Under this treatment the pain should be relieved and the bulging of the drum should disappear in from two to twelve hours. If this is not accomplished or if the condition grows worse, the drum should be lanced. See some text on otology for technique. In my experience, very few cases have required paracentesis. It must be remembered that treatment should be continued regularly and for some time after the pain and other symptoms have been relieved or a recurrence is probable. Patients should have daily treatment until the physician is sure that no complication or recurrence is likely to result. If the patient is not seen until after the drum has ruptured, the same treatment may be applied except the irrigation or syringing of the meatus. This, in case of ruptured drum, may force pus into the mastoid cells resulting in mastoiditis. Instead of syringing, the auditory meatus is cleaned by means of a cotton applicator or by aspirating with a catheter. At all times drainage through the meatus must be maintained until the drum begins to heal. Acute Mastoiditis Acute mastoiditis results from acute or chronic otitis media. In some cases the otitis media may have been only a mild attack. =Diagnosis.=—There is no one symptom that is positively diagnostic but a number of signs and symptoms must be considered as follows: 1. Always suspect mastoid complications in acute otitis media and watch for this complication daily. Most cases have some mastoid inflammation. 2. Pain or swelling over mastoid. Pain may not be present, but usually is, sometimes radiating over temples and eye on affected side. 3. Tenderness on pressure not always present. May be very marked. Tenderness extending to tip or above ear means extension of infection. If persistent tenderness over tips with marked swelling and discoloration—operation is indicated. 4. Swelling, not always present, but sometimes very marked. If extreme swelling and bluish discoloration—usually means operation. 5. Temperature varies from normal to 104° or 105° F. Temperature of more than one or two degrees means systemic absorption and suggests surgical drainage. Streptococcus or staphylococcus infections cause higher temperatures and require drainage earlier than other infections. 6. Transillumination not positive, but of some value. Like X-ray, usually shows dark, because of inflammation, but must rely upon symptoms, as above. 7. =Microscopic.=—Stain for pus, bacteria and bone debris. Hematoxylin stain shows dark bone particles if there is bone disintegration. 8. =Blood Count.=—If absorption, there will be some variation in proportions of leucocytes. Any high leucocytosis shows systemic absorption and the natural attempt to overcome the infection. =Non-Surgical Treatment.=—1. Drainage must be maintained from middle ear through tube or drum or both. Catheter aspiration through tube. Sometimes gentle inflation to clear the tube, followed by aspiration is effective.