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Modern Trends in the Treatment of Chronic Suppurative Middle Ear Disease *

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MODERN TRENDS IN THE TREATMENT OF CHRONIC SUPPURATIVE MIDDLE EAR DISEASE* By G. D. L. SMYTH, M.D., F.R.C.S., D.L.O. Royal Victoria and Belfast City Hospitals WE are now at a most exciting period in the history of otology-you might even call it a renaissance. Certainly the basic structure of the subject is under- going vast changes, and to keep in the front line of these changes and the impact they make is a challenge in itself. Even the theories about the pathogenesis of chronic suppurative otitis media, unchallenged for one hundred years, are being critically reassessed. A patient suffering from this condition usually gives a history of a discharging ear, often intermittent, frequenitlv beginninig in earl,y life and sometimes accom- panied by pain. Hearing is impaired to a variable degree, often severely, but Q~~~~~~~~~ u ATTIC MARGINAL "BENIGN" "MALIGNANT" Fig. 1-Types of perforation of the ear drum. because this symptom has usually progressed gradually, it causes less concern than does the discharge. This is particularlv the case when the other ear is normal. Always in the affected ear, there is a perforation of the drum, and perforations mlay be classified into two distinct groups (Fig. 1):- "Benign" perforations which do not reach the drum margin, and usually indicate only mild chaniges in the middle ear. "Malignant" perforations which involve the posterior margin of the drum or the 'attic,' that is the upper I of the drum. *An address to the Surgical Journal Club, Belfast. 44 A perforation of this type is frequently accompanied by chronic inflammation in the middle ear and mastoid, with granulations, ulceration of the mucosa, and underlying osteitis. These changes frequently appear to start close to the perforation, and to extend in time to involve the attic, and its contents, particularly the incus and the mastoid air cells. The thing which gives these perforations their sinister character is the frequency with which squamous epithelium migrates from the perforation edge

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