident hyperemia of the labyrinth, in which case the dulness of hearing may not improve after the local condition in the external canal has been remedied. A case illustrating this came under my care some years ago. A young lady,
20 years of age, had a furuncular inflammation on the
posterior wall of the external auditory canal. The history was suggestive of recurrent furuncle in the same ear for about two months previous to my seeing her. She complained

External Auditory Canal.

5

of great pain in the ear, but would not allow an incision to be made. In about a week's time the furuncle discharged into the canal. She was extremely dull of hearing in the affected ear, and the tuning-fork reactions pointed to disturbance of the labyrinth. There has been no improvement in the hearing since. The objection to this theory is, that I had no opportunity of testing the hearing before she presented

Fig. 3. Man, 26 years of age.. Furuncle in the left external auditory canal.
the mastoid, displacing the auricle forwards.

Swelling over

herself complaining of pain in the ear. Still, when an intelligent patient speaks bitterly of dulness of hearing in an ear with which she asserts she formerly heard well, one may be assured that at all events there has been a marked aggravation
of the deafness. These cases are, however, rare.
The tinnitus aurium?which in this affection is usually described as of a buzzing, beating, or hammering character? and also the giddiness, are generally mechanical in their

6

Mr. Connal?Furunculosis of the

origin, and disappear on the removal of the cause. When subjective noises in the ear are described as beating or hammering, we refer them to some vascular derangement either in the labyrinth or middle ear, and in this affection we
know that the middle ear shares in the vascular excitement of the outer canal.
In cases of primary furunculosis one sometimes meets with

FigF.ig4.. 4.
GirGlmi,arsl1,t9o1yi9edayraesanrdosf oafgea.ge.FurFuunrculneclien ilnefltefetxteexrtnearlnaaludaiutdoirtyorcyancaaln.al.(E(dEedmeamtaotuosussweslwleilnlginogveorvetrhethe mastoid ansdqusaqmuoaumsoupsorptoirotnisonosf otfemtpeomrpaolrablonbeo,nea,nadnedxteexntdeinndginfgorfwoarrwdasrdtso ttohetheeyeelyiedlsi.ds.
a history of disci large from the affected ear. On enquiry, this discharge will be found to be scanty, and often ropy. It is to be distinguished from the serous discharge of an eczema, and is one exception to a general rule that purulent discharge from the ear denotes a purulent otitis media. As previously mentioned, the pus contains the staphylococcus aureus or albus. Out of a fair number of culture experiments which I have made, or which Dr. R. M. Buchanan has done for me, the

External Auditory Canal.

7

large majority of cases showed the organism to be staphylococcus aureus, a few the staphylococcus albus, and rarely a mixed growth of these organisms.
Of the constitutional symptoms, a moderate degree of febrile reaction is common. As a rare symptom, I lately met with a case of spasmodic torticollis, which I thought was due to recurrent furuncle in the external auditory canal.

Same case as Fig. 4.

Fig. 5. Shows the ooeedcckmmaattoous condition of the eyelids on the left side.

While these are the main subjective symptoms, the objective are the more important. Examination, however, must be carefully undertaken. Movements of the auricle or attempts to introduce an aural speculum may cause the most exquisite pain. Commonly, an examination can be made without introducing a speculum into the canal. Reflected light from
a forehead mirror will in most cases show the characteristic
swelling, and on touching this with a probe, even gently, the

8

Mr. Connal?Furunculosia of the

patient will complain of pain. In some cases, instead of a boil, all that can be seen is a circumscribed reddish-yellow discolouration of the skin; but the characteristic is, that on touching this spot with a probe, you elicit very smart pain.
In the differential diagnosis one must remember (1) that an
exostosis in the external meatus is often very sensitive to
touch, but a little care will generally exclude this condition; (2) purulent middle ear mischief involving the antrum and mastoid cells may burst through the cortex of the bone, and present in the external auditory canal as (a) a saccular bulging on the posterior wall, or (b) having burst into the canal, may give rise to a sinus with small pouting granulations. Here the differential diagnosis is greatly assisted by the presence of middle ear mischief, and by the fact that these two conditions (a and b) always occur on the posterior wall of the osseous
canal.
Treatment.?Locally I believe in early incision of the furuncle, and the application of an ointment which Dr. Barr recommends, and which experience has shown to be of value :?Iodoform, 4 gr.; menthol, 2 gr.; vaseline, 1 dr.; smeared on cotton plugs, and introduced into the canal of the ear twice or thrice daily. Gruber's gelatine bougies containing morphia are also of service, more especially in the earlier part of the illness, or if the patient will not allow the boil
to be incised.
Ointments and instillations applied locally are numerous, but the main purpose of them all depends on their antiseptic properties. Poultices generally do harm by producing a sodden condition of the tissues, which favours microbic pro-
liferation.
If, however, the furuncle is not a primary condition, but occurs associated with some other lesion?suppurative middle ear mischief, eczema of the canal or plugs of cerumen?these conditions would demand appropriate treatment. In furuncle associated with purulent otitis media, one is occasionally surprised to note how quickly the middle ear discharge dries up after the inflammatory condition in the outer canal has been
remedied.
The constitutional treatment of this affection is of prime importance, and more especially where there is a tendency for the boils to recur in crops. In such cases the dietary must be carefully regulated?starchy and sugary foods should be withdrawn. Each individual patient should be treated according to his requirements. Tonics and aperients may be necessary. The aim in view should be a plain, wholesome,

External Auditory Canal.

9

nourishing diet, with plenty of outdoor exercise. In emphasising the necessity for supervising the dietary in this complaint, Sir Wm. Dalby (Diseases of the Ear) relates the ease of a strong athletic young man, who for three years had never been one week quite free from a boil in either ear. In this instance the patient had been in the habit of taking a pint of beer daily. This was withdrawn and a little claret substituted, with the happiest result.
In discussing the constitutional treatment of furuncle, the tendency of bromides and iodides to produce a pustular eruption must be borne in mind. Alum and nitrate of silver applied locally are also said to favour their development.
This is the type of case commonly met with; but there is another class where, in addition to the extreme pain, dulness of hearing, and other symptoms we have already mentioned, there is marked swelling over the mastoid, which is confusing, and leads to errors in diagnosis. The error is pardonable. The severity of the pain in the ear and head, the dulness of hearing, the tinnitus, the giddiness, the constitutional disturbance, feverishness, with the presence of a scanty discharge from the ear and swelling over the mastoid, give a clinical picture which is alarming, and strongly suggestive of mastoid mischief. Apart from a local examination of the external auditory canal, it is hardly conceivable that such local and
constitutional disturbance can arise from a boil in the
outer ear.
To rightly understand this condition, the anatomical struc-
ture of the outer ear must be borne in mind.
Anatomical considerations.?The outer part of the external auditory canal is not a complete cartilaginous tube. Its continuity is interrupted by two or three transverse fissures?the fissures of Santorini. These transverse clefts are filled in by fibrous tissue, which is continuous with the cellular tissue over the mastoid process. Again, the upper part of the cartilaginous tube does not meet, the roof of the canal being filled in with dense fibrous tissue, which serves the function of closing this upper gap, and at the same time unites the cartilaginous part of the auricle to the bony part of the canal. This upper
fibrous structure is continuous with the loose cellular tissue
around the ear, in front, above and behind. Hence it will readily be understood that inflammatory, and more especially septic inflammatory conditions may spread by continuity of tissue from the external auditory canal, through the fissures of Santorini or along the fibrous band in the roof of the canal, to the cellular tissue over the mastoid, simulating closely

10 Mr. Connal?Furunculosis of External Auditory Canal.

mastoid periostitis, and that the oedema may extend forwards, and give rise to an cedematous condition of the eyelids on the
same side.
A reference to the accompanying illustrations will make this clear, and show how closely this condition arising from a furuncle in the external auditory canal may simulate graver conditions involving bone lesions, and will emphasise the fact that a correct diagnosis and prognosis can only be made after a thorough inspection of the external auditory canal.
Fig. 1.?A boy, 8 years of age, complained of deafness and great pain in right ear of eight days' duration. The pain was severe, and prevented him sleeping at night. He had always been a strong healthy boy till onset of present
illness. He was seen on the 5th September for the first time
(Fig. 1 shows his condition at this date). Examination showed two furunculi?one on the floor and one on the posterior cartilaginous wall of the canal. There was marked swelling over the mastoid, displacing the auricle downwards and forwards, while the oedema involved the eyelids on the
same side.

An incision was made into the furunculi in the canal. The

pus showed a pure culture of staphylococcus aureus. By the 13th September (eight days later) he was quite better.
Fig. ?Boy, 11 years of age, with much the same clinical history. It shows pretty marked forward displacement of the auricle. Here there was a furuncle in the canal, at the

junction of the floor and' posterior wall. One week after

incision the patient was quite well.

Fig 3.?Man, 26 years of age, complained of deafness, pain

in the left ear, tinnitus, and occasional giddiness. Hearing

power (watch)?right ear, | J; left ear,

Furuncle in left

ear at junction of floor and posterior wall of the canal. The

pus showed mixed growth of staphylococcus aureus and albus.

Figs. Jf. and 5 show different aspects of the same case?a

girl, 19 years of age, seen for the first time on the 22nd

December, with a history of dulness of hearing, severe pain in the left ear of three weeks' duration. She was feverish, and had profuse sweatings at night. There was swelling behind the auricle, extending over the squamous portion of the temporal bone to the front of the ear, and forwards to the left eyelids, which were nearly closed. Examination showed a large furuncle at the junction of the roof and posterior wall of the canal, from which pus was liberated by incision.
Bacteriologically, the pus showed a pure culture of staphylo-
coccus aureus. In about ten days she was quite well.