OTITIS MEDIA-ABSCESS OF NECK 
DEATH. 
By E. OLIVER BELT, M.D., 
WASHINGTON, D. C. 
Reprint from The Ophthalmic Record, Nashville, Tenn. 
NASHVILLE, TENN.: 
A. IL Gray & Son, Book and Job PrinTrs 
1892.  OF THE MIDDLE EAR, 
COMPLICATED WITH ABSCESS OF 
THE NECK, WITH REPORT OF A CASE. 
Written for the Ophthalmic Record by 
E. OLIVER BELT, M. D., 
Washington, D. C. 
Abscess of the neck as a complication of otitis media is of 
such infrequent occurrence, and of such grave import in making 
a prognosis, that I feel I need make no apology for reporting the 
following case. 
On Feb. 17, I was called in consultation with Dr. W. Sinclair 
Bowen, to see Mr. S, a lawyer, aged 53 years who presented 
the following history. With the exception of an attack of menin- 
gitis some years back which left him blind in the left eye, his 
general health had been very good up to a few years ago when he 
commenced to drink excessively. He suddenly gave up 
drinking about three months ago and a few weeks later was 
taken ill with grippe. The right ear soon became involved, 
and he suffered intensely until relieved by bursting of the drum 
Dr. Bowen was then called in and found a discharge from the ear 
which continued in spite of treatment, after the patient had 
sufficiently recovered from the grippe to resume his usual work 
at his office. After several weeks he became restless at night, 
was not able to sleep, and complained of pain in the right ear 
and over that side of the head. I first saw the patient on Feb. 
17th, which was about six weeks' after the beginning of the 
otorrhoea. I found the discharge still profuse, the ear and 
*Read before the Medical Society of the District of Columbia, March 
16th.1892. 4 
Otitis Media-Abscess of Neck-Death. 
surrounding tissues somewhat painful and swollen, and hearing 
with my watch The external and middle ear were full of 
pus, which was evacuated with syringe and hot water and by 
inflation with the Politzer ear bag. The ear was ordered to be 
syringed with hot water every two hours and a sol. of Pyoktanin 
(1-1000) instilled after each cleansing. The mastoid region was 
painted with Iodine. Inflation by the Politzer method was 
practised once or twice a day, after which fluid injected into the 
ear would pass into the throat, showing that there was good 
drainage through the Eustachean tube. For the next few days 
he suffered much less pain, and rested well. Leeches were not 
found necessary. The slight swelling about the ear subsided, 
but the discharge continued very profuse. Zinc, sulph. gr. ij to 
5j of a saturated solution of boracic acid was ordered to be 
used after each cleansing of the ear, the pyoktanin then being 
used only once a day. Feb. 22nd. there was some swelling along 
the sterno-cleido-mastoid muscle about two inches below the 
auricle. Appetite poor, ordered phospho-muriate of quinine 
comp. The next few days the swelling and discharge were less. 
25th, quinine grs. v. twice a day was ordered. 26 and 27th. much 
less discharge, weather was fine and he had been going to his 
office a few hours each day, stopping to see me going and return- 
ing. 28th, a cold wintry day I insisted upon his remaining in 
doors which he did henceforth. Temp, and pulse normal, but 
swelling below the auricle was a little greater and more painful. 
Poultices were ordered to be applied constantly. The mastoid 
was not red, swollen or tender, the discharge was less but was 
very thick and Tenacious but not offensive. There were no 
granulations about the meatus or drum-head. Condition re- 
mained about the same for the next several days, but he would 
take very little nourishment. He was usually constipated, for 
this calomel and magnesia were given. On March 3rd. he had 
considerable thirst, temp. 97° pulse 100, swelling of the neck 
muscles greater. March 4th. Dr. James Kerr was called in 
consultation. Patient was decidedly weaker than he had been, 
somewhat listless, and indifferent to what was being done, pulse 
100, temp. 97° a. m., 98° p. m. Deep fluctuation could be made 
out under the sterno-cleido-mastoid muscle for the first time. E. Oliver Belt, M.D. 
5 
We decided that the pus should be evacuated, and at 12:30 the 
next day we met for that purpose. At first the patient was 
averse to having the operation performed but finally consented. 
He was dull and much weaker than usual. After much per- 
suasion he sat up for me to cleanse the ear, then walked into the 
adjoining room to be operated upon. He was opposed to taking 
chloroform or ether, so a few injections of cocaine were made 
over the mastoid process and over the abscess. Under strict 
antisepsis Dr. Kerr operated, assisted by Dr. Bowen and myself. 
Carefully cutting through the sterno-cleido-mastoid muscle and 
deep fascia, quite a large quantity of pus was evacuated. 
While cutting through the muscle the ear filled with pus. As 
these abscesses are nearly always the result of inflammation of 
the mastoid cells or periosteum, the mastoid was cut down upon. 
There was no evidence of peri-ostitis. The cells were then per- 
forated with a drill but no pus was found A bichloride solution 
1-2000 was injected but it did not pass through into the tym- 
panum. Pus seemed to be entering the abscess cavity directly 
from under the auricle. This cavity was syringed with the 
bichloride solution and both wounds filled with iodoform gauze. 
The patient stood the operation very well, had a good pulse but 
his face and extremities were a little cold. There was less 
sensibility to cutting than was expected from the cocaine alone. 
At five o'clock Dr. Bowen and I saw him again. He had been 
sleeping since the operation and we found him in a semi conscious 
state. An enema of warm water was given and he was induced 
to take some beef tea. Very little pus was found in the ear. 
Dr. Bowen called again at 11 o'clock, condition about the same. 
There was no pus in the ear. At 12:30 just twelve hours after 
the operation the patient quietly died, apparently of exhaustion. 
No autopsy was held. 
Cases of suppuration of the middle ear which terminate 
fatally are usually complicated with mastoid disease. But 
this is not always so. and death results from meningitis, 
cerebral abscess, hemorrhage, thrombosis, septicemia or ex- 
haustion. In this case there was no evidence of meningitis, 
hemorrhage, thrombosis or septicemia. There was no headache 
except occasionally over the right side of the head, and there 6 
Otitis Media-Abcess of Neck-Death. 
was absence of delirium, vertigo, nausea, vomiting, chills, sweats 
and paralysis. The pupil was normal and vision was not 
impaired. There was no fever, and during the last few days of 
his illness his pulse ranged from 100 to 110. The slight stupidity 
and sub-normal temperature for two or three days suggested the 
presence of cerebral abscess, but this complication is usually ac- 
companied with a slow pulse, and the sub-normal temperature 
in such cases is most marked in the evening,* which was not so 
in this case ; and in the absence of all other symptoms of brain 
abscess I am inclined to think that the fatal ending was due 
entirely to exhaustion. In looking over the literature of the 
subject I find very few cases of abscess of the neck secondary 
to ear trouble reported. Many text books do not refer to the 
subject more than to say that it is a grave complication. 
Pomeroy says that "Bezold, in the Deutsche Med. Wochenschrift, 
July 9th. 1881, describes a rather exceptional manner in which 
mastoid cell disease involves the muscles of the neck. lie has 
found that in some cases the mastoid bone at the digastric fossa, 
that is on the inner surface of the process, contains numerous 
cells which approach so near the surface of the bone that it is 
readily cut into with a knife, or even a probe may break through. 
At this unprotected point the pus escapes, and burrows deeply 
among the muscles of the neck. Such cases usually terminate 
fatally, either by exhaustion, or by involvement of the vertebra 
or base of the cranium with symptoms of paralysis, by oedema 
glottidis, or by burrowing of pus in the thoracic cavity. Deep 
incision and drainage caused a few of these cases to recover." 
Further on in speaking of fatal complications arising from 
suppurative otitis, Pomeroy says: "Purulent inflammation of 
the mastoid cells, when the mastoid ruptures at the inferior 
portion, at or near the digastric fossa, or in the outer part of the 
osseous meatus, causing the pus to burrow beneath the muscles 
of the neck may result fatally from the exhaustion incident to 
the purulent process." 
Dr. J. Orne Green, in speaking of such cases saysf " In case 
of extension into the digastric fossa, the indications are to 
*E. A. Baker. The Lancet 1887 vol. j p. 1175 
tReference Hand book of the Med. Science, Vol. ii p. 619. E. Oliver Belt, M.D. 
7 
evacuate the pus as soon after the carious perforation of the 
bone as possible." The accident he says is a rare one, his ex- 
perience, being limited to three cases, all of which showed the 
characteristic cellulitis of the neck described by Bezold. Two 
of the cases occurred years ago, and after developing deep 
abscesses in the neck died, one from pyemia, and one from ex- 
haustion, the third after an incision into the mastoid made a 
tedious recovery. 
Dr. Roosa in his treatise on diseases of the ear refers to two 
somewhat similar cases which recovered. 
In one case aged 23, the neck was swollen down to the clavicle, 
the mastoid region was swollen but not red or tender. The 
mastoid cells were opened with a drill, pus was found. Three 
weeks later an incision was made through the sterno-cleido- 
mastoid muscle and a large quantity of pus was evacuated. 
From this time the patient began to improve and finally recover- 
ed. The second patient was 45 years of age. lie had acute 
otitis media with great pain, the drum head was incised, sup- 
puration followed. Later on there was slight tenderness and 
swelling of the mastoid. A month after the beginning of the 
trouble the muscles of the neck were pronounced to be in a 
state of inflammation. For the next ten days the temperature 
ranged from 98| to 99J, with the pulse from 90 to 100. The 
swelling in the course of the sterno-cleido-mastoid muscle, and 
about the neck increased and the symptoms pointed to abscess. 
Consultations were held with six or eight of the leading aurists 
and surgeons of New York. They decided that operative in 
terference was not indicated and that supporting treatment was 
demanded. Whiskey and milk, iron and quinine were given, 
and poultices were constantly applied to the neck, after much 
suffering the swelling of the neck gradually subsided and the 
patient recovered. 
From a careful study of these cases I am inclined to think 
that we may be too conservative in regard to operating. Pus 
may form under the deep fascia of the neck some time before 
we have any positive external indication of it, and though it is 
possible for the suppuration to cease and the pus to be absorbed 
without surgical interference, it is usually after a great deal of 8 
Otitis Media-Abcess of Neck-Death. 
suffering and there is risk of septicemia ; and by the time we have 
positive evidence of the presence of pus the patient may be too 
exhausted to stand the operation. So in these cases when the 
cervical swelling does not promptly yield to our usual treatment 
and there is much suffering or exhaustion, cutting down upon 
the mastoid, and into the cells if necessary and through the 
muscles of the neck would seem to be indicated. Under the 
careful antiseptic surgery of the present day there is but little 
risk in the operations, and though pus should not be found the 
depletion of the parts would usually be beneficial. 
Too much attention cannot be given to keeping up the strength 
of the patient by good food, tonics and stimulants.