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Coalescent petrositis is an uncommon condition and is now most commonly observed complicating chronic, antibiotic resistant ear infections. Tomography defines areas of bone destruction which are equivocal on conventional views. Four cases are presented which demonstrate accurate localization of the petrositis by tomography, providing preoperative assessment of the approach and extent of the necessary surgical procedure.

Three temporal bones were serially sectioned to study the postoperative fate of the meatally based postauricular musculoperiosteal flap. In all three ears, the flap sealed off the middle ear effectively from the mastoid cavity and in one, with resected canal wall, formed a new soft posterior wall with good meatus. All flaps contained viable muscle, fat, collagen, reticulin, and elastin, and were richly vascularized. In two flaps, small granulating foci of infection were noted. In two temporal bones, from a child with hypogammaglobulinemia, small cholesterol cysts formed behind the flap during the delayed healing of the mastoid wounds.

Meningitis is a rare complication following stapedectomy. Most cases are preceeded by a fistula in the oval window. Although fatalities have been reported, most cases respond to parenteral and intrathecal antibiotics if diagnosed and treated early. Gram-positive organisms are the usual pathogens, but Gram-negative organisms may be found, especially as a superinfection following antibiotics administered prophylacticly or for the treatment of otitis media or mastoiditis. A case of Pseudomonas aeruginosa meningitis five weeks after stapedectomy, successfully treated with gentamicin, is reported. The discussion included the diagnosis of post-stapedectomy fistula and meningitis and current trends in treatment.

A one-month-old infant with chronic diarrhea, staphylococcus septicemia, otitis, mastoiditis, and malnutrition was treated by intravenous alimentation and multiple antibiotics. He developed an abscess at the site of an intrajugular indwelling plastic catheter, from which Candida was grown. He died suddenly with signs of endocarditis with embolization. Autopsy revealed disseminated candidiasis, endocarditis with large candidal vegetations on all valves, with multiple granulomata and microabscesses in the brain. The possible role of indwelling plastic catheters, mastoiditis, malnutrition, and antibiotics in the pathogenesis of disseminated candidiasis in infants is discussed. Candida endocarditis is very rare in children, and this case is the fourth to be reported in the literature.

To our knowledge this is the first report of a patient with infectious mononucleosis associated with a mononuclear granulomatous mastoiditis and facial paralysis. Pathologic examination of tissue from this patient, removed at the time of radical mastoidectomy, provides a basis for further speculation about the relationship between facial paralysis and infectious mononucleosis.

A Case of Mastoiditis; Lateral Sinus Phlebitis with Septicemia. Reported by Dr. F. Bogan and Dr. L. Happ. A girl, aged 7 years, was admitted to the infirmary with the history that a month before there was pain in the right ear for two or three days, without discharge. She felt perfectly well until the day before admission, when she became suddenly ill with general malaise and acute pain in the ear. On admission the child had a temperature of 105 F. There was redness of the membrana tympani, with definite tenderness over the mastoid region, but there were no other clinical signs. Incision of the membrane yielded a serohemorrhagic fluid. Neurologic examination showed transitory stiffness of the neck and a positive Kernig sign. The white blood cell count was 18,000. The Shillinggram showed 42 per cent immature cells, and a spinal puncture showed normal

Progressive osteomyelitis of the skull originating in the temporal bone is rare, and comparatively few cases have been reported. Tobey, in a review of the literature in 1926, gave disease of the ear as the etiologic factor in 53 of the 61 cases reported, with a mortality rate of 50 per cent. He further stated that the mortality rate is invariably higher in cases in which conservative treatment is employed. Because of the meager personal experience available, the physician is dependent on the literature for guidance in the treatment of this unfortunate complication. I therefore record observations, symptoms and signs from my experience with 2 cases, in the hope that the decision as to the management of my next case of progressive osteomyelitis of the skull and the conclusions on which I base that decision may be of help to others. In analyzing the records of published cases, I find

OTITIS MEDIA; CARCINOMA OF ANTRUM; TUMOR OF PHARYNX. DR. JOSEPH C. BECK. The first patient was a woman, aged 23, who was first seen sixteen years before presentation. At that time she had an acute exacerbation of chronic otitis media, with subacute mastoiditis and cholesteatoma. The condition required immediate operation, and with the assistance of Dr. William Ballinger a Heath operation was performed on one side and a radical mastoid operation on the other. The patient was presented to demonstrate the effects of the treatment. She could hear the whispered voice at a distance of 20 feet and the high tones with the audiogram were preserved. This was one of the few cases in which the Heath operation gave permanently successful results. The case was interesting also because ether anesthesia was used, and the patient developed an infective bronchitis which persisted at the time of presentation. She

The cerebrospinal fluid pressure as determined by lumbar puncture is used as a routine as a measure of intracranial pressure. For otolaryngologic purposes, the Queckenstedt or Tobey-Ayer 1 test is used to ascertain the degree of obliteration of the lateral sinus by thrombosis in cases of mastoiditis. In a summary of results obtained during twelve years at the Massachusetts Charitable Eye and Ear Infirmary, Meltzer 2 found the Tobey-Ayer test valuable and reliable in approximately from 70 to 80 per cent of the cases and a complete failure in 18.2 per cent. He considered this test one of the best diagnostic aids in cases of thrombosis of the lateral sinus. The Queckenstedt and Tobey-Ayer tests are of special importance in the differentiation between the two lateral sinuses when both mastoids are involved. Under these conditions the percentage of failure is highest and the tests less accurate in determining

The most important micro-organisms responsible for otitis media and mastoiditis are group A hemolytic streptococci, pneumococci and staphylococci. There is, however, a marked difference in incidence of these bacteria between otitis media and mastoiditis, inasmuch as staphylococci are rather frequently encountered in the former condition but only rarely in the latter. The question arises, therefore, whether or not staphylococci are the cause of otitis media without tendency to invade the mastoid cells or whether staphylococci found in otitis media may be nonpathogenic and outgrow on culture the true pathogens. It is generally agreed today that the best in vitro method to determine pathogenicity or nonpathogenicity of staphylococci is the plasma coagulation test. Pigment and hemolysin production, formerly considered to reflect pathogenicity, are not as reliable indicators as the production of coagulase. It was decided, therefore, to carry out a bacteriologic study on cases of otitis media and mastoiditis and to

Physicians too often fail to recognize that what they tell patients is sometimes not understood by patients. The conditions which interfere with adequate understanding include the anxiety of the patient about what is being told to him as well as his intelligence, experience and opportunities to question his medical informant. Factors affecting the physician's ability to communicate clearly relate primarily to the clarity and simplicity of his language, his own anxiety about what he is telling the patient and his providing opportunities for the patient to feed back to him indications of comprehension. The ethical implications of distorted communication between doctors and patients are of great importance. With increasingly complex mutilating and debilitating procedures available to physicians, the patient's capacity to understand what is explained to him is crucial to his ability to give informed consent. By studying actual transcripts of conversations between varieties of physicians and patients, one can define factors which contribute to both clarity and distortion in doctor-patient communication.

Buford (1), who has recently reviewed the incidence of Graves’ disease in young children, states: “I have reviewed both American and foreign literature carefully for the last twenty years and find eighteen cases reported in children under twelve years of age. I find only two cases in which operation has been performed. My patient (third to be operated) was six years old, the youngest one that has been reported as operated.” Nine cases, including the one reported by Buford, have been reported in children under five years of age. Another case is herewith presented. Case No. C. 966; 5-26-1922; C.C., female, age 4 years and 7 months. Family History: The father is somewhat nervous, has high blood pressure and a rapid pulse; his eyes are moderately prominent, but apparently normal. The mother’s eyes are also prominent. The paternal grandmother died of heart trouble; the maternal grandmother died at child birth

IN THE temperate zones otologic practice can be divided generally into two distinct seasonal phases. One is the summer phase, during which conditions are essentially the same both indoors and out as regards temperature and humidity. During the second, or winter, phase people live in different environments, the dry, warm indoors and the variable, cold outdoors. During this phase the human economy is subject to great fluctuations of temperature and humidity over relatively short periods. As a result, people have fall, winter and spring colds, with the ensuing complications, not the least of which are otogenic infections, such as otitis media and mastoiditis. During the summer phase otologists see relatively few infections of this type but a greatly increased number of external otogenic infections. In addition, they frequently encounter exacerbations of chronic otogenic infections, which have been artificially activated by swimming, excessive sweating and bathing, with consequent pathologic aural changes.

The belief that there is impairment of immunity to infection in the tissues of the diabetic patient has been widely held for many years. In the field of otology this concept finds expression in the doctrine that in the presence of diabetes infections in the mastoid process are associated with relatively early and extensive bone destruction and are particularly prone to intracranial complications. Recently, however, exception has been taken to this view, 1 and it has been asserted that with the present improved therapy in diabetes, with especial reference to the use of insulin and a dietary regimen, the course of mastoiditis in the diabetic patient does not differ essentially from that in one who does not have diabetes. In an attempt to clarify this matter and to obtain, if possible, a better understanding of the influence of diabetes on the clinical manifestations, pathologic changes and treatment of mastoiditis, we

History.-Primary and secondary types.-Incidence in (a) Phthisical patients, (b) Patients with suppurating ears, (c) Children.-Modes of infection: (a) by Eustachian tube, (b) by blood-stream.-Signs and symptoms: Painless onset; Early appearances of middle-ear; Infiltration of tympanic membrane; Multiple perforation; Granulation tissue; Type of discharge.-Examination of discharge and of granulation tissue.-Course of disease in middle-ear; Extensions; Complications.-Special types: Mastoiditis in children; Tumour formation.-Deafness.-Reports of twenty cases.

Serous otitis media is arousing increasing interest among otologists, partly because the incidence of the disease seems to have grown and partly because its treatment in many cases affords difficult problems. If left untreated, it changes into chronic adhesive otitis and resultant severely impaired hearing. Treatment must be started before irreversible changes have occurred in the tympanum and the eustachian tube. Chronic cases of serous otitis media which are often refractory to all conventional therapy can be successfully treated by an indwelling plastic tube in the tympanum. The latent mastoiditis which frequently accompanies the condition must first be cured.

The management of temporal bone infections due to Proteus vulgaris (Bacillus proteus) continues to be a perplexing problem in otology. The success of antiobiotic therapy in treating most infections of the ear is often not evident when this organism is involved. In fact our concern with P. vulgaris has not materially changed since the report 1 made in 1936. This situation is illustrated by four cases in which the usually ubiquitous saprophytic Proteus, flourishing in the confined space of a chronic otitis media extended centrally to produce a fatal intracranial complication. These cases warrant discussion for a number of reasons. Chronic otitis media is one of the major problems in otology. When P. vulgaris is implicated, because of its insidious nature, the disease becomes more complex. Also there appears to be an increased incidence of Proteus found in routine cultures of all sorts in recent years, perhaps because bacteriologists are

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Summary A study has been presented dealing with 30 instances of thrombosis of the dural sinuses in infancy and childhood. These have been tabulated in connection with 50 instances previously reported 1 forming a total series of 80 cases. Of these, 42 cases were associated with various forms of sepsis: meningitis, scalp infections, otitis media, mastoiditis, and bacteremias without meningeal localization. Four instances followed surgical procedures. Thirty-three patients presented no evidence of infection of the centralnervous system or blood stream. They were all infants under thirty months of age. The illness began with an acute nutritional disturbance usually followed after a period of days or weeks by evidences of meningeal irritation, marked hyperpyrexia, and convulsions or other abnormal neurologic manifestations. Some infants died without any evidence of neurologic disturbance. In all of these patients, the superior longitudinal sinus was thrombosed in entirety or in part with variable involvement of other sinuses and cerebral veins. Twenty-one of these patients presented hemorrhages into the meninges associated in 19 cases with intracerebral hemorrhage and necrosis. Some of the patients succumbed within a few hours after the onset of the symptoms referable to involvement of the central nervous system. A few lived for ten days to one month. Finally, two patients recovered from their acute attacks and died later with organized and canalized thrombi in their superior longitudinal sinuses. These together with another patient with similar thrombi of different pathogenesis, form the basis of a separate report. This peculiar "nonseptic" type of sinus thrombosis has no counterpart in adult life and largely accounts for the much greater incidence of dural sinus thrombosis in early life than in adult life. The usual severity of the brain injury resulting from occlusion of the superior longitudinal sinus, the protean character of the associated clinical picture and its frequent occurrence make its recognition a matter of importance in neurologic diagnosis in childhood.

The recent papers of Eagleton and of Kopetzky and Almour 1 on suppuration in the petrous pyramid have called to the attention of the otologist a condition that undoubtedly has been responsible for many failures in operations on the mastoid processes. Eagleton's 2 recognition and description of the symptoms associated with the condition are significant, and will be of use in preventing untoward complications of mastoiditis. We are reporting two cases in which the condition was recognized by the use of these diagnostic criteria, and wish to suggest that in some of these cases, at least, any alterations in the usual technic of mastoidectomy may be unnecessary. CASE1.—A girl, aged 8 years, was brought to the Mayo Clinic with the history that six weeks previously drainage from the ears had developed following acute infection of the upper part of the respiratory tract. The acute otitis media of the right

There has been considerable study of acute, uncomplicated involvement of the mastoid in its preoperative and operative stages, 1 and a tremendous amount of literature has been published on the subject. The clinical signs and symptoms of mastoiditis, a study of roentgenograms and a combined discussion by both the roentgenologist and the otologist 2 have been a topic of interest. Law 3 has written much in both periodical and book form on the roentgenologic aspects of mastoids. Granger's 4 book on sinuses and mastoids is popular, and numerous other otologists 5 have devoted much time and labor to the subject; however, the study stopped there. The literature contains little on the roentgenologic aspect of the mastoid which has been operated on for acute uncomplicated disease. When complications such as sinus thrombosis and brain abscess occur, additional roentgenograms are required, but as to what the normal postoperative roentgenogram of the mastoid discloses there is little to

There is a high incidence of otitis media in infancy. The infant is anatomically predisposed to infection of the middle ear. The recumbent position prevents drainage of pus through the auditory tube. Dehydration is the greatest factor affecting the prognosis. Mastoiditis is part of the morbid anatomy. Penicillin is of value in most cases and has considerably reduced the mortality.

Considering the close proximity of the mandibular fossa to the middle ear, it is remarkable that extension of infection from the middle ear to the jaw joint does not occur more often. It is not mentioned in any of the standard texts on otology, and the literature contains only one reference to it. This report is being made because suppuration in the mandibular fossa does occur secondary to otitis media, it must be differentiated from zygomatic mastoiditis and it requires special treatment. Three patients with involvement of the jaw joint secondary to acute suppurative otitis media came under my care during a two year period. REPORT OF CASES Case1.—W. F., a boy of 7, was first seen Feb. 11, 1935, four days after the onset of earache on the right side. The right drum membrane was red, thickened and bulging; the temperature was 103 F., and the child had

Cerebral abscess represents one of the more serious complications of chronic ear disease. Patient morbidity and mortality is dependent on prompt diagnosis and treatment. The pathogenesis, diagnosis and treatment of cerebral abscesses have been reviewed in order to refamiliarize the otolaryngologist with the management of this clinical problem.

An attack of acute otitis and mastoiditis in a deformed ear brought the patient to the hospital and permitted study of an interesting group of congenital deformities. REPORT OF A CASE A pleasant though mentally sluggish little girl of 8 years came to the outpatient department with a history of cold in the head and pain in the left ear of three days' duration. Fever and dizziness had been noted for twenty-four hours. The child looked ill, cried, held her hand to the deformed ear and complained of pain and fulness. Her temperature was 103.2 F. and her pulse rate 96. There was obvious acute nasopharyngitis. Nystagmus and vertigo were absent. The left ear was microtic, with no external canal. However, the mastoid process and the region of the buried cartilaginous canal were tender. While the child was under care in the hospital the acute symptoms quickly subsided, and the