Labyrinthitis

MY special interest in Labyrinthitis commenced in Edinburgh in 1920 when I was a clinical Tutor in the clinic of the late Mr. T. S. Fraser. Here I learnt the rotation caloric and table tilting methods of testing the labyrinth, then in vogue. Every case of chronic mastoiditis was tested by rotation and caloric tests. I saw several labyrinthine operations, but all were fatal, death being due to meningitis. In 1922, I went to Bradford where I carried on the methods of testing the labyrinth that I had been taught in Edinburgh, with the same results, namely that in three years, 1922 to 1925, / had three cases of labyrinthitis on which I operated and three deaths from meningitis. My_ colleague, during this period, had done no operating on the labyrinth and so he had had no deaths from meningitis following labyrinthitis. When I, a young surgeon, became aware of this, I was extremely worried and thought about the matter a great deal. I soon discovered that my colleague did not test any labyrinth and I concluded that my testing of labyrinths in the presence of pus in the middle ear was responsible for the acute labyrinthitis and so the meningitis. In 1926, I decided to conduct an experiment. I stopped all testing of labyrinthine function in cases of infectedjnastoiditis. When there was a labyrinthine upset with symptoms, I rested the patient in bed, lying on his back, keeping the head steady with sand bags, the affected ear being uppermost. This experiment has now been going on for 27 years, but alas, as my clinical life is over, it is now ended. I gave some details of this work in my Presidential address to the Section of Otology of the Royal Society of Medicine in 1947 and this paper is a more detailed account of my views.

Vertigo, nystagmus, etc., which one is inclined to do aS c^arac^eristic of labyrinthitis. Many patients who sP?ntaneously complain of vertigo say that they can r ^"a^e more in the morning than a cup of tea ; they do the a&S?c^a*e this slight nausea with any aural trouble. On So hand, acute labyrinthitis may render the patient ^at his vertigo does not attract notice ; fever, prostra-0j anc^ Sequent vomiting lead to the mistaken diagnosis ?astric influenza. Between these extremes giddiness is *35 the common complaint, and may vary from unsteadiness on stooping or on exertion to attacks in which the sufferer falls to the ground. Varying degrees of ataxia may also be seen, e.g. the patient may complain that in hammering he frequently misses the nail and hits his left hand ; or he may find that in walking he must always keep to one side of a companion?if he tries the other he constantly jostles him-In the presence of middle-ear disease, even though the latter is of old standing and apparently unchanged disturbances of the stomach or of equilibrium (in its widest sense) demand the consideration of a possible connection.
A word may be said of one sign of labyrinthine diseaser the fistula sign. Otogenic labyrinthitis may be acute or chronic ; it may further involve the whole labyrinth, or a part only. In the latter case?circumscribed labyrinthitis?the labyrinth will resP?nd to some of the tests of function ; in the former?

As originally described by Barany
Pan-labyrinthitis?there will be no response, except perhaps during the first five or six hours. The distinction has been made between acute serous and acute suppurative Pan-labyrinthitis ; the diagnosis rests on whether there is 0r is not eventually some restoration of function, and clinically can hardly be made in the acute stage. Further, acute labyrinthitis may supervene on acute or on chronic uuddle-ear disease, or on chronic circumscribed labyrinthitis ; chronic labyrinthitis may follow an acute attack, or may be chronic ab initio ; indeed, cases have been described where entire labyrinth is destroyed, but so insidiously that *abyrinthine symptoms have never attracted attention, ^he severity of symptoms is related to the rapidity of destruction of function, rather than simply the extent of SUch destruction. The attacks were not severe, two or three a week. Auditory bone conduction was present, but diminished; labyrinth responded to tests ; never vomiting. Treatment greatly improved the condition.
At the end of February, 1924, he had an attack of vertigo very much more severe than ever before, with increase of discharge and pain in the ear. There was complete prostration, with much vomiting. Seen the next day he was still very ill> unable to walk alone.
Temp. ioo? F. Severe vertigo, spontaneous nystagmus (mixed) to the left. Ear deaf to tuning forks, labyrinthine tests entirely negative. He was admitted at once to hospital, and I curetted out the vestibular contents.
He made a good recovery, and is now free from all vertigo.
If the case is not seen within the first three days?the prognosis gets steadily worse hour by hour?different considerations arise. Either signs of meningitis will be appearing, or there is some hope that the infective invasion has been arrested. In the first case, surgical measures outside the scope of this paper may be proper ; in the second, we may congratulate our patient on a very fortunate issue. When the labyrinth is dead, either no operation should be done ; or if it is decided that a mastoid operation is necessary the labyrinth should be drained at the same time. The reason for this is the same as that applying in Case 1 above, tamely, that as the labyrinth is dead we shall get no warning a possible spread of acute infection (much more probable ln a case where the labyrinth is already the site of chronic disease than when the labyrinth is healthy), until meningitis occurs.
inf ^t'S8 ^?Chronic pan-labyrinthitis, following acute M., male, aged 53, miner. ^ay, 1921, c.c ' .,?P?ra^on n?t indicated. The left ear gives the " pseudoa sign, with a well-healed mastoid cavity. i It will be noticed that in Case 4 the prognosis is in doubt.
The patient is only 26, yet his vertigo, etc., quite prevent even the lightest work. Although one should regard with great reluctance the proposal to eviscerate a living labyrinth, circumstances may arise where this must be considered ; the risk, while definite, is not prohibitive, and the result may justify a bold course. Case 6.?Chronic progressive labyrinthitis, with fistula of the external semicircular canal; and disabling vertigo. Barany fistula test negative. Operation : relief.
S. P., male, aged 38, tin miner. June, 1922, c.c.o. deafness and discharge from the right ear ; occasional attacks of vertigo and vomiting. A radical mastoid operation was performed in 1916.
The ear showed a sodden, discharging mastoid cavity- Nausea became of daily occurrence, at first in the morning, then through the day ; vomiting became more and more frequent. Vertiginous attacks occurred two or three times a day; he felt as if spinning round to the left (diseased side) and objects seemed to move round to the right* he staggered but did not fall to the left. Several severe attack's overtook him, in which he fell to the right ; the other sensation were much more violent than usual, but he did not notice whether they were otherwise different. Such attacks may express the rarely seen phenomenon of dysharmony fro111 stimulation of the labyrinth?nearly always, the signs of diS" turbance due to disease point to dysharmony from depression of the labyrinthine function.
The man had for months been unable to do any work, and was steadily getting worse; Inasmuch as his whole hfe was becoming unbearably wretched, I put the situation befoi"e him, and it was decided to operate. March, 1924. At the operation I found a fistula fully 2 nu^wide leading into the external semicircular canal. I did a double vestibulotomy, carefully curetting the vestibular contents, and each ampulla in turn ; this point is of importance I; Vertigo immediately after the operation is to be avoided. r?m the time he recovered from the anaesthetic, he has not ad nausea, vomiting, or vertigo ; except that for the first hree weeks he had slight vertigo?much less than the mildest T^cks fr?m which he had suffered?on sudden movement. here was some trouble at first in walking, though at the Meeting this had disappeared, and he could walk even with the eyes shut, without difficulty. Facial paralysis came on on the second day, and was complete by the fourth ; this is now lrriproving. , The man's entire carriage and expression have altered. He as pU? Qn and feels well. His own description is : 3m quite my old self again."