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Forty years of ear after ear, year after year
ACADEMY FOUNDATION DISTINGUISHED AWARD FOR CONTRIBUTIONS IN CLINICAL OTOLOGY
Forty years of ear after ear, year after year WILLIAM F. HOUSE, DDS, MD, Newport Beach, California
Dr. William E House has been selected to receive the 1995 Academy Foundation's Distinguished Award for Contributions in Clinical Otology. Dr. House is regarded by many as the founder of the field of neurotology as a distinct discipline. By applying the surgical William F. House, MD microscope and a detailed knowledge of the anatomy of the temporal bone, Dr. House's contributions have been numerous and varied. Among the many accomplishments cited by the special nomination and selection committee, Dr. House made practical the translabyrinthine approach for removal of acoustic tumors, resulting in faster recovery and improved preservation of facial nerve function. He developed the middle cranial fossa approach for temporal bone surgery, including the selective vestibular neurectomy. He developed the first practical cochlear implant and courageously applied it to children. He has developed more new concepts in otology than almost any other single person in history and thus has had a significant impact on otology and neurotology worldwide.
Presented at the Annual Meeting of the American Academy of Otolaryngology-Headand Neck Surgery, New Orleans, La., Sept. 17-20, 1995. Received for publication Oct. 23, 1995; accepted Oct. 23, 1995. Reprints not available from the author. Otolaryngol Head Neck Surg 1996;114:717-9. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00+ 0 23/39/71664
In July 1956 I finished a 3-year residency at Los Angeles County Hospital and started practice with my brother Howard. June and I had been married for 10 years, and Karen and David were in grammar school. It was the start of a great adventure that has lasted until this very day. It has taken us all over the world and given us many dear friends from countries everywhere. Through Howard's influence I had decided to limit my practice to the fledgling field of otology. I could not have had a better teacher to give me hands-on training in the art and practice of medicine and to show me what was then the state-of-the-art and practice of otology. Howard was very busy doing fenestration surgery, and it kept Jim Sheehy, Fred Linthicum, and me busy examining his patients and taking care of them after surgery. He was very willing to turn over his patients with chronic ear disease and dizziness to Fred, Jim, and me and would encourage these patients to let us do their surgery. I can remember taking 4 or 5 hours to do a radical mastoid with the headlight and loops, the two hands on the drill, and the squirt and suck technique, which was the way that mastoid surgery was done. But times were changing. The Zeiss microscope had just been introduced from Germany, and soon Howard had several of them, including one at the Los Angeles County morgue. Stapes mobilization was started by Rosen, and soon mobilizing the stapes through an otoscope was replaced by the John Shea stapedectomy using a microscope. I became a microscope afficionado and spent many evenings with, June at the morgue developing instrumentation to allow the suction irrigator to be used in one hand and the drill in the other. My dental background, which taught me to use a mirror in one hand and a drill in the other, helped me here. Within a couple of years 1 was doing two or three mastoid surgeries a week. Howard encouraged me, but I remember many of Howard's students and visitors being aghast at such a reckless technique. Several told me they could not understand why a young man with good eyesight should need a microscope just to drill out the mastoid. 717
718
HOUSE
Fortunately, I did not have a residency staff to take care of my patients, so I examined them, treated or operated on them, and took care of their cavities after surgery. Tympanoplasty with middle ear skin grafting was coming into vogue. I remember an older colleague telling me that he had decided that tympanoplasty was the new name for a three-stage radical mastoid. I must say I felt obliged to agree with him. Gradually, over the years, the concept of meticulous removal of all diseased middle ear and mastoid tissue, the facial recess approach with the intact canal wall, aeration of the middle ear and mastoid, and reconstruction of the ossicular chain developed. I remember presenting some of these concepts at a meeting of the American Otologic Society, and in the discussion an older colleague asked, "What's wrong with the tried and true radical mastoid?" The audience cheered. Seeing the sheer number of patients with otosclerosis who came to Howard and who had been treated by him over the years convinced me that progressive sensorineural hearing loss was a part of otosclerosis. Howard had developed a temporal bone bank program that has now become a national effort. Fred Linthicum in his early work with these willed temporal bones also became convinced that otosclerosis could cause sensorineural hearing loss and showed me temporal bones with extensive otosclerosis around the cochlea. At the time, this concept was strongly opposed by Hal Schuknecht. I became curious about how otosclerosis could cause progressive sensorineural hearing loss. A review of the literature on otosclerosis, which had been collected by the American Otologic Society into a two-volume book, provided some interesting leads. I was fascinated by several studies that showed otosclerotic lesions over the lateral end of the internal auditory canal, which the authors ascribed to progressive sensorineural hearing loss caused by cochlear nerve compression. The thought came to me that if only we could drill out these lesions somewhat like we drill out oval window otosclerotic lesions, maybe we could reverse the hearing loss. The trick would be to get to the lateral end of the internal auditory canal without injuring the cochlea or the facial nerve. I began a series of dissections in the morgue that ultimately led me to use the superior petrosal and facial nerve with continuous irrigation and diamond stones to guide me to the internal auditory canal. This has become known as the middle fossa approach. With a neurosurgeon colleague, Dr. Kurze, I first tried this on a totally deaf patient who I knew had otosclerosis from the studies done during the previous years in our office. I remember the date, because June was helping me in the operating room on her birthday, August 1, 1958. Unfortunately, the patient
Otolaryngology Head and Neck Surgery June 1996
did not regain any hearing, but in later years became one of my first 10 cochlear implant patients. In 1959 at an otosclerosis symposium in Detroit that was sponsored by Hal Schuknecht, I presented three patients who had middle fossa decompression of the internal auditory canal. None of them regained any hearing. I did indicate, however, that the approach could have other uses in terms of facial nerve problems or vestibular nerve section. I showed a slide of the incision with the patient's head upside-down. I was crushed when during the discussion a doctor stated that it was the first time he had seen a patient operated on upside-down. T h e audience laughed. Another discussant said he thought this was "ruthless human vivisection." This criticism affected my willingness to report my early work on cochlear implants, which Was just beginning and had resulted in two failures, but convinced me that cochlear implants had great promise. I simply did not want to be looked at like a crazy human vivisectionist. Fortunately, Howard backed me up and encouraged me to continue my efforts. During my residency I came under the influence of Gilbert Roy Owens, a wonderful otolaryngologist who invited me on a regular basis to his office to learn about sinus and mastoid x-ray techniques. He even had a special mastoid view called the Owen view that showed the petrous apex in a special way. He was a Strong advocate of x-raying all unilateral sensorineural hearing losses. He showed me x-ray studies of cases of blown out internal auditory canals that were later operated on for acoustic neuroma. I remember one of my teachers, Victor Goodhill, being an advocate of early diagnosis of acoustic neuromas. In my first year of practice I diagnosed, in a young fireman, an acoustic neuroma on the basis of x-ray films and unilateral hearing loss: I sent him to a neurosurgical colleague who told me he agreed with my diagnosis, but he did not believe the patient would be willing to trade a little hearing loss and tinnitus for a facial paralysis and a significant chance of mortality. A year later, the patient developed papilledema and underwent operation. I witnessed the very bloody operation with the patient in a seated position. He never regained consciousness. The surgeons remark was, "Of course you realize he had a very big tumor." It occurred to me that the only solution to early treatment of acoustic neuromas was to save the facial nerve. In the ensuing years, my first acoustic tumor approaches, which were done as a team with neurosurgeons, were through the middle fossa with the patient in the sitting position. It soon became apparent that it would be better to use a more otologic approach through the mastoid with the patient lying on the table, the translabyrinthine approach. A most unfortunate turf war developed with
Otolaryngology Head and Neck Surgery V o l u m e 114
HOUSE
Number 6
hearings before the executive committee of St. Vincent's hospital, in which the neurosurgical staff insisted that all patients with acoustic neuroma admitted to the hospital would be evaluated by them and that they would decide the approach to be used. By then I was working very harmoniously with Bill Hitselberger, and through Howard's intervention we were allowed to continue our acoustic neuroma work. One neurosurgeon, who was chairman of neurosurgery at the University of Southern California, resigned from St. Vincent's staff over the dispute. I was fortunate to have the Los Angeles County library nearby, and I remember deciding to peruse the literature on Meniere's disease. I came across an interesting article by Georges Portman published in 1925 about comparing Meniere's disease to glaucoma and therefore draining the endolymphatic sac to release the endolymphatic pressure. This prompted a series of dissections to surgically locate the endolymphatic sac and see whether it could be opened. During the next few years I developed endolymphatic sac surgery as a method of controlling the vertigo by correcting the endolymphatic fluid pressure and at the same time conserving the hearing. This surgical management of Meniere's disease was considerably different from the trans oval window destructive procedures of Day and Cauthorne or the vestibular nerve section of Dandy. In the discussion of this work when I first presented it at a medical meeting, a prominent otologist stated he had never seen a patient with Meniere's disease who needed surgery. I had seen a patient treated by this doctor, and the patient stated that he had been told nothing could be done for the dizzy spells and he would simply have to learn to live with them. I was surprised that the otologist
719
did not realize that once a patient is told that nothing can be done they are not likely to return with a request for more treatment. To assume that their lack of return was because they were cured seemed illogical to me. Today my emphasis is on the alleviation of sensorineural hearing loss through the cochlear implant. This has been an interesting saga of how clinical observation can lead to a different approach than would seem logical from trying to apply the theories of how the cochlea works. To understand the management of any otologic problem, you must continue long-term observation of the patients and do your best to try to help them. This commitment to clinical observation constantly pressures you to face the limitation of the present management of a particular clinical entity and think the problem through. You will be amazed at how this approach leads you to new solutions to difficult cases. Realize there will be criticism, but overcome this by keeping your eye on what you are trying to achieve. I hope only that the pressure of cost cutting medicine does not eliminate this time-consuming, hands-on doctor-patient relationship and the commitment to constantly improve what can be done for our patients. I am very disturbed by the ruthless cost cutting and emphasis on mass-production medicine that we are seeing today. I urge you as young doctors to realize how gratifying it can be to, above all else, work with your patients' problems and come up with better ways of solving their needs. I can tell you from personal experience that your patients' gratitude is very rewarding. The constant challenge to find new solutions to seemingly impossible problems will keep you from the burnout of monotony and make you proud to be a healer.
1-800-55-MOSBY This number links you to the full text of articles published in over 25,000 journals, including all Mosby journals. IVIOSBY Document Express ®, a rapid response information retrieval service, provides quick turnaround, 24-hour availability, and speedy delivery methods. For inquiries and pricing information, call our toll-free, 24-hour order line: 1-800-55-MOSBY; outside the United States: 415-259-5046; fax: 415-259-5019; E-mail: [email protected]. MOSBY Document Express® is offered in cooperation with Dynamic Information Corp.
Forty years of ear after ear, year after year WILLIAM F. HOUSE, DDS, MD, Newport Beach, California
Dr. William E House has been selected to receive the 1995 Academy Foundation's Distinguished Award for Contributions in Clinical Otology. Dr. House is regarded by many as the founder of the field of neurotology as a distinct discipline. By applying the surgical William F. House, MD microscope and a detailed knowledge of the anatomy of the temporal bone, Dr. House's contributions have been numerous and varied. Among the many accomplishments cited by the special nomination and selection committee, Dr. House made practical the translabyrinthine approach for removal of acoustic tumors, resulting in faster recovery and improved preservation of facial nerve function. He developed the middle cranial fossa approach for temporal bone surgery, including the selective vestibular neurectomy. He developed the first practical cochlear implant and courageously applied it to children. He has developed more new concepts in otology than almost any other single person in history and thus has had a significant impact on otology and neurotology worldwide.
Presented at the Annual Meeting of the American Academy of Otolaryngology-Headand Neck Surgery, New Orleans, La., Sept. 17-20, 1995. Received for publication Oct. 23, 1995; accepted Oct. 23, 1995. Reprints not available from the author. Otolaryngol Head Neck Surg 1996;114:717-9. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00+ 0 23/39/71664
In July 1956 I finished a 3-year residency at Los Angeles County Hospital and started practice with my brother Howard. June and I had been married for 10 years, and Karen and David were in grammar school. It was the start of a great adventure that has lasted until this very day. It has taken us all over the world and given us many dear friends from countries everywhere. Through Howard's influence I had decided to limit my practice to the fledgling field of otology. I could not have had a better teacher to give me hands-on training in the art and practice of medicine and to show me what was then the state-of-the-art and practice of otology. Howard was very busy doing fenestration surgery, and it kept Jim Sheehy, Fred Linthicum, and me busy examining his patients and taking care of them after surgery. He was very willing to turn over his patients with chronic ear disease and dizziness to Fred, Jim, and me and would encourage these patients to let us do their surgery. I can remember taking 4 or 5 hours to do a radical mastoid with the headlight and loops, the two hands on the drill, and the squirt and suck technique, which was the way that mastoid surgery was done. But times were changing. The Zeiss microscope had just been introduced from Germany, and soon Howard had several of them, including one at the Los Angeles County morgue. Stapes mobilization was started by Rosen, and soon mobilizing the stapes through an otoscope was replaced by the John Shea stapedectomy using a microscope. I became a microscope afficionado and spent many evenings with, June at the morgue developing instrumentation to allow the suction irrigator to be used in one hand and the drill in the other. My dental background, which taught me to use a mirror in one hand and a drill in the other, helped me here. Within a couple of years 1 was doing two or three mastoid surgeries a week. Howard encouraged me, but I remember many of Howard's students and visitors being aghast at such a reckless technique. Several told me they could not understand why a young man with good eyesight should need a microscope just to drill out the mastoid. 717
718
HOUSE
Fortunately, I did not have a residency staff to take care of my patients, so I examined them, treated or operated on them, and took care of their cavities after surgery. Tympanoplasty with middle ear skin grafting was coming into vogue. I remember an older colleague telling me that he had decided that tympanoplasty was the new name for a three-stage radical mastoid. I must say I felt obliged to agree with him. Gradually, over the years, the concept of meticulous removal of all diseased middle ear and mastoid tissue, the facial recess approach with the intact canal wall, aeration of the middle ear and mastoid, and reconstruction of the ossicular chain developed. I remember presenting some of these concepts at a meeting of the American Otologic Society, and in the discussion an older colleague asked, "What's wrong with the tried and true radical mastoid?" The audience cheered. Seeing the sheer number of patients with otosclerosis who came to Howard and who had been treated by him over the years convinced me that progressive sensorineural hearing loss was a part of otosclerosis. Howard had developed a temporal bone bank program that has now become a national effort. Fred Linthicum in his early work with these willed temporal bones also became convinced that otosclerosis could cause sensorineural hearing loss and showed me temporal bones with extensive otosclerosis around the cochlea. At the time, this concept was strongly opposed by Hal Schuknecht. I became curious about how otosclerosis could cause progressive sensorineural hearing loss. A review of the literature on otosclerosis, which had been collected by the American Otologic Society into a two-volume book, provided some interesting leads. I was fascinated by several studies that showed otosclerotic lesions over the lateral end of the internal auditory canal, which the authors ascribed to progressive sensorineural hearing loss caused by cochlear nerve compression. The thought came to me that if only we could drill out these lesions somewhat like we drill out oval window otosclerotic lesions, maybe we could reverse the hearing loss. The trick would be to get to the lateral end of the internal auditory canal without injuring the cochlea or the facial nerve. I began a series of dissections in the morgue that ultimately led me to use the superior petrosal and facial nerve with continuous irrigation and diamond stones to guide me to the internal auditory canal. This has become known as the middle fossa approach. With a neurosurgeon colleague, Dr. Kurze, I first tried this on a totally deaf patient who I knew had otosclerosis from the studies done during the previous years in our office. I remember the date, because June was helping me in the operating room on her birthday, August 1, 1958. Unfortunately, the patient
Otolaryngology Head and Neck Surgery June 1996
did not regain any hearing, but in later years became one of my first 10 cochlear implant patients. In 1959 at an otosclerosis symposium in Detroit that was sponsored by Hal Schuknecht, I presented three patients who had middle fossa decompression of the internal auditory canal. None of them regained any hearing. I did indicate, however, that the approach could have other uses in terms of facial nerve problems or vestibular nerve section. I showed a slide of the incision with the patient's head upside-down. I was crushed when during the discussion a doctor stated that it was the first time he had seen a patient operated on upside-down. T h e audience laughed. Another discussant said he thought this was "ruthless human vivisection." This criticism affected my willingness to report my early work on cochlear implants, which Was just beginning and had resulted in two failures, but convinced me that cochlear implants had great promise. I simply did not want to be looked at like a crazy human vivisectionist. Fortunately, Howard backed me up and encouraged me to continue my efforts. During my residency I came under the influence of Gilbert Roy Owens, a wonderful otolaryngologist who invited me on a regular basis to his office to learn about sinus and mastoid x-ray techniques. He even had a special mastoid view called the Owen view that showed the petrous apex in a special way. He was a Strong advocate of x-raying all unilateral sensorineural hearing losses. He showed me x-ray studies of cases of blown out internal auditory canals that were later operated on for acoustic neuroma. I remember one of my teachers, Victor Goodhill, being an advocate of early diagnosis of acoustic neuromas. In my first year of practice I diagnosed, in a young fireman, an acoustic neuroma on the basis of x-ray films and unilateral hearing loss: I sent him to a neurosurgical colleague who told me he agreed with my diagnosis, but he did not believe the patient would be willing to trade a little hearing loss and tinnitus for a facial paralysis and a significant chance of mortality. A year later, the patient developed papilledema and underwent operation. I witnessed the very bloody operation with the patient in a seated position. He never regained consciousness. The surgeons remark was, "Of course you realize he had a very big tumor." It occurred to me that the only solution to early treatment of acoustic neuromas was to save the facial nerve. In the ensuing years, my first acoustic tumor approaches, which were done as a team with neurosurgeons, were through the middle fossa with the patient in the sitting position. It soon became apparent that it would be better to use a more otologic approach through the mastoid with the patient lying on the table, the translabyrinthine approach. A most unfortunate turf war developed with
Otolaryngology Head and Neck Surgery V o l u m e 114
HOUSE
Number 6
hearings before the executive committee of St. Vincent's hospital, in which the neurosurgical staff insisted that all patients with acoustic neuroma admitted to the hospital would be evaluated by them and that they would decide the approach to be used. By then I was working very harmoniously with Bill Hitselberger, and through Howard's intervention we were allowed to continue our acoustic neuroma work. One neurosurgeon, who was chairman of neurosurgery at the University of Southern California, resigned from St. Vincent's staff over the dispute. I was fortunate to have the Los Angeles County library nearby, and I remember deciding to peruse the literature on Meniere's disease. I came across an interesting article by Georges Portman published in 1925 about comparing Meniere's disease to glaucoma and therefore draining the endolymphatic sac to release the endolymphatic pressure. This prompted a series of dissections to surgically locate the endolymphatic sac and see whether it could be opened. During the next few years I developed endolymphatic sac surgery as a method of controlling the vertigo by correcting the endolymphatic fluid pressure and at the same time conserving the hearing. This surgical management of Meniere's disease was considerably different from the trans oval window destructive procedures of Day and Cauthorne or the vestibular nerve section of Dandy. In the discussion of this work when I first presented it at a medical meeting, a prominent otologist stated he had never seen a patient with Meniere's disease who needed surgery. I had seen a patient treated by this doctor, and the patient stated that he had been told nothing could be done for the dizzy spells and he would simply have to learn to live with them. I was surprised that the otologist
719
did not realize that once a patient is told that nothing can be done they are not likely to return with a request for more treatment. To assume that their lack of return was because they were cured seemed illogical to me. Today my emphasis is on the alleviation of sensorineural hearing loss through the cochlear implant. This has been an interesting saga of how clinical observation can lead to a different approach than would seem logical from trying to apply the theories of how the cochlea works. To understand the management of any otologic problem, you must continue long-term observation of the patients and do your best to try to help them. This commitment to clinical observation constantly pressures you to face the limitation of the present management of a particular clinical entity and think the problem through. You will be amazed at how this approach leads you to new solutions to difficult cases. Realize there will be criticism, but overcome this by keeping your eye on what you are trying to achieve. I hope only that the pressure of cost cutting medicine does not eliminate this time-consuming, hands-on doctor-patient relationship and the commitment to constantly improve what can be done for our patients. I am very disturbed by the ruthless cost cutting and emphasis on mass-production medicine that we are seeing today. I urge you as young doctors to realize how gratifying it can be to, above all else, work with your patients' problems and come up with better ways of solving their needs. I can tell you from personal experience that your patients' gratitude is very rewarding. The constant challenge to find new solutions to seemingly impossible problems will keep you from the burnout of monotony and make you proud to be a healer.
1-800-55-MOSBY This number links you to the full text of articles published in over 25,000 journals, including all Mosby journals. IVIOSBY Document Express ®, a rapid response information retrieval service, provides quick turnaround, 24-hour availability, and speedy delivery methods. For inquiries and pricing information, call our toll-free, 24-hour order line: 1-800-55-MOSBY; outside the United States: 415-259-5046; fax: 415-259-5019; E-mail: [email protected]. MOSBY Document Express® is offered in cooperation with Dynamic Information Corp.