A CASE 
OF 
EXOSTOSIS OF THE EXTERNAL 
AUDITORY MEATUS 
DRILLED OUT BY THE 
“DEN TA L E N GT N E.” 
BY 
AETHUE MATIIEWSOX, M. I)., 
BROOKLYN, N. Y. 
[REPRINT FROM THE TRANSACTIONS OF THE INTERNATIONAL 
OTOLOOICAL CONGRESS, 1876.1 
NEWYORK ; 
D. APPLETON AND COMPANY, 
54 9 & 551 BROADWAY. 
1 8 7 7. A CASE ’ 
OF 
EXOSTOSIS OF THE EXTERNAL 
AUDITORY MEATUS 
DRILLED OUT BY THE 
“DENTAL ENGINE” 
BY 
ARTHUR MATHEWSON, M. D., 
BROOKLYN, N. Y. 
[.REPRINT FROM THE TRANSACTIONS OF THE INTERNATIONAL 
OTOLOGICAL CONGRESS, 1816.] 
NEW YORK : 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY, 
1877. A CASE OF EXOSTOSIS OF THE EXTERNAL 
AUDITORY MEATUS DRILLED OUT BY 
THE “DENTAL ENGINE.” 
ARTHUR MATHEWSON, M. D., Brooklyn, N. Y. 
The following case is presented as worthy of record from 
the fact of its being one of the very few cases of exostosis of 
the auditory meatus successfully removed by surgical opera- 
tion, and because it illustrates a new and, as it seems to me, 
better method of operation—namely, the application of the 
“ dental engine,” or lathe. 
The class of cases to which it belongs is not unimportant, 
for aural exostosis may not only impair the hearing but en- 
danger life. The patient was the one whose previous history 
is given on page 407 of Dr. Roosa’s treatise on “ The Dis- 
eases of the Ear.” 
Miss M. M., aged twenty-five, small, delicate, and subject 
to neuralgic pains, but in fair general health, was put under 
the influence of ether in March, 1873, for the purpose of thor- 
oughly examining, and, if practicable, removing a tumor 
blocking up the right external auditory canal. The examina- 
tion was conducted by Dr. Loring, under whose care she wras, 
assisted by Drs. Roosa and Pardee. 
“ The tumor arose from the posterior portion of the osseous 
canal of the right ear, and nearly occluded the passage. There 
was a minute opening between it and the anterior wall, 
through which a Ko. 2 Bowman’s probe could be passed into 
the cavity of the tympanum. The tumor was of bone, and 
covered by a movable integument, wdiich was red, and very 
sensitive. On passing the probe into the minute opening that 4 
has been mentioned, it could be passed under the growth, and, 
when pressed upon, the growth was seen to move slightly. 
“ The history of the case was, that there were frequent at- 
tacks of pain in the ear, without discharge, until the patient 
was eleven years old ; since which time there has been no c true 
earache,’ although the parts are tender, and there is a great 
feeling; of "fullness in the ear. The watch is not heard at all 
on the affected side.” The voice was heard very imperfectly. 
At this time Dr. Loring, using one branch of a pair of short, 
straight scissors, passed in with a boring motion through the 
opening by the side of the tumor, and removed some of the soft 
tissue covering the exostosis. On May 8, 1873, as there was 
considerable pain in the depth of the ear, Drs. Loring and 
Roosa advised that some operative means be taken to remove 
the growth. After a time, however, there was a cicatricial 
shrinking of the soft tissues attacked by Dr. Loring, so as to 
leave the opening larger and the hearing much better. 
The case went on without serious symptoms until the win- 
ter of 1875-’76, when she began to experience a sense of press- 
ure in the head, and had attacks of loss of consciousness, and 
other cerebral symptoms, recurring at intervals until the time 
of the operation in May. Dr. Loring had seen her at inter- 
vals, and advised an operation, intending, he has told me, to 
resort to the same method as was employed by me; but, as 
she came to reside in Brooklyn, kindly referred her to me for 
further treatment. 
I found the meatus nearly occluded by the exostosis, over 
which the integument was thin and very sensitive. The 
growth had become immovable, and had evidently increased 
somewhat since the time of Dr. Roosa’s report. There was 
no discharge. The hearing was much impaired. 
The history of similar cases showing that they sometimes 
have had a fatal termination, and the symptoms in this case 
seeming threatening, an operation for the removal of the 
growth, or the formation of a larger opening in the meatus, 
was urgently advised, and finally consented to. It had oc- 
curred to me, at my first examination of the case, that the 
engine used by dentists in their operations might be satisfac- 
torily employed for the purpose. The machine used was that 5 
known as Elliott’s suspension dental engine, shown in Fig. 1, 
in which the power is supplied by a treadle worked with the 
Fig. 1. 6 
foot, while the hand-piece, to which the burrs or drills are at- 
tached, held like a pen, can be raised or lowered, and turned 
in any direction desired. 
Under the instruction of my friend Dr. William Jarvie, 
dental surgeon, I experimented with this engine on teeth and 
bone, so as to get some appreciation of its power, and of the 
proper degree of pressure in applying it. Dr. Jarvie also 
ground the burrs figured to a form which seemed best adapted 
to the work proposed—to use the technical terms, making a 
square drill out of a ..fissure burr. The engine was set up 
under his supervision, and arranged properly with reference 
to the height and position of the bed on which the patient 
was to lie during the operation. 
Fig. 2. 
The operation was performed, May 21, 1876, with the as- 
sistance of Drs. Uushmore, Colton, Cornwell, and Jarvie, the 
latter working the treadle of the engine with which his daily 
practice had made him familiar. The patient was under the 
influence of ether. The meatus was illuminated by a mirror 
on the forehead of the operator. The first step was to remove 
the integument covering the growth, that it might not clog 
and impede the action of the drill. This was done by another 
dental instrument known as the scaler, the skin being circum- 
scribed and scraped off with it. The bony growth wTas then 
perforated at several points near its centre with the smallest 
of the drills, about one and a half him. in diameter, which 
penetrated without difficulty, with so slight a pressure, that 
there was but little danger of its slipping forward and injur- 
ing the deeper parts, though the growth was eburnated and 
excessively hard. The larger drills (two and a half and three 
mm. in diameter) were next used successively to enlarge the 7 
perforations and run them together, and by lateral pressure to 
ream out the meatus. 
There was so much bleeding that I was obliged, in spite 
of frequent swabbing with styptic-cotton, to depend much on 
the probe for guidance in the operation. The excavation was 
continued cautiously till the largest drill—about three mm. 
in diameter—passed freely through, with room to spare, and 
the probe could be carried in the whole length of the meatus. 
Besides using the styptic-cotton on cotton-holders, the meatus 
was repeatedly syringed during the operation for the removal 
of blood and debris of soft and bony tissues. 
The operation occupied twenty to thirty minutes. ISTo 
troublesome haemorrhage followed, and the pain experienced 
by the patient on recovery from the influence of ether was 
easily subdued by the warm-water douche and moderate doses 
of opiates. A purulent discharge from the meatus soon came 
on, for which a weak solution of sulphate of zinc was used, at 
flrst after syringing, and later the parts were touched with so- 
lutions of nitrate of silver. Tor weeks after the operation the 
meatus was so nearly filled with swollen and granulating soft 
tissues that nothing could be seen of the membrana tympani, 
but examinations with the probe showed that a considerable 
opening in the hard structures existed. Gradually, and with 
occasional applications of nitrate of silver, these soft, granu- 
lating tissues thinned down, till now there is an opening of 
nearly the full size of the meatus, except at one point where 
there is a thin remnant of the exostosis projecting from the 
anterior upper wall of the meatus. The posterior lowmr part 
of the membrana tympani can be seen. 
All discharge has ceased ; there is no irritation or unpleas- 
ant symptoms of any kind, and the hearing has risen to nearly 
the normal standard. 
In connection with the foregoing case, a brief resume of 
the history of the therapeutics of exostosis of the auditory 
meatus may not be inappropriate. 
Toynbee reports nine cases, one of which was treated by 
local applications of strong solutions of nitrate of silver fre- 
quently repeated for a long period, with the ultimate result of 8 
a perceptible diminution of the tumor, due, as he thinks, to 
decrease in thickness of investing membranes. 
In another case the size of the growth was diminished 
and the hearing improved by the application of the tincture 
of iodine to the tumor and behind the ear, with the internal 
administration of iodide of potassium in four-grain doses, re- 
peated thrice daily between two and three months. 
Wilde recommends in the earlier stages of the growth, 
when it is the result of chronic periostitis, counter-irritation, 
bleeding, and bichloride of mercury internally, but has not 
much confidence in treatment when the growth is farther ad- 
vanced. 
In one of the cases of exostosis reported in Dr. Roosa’s 
work, it is stated by the attending physician that u any in- 
crease of the impairment of hearing is always relieved by an 
application of the tincture of iodine to the bony growth,” 
Gruber, in his book, published in 1870, reports no case, but 
says in general that the prognosis is unfavorable with all the 
means of treatment hitherto applied. The soft tissues cover- 
ing the tumors may be diminished, but not the bony mass it- 
self. Compression by bougies, he thinks, could not, in most 
cases, be endured. 
Yon Troltsch reports a case in which a laminaria bougie, 
introduced for the purpose of dilating the meatus, could not 
be removed for two months. Small sequestra came away, 
and the passage was so enlarged that the hearing was restored. 
Oneof the cases of exostosis recorded by Dr, Roosa was 
treated while in London by Toynbee with bougies to dilate 
the meatus, but they caused much pain, and accomplished 
nothing. Besides causing great suffering and aggravating the 
symptoms of pressure, it is logical to suppose that bougies 
would as readily cause necrosis of the walls of the meatus as 
of the exostosis. The last-mentioned case had afterward a fatal 
termination from retention of pus. 
The first reported case of surgical operation on exostosis 
of the auditory meatus is the celebrated one of Bonnafont, 
of which there is an account in Id Union Medicate, May, 
1868, The growth filled up the meatus and obstructed the 
hearing. The soft tissues over the bony growth were first 9 
destroyed by applications of nitrate of silver for five or six 
days, and then the attempt was made to bore through the 
bone with a fine rat-tailed file. It was only at the fourth sitting, 
and after causing much pain, that he succeeded in gaining 
a starting-point for the end of the file. The boring was con- 
tinued for ten days. After each sitting a whale-bone probe 
was introduced to maintain the opening gained. The perfo- 
ration finally made was still open some years after with satis- 
factory results in improvement of hearing. 
Since this case of Bonnafont’s, the following cases of 
operation have been reported: Dr. L. 8., of Hamburg, re- 
lates, in the Archiv fur Ohrenheilkunde, vol. x., p. 110, the 
history of his own case. Having been troubled at intervals 
for several years with deafness and tinnitus, caused by the 
presence of exostoses in each auditory meatus, operations were 
begun by Dr. Knorre, in July, 1813, with a drill—kind not 
stated—and continued for four days, with much, pain, caused 
by slipping of instruments and inflammatory reaction of mea- 
tus. After a pause of two days an unsuccessful attack on the 
growth with a chisel and hammer caused severe headache. 
In ten more sittings, in which forceps as well as drills were 
used, small pieces of bone of cancellated structure were 
brought away, the operation being attended with great pain. 
Muriatic and sulphuric acids were next applied to the tumor 
for eight weeks two or three times a day with small effect. 
The actual cautery was applied several times. * After a cessa- 
tion of treatment, when the swelling of the «soft tissues had 
subsided, it was found that a probe could be passed between 
the tumor and the walls of the meatus. On the 29th of Octo- 
ber the patient began to operate on himself with a small, 
blunt file, roughened only on one surface, which could be in- 
troduced along by the side of the growth, and continued filing 
at it at intervals till the end of the following January, An 
opening, through which a pretty thick probe could be passed, 
was finally attained with restoration of hearing and relief of 
tinnitus. He states that the sensitiveness of the parts in- 
creased after each operation. Probably few patients could 
be found to voluntarily endure so long a course of suffering. 
In a note to this case, Schwartze states that two eases of 10 
successful operation on exostosis of the auditory meatus by 
chisel and hammer had recently come to his knowledge, but 
gives no details. Whether they are the same as the two re- 
ported by Aldinger, of Fiirth, near [Nuremberg, in vol. xi., part 
ii., of the Archiv fur Ohrenheilkunde, does not appear. The 
latter were both performed on the same subject by Prof. 
Heinecke in 1815. Exostosis had first been found in both 
ears of a middle-aged man eight years before, and. had grown 
slowly till 1874, when the right meatus was completely filled, 
and the hearing abolished. In December, 1874, severe pain 
came on in the right ear, and four days later profuse discharge 
of pus. On the 2d of January following, the indications for 
the removal of the growth seeming urgent, Prof. Heinecke 
made an attempt to cut through the base of the tumor with a 
gouge three lines in breadth, driven by heavy blows of a ham- 
mer. It was unsuccessful on account of the hardness of the 
growth. After repeated efforts, several small fragments were 
chipped off the edge of the exostosis, so that a sound could be 
passed through to the membrana tympani. Other fragments 
were removed by the forceps during the next ten days, and 
the caliber of the meatus opened to half the normal size. The 
membrana tympani was found perforated; granulations which 
formed were removed by the snare, and treated also with 
astringents and applications of nitrate of silver. In March, 
1876, the opening in the meatus was stated to be four lines 
by two ; the perforation in the drum membrane closed and 
the hearing was completely restored. 
In August, 1875, the left ear of this patient became com- 
pletely deaf and painfully inflamed in consequence of the 
growth of the exostosis on that side, and Prof. Heinecke oper- 
ated for its removal with gouge and hammer on the 25th of 
October, 1875. Setting the gouge near the base of the tumor, 
he succeeded in starting a considerable piece of the growth by 
repeated powerful blows with the hammer, and prying it off 
so that it was removed by the forceps. Several small pieces 
were chipped off, and a free passage opened through the mea- 
tus. On the third or fourth day after the operation there 
was great pain in the ear, and a sense of pressure in the occi- 
put. In March, 1876, the opening in the meatus remained, 11 
though smaller than it had been at one time after the opera- 
tion, and the hearing was very good. 
Yoltolini has suggested the application of galvano-cautery 
to the periosteum of exostosis, with the hope of causing it to 
be thrown off. According to Schwartze’s experience, there is 
danger to the walls of the meatus, from slipping of the gal- 
vano-caustic noose from the smooth surface of the growth. 
In a note to Aldinger’s paper, the editor of the Archiv 
refers to a case of exostosis reported by Hinton, which had 
been operated on by Clark, of Clifton, England, with the con- 
stant galvanic current. He says, briefly, “ After two applica- 
tions of three needles under chloroform, the exostosis came 
away in mass, and the patient heard again; entirely well.” 
There is no history of the size or shape of the growth, or of 
its attachment, but it seems hardly probably that such a re- 
sult could have been attained in a broad-based, eburnated 
tumor. 
In comparison with any of the methods of operation em- 
ployed in the cases collated, that with the dental engine 
seems to me the best, as being less tedious, less dangerous, and 
more effective. That it is less tedious, a few tests of this and 
any hand-drills in perforating dense bone will demonstrate. 
It is less dangerous for the reason that, with the rapidly re- 
volving drills, perforations can be quickly made with so slight 
a pressure that there is little risk of injuring the deeper parts 
of the ear, or the walls of the meatus, by the slipping so like- 
ly to occur in operations with hand-drills, or with hammer 
and chisel. The instrument is also held between the thumb 
and fingers in such a way as to interfere to a less degree with 
the illumination and inspection of the meatus during the 
operation. The drills and burrs can also be used, not 
only to perforate with their points, but also to enlarge open- 
ings, already made, to any desired extent or direction by lateral 
pressure with their sides. 
Other uses for the dental engine in surgery readily sug, 
gest themselves. There is a great variety of burrs, drills, and 
saws—more than three hundred in all—figured in the manu- 
facturer’s catalogue, which can be attached to the engine 
and would be of great 1 assistance in operations on bony 12 
growths occurring elsewhere, like those of the orbit, in some 
cases of resection, and in any case where there is small space 
to employ the ordinary instruments effectually without en- 
dangering the neighboring parts. The form of dental engine 
which seemed to me best fitted for the purpose is that figured, 
known as Elliott’s suspension engine, the price of which is fifty 
dollars. Another form called the Morrison engine, which costs 
only twenty-five dollars, can be set up without the necessity of 
screwing a fusee into the ceiling, as is the case with the suspen- 
sion engine, and for most surgical purposes may do sufficient- 
ly well. These engines and their attachments can be seen 
at Johnston Bros., 812 Broadway, ISTew York. 
There is no necessity, however, for the surgeon to increase 
his armamentarium—already perhaps too large—by the pur- 
chase of an instrument so costly, as most dentists are now pro- 
vided with them, and their services can be readily engaged for 
special occasions.