A Case of Streptococcic Haemolytic Infection of the Middle Ear following Tonsillar Infection

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 4, 1 October 1927, Page 213

A Case of Streptococcic Haemolytic Infection of the Middle Ear following Tonsillar Infection

Jas. Hardie Neil, M.8., N.Z., F.C.5.A.., F.A.C.S., Aural Surgeon, Auckland Hospital.

On May 31st, 1927, Dr. Derrick kindly asked me to see a lady aged 29, who had been admitted to a private hospital three days previously, with severe tonsilitis. The history was, that for six days prior to admission she had suffered from acute sore throat, general malaise, and aching limbs. Her temperature was 99.4, pulse 96, respiration 24. The tonsils were enlarged and acutely inflamed without the cryptic spots usually seen. The right side was the more painful. The gland beneath the angle of the jaw was slightly tender on both sides. She was given gargles of Milton, and hot foments to the neck m front of the ear. Her dentures were removed.

The urine was examined and found normal. Shortly after admission the left side became the more painful, and at the consultation examination a left side quinzy was located and opened. She was more comfortable during the next few hours, but twenty-four hours later the temperature went up to 104deg. and she complained of pain m the left ear. She was not certain that it had not been present to some extent prior to this, but masked by the predominant throat pain. Previous to this illness she never had any ear trouble.

She had had a restless night, was flushed and bright-eyed and her mind wandered at times. In the morning the drum had perforated, as a quantity of mucoid fluid like saliva appeared at the orifice of the meatus. This was sent up at once to the Hospital Laboratory, and Dr. Gilmour subsequently reported that

it gave a pure culture of Hsemolytic Streptococcus. Movement of the outer ear was objected to, and severe tenderness complained of, on pressure over the antrum, front of the tip and behind the mastoid. The drum could only be seen with difficulty. In the posterior inferior quadrant could be seen a large perforation through which a mucoid like fluid Avas pulsing. There was no sagging of the posterior superior wall of the canal, nor was there any noticed m the frequent examinations subsequently made. A slit flap dressing was placed over the outer ear and the discharge wiped away fourhourly. The patient presented a marked toxic appearance with confused and dulled sensorium. For a week the temperature swung up to between 103 and 104. Head pains and constant throbbing were consistently complained of. The tongue was dry, glazed, and fissured, and with the marked accumulation of sordes, demanded the constant care of the nursing sister, who realised that any addition to the residual tonsillar sepsis would be a menace to the lungs. She made constant use of lemon juice to clean the mouth and necks of the teeth. Consistent efforts were necessary to counteract the effects of the rapid bodily wasting on the skin and to administer nourishment to the patient who was more anxious for fluids. Three doses of scarlet fever antitoxin (P.D. & Co.) of 500,000 units were administered at two-day intervals. These were each followed by a drop of three or four degrees on the following morning; otherwise the fluctua-

tion was two degrees. None of the characteristic chills or sweats of Lateral Sinus infection were noticed.

The mental condition persisted, except that slowness of response to questions increased. Eleven days after the commencement of the discharges from the ear, the nursing sister reported that there was albumin m the urine to the extent of 12 on the Esbach scale, and as the patient showed resentment on moving the head. Dr. T. W. Johnson was called m consultation. He made a careful examination and excluded meningitis, and superintended the medical side of the case, ordering a diet non-irritant to the kidneys.

The result of the bacteriological examination and the onset of the case recalled a comprehensive article by Ballinger, m the "Archives of Laryngology," August, 1926. He recounted an epidemic of 56 cases of acute otitis media, secondary to an acute infection of the throat. He drew attention to the fact that many cases simulated the up and down temperature of lateral sinus thrombosis, and that the temperature was uninfluenced by the free drainage obtained from an early and wide opening of the drum. He pointed out that many cases of mastoidectomy m the first week were reported m the literature ,and that when the Hsemolytic Streptococcus was the offending organism, an almost equal number of grave blood borne complications were reported. He thought it logical to assume that with this organism present, these symptoms and complications were accounted for by the entrance of the bacteria (not necessarily a thrombus) into the blood stream. In the secondary infected area (the middle ear and mastoid) too early an interference would greatly increase the bacteremia by opening up new channels before the area was walled off by nature's protective measures, and so overwhelm the general immunising mechanism. He stated that the vast majority recovered without surgical interference and without lateral sinus thrombosis. As regards our patient it may be advisable to state the reasoning that guided us m the handling of this case that naturally caused us great anxiety.

Clinically she presented a picture of acute suppurative otitis media with toxic

symptoms compatible with virulent mastoid infection involving the Lateral Sinus.

In acute mastoiditis the cases can be grouped into the coalescent and the ruemorrhagic types. The former, usually with an exacerbation of symptoms, follows some days after an otitis from nasopharyngeal infection, and may be painful, or more rarely, painless. There is stagnation of pus m the mastoid cells with decalcification and necrosis of the inter-cellular bone. With the profuse purulent discharge, there is sinking or sagging of the posterior superior Avail of the canal, and narrowing of the inner part of the lumen. With variations, pain m and behind the ear, tenderness over the mastoid, head pains, pulsing noises, restless nights and the general signs of septic absorption form a typical picture. The hasmorrhagic type is usually influenzal m origin, and is not a preliminary to the coalescent type. It is comparatively rare m this district. It is accompanied by symptoms of acute otitis. An incision of the drum lets out only thin blood-stained discharge. The other signs of mastoiditis are present, but there is no sagging of the canal wall, and the temperature remains constantly about lOOdeg. from the outset. The cases all present clinical manifestations of severe sepsis, the course is stormy and prostration is marked from the outset. The principal lesion is confined to the small veins m the mucosa lining the mastoid cells. When the mastoid is opened the cells are free from pus and not broken down. Excessive bleeding is encountered with every disturbance of the mastoid substance. The frequency of Lateral Sinus infection m this type is well known. It occurs about four times more frequently than m the coalescent type, and is due to direct extension of the infection through the tributary veins from the mucosa.

The well-known authority, Kopetzky, who named the condition, sets down its complications and terminations as: Resolution rarely. Lateral Sinus thrombosis. Acute Brain abscess, meningitis and metastatic lesions. He states that this type of case requires early surgical intervention, operation m the first week will usually clear up the case. We were thus con-

fronted with the necessity of making a diagnosis between acute Hsemolytic Streptococcis Infection mainly confined to the middle ear, where early intervention would m general increase the gravity of the prognosis, and acute hsemorrhagic mastoiditis that demanded early surgery to save the patient from the most serious complications.

The discharge from the ear was profuse and was never blood-stained. The spontaneous perforation was adequate for drainage. The Sister, to whom we must pay tribute for skilful observation and meticulous nursing care, reported that the patient appeared to be more hyperaesthetic when we were making our regular examinations, than when she was doing the dressings.

The patient maintained her blood colour comparatively well. Circumstances made it impossible for us to seek frequent help from the Laboratory, but signs were absent of marked destruction of the haemoglobin so characteristic of local Hasmolytic Streptococcal infection of the Lateral Sinus by direct extension into that vessel. The absence of chills (or even transient coldness of the extremities), the absence of rapid rises m the pulse and respiration rates to correspond with the height of temperature rises — the non-appearance of nausea and vomiting on being roused or on the head being moved, or on partaking of fluids, and the constancy of the mental condition all tended to show that the Lateral Sinus was not involved. The X-ray, taken with a portable apparatus, was not convincing. The cloudiness stated to be present was not sufficiently definite. Our diagnosis was Bacteremia, m which the ear condition was a secondary focus, the infection being confined to the middle ear. The mastoid involvement we deemed to be that usually concomitant m the antrum m acute otitis media. The nephritis was very disturbing. Ballenger did not mention this as a complication m his series. Dr. Johnson has kindly supplied a memo, on the subject :

"On account of its initial severity, microscopic examination of the centrifuged deposit showed the field crowded with epithelial cell casts, epithelial cells and

red blood cells. It was obvious that the excretory organs were feeling the effect of their attempt to reduce the Bacteremia, and were giving way to the attack of the virulent streptococci. An acute tubular nephritis had thus arisen. This helped to increase the severity of the general symptoms.

"Fortunately, within a few days, the resistance of the patient began to gain ascendancy over the Bacteremia. The kidneys immediately responded to the lessened attack, and the acute nephritis began to subside. The cell casts rapidly disappeared, and the urinary output rose to normal. The albuminuria persisted to the same degree, but at the end of a week it was decreasing, and m three weeks it had almost completely gone. Estimation of the urinary functions at the end of six weeks showed that the kidneys had completely recovered, and the possibility of a chronic nephritis supervening was removed.

"The kidney lesion was interesting m that it demonstrated the bacterial cause of acute nephritis and also the complete recovery that is possible m a severe lesion/

In another four days the evening temperature began to hover about the normal line, and convalescence after the typhoid type set m. The tongue cleared slowly, and the mentality became acute and bright. The ear discharge which became purulent m the first week gradually diminished and dried up m another two weeks.

We must express our thanks to Miss Wilson, the Matron of Huia Private Hospital, to Sister Curtis and the staff, whose efforts m no small way contributed to the recovery of the patient.