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History of stapedectomy
History Am ) Otolaryngol ,~:131-140, 1083
History of Stapedectomy ALLEND, H1LLEL,M,D.* The history of stapedectomy dates back to the late 19th century. Ntheugh oto~ogists in both the United States and Europe were performing stapedectomy operations at the turn of the century, stapes surgery ceased in the early 1900s. This paper examines the early and recent history of stapes surgery. An analysis of the early literature elucidates the reasons for the previous discontinuation of stapes surgery. (Key words: History; Stapedectomy.)
THE EARLY ERA OF STAPEDECTOMY . . . After the incision of the membrana tympani . . . . the incudo-stapedal articulation should be divided by means of the angular knife, the principal cutting being done from behind forward, the pressure in this direction being made against the pull of the stapedius muscle,
The tendon of the stapedius muscle may be next divided, and the straight knife used for the purpose also passed around the niche of the stapes, in order to divide any adhesions; the stapes may then be extracted either by means of the hook forceps, curved forceps or by a bhmt hook passed beneath the head of the stapes between the crura . . . .
This description of the technique of stapedectomy, in an article "Middle ear operations," by Clarence Blake of Boston, was published in the Transactions of the American Otologic Society in 1892. The similarity of Blake's description to Shambaugh's ~ description and illustration is striking. The history of stapes surgery dates back at least to 1853, when Toynbee a presented his description of ankylosis of the stapes and gave the first description of otosclerosis of the footplate. In 1876, KesseP removed the columella of pigeons, but also went on to remove the stapes in dogs. His audiometrics consisted of whistling and creating other sounds while the animals were sitting quietly or were asleep. Kessel concluded that it took eight days for a new membrane to form over the oval window and for the animals to regain hearing. However, one can be led to the conclusion that some of his animals did not hear too well, because Kessel apparently also resorted to the use of a pistol for some of his hearing tests. Received June 10, 1982; accepted for publication November 19, 1982. * Division of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, Stanford, California 94305. Address correspondence and reprint requests to Dr. Hill~l.
Clinically, Kessel proposed the removal of the tympanic membrane, malleus, and incus for the treatment of deafness. Baracz, '~ in 1887, used Kessel's methods; a description of the technique follows: "After tanotomy of the tensor tympani, a circumferential incision was made around the handle of the malleus to its base, by two perpendicular incisions and a lower transverse incision; the handle brought out by means of leverage from within and above downwards and outwards. The remnants of the tympanic membranes were seized in small hooks and excised, aiming especially at excision of the posterior inferior quadrant.' '~ In 1885, Lucae 7 reported his results using Kessel's stapes operation in 53 ears of 47 patients. He removed the malleus in all cases and the incus in six. Nine patients had considerable hearing improvement, and 19 slight improvement. In 1888, Boucheron s reported on 60 cases of stapes mobilization, as summarized in Otosclerosis~: "The operation consisted in separation of the incus from the stapes; exci.sioa of the posterior half of the tympanic membrane; mobilization of the stapes by gentle traction by means of a hook, moving th0 stapes back and forth and up and down by traction of the stapedial muscle; and, in some cases, removal of the malleus and incus." Boucheron found that the most favorable results are obtained in the early stages of stapes ankylosis: "If there is bony ankylosis and any involvement of the soundperceiving apparatus, it is too late to operate." Miot, ~ in France, reported in 1896 on the most consistent clinical trial of stapes surgery to that date. He used sterilized instruments, antiseptic preparation of the ear, and handwashing techniques described by Lister. He used general anesthesia with chloroform or topical anesthesia with cocaine. He reported on 200 cases, and his conclusion was similar to that of Boucheron, 131
HISTORY OF STAPEDECTOMY " . . . that the procedure gives its best results with beginning stapes ankylosis, and that it is useless with complete bony ankylosis of the baseplate." In his preoperative evaluation, Miot used the sign of paracusia willisiana as an indication for surgery. Miot also used the tuning fork, but his indication for surgery was that the "cranial perception of the tuning fork is better in the less affected ear. ''6 In 1892, Blake gave one of the first reports of stapedectomy in this country. L~Removal of the stapes in chronic nonsuppurative disease of the middle ear was attempted in 21 patients. The stapes was removed entirely in nine. Fracture of both arms occurred in ten. The stapes was immovable in two. A change in the pulse rate incident to traction on the stapes occurred in 12 patients. Vertigo occurred in six patients, with vertigo persisting for more than a month in three. Hearing improved in three patients. Frederick Jack, Blake's pupil, also reported a number of cases of stapedectomy in 1892." He concluded that his results were not consistently of benefit. By 1893, Jack had compiled a study of 60 cases, and he remarked that "most operations for mobilizing the stapes must be looked upon as largely experimental. '''2 In 1896, Grunert '~ made an astute observation. He realized the need for a normal round window for successful stapes surgery and wrote that pathologic changes at the r ound w i n d o w could ruin the results of a perfect operation. This description of the middle ear was the first that suggested an association between the round and oval windows. OBSERVATIONS OF THE EARLY ERA
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After reading the reports of so many efforts at stapes surgery in the 1890s, the discovery of successful middle ear surgery seemed imminent. If one did not know the results of the following 80 years of ear surgery, one would predict that one of these early investigators would have found our present-day s t a p e d e c t o m y t e c h n i q u e by about 1910. But that was not the case. Shambaugh, ~ in his d i s c u s s i o n of the h i s t o r y of stapedectomy, says, "It is remarkable, after these encouraging reports, including cases of successful stapedectomy, that Siebenmann, in 1900, should have stated: 'Clinical experience teaches that all endeavors at mobilization of the stapes in o t o s c l e r o s i s are not only useless, b u t often harmful.' The reasons for this concerted opposition are not clear . . . . At any rate, operations upon the stapes for otosclerosis were rather ab-
ruptly abandoned and remained in eclipse for half a century." Perhaps Blake, in his 1906 text co-authored by Henry Reiks of Johns Hopkins University, summarizes the experience of the late 1800s. In his 350-page book, Surgical Pathology and Treatment of Diseases of the Ear, 14 Blake devoted a mere two pages to the subject of stapedectomy. He remarked on his experience with 21 patients: In six of the cases, which had not before been dizzy, vertigo, more or less severe, followed the operation, in three cases persisting for more than a month, and in one for nearly a year; in but three out of the 21 cases was there other than temporary improvement in hearing, and then only in a moderate degree. In two cases the bone was found to be so absolutely immovable as to make it possible to rotate the head of the patients in a sitting position by traction upon the blunt hook inserted between the crura . . . . The operation of stapedectomy, while very simple in itself, is open to question as to its advisability, because of the varied consequences which may follow invasion of the cavity of the internal ear, and because of its doubtful value for the purpose for which it is usually demanded, amelioration of an extreme degree of deafness . . . . It should be borne in mind, that the fixation which causes extreme symptoms, either of deafness or vertigo, is not infrequently only secondary to a hyperosmotic process in labyrinthine capsule, which removal of the stapes cannot relieve. In 1897, Politzer wrote, " T h e m an y attempts by Kessel, Boucheron and Miot to mobilize and remobilize the rigid stapes in the niche of the oval window, which sometimes had a temporary, but short lived improvement of hearing, is completely abandoned. The same is sure with the extraction of the stapes w hi ch was tried out by Kessel, Jack, Dench and others. Experiments on animals in this d i r e c t i o n w ere m a d e by Botey, Faraci, Politzer and others. Blake, Knapp, Cheatle, and Politzer do not advocate this operation.",s Impressions as to why these pioneers failed to discover st apedect om y as it was done in the 1950s can be based on the reading of the discussion sessions that are the postscripts to some of the early articles, as well as from reading the texts. First, their surgical equipment, means of magnification, and light sources were primitive. As an example, their best light source was Lucae's reflector (Fig. 1) as described in Heine's text, Operations of the Ear, 16published in 1908. "The light must be good and for this, reflected daylight rarely suffices. I use mostly incandescent gaslight . . . . The reflector I always use is that s u g g e s t e d b y L u c a e , w h i c h is h e l d in the operator's teeth. This may seem unpleasant, but
HILLEL 9 . . Lucae's mirror can be brought nearer to the eye, and remains fixed in w h a t e v e r position it is placed, se that the constant fixing and altering of the position of the mirror is unnecessary. The m o u t h p i e c e is m a d e to fit the teeth accurately f r o m a cast p r e v i o u s l y taken a n d the metal parts are of a l u m i n u m , so that h o l d i n g it does not cause any discomfort." A n o t h e r great h a n d i c a p was the lack of stand a r d i z e d and r e p r o d u c i b l e a u d i o m e t r y . Their m e a n s of h u m a n audiologic evaluation were not too m u c h better t h a n Kessel's a u d i o m e t r y for his s t a p e d e c t o m i z e d dogs. Masking was not available, and the opposite ear was o c c l u d e d only by c o t t o n d u r i n g s p o k e n s p e e c h at various dist a n c e s . T o n e t e s t i n g was d o n e w i t h Koenig's rods and Galton's whistle. The original Galton whistle was felt to be unreliable above "14,000 s i m p l e vibrations in the second, ''~4 but the imp r o v e d G a l t o n w h i s t l e o v e r c a m e these inacc u r a c i e s a n d was t h o u g h t to be r e l i a b l e to "84,000 simple vibrations in the second. '''4 The w a t c h tick was felt to be too variable to be of m u c h use, so Politzer d e v e l o p e d the acoumeter (Fig. 2) in w h i c h a steel c y l i n d e r was struck by a steel h a m m e r , b o t h m o u n t e d in a " v u l c a n i t e f r a m e . " T h e n o r m a l ear h e a r d t h e P o l i t z e r a c o u m e t e r at 15 meters.'4 T u n i n g forks were used by otologists of the early 20th century, b u t their utility did not seem to have been recognized. This is exemplified by t h e i r incorrect usage by Miot e and by their cons p i c u o u s absence as preoperative versus postoperative examinations. P e r h a p s the greatest h a n d i c a p facing early otologists in their quest of a surgical cure for deafness was their a p p a r e n t lack of understanding of the m i d d l e ear transformer. Their ignor a n c e of assicular chain f u n c t i o n was demonstrated by their not infrequent performance of K e s s e l ' s o p e r a t i o n , r e m o v i n g the t y m p a n i c m e m b r a n e and ossicles to treat deafness. Even in the 1900s, the significance of the ossicular chain was not clear. Heine, in this 1908 textbook 18 on ear s u r g e r y , s e e m e d to a p p r o a c h an u n d e r s t a n d i n g of the m i d d l e ear w h e n he wrote: I admit that in many cases the discharge dries up mare rapidly after ossiculectomy, but we must also take into consideration the question of the hearing. If we have to deal with a perforation in Shrapnell's membrane (from which we conclude that the malleus is carious), the rest of the drum being intact, the hearing is generally normal or nearly so. The suppuration, we may take it, is confined to the attic; the remainder of the tympanic cavity is free and there is no pathological change in the parts most important for sound conduction--namely, round the fenestra ovalis and
Figure 1. Lucae'sreflector. Reflectormirror used to provide a light for ear surgery. The operator held the cast mouthpiece between his teeth. (Reprinted from Heine.'") the fenestra rotunda, If, however, in such a case, the malleus and the tympanic membrane are excised, injury to the hearing is possible or even probable. Further marked deafness is almost certain to be the result if we follow Schwartze who recommends removal of the incus as well. Blake, in his 1893 paper, '~ describes a patient who had "a past suppurative disease of the middle ear, a large perforation in the posterior segment of the right membrana tympani leaving the head of the stapes free . . . . A piece of sized paper of the kind ordinarily used for paper dressings and about 4 mm in diameter was pasted upon the head of the stapes, one edge resting upon the u p p e r rim of the perforation. With this paper in position, the hearing for the voice was doubled and the improvement continued so long as the paper remained in place." Although this might lead one to believe that Blake understood the middle ear, that illusion is shattered by a section in his paper' published slightly earlier. He was discussing the historical consideration of stapes operations: "The next step was the bolder one of Kessell's later suggestion . . . . which included the removal, not only of the membrana tympani, but also of the two larger
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HISTORY OF STAPEDECTOMY
Figure 2. Politzer'sacoumeterto measure hearing. The normal ear heard the sound made at 15 meters when the steel cylifider was struck by a steel hammer. (Reprinted from Blake and Reiks.~'t)
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elements of the ossicular chain, thus, not only allowing the sound waves to fall upon the stapes directly, but also of relieving that bone of the superincumbent weight and immobilizing effect of the larger ossicles." There were, however, many anecdotes that would lead one to believe that in the 1890s, understanding of middle ear surgery was near. A near-miss at understanding the tympanic membrane was the astute observation of Faraci,~7 who in 1899 reported 11 stapes mobilizations in 30 attempts (this is the same rate of successful mobilizations that Samuel Rosen reported in the 1950s). Although it is not stated in the source, the tympanic membrane and the malleus were probably removed, as that was the technique at the time. Seven of the 11 patients whose stapes were mobilized noticed improvements in hearing. In four of these cases hearing worsened, and in three or four others, Faraci observed that hearing worsened with closure of the surgically created tympanic perforation. Although we are now quick to recognize the correlation, Faraci did not understand the concept of hearing loss from membrane closure with ossicular discontinuity. The most tantalizing paper in terms of making one think that the comprehensive discovery of modern-day stapes surgery was imminent was published in 1898, by Dr. H.A. Alderton Ls of Brooklyn. He describes a patient who in 1896 was seen in his office with bilateral hearing loss. In March 1897, after the current conservative t h e r a p y failed, Alderton removed the incus through a p o s t e r i o r - s u p e r i o r quadrant tyro-
panic membrane flap. The patient's hearing did not improve. With the t y m p a n i c m e m b r a n e healed, Alderton, in the a u t u m n of 1897, attempted a stapedectomy, leaving the footplate behind as the crura broke and the patient became dizzy. After the operation, the patient heard much better, only to have her hearing return to the preoperative level in a few days. Possibly this relapse in hearing was related to the tympanic membrane healing. In January 1898, A1derton performed his third procedure: " . . . . The w r i t e r a g a i n t u r n e d d o w n the p o s t e r i o r superior quadrant of the drum membrane . . . . and, with a guarded trephine, drilled a hole through the stapedial footplate. Labyrinthine fluid escaped. No dizziness followed. The patient c o m p l a i n e d of m a r k e d a u t o p h o n y and bubbling noises in the ear." In March, A l d e r t o n n o t i c e d t h a t the flap sloughed. Although crude hearing tests showed no improvement, in September 1898, the pat i e n t wrote, " S i n c e the o p e r a t i o n p e r f o r m e d January 25th last, I have noticed some changes for the better in general hearing. I am not making the same amount of effort, every nerve strained to hear, and I can hear at longer distances and in larger places. Voices are clearer and sound more natural. My head feels more comfortable and clearer, not the 'shut up' sensation that has been there so long." Shortly afterwards, Alderton found that the perforation was nearly closed. No further follow-up is reported, but surely the patient was shortly due to return to a maximum conductive loss as the t y m p a n i c m e m b r a n e healed.
HILLEL This e n c o u r a g i n g close call at successful stapes surgery is countered by the work of Dr. Noltenius, who, in the same year, reported TM his efforts. As abstracted in Otosclerasis, 6 "The operation consisted in the first place, of turning forwards the concha together with detachment of the auditory meatus, ablation of the lateral tympanic wall, removal of the malleus and the incus; as the stapes was immovable fixed and its branches broke off on an attempt at extraction, the author took a blunt hook and with it pushed the stapes footplate inwards. Three days after the operation, a mild facial paresis followed increasing up to complete paralysis, but subsiding after six weeks . . . . " Noltenius stated that this operation had been done in three cases of advanced sclerosis with stapes ankylosis: in one the result was very favorable, in one negative; in the third case, tinnitus was relieved and the hearing somewhat improved: "Thus, it would seem that crushing the ankylosed footplate of the stapes and pushing it into the vestibule may be considered a justifiable and apparently safe operation in cases of sclerosis with stapes ankylosis, particularly if tinnitus is severe and if the sound-perceiving apparatus is intact." On that sad note, we entered the 20th century. THE EARLY 20th CENTURY
The next historic era belonged to Julius Lempert and his revolutionary fenestration opera t i o n - t h e first operation that successfully and practically restored hearing. With Lempert's operation, otology advanced from simply a practice of draining infected ears to the art and science of restoring the sense of hearing. Lempert's predecessors date back to 1897, when Passow 2~made a window in the promontory and covered it with a piece of periosteum. An improvement of hearing resulted but the improvement was transitory. In 1899, Floderus 2' described "sound fistulas" made at the outer wall of the labyrinthine capsule or in the ampulla of the external horizontal canal. He also dabbled in stapes and other middle ear surgery and dismissed the entire topic of stapes sclerosis by proclaiming that stapes mobilization is practically without value; that other operations give but temporary, if any, relief; and that extraction of the stapes is not recommended. In 1913, Jenkins '~2 made a window in the horizontal canal with excellent, although only temporary, results. In 1923, Holmgren 2~began using 10x magnification during his surgery, thereby formally beginning the era of microsurgical
otology. He described four patients in whom he attempted the creation of a w i n d o w in the labyrinthine capsule between the round and oval windows. He had good success in one patient, moderate success in another, and very little success in the third, due, according to Holmgren, to making too small a fenestra. In his fourth patient, after removing the tympanic membrane, malleus, and incus, he accidentally mobilized the stapes with good results. Holmgren, in addition to his innovative use of the microscope, described the use of the rotating burr drill for bone removal during ear surgery. In 1924, SourdilF 4 devised a three- or fourstage (later reduced to a two-stage) operation to put a window in the horizontal canal. The interval to complete all the stages was about a year. Sourdille's operation was never popular because of the extensive time of treatment and frequent bony closure of the window. In the late 1920s, the American Otolagic Society commissioned a committee to compile a resum~ of the literature to July 1928. The commission was funded by a $90,000 grant from the Carnegie Corporation. The product of the commission's efforts was a 700-page, two-volume publication entitled Otosclerosis, U which was published in 1929. This publication reported on the histologic changes of the eric capsule, heredity, symptoms, audiology, and treatment of otosclerosis, and gave illustrative cases. The summary of surgical treatment was to the time of Holmgren's work on labyrinthine windows. Sourdille's work in 1924 with horizontal canal windows was not mentioned. The summary of the nonsurgical treatment of otosclerosis is historical, and merits a brief chronological presentation of medical management of otasclerosis to that time. In the 1870s, treatments included politzerizatian, and also a Siegle otoscope attached to a double-valved stomach pump for forcible massage of the tympanic membrane. During the 1880s, forcible iodine vapor treatments, sound pressure, iodoform petroleum jelly applied through the eustachian tube, tragal massage to "exercise the ossicles," iodized air in conjunction with galvanic current, and eustachian tube instillation with a mixture of sodium bicarbonate, distilled water, and glycerine were in vogue. The 1890s brought catheter instillation of the eustachian tube, eustachian bougies; chloroform, ether, bromethyl, or iodine crystals in the Roosa bulb inhaler; also, vapor of camphor, eustachian tube air douche, oil injections and methyl vapor through the eustachian tube. In
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1895, Dr. Bellous i n t r o d u c e d the "vibrometer," which i m pr oved hearing with an average gain of 11.3 per cent during its first six months of use, and an average gain of 14.1 per cent in the second six months of its use. The better results in the s e cond group of patients were probably attributable to added e x p e r i e n c e in the use of the vibrometer. The 1900s brought Lucae's "vibratory massage instrument," the tip of w h i c h was placed on the short process of the malleus. In 1901, Bonnfer's " t y m p a n a - m o t o r " g r a s p e d the h a n d l e of the malleus and moved it with control by aspiration th r o u gh an attached r ubbe r tube. Koenig and Lucae developed the " s p r i n g sound direct massage" w i t h a mold of w a r m paraffin pressed onto the short process. Other methods in the 1900s were electrolytic dilation of the eustachian tube, instillation into the ear of Watson's preparation from b one marrow, w h i c h he called myelocene, s o u n d m a s s a g e w i t h M a r age's w h i s t l e , and Jaulin's radiation t h e r a p y directed t h r o u g h a tu b e t h r o u g h a s p e c u l u m onto the t y m p a n i c membrane. The 1910s offered electric treatment with one electrode on a metal ear s pe c ul um and the other in the eustachian tube. On occasion, mercury was p o u r e d on the t y m p a n i c membrane for better attachment of the external electrode. Cotton pledgers were glued to the tympanic m e m b r a n e so that traction t r e a t m e n t s could be applied. Radium pencils w e r e p l a c e d in the external canal for 40-minute treatments to "destroy the terminal acousticus." The 1920s were years of further refinement of electric currents, r a d i a t i o n therapy, and subperiosteal injections of " p a n i t r i n . " The ElectroP h o n o i d e method of Z u n d and Burgust was used as a means to reeducate t he ears by applying s o u n d f r e q u e n c i e s to the ear t h r o u g h o u t the h u m a n s peech range. A treatment of the late 1920s was Hollender and Cattle's electric diathermy to heat the petrous portion of the temporal bone: T he head was treated with a 3- to 400-mA current a p p l i e d three to four times per week through a headband with suitable electrodes.
THE EARLY ERA OF SUCCESSFUL SURGERY FOR THE RESTORATION OF HEARING AmericQn Journal
of Otolaryngology 136
In 1938, Julius L e m p e r t "~ i n t r o d u c e d the single-stage endaural a p p r o a c h that he called the Lempert fenestration procedure. I,empert also had problems with b o n y closure of the window,
but the s i m p l i c i t y , r e l a t i v e to S o u r d i l l e ' s method, merited the failure rate. L e m p e r t improved the operation by rem ovi ng th e i n c u s , w hi ch he found did not affect the hearing, a n d thus with more exposure, moved the w i n d o w down on the ampullate end of the h o r i z o n t a l canal. F u r t h e r i m p r o v e m e n t s were m a d e b y Shambaugh's '26 use of constant irrigation w h i l e drilling in order to wash away the b o n e dust. Shambaugh also advocated the use of a seven-
power operating microscope. As an overview of otology before th e " n e w 1950s era" of middle ear surgery, one can r e v i e w an article w ri t t en for the n o n - o t o l o g y w o r l d p u b l i s h e d in a 1945 issue of California and Western Medicine. The articles 7 by Dr. H o w a r d House, was entitled "What can be done for the deafened today." The lack of u n d e r s t a n d i n g of the middle ear that seemingly d o m i n a t e d t h e 1890s was no longer present. Even t h o u g h th e function of the ossicles was known, little was being done to use that knowledge to r e c o n s t r u c t the ear. The treatment of nonotosclerotic deafness, o n occasion, still included the use of o s s i c u l e c t o m y to allow for proper contact of an artificial tympanic membrane. These artificial m e m b r a n e s were constructed of cotton pledgers, c e l l o p h a n e cones, molded rubber, or a diaphragm rod. In each patient, the "hearing-sensitive a r e a " was found, and the new ear drum was a p p l i e d to it. The Pohlman insert was a small artificial d r u m on a toothpick-sized rod. The patient a p p l i e d t h e insert until it t o u c h e d the hearing-sensitive area. Hearing was measured by audiometers t h e n , a n d it was estimated that the gain provided by t h e artificial tympanic membranes was 20 to 30 dB. For otosclerosis, Dr. H o u s e e x p l a i n e d t h e Lempert fenestration procedure. He cited a 65 per cent chance of the fenestra's r e m a i n i n g o p e n and remarked that closure, if it occurs, is rare past six months. He also cited a 2 per c e n t incidence of severe complications and listed these as labyrinthine damage, infection, meningitis, a n d facial paralysis. Before leaving the 1940s, one other m i d d l e ear operation introduced then should be d i s c u s s e d , not because of its merit in restoring hearing, but because its surgical approach was a f o r e r u n n e r of modern stapedectomy. In 1946, L e m p e rt published his results "8 of t y m p a n o s y m p a t h e c t o m y performed in 15 patients to treat vertigo. Lempert first explained his research into the matter. During fenestration operations, he u s e d Zeiss magnifying lenses to examine the p r o m o n t o r y in 100 patients who complained of tinnitus. In all
HILLEL
Fiftystapes removed from fresh cadavers with the footplates fixed in cement. Rosen used this arrangementto pracrice palpation of the capitulum. [Reprinted with permission from Rosen.:"}
Figure 3.
100 patients, he found either a normal or, occasionally, an enlarged tympanic plexus. Lempert also e x a m i n e d the promontory in 60 patients who h a d no tinnitus and found total absence of the t y m p a n i c p l e x u s . He p e r f o r m e d tymp a n o s y m p a t h e c t o m y procedures in 15 patients who complained of severe vertigo, and recorded results that showed complete resolution of the s y m p t o m s of tinnitus in ten of the 15 patients. Lempert's presentation of his surgical technique of t y m p a n o s y m p a t h e c t o m y described a nondestructive approach to the middle ear by elevating an a n n u l a r flap in conjunction with preservation of the tympanic membrane. THE MODERN ERA OF MIDDLE EAR SURGERY
The era of contemporary middle ear surgery began with Dr. Samuel Rosen. In the late 1940s, Rosen ~'J was in practice at Mt. Sinai Hospital in New York City. Also in New York City was the Endaural Hospital, Julius Lempert's private hospital, where he did his fenestration procedures. The Endaural Hospital was also where Lempert c o n d u c t e d his six-week fenestration course for ear surgeons and, in addition, was the location of the Lempert Otolagic Society and the Lempert Research Foundation. In 1947, Rosen studied with Lempert. He then r e t u r n e d to Mt. Sinai to become a well-known fenestration surgeon. Rosen also had learned L e m p e r t ' s t y m p a n o s y m p a t h e c t o m y procedure and e x p a n d e d on it to develop a new operation for M~ni~re's disease2 ~ In 1952, Rosen was demonstrating a fenestration operation for Dr. Franz Altmann of Vienna. After removing the incus and cutting between the head and neck of the malleus, Rosen palpated the stapes and saw that it moved. Rosen knew that a mobile stapes would cancel the perilymph wave from the fenestra and realized that, in this patient, the fenestration operation would not be
of much benefit. Because of the removal of the ossicular chain, Rosen felt compelled to complete the procedure and, as expected, the patient had a poor result. Altmann admitted that this experience had occurred at least once to him too, and Rosen became convinced that palpation of the stapes before fenestration was necessary. He recalled his abandoned operation for M6ni~re's disease and realized that the same approach that he had used for it would expose the head of the stapes for palpation. He first experimented by glueing 50 stapes to a board (Fig. 3) and palpated the capitulum of each to be sure that in all stapes the crura are rigid so as not to allow movement of the capitulurn and mimic a mobile footplate. 'a' Rosen went on to do a preliminary stapes palpation in his next six candidates for fenestration, and published his results in 19522' Three of the six had fixed stapes so he accepted them for fenestration. Rosen felt that two patients had partially mobile stapes and chose not to operate on them. The sixth patient claimed that after Rosen palpated his stapes, he could hear everything. Rosen's paper was very reserved. It emphasized the recommendation of palpating the stapes before f e n e s t r a t i o n , a n d c a s u a l l y remarked that loosening the stapes might be of benefit. (Rosen's description of the event in a film ~'-'with Howard House and John Shea, and in Rosen's autobiography, is rather dramatic, however.) Rosen described his palpation of the patient's stapes. Unsure whether it had moved, he pushed it a little harder until he was sure it moved. Disappointed that he would be unable to help this man, Rosen asked for the suction, and the patient stated that he now heard everything. The patient went on to tell of a metal instrument that had hit a bucket a few rooms down the hall, and Rosen recalled the sound that he had ignored because it was so familiar. Rosen asked him whether he could hear, and the patient replied, " S u r e . "
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Figure 4. Eight-ounceweight suspended from the neck of the stapes to determinepressure required to fracturethe neck of the crura. This apparatus formed another of Rasen's experiments to determine the characteristics of the normal stapes. (Reprintedwith permission from Rosen.a3)
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Rosen was concerned that the response was the reply of a hopeful patient who had anticipated his doctor's obvious first question, so Rosen asked him the famous egg question, "Do you like your eggs scrambled or fried? . . . . Oh, I prefer them scrambled," was the reply. The patient's hearing remained good, and reluctantly Rosen allowed him to return home to Wisconsin. The patient dutifully called every two weeks and reported normal hearing. At the end of each call, he would ask Rosen when he could have the other ear done. Rosen delayed because he had to have time to determine what had happened. Rosen began night work in a basement on cadavers he had illegally purchased from the diener of a medical school. Once or twice, he narrowly escaped disclosure. One example of the difficulty he had with his research occurred at his summer home in Katonah, where he practiced at night on summer weekends. One morning the police arrived to investigate, telling of a witness who had seen Dr. Rosen with parts of human bodies. There had recently been two murders in the area, and they were there to investigate. Rosen s h o w e d them his cadaver heads, ex-
plained his work, and, somewhat reluctantly, the police drove off. Rosen had special instruments made by Fred Grafrath and practiced incessantly. He developed his touch by lying awake in bed pushing the tip of his instruments through apple peels held on his thumb, considering it a success only when he could push the tip through the peel without its being f e l t b y his t h u m b b e n e a t h . Rosen learned to curet the scutum for more exposure, and did experiments on the stapes. He demonstrated the strength of the stapes with wires and weights (Fig. 4).3s He might have been assured of the stapes' incredible strength if he h a d read Blake's text where Blake describes turning the heads of two patients by pulling on the stapes when attempting stapedectomy. '~ When Rosen had finished his experiments, he scientifically proceeded with a second patient. Fortunately, his second patient was also one of the three per ten in w h o m mobilization was possible. Rosen took the care to obtain irrefutable independent audiologic documentation for his patients. In May 1953, he presented his first five patients who had undergone mobilization at the Medical Society of the State of New York. ~ He then began a persistent battle to overcome the resistance of his colleagues who claimed that the Rosen procedure existed, but was dangerous, and caused permanent nerve damage to the unfortunate victim. Rosen's liberal political beliefs were implicated as his work was proclaimed to be part of what critics called his communist proclivities. Rosen went abroad and presented his data to Sir Terrence Cawthorne, the leading otologist in England. Warmly received by Cawthorne, Rosen attempted to mobilize the stapes of one of Cawthorne's patients. Again, fortune was with him, for this patient was also one of the three per ten who had a stapes that could be mobilized. Cawthorne's high opinion of Rosen accompanied the pioneer back to New York, and Rosen was on his way to educating American otologistsY 4 The early events of acceptance of Rosen's work in the United States have been summarized by Dr. Victor Goodhill (personal communication): A Los Angeles otolaryngologist, Dr. George Frankel, who had otosclerosis went to see Dr. Rosen and was operated on by him. A mobilization apparently was successful on Dr. Frankel. He in turn began to perform mobilizations in the Los Angeles area. Shortly thereafter Dr. Rosen placed two long-distance telephone calls, one to Dr, George Shambaugh and the other to me. He told us both of his difficulties with the otologic fraternity in New York City and the problems at some of the hospitals where he was allowed to operate because of a good deal of opposition to his
HILLEL mobilization procedures. Dr. Shambaugh and I agreed to come to New York specifically for the purpose of examining Dr. Rosen's patients otologically and audiometrically, personally, preoperatively, observing the surgical procedure, and then doing independent postoperative examinations and audiograms without the use of technicians. I believe Dr. Shambaugh and I spent about ten to 14 days in New York at that time on this project. Both of us very definitely saw some substantive improvements in hearing in patients we examined and observed. Dr. Shambaugh returned to Chicago and I returned to Los Angeles. I was sufficiently impressed with this experience that I began to perform stapes mobilizations as soon as I returned. To the best of my knowledge, therefore, the first stapes operations performed in California were perfermed by Dr. Frankel and I followed him. My colleagues soon joined me. Within a few months Dr. Eugene Derlacki, Dr. Shambaugh's associate at that time, came to visit me in Los Angeles and observed a number of my cases. He was sufficiently impressed that when he returned to Chicago both he and Dr. Shambaugh began to do stapes mobilization in the Chicago area. E d w a r d (Edmund) Fowler d e v e l o p e d the anterior c r u r o t o m y t e c h n i q u e a'5 of stapes mobilizat i o n for cases in w h i c h there was a simple focus of otosclerotic p l a q u e fixing the footplate. Rosen b e g a n to scratch holes in the t h i c k e n e d plaques to enable him to mobilize an otherwise inoperable stapes. With these techniques, stapes mobilization became a 50 to 60 per cent successful proc e d u r e rather t h a n a 30 per cent successful procedure. John Shea also came to N e w York to study w i t h Rosen, and at Rosen's insistence, went to s t u d y in Vienna, w h e r e there was a more available s u p p l y of cadavers. Shea r e t u r n e d and, in 1956, r e o p e n e d the era of s t a p e d e c t o m y with a skin graft to cover the o p e n oval window. 36 His first prosthesis was based on extensive studies by h i m and an engineer w h o h a d t h o r o u g h l y investigated the stress lines of a h u m a n stapes. Shea, in the film with House and Rosen, laughed about his first belief that the prosthesis must look like a h u m a n stapes a6 (Fig. 5). In 1958, Shea s7 described the operative t e c h n i q u e of modern-day s t a p e d e c t o m y and i n t r o d u c e d the use of the vein graft in conjunction w i t h a p o l y e t h y l e n e strut as the ossicular replacement. Mobilization had b e c o m e the preliminary to the Lempert fenestration and the stapedectomy p r o c e d u r e rapidly replaced both of its immediate a n c e s t o r s . In the 1950s a n d all t h r o u g h the 1960s, thousands of stapedectomies were being p e r f o r m e d o n all t h e p r e v i o u s l y u n t r e a t e d otosclerotic ears. Since Shea's r e d i s c o v e r y , the stapedectomy p r o c e d u r e has been constantly refined, and the r e s u l t s h a v e i m p r o v e d . M e a n w h i l e , as the
Figure 5. An early stapes prosthesis designed by John Shea and his engineer. (Reprinted with permission from Shea.~") backlog of otosclerotic patients has diminished, there has been a decrease in the n u m b e r of such procedures being performed, and the stapes ope r a t i o n is b e c o m i n g a rare one for m a n y otolaryngologists. An interesting note in the h u m a n aspect of the history of stapedectomy is the life of Julius Lempert, after the work of Sam Rosen and John Shea. Rosen, in his autobiography, describes a great admiration for Lempert's talents, but tells of a rather sad ending to the relationship. In 1956, Rosen had a poster exhibit at the American Medical Association meeting. He left the exhibit during a recess a n d w h e n he c a m e back, he saw Lempert staring at it from about 20 feet away. Rosen approached him a n d tried to induce h i m to walk to the exhibit and allow Rosen to show it to him. "He stood there, saying not a word. His hands thrust into the side pockets of his jacket, his eyes seemingly looking right t h r o u g h me. It was as if he had h e a r d nothing, seen nothing. Then abruptly he turned and walked away quickly." As late as 1959, Lempert published an article s8 entitled "Principles used in the development of modern temporal bone surgery." He discussed the history of ear surgery, and again spoke of the success of the Lempert fenestration. He concluded his article with some words about stapes mobilization: It does not seem reasonable to assume that the great surgeons of that period [late 1800s] . . . would have abandoned the use of a technique which initially seemed to offer so much . . . . Given a group of outstanding ear surgeons and any technique for possible improvement of hearing, is it not logical to assume that if the procedure offered even limited success, it would have been tried?... As of this writing, no one has attempted to explain this historical anomaly. Although there are many accounts of the clinical success of the procedure since its reintroduction five years ago, there is yet a complete dearth of convincing evidence which would justify its use on fundamental surgical principles . . . . Mobilization of the stapes, as practiced today, is a destructive, nonsurgical orthopedic procedure with complete disregard for the
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HISTORY OF STAPEDECTOMY b i o l o g i c a l and p h y s i o l o g i c a l factors u p o n w h i c h m a i n t e n a n c e of t h e i m p r o v e m e n t w i l l d e p e n d .
COMMENT It is clear that in the 1880s there were some isolated results that were as dramatic as Sam Reson's first mobilization. These few patients were the cause of as much excitement for their physicians as were Dr. Rosen's. The difference between the 1880s and the 1950s lay in the understanding of the middle ear transformer and the availability of audiometry as a diagnostic tool. In the 1890s, the excellent results in the few patients were not reproducible. None knew what had caused the return of hearing, and no one could accurately measure the patients' hearing before or after surgery. The ossicular chain was not understood. Most of all, because of these shortcomings, the true otosclerotic patient was not always the one w h o h a d the attempted stapes mobilization. Therefore, the operation was doomed to bad repute, and with its abandonment came the essential abandonment of middle ear reconstructive surgery. Stapedectomy, an operation discovered ahead of its time, became dormant for the half century needed for otologists to discover the principles to harness it.
References
American Journal of Otolaryngolagy 140
1. Blake C: Middle ear operations. Trans Am Otol Sac 512:306, 1982 2. Shambaugh G: Surgery of the Ear. Philadelphia, W. B. Sounders, 1967 3. Toynbee i: Case of complete bony ankylosis of the stapes to the fenestra ovalis. Trans Pathol Sos London 4:253, 1853 4. Kessel J: Ueber die Durchschneidung des Steigbugelmuskels beim Menschen Arch Ohrenheilkd 8:321, 1874; 11'.199, 1876; 12:237, 1877, as abstracted from Bellucci R: Repair and consequences of surgical trauma to the ossicles and oval window of experimental animals. Trans Am Oral Sac 1958 5. Baracz R: Die Exzisien des Trommeifells sammt Hammer bei Sklerose der Paukenschleimhaut. Wien Mad Wochenschr 37:290, 1887 (as described in Otosclerosis ~1 6. Otosclerosis. American Otologic Society, 1929 7. Lucae A: Uabet operative Entfernung des Trommelfells und der beiden grosseren Gehorknochelchen bei Sklerose de Paukenschleimhaug. Arch Ohrenheilkd 22'.233, 1885 [as described in Otosclerosis") 8. Boucheron E: La mobilisetion de i'etrier et son precede operatoine union, Mad Paris 46:412, 1888 (as described in Otosclerosis G) 9, Miot C: De la mobilisetion de l'etrier. Rev Laryngol :[0"49, 83,145,200, 1690 (as described in Shambaugh~ and Otosclerosis s)
10. Blake C: Stapedectomy and other middle ear operations. Trans Am Otol Sac 5:464, 1891-1893 11. Jack F: Further observations on removal of the stapes. Traus Am Otal Sac 1893 12. Jack F: Remarks on stapedectomy. Trans Am Otol Sac 6:102, 1893 13. Grunert K: Was Konnen wir van der operativen Entferhung de Steigbugels bei Steigbugel-Vorhofankylose zum z w e k der Horrerbesserung e r h o f f e n ? Arch Ohrenheilkd 41:294, 1896 (as described in Otosclerosis ~) 14. Blake C, Reiks H: Surgicat Pathology and Treatment of Diseases of the Ear. New York, D. Appleton & Co., 1906 15. Politzer A, as quoted in Lempert J: Principles used in the development of modern temporal bone surgery. Arch Otolaryngol 69:515, 1959 16. Heine: Operations of the Ear. New York, William Wood & Co., 1908 17. Faraci G: Importanza acustica e funzgionale della mobilizzazione della statta; risultati di una nuova serie di operazioni. Arch Ital Oral 9:209, 1899 (as described in Otosclerosis 6) 18. Alderton HA: Trephining of the stapedial footp[ate for otitis media sclerosa. Trans Am eta( Sac 4(1):60, 1899 19. Noltenius: Zur Frage der operativen Behandlung der Stapesankylese. Verh Dtsch Otol Ges 7:173, 1899 (abstracted in Otosclerosid ~) 20. Passow H, in Panse R: Discussion. Verh Dtsch Otol Ges 6;141, 1897 (as described in Otosclerosis ~) 21. Floderus B: Bidrag till stigbygelankylosens operativa radikalbehandlung. Nard Mad Arch 32:1, 1899 (as described in Shambaugh 2 and Otosclerosis ~) 22. Jenkins GJ: Otosclerosis: certain clinical features and experimental operative procedures. Trans XVII Int Congr Mad 16:609, 1913 (as described in Shambaugh '2 and Otosclerosis") 23. H o l m g r e n G: Some experiences in the surgery of otosclerosis. Acta Otolaryngol 5:460, 1923 24. Sourdille M: New techniques in the surgical treatment of progressive deafness from otosclerosis. Bull NY Acad Mad 13:673, 1.937 25. Lempert ]: h n p r o v e m e n t of h e a r i n g in cases of otosclerosis. Arch Otolaryngol 28:42, 1938 26. Shambaugh G: The surgical treatment of deafness. Ill Mad I, February 1942, p 104 27. House H: What can be done for the deafened today. Calif Western Med 63:3, 1945 28. Lempert J: Tympanosympathectomy. Arch Otolaxyngol 43:199, 1946 29. Rosen S: The Autobiography of Dr. Samuel Rosen. New York, Alfred Knopf, 1973 30. Rosen S: Surgery in Meniere's disease: a new operation which preserves the labyrinth. Ann Otol 60:657, 1951 31. Rosen S: Palpation of the stapes for fixation. Arch Otolaryngol 56:619, 1952 32. Rosen S, House H, Shea J: Film discussion. Los Angeles, Ear Research institute 33. Rosen S: Mobilization af the stapes to restore hearing in etosclerosis. NY State J Mad 53:2650, 1953 34. Rosen S: Results of mobilization of fixed stapedial footplate in otosclerottc deafness. JAMA 161:595, 1956 35. Goodhill V, Shea J, Derlacki E, Schuknecht H, Fowler E, Juers A, House H: Otosclerosis symposium. Arch Otolaryngol 71;246, 1960 36. Shea J: The operation for the mobilization of the stapes in otosclerotic deafness. Laryngoscope 66:729, 1956 37. Shea J: Fenestration of the oval window. A n n Otol 67:932, 1958 38. Lempert J: Principles used in the development of modern temporal bone surgery. Arch Otolaryngol 69:515, 1959
History of Stapedectomy ALLEND, H1LLEL,M,D.* The history of stapedectomy dates back to the late 19th century. Ntheugh oto~ogists in both the United States and Europe were performing stapedectomy operations at the turn of the century, stapes surgery ceased in the early 1900s. This paper examines the early and recent history of stapes surgery. An analysis of the early literature elucidates the reasons for the previous discontinuation of stapes surgery. (Key words: History; Stapedectomy.)
THE EARLY ERA OF STAPEDECTOMY . . . After the incision of the membrana tympani . . . . the incudo-stapedal articulation should be divided by means of the angular knife, the principal cutting being done from behind forward, the pressure in this direction being made against the pull of the stapedius muscle,
The tendon of the stapedius muscle may be next divided, and the straight knife used for the purpose also passed around the niche of the stapes, in order to divide any adhesions; the stapes may then be extracted either by means of the hook forceps, curved forceps or by a bhmt hook passed beneath the head of the stapes between the crura . . . .
This description of the technique of stapedectomy, in an article "Middle ear operations," by Clarence Blake of Boston, was published in the Transactions of the American Otologic Society in 1892. The similarity of Blake's description to Shambaugh's ~ description and illustration is striking. The history of stapes surgery dates back at least to 1853, when Toynbee a presented his description of ankylosis of the stapes and gave the first description of otosclerosis of the footplate. In 1876, KesseP removed the columella of pigeons, but also went on to remove the stapes in dogs. His audiometrics consisted of whistling and creating other sounds while the animals were sitting quietly or were asleep. Kessel concluded that it took eight days for a new membrane to form over the oval window and for the animals to regain hearing. However, one can be led to the conclusion that some of his animals did not hear too well, because Kessel apparently also resorted to the use of a pistol for some of his hearing tests. Received June 10, 1982; accepted for publication November 19, 1982. * Division of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, Stanford, California 94305. Address correspondence and reprint requests to Dr. Hill~l.
Clinically, Kessel proposed the removal of the tympanic membrane, malleus, and incus for the treatment of deafness. Baracz, '~ in 1887, used Kessel's methods; a description of the technique follows: "After tanotomy of the tensor tympani, a circumferential incision was made around the handle of the malleus to its base, by two perpendicular incisions and a lower transverse incision; the handle brought out by means of leverage from within and above downwards and outwards. The remnants of the tympanic membranes were seized in small hooks and excised, aiming especially at excision of the posterior inferior quadrant.' '~ In 1885, Lucae 7 reported his results using Kessel's stapes operation in 53 ears of 47 patients. He removed the malleus in all cases and the incus in six. Nine patients had considerable hearing improvement, and 19 slight improvement. In 1888, Boucheron s reported on 60 cases of stapes mobilization, as summarized in Otosclerosis~: "The operation consisted in separation of the incus from the stapes; exci.sioa of the posterior half of the tympanic membrane; mobilization of the stapes by gentle traction by means of a hook, moving th0 stapes back and forth and up and down by traction of the stapedial muscle; and, in some cases, removal of the malleus and incus." Boucheron found that the most favorable results are obtained in the early stages of stapes ankylosis: "If there is bony ankylosis and any involvement of the soundperceiving apparatus, it is too late to operate." Miot, ~ in France, reported in 1896 on the most consistent clinical trial of stapes surgery to that date. He used sterilized instruments, antiseptic preparation of the ear, and handwashing techniques described by Lister. He used general anesthesia with chloroform or topical anesthesia with cocaine. He reported on 200 cases, and his conclusion was similar to that of Boucheron, 131
HISTORY OF STAPEDECTOMY " . . . that the procedure gives its best results with beginning stapes ankylosis, and that it is useless with complete bony ankylosis of the baseplate." In his preoperative evaluation, Miot used the sign of paracusia willisiana as an indication for surgery. Miot also used the tuning fork, but his indication for surgery was that the "cranial perception of the tuning fork is better in the less affected ear. ''6 In 1892, Blake gave one of the first reports of stapedectomy in this country. L~Removal of the stapes in chronic nonsuppurative disease of the middle ear was attempted in 21 patients. The stapes was removed entirely in nine. Fracture of both arms occurred in ten. The stapes was immovable in two. A change in the pulse rate incident to traction on the stapes occurred in 12 patients. Vertigo occurred in six patients, with vertigo persisting for more than a month in three. Hearing improved in three patients. Frederick Jack, Blake's pupil, also reported a number of cases of stapedectomy in 1892." He concluded that his results were not consistently of benefit. By 1893, Jack had compiled a study of 60 cases, and he remarked that "most operations for mobilizing the stapes must be looked upon as largely experimental. '''2 In 1896, Grunert '~ made an astute observation. He realized the need for a normal round window for successful stapes surgery and wrote that pathologic changes at the r ound w i n d o w could ruin the results of a perfect operation. This description of the middle ear was the first that suggested an association between the round and oval windows. OBSERVATIONS OF THE EARLY ERA
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After reading the reports of so many efforts at stapes surgery in the 1890s, the discovery of successful middle ear surgery seemed imminent. If one did not know the results of the following 80 years of ear surgery, one would predict that one of these early investigators would have found our present-day s t a p e d e c t o m y t e c h n i q u e by about 1910. But that was not the case. Shambaugh, ~ in his d i s c u s s i o n of the h i s t o r y of stapedectomy, says, "It is remarkable, after these encouraging reports, including cases of successful stapedectomy, that Siebenmann, in 1900, should have stated: 'Clinical experience teaches that all endeavors at mobilization of the stapes in o t o s c l e r o s i s are not only useless, b u t often harmful.' The reasons for this concerted opposition are not clear . . . . At any rate, operations upon the stapes for otosclerosis were rather ab-
ruptly abandoned and remained in eclipse for half a century." Perhaps Blake, in his 1906 text co-authored by Henry Reiks of Johns Hopkins University, summarizes the experience of the late 1800s. In his 350-page book, Surgical Pathology and Treatment of Diseases of the Ear, 14 Blake devoted a mere two pages to the subject of stapedectomy. He remarked on his experience with 21 patients: In six of the cases, which had not before been dizzy, vertigo, more or less severe, followed the operation, in three cases persisting for more than a month, and in one for nearly a year; in but three out of the 21 cases was there other than temporary improvement in hearing, and then only in a moderate degree. In two cases the bone was found to be so absolutely immovable as to make it possible to rotate the head of the patients in a sitting position by traction upon the blunt hook inserted between the crura . . . . The operation of stapedectomy, while very simple in itself, is open to question as to its advisability, because of the varied consequences which may follow invasion of the cavity of the internal ear, and because of its doubtful value for the purpose for which it is usually demanded, amelioration of an extreme degree of deafness . . . . It should be borne in mind, that the fixation which causes extreme symptoms, either of deafness or vertigo, is not infrequently only secondary to a hyperosmotic process in labyrinthine capsule, which removal of the stapes cannot relieve. In 1897, Politzer wrote, " T h e m an y attempts by Kessel, Boucheron and Miot to mobilize and remobilize the rigid stapes in the niche of the oval window, which sometimes had a temporary, but short lived improvement of hearing, is completely abandoned. The same is sure with the extraction of the stapes w hi ch was tried out by Kessel, Jack, Dench and others. Experiments on animals in this d i r e c t i o n w ere m a d e by Botey, Faraci, Politzer and others. Blake, Knapp, Cheatle, and Politzer do not advocate this operation.",s Impressions as to why these pioneers failed to discover st apedect om y as it was done in the 1950s can be based on the reading of the discussion sessions that are the postscripts to some of the early articles, as well as from reading the texts. First, their surgical equipment, means of magnification, and light sources were primitive. As an example, their best light source was Lucae's reflector (Fig. 1) as described in Heine's text, Operations of the Ear, 16published in 1908. "The light must be good and for this, reflected daylight rarely suffices. I use mostly incandescent gaslight . . . . The reflector I always use is that s u g g e s t e d b y L u c a e , w h i c h is h e l d in the operator's teeth. This may seem unpleasant, but
HILLEL 9 . . Lucae's mirror can be brought nearer to the eye, and remains fixed in w h a t e v e r position it is placed, se that the constant fixing and altering of the position of the mirror is unnecessary. The m o u t h p i e c e is m a d e to fit the teeth accurately f r o m a cast p r e v i o u s l y taken a n d the metal parts are of a l u m i n u m , so that h o l d i n g it does not cause any discomfort." A n o t h e r great h a n d i c a p was the lack of stand a r d i z e d and r e p r o d u c i b l e a u d i o m e t r y . Their m e a n s of h u m a n audiologic evaluation were not too m u c h better t h a n Kessel's a u d i o m e t r y for his s t a p e d e c t o m i z e d dogs. Masking was not available, and the opposite ear was o c c l u d e d only by c o t t o n d u r i n g s p o k e n s p e e c h at various dist a n c e s . T o n e t e s t i n g was d o n e w i t h Koenig's rods and Galton's whistle. The original Galton whistle was felt to be unreliable above "14,000 s i m p l e vibrations in the second, ''~4 but the imp r o v e d G a l t o n w h i s t l e o v e r c a m e these inacc u r a c i e s a n d was t h o u g h t to be r e l i a b l e to "84,000 simple vibrations in the second. '''4 The w a t c h tick was felt to be too variable to be of m u c h use, so Politzer d e v e l o p e d the acoumeter (Fig. 2) in w h i c h a steel c y l i n d e r was struck by a steel h a m m e r , b o t h m o u n t e d in a " v u l c a n i t e f r a m e . " T h e n o r m a l ear h e a r d t h e P o l i t z e r a c o u m e t e r at 15 meters.'4 T u n i n g forks were used by otologists of the early 20th century, b u t their utility did not seem to have been recognized. This is exemplified by t h e i r incorrect usage by Miot e and by their cons p i c u o u s absence as preoperative versus postoperative examinations. P e r h a p s the greatest h a n d i c a p facing early otologists in their quest of a surgical cure for deafness was their a p p a r e n t lack of understanding of the m i d d l e ear transformer. Their ignor a n c e of assicular chain f u n c t i o n was demonstrated by their not infrequent performance of K e s s e l ' s o p e r a t i o n , r e m o v i n g the t y m p a n i c m e m b r a n e and ossicles to treat deafness. Even in the 1900s, the significance of the ossicular chain was not clear. Heine, in this 1908 textbook 18 on ear s u r g e r y , s e e m e d to a p p r o a c h an u n d e r s t a n d i n g of the m i d d l e ear w h e n he wrote: I admit that in many cases the discharge dries up mare rapidly after ossiculectomy, but we must also take into consideration the question of the hearing. If we have to deal with a perforation in Shrapnell's membrane (from which we conclude that the malleus is carious), the rest of the drum being intact, the hearing is generally normal or nearly so. The suppuration, we may take it, is confined to the attic; the remainder of the tympanic cavity is free and there is no pathological change in the parts most important for sound conduction--namely, round the fenestra ovalis and
Figure 1. Lucae'sreflector. Reflectormirror used to provide a light for ear surgery. The operator held the cast mouthpiece between his teeth. (Reprinted from Heine.'") the fenestra rotunda, If, however, in such a case, the malleus and the tympanic membrane are excised, injury to the hearing is possible or even probable. Further marked deafness is almost certain to be the result if we follow Schwartze who recommends removal of the incus as well. Blake, in his 1893 paper, '~ describes a patient who had "a past suppurative disease of the middle ear, a large perforation in the posterior segment of the right membrana tympani leaving the head of the stapes free . . . . A piece of sized paper of the kind ordinarily used for paper dressings and about 4 mm in diameter was pasted upon the head of the stapes, one edge resting upon the u p p e r rim of the perforation. With this paper in position, the hearing for the voice was doubled and the improvement continued so long as the paper remained in place." Although this might lead one to believe that Blake understood the middle ear, that illusion is shattered by a section in his paper' published slightly earlier. He was discussing the historical consideration of stapes operations: "The next step was the bolder one of Kessell's later suggestion . . . . which included the removal, not only of the membrana tympani, but also of the two larger
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Figure 2. Politzer'sacoumeterto measure hearing. The normal ear heard the sound made at 15 meters when the steel cylifider was struck by a steel hammer. (Reprinted from Blake and Reiks.~'t)
Americon Journal of Otolo ryngology 134
elements of the ossicular chain, thus, not only allowing the sound waves to fall upon the stapes directly, but also of relieving that bone of the superincumbent weight and immobilizing effect of the larger ossicles." There were, however, many anecdotes that would lead one to believe that in the 1890s, understanding of middle ear surgery was near. A near-miss at understanding the tympanic membrane was the astute observation of Faraci,~7 who in 1899 reported 11 stapes mobilizations in 30 attempts (this is the same rate of successful mobilizations that Samuel Rosen reported in the 1950s). Although it is not stated in the source, the tympanic membrane and the malleus were probably removed, as that was the technique at the time. Seven of the 11 patients whose stapes were mobilized noticed improvements in hearing. In four of these cases hearing worsened, and in three or four others, Faraci observed that hearing worsened with closure of the surgically created tympanic perforation. Although we are now quick to recognize the correlation, Faraci did not understand the concept of hearing loss from membrane closure with ossicular discontinuity. The most tantalizing paper in terms of making one think that the comprehensive discovery of modern-day stapes surgery was imminent was published in 1898, by Dr. H.A. Alderton Ls of Brooklyn. He describes a patient who in 1896 was seen in his office with bilateral hearing loss. In March 1897, after the current conservative t h e r a p y failed, Alderton removed the incus through a p o s t e r i o r - s u p e r i o r quadrant tyro-
panic membrane flap. The patient's hearing did not improve. With the t y m p a n i c m e m b r a n e healed, Alderton, in the a u t u m n of 1897, attempted a stapedectomy, leaving the footplate behind as the crura broke and the patient became dizzy. After the operation, the patient heard much better, only to have her hearing return to the preoperative level in a few days. Possibly this relapse in hearing was related to the tympanic membrane healing. In January 1898, A1derton performed his third procedure: " . . . . The w r i t e r a g a i n t u r n e d d o w n the p o s t e r i o r superior quadrant of the drum membrane . . . . and, with a guarded trephine, drilled a hole through the stapedial footplate. Labyrinthine fluid escaped. No dizziness followed. The patient c o m p l a i n e d of m a r k e d a u t o p h o n y and bubbling noises in the ear." In March, A l d e r t o n n o t i c e d t h a t the flap sloughed. Although crude hearing tests showed no improvement, in September 1898, the pat i e n t wrote, " S i n c e the o p e r a t i o n p e r f o r m e d January 25th last, I have noticed some changes for the better in general hearing. I am not making the same amount of effort, every nerve strained to hear, and I can hear at longer distances and in larger places. Voices are clearer and sound more natural. My head feels more comfortable and clearer, not the 'shut up' sensation that has been there so long." Shortly afterwards, Alderton found that the perforation was nearly closed. No further follow-up is reported, but surely the patient was shortly due to return to a maximum conductive loss as the t y m p a n i c m e m b r a n e healed.
HILLEL This e n c o u r a g i n g close call at successful stapes surgery is countered by the work of Dr. Noltenius, who, in the same year, reported TM his efforts. As abstracted in Otosclerasis, 6 "The operation consisted in the first place, of turning forwards the concha together with detachment of the auditory meatus, ablation of the lateral tympanic wall, removal of the malleus and the incus; as the stapes was immovable fixed and its branches broke off on an attempt at extraction, the author took a blunt hook and with it pushed the stapes footplate inwards. Three days after the operation, a mild facial paresis followed increasing up to complete paralysis, but subsiding after six weeks . . . . " Noltenius stated that this operation had been done in three cases of advanced sclerosis with stapes ankylosis: in one the result was very favorable, in one negative; in the third case, tinnitus was relieved and the hearing somewhat improved: "Thus, it would seem that crushing the ankylosed footplate of the stapes and pushing it into the vestibule may be considered a justifiable and apparently safe operation in cases of sclerosis with stapes ankylosis, particularly if tinnitus is severe and if the sound-perceiving apparatus is intact." On that sad note, we entered the 20th century. THE EARLY 20th CENTURY
The next historic era belonged to Julius Lempert and his revolutionary fenestration opera t i o n - t h e first operation that successfully and practically restored hearing. With Lempert's operation, otology advanced from simply a practice of draining infected ears to the art and science of restoring the sense of hearing. Lempert's predecessors date back to 1897, when Passow 2~made a window in the promontory and covered it with a piece of periosteum. An improvement of hearing resulted but the improvement was transitory. In 1899, Floderus 2' described "sound fistulas" made at the outer wall of the labyrinthine capsule or in the ampulla of the external horizontal canal. He also dabbled in stapes and other middle ear surgery and dismissed the entire topic of stapes sclerosis by proclaiming that stapes mobilization is practically without value; that other operations give but temporary, if any, relief; and that extraction of the stapes is not recommended. In 1913, Jenkins '~2 made a window in the horizontal canal with excellent, although only temporary, results. In 1923, Holmgren 2~began using 10x magnification during his surgery, thereby formally beginning the era of microsurgical
otology. He described four patients in whom he attempted the creation of a w i n d o w in the labyrinthine capsule between the round and oval windows. He had good success in one patient, moderate success in another, and very little success in the third, due, according to Holmgren, to making too small a fenestra. In his fourth patient, after removing the tympanic membrane, malleus, and incus, he accidentally mobilized the stapes with good results. Holmgren, in addition to his innovative use of the microscope, described the use of the rotating burr drill for bone removal during ear surgery. In 1924, SourdilF 4 devised a three- or fourstage (later reduced to a two-stage) operation to put a window in the horizontal canal. The interval to complete all the stages was about a year. Sourdille's operation was never popular because of the extensive time of treatment and frequent bony closure of the window. In the late 1920s, the American Otolagic Society commissioned a committee to compile a resum~ of the literature to July 1928. The commission was funded by a $90,000 grant from the Carnegie Corporation. The product of the commission's efforts was a 700-page, two-volume publication entitled Otosclerosis, U which was published in 1929. This publication reported on the histologic changes of the eric capsule, heredity, symptoms, audiology, and treatment of otosclerosis, and gave illustrative cases. The summary of surgical treatment was to the time of Holmgren's work on labyrinthine windows. Sourdille's work in 1924 with horizontal canal windows was not mentioned. The summary of the nonsurgical treatment of otosclerosis is historical, and merits a brief chronological presentation of medical management of otasclerosis to that time. In the 1870s, treatments included politzerizatian, and also a Siegle otoscope attached to a double-valved stomach pump for forcible massage of the tympanic membrane. During the 1880s, forcible iodine vapor treatments, sound pressure, iodoform petroleum jelly applied through the eustachian tube, tragal massage to "exercise the ossicles," iodized air in conjunction with galvanic current, and eustachian tube instillation with a mixture of sodium bicarbonate, distilled water, and glycerine were in vogue. The 1890s brought catheter instillation of the eustachian tube, eustachian bougies; chloroform, ether, bromethyl, or iodine crystals in the Roosa bulb inhaler; also, vapor of camphor, eustachian tube air douche, oil injections and methyl vapor through the eustachian tube. In
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1895, Dr. Bellous i n t r o d u c e d the "vibrometer," which i m pr oved hearing with an average gain of 11.3 per cent during its first six months of use, and an average gain of 14.1 per cent in the second six months of its use. The better results in the s e cond group of patients were probably attributable to added e x p e r i e n c e in the use of the vibrometer. The 1900s brought Lucae's "vibratory massage instrument," the tip of w h i c h was placed on the short process of the malleus. In 1901, Bonnfer's " t y m p a n a - m o t o r " g r a s p e d the h a n d l e of the malleus and moved it with control by aspiration th r o u gh an attached r ubbe r tube. Koenig and Lucae developed the " s p r i n g sound direct massage" w i t h a mold of w a r m paraffin pressed onto the short process. Other methods in the 1900s were electrolytic dilation of the eustachian tube, instillation into the ear of Watson's preparation from b one marrow, w h i c h he called myelocene, s o u n d m a s s a g e w i t h M a r age's w h i s t l e , and Jaulin's radiation t h e r a p y directed t h r o u g h a tu b e t h r o u g h a s p e c u l u m onto the t y m p a n i c membrane. The 1910s offered electric treatment with one electrode on a metal ear s pe c ul um and the other in the eustachian tube. On occasion, mercury was p o u r e d on the t y m p a n i c membrane for better attachment of the external electrode. Cotton pledgers were glued to the tympanic m e m b r a n e so that traction t r e a t m e n t s could be applied. Radium pencils w e r e p l a c e d in the external canal for 40-minute treatments to "destroy the terminal acousticus." The 1920s were years of further refinement of electric currents, r a d i a t i o n therapy, and subperiosteal injections of " p a n i t r i n . " The ElectroP h o n o i d e method of Z u n d and Burgust was used as a means to reeducate t he ears by applying s o u n d f r e q u e n c i e s to the ear t h r o u g h o u t the h u m a n s peech range. A treatment of the late 1920s was Hollender and Cattle's electric diathermy to heat the petrous portion of the temporal bone: T he head was treated with a 3- to 400-mA current a p p l i e d three to four times per week through a headband with suitable electrodes.
THE EARLY ERA OF SUCCESSFUL SURGERY FOR THE RESTORATION OF HEARING AmericQn Journal
of Otolaryngology 136
In 1938, Julius L e m p e r t "~ i n t r o d u c e d the single-stage endaural a p p r o a c h that he called the Lempert fenestration procedure. I,empert also had problems with b o n y closure of the window,
but the s i m p l i c i t y , r e l a t i v e to S o u r d i l l e ' s method, merited the failure rate. L e m p e r t improved the operation by rem ovi ng th e i n c u s , w hi ch he found did not affect the hearing, a n d thus with more exposure, moved the w i n d o w down on the ampullate end of the h o r i z o n t a l canal. F u r t h e r i m p r o v e m e n t s were m a d e b y Shambaugh's '26 use of constant irrigation w h i l e drilling in order to wash away the b o n e dust. Shambaugh also advocated the use of a seven-
power operating microscope. As an overview of otology before th e " n e w 1950s era" of middle ear surgery, one can r e v i e w an article w ri t t en for the n o n - o t o l o g y w o r l d p u b l i s h e d in a 1945 issue of California and Western Medicine. The articles 7 by Dr. H o w a r d House, was entitled "What can be done for the deafened today." The lack of u n d e r s t a n d i n g of the middle ear that seemingly d o m i n a t e d t h e 1890s was no longer present. Even t h o u g h th e function of the ossicles was known, little was being done to use that knowledge to r e c o n s t r u c t the ear. The treatment of nonotosclerotic deafness, o n occasion, still included the use of o s s i c u l e c t o m y to allow for proper contact of an artificial tympanic membrane. These artificial m e m b r a n e s were constructed of cotton pledgers, c e l l o p h a n e cones, molded rubber, or a diaphragm rod. In each patient, the "hearing-sensitive a r e a " was found, and the new ear drum was a p p l i e d to it. The Pohlman insert was a small artificial d r u m on a toothpick-sized rod. The patient a p p l i e d t h e insert until it t o u c h e d the hearing-sensitive area. Hearing was measured by audiometers t h e n , a n d it was estimated that the gain provided by t h e artificial tympanic membranes was 20 to 30 dB. For otosclerosis, Dr. H o u s e e x p l a i n e d t h e Lempert fenestration procedure. He cited a 65 per cent chance of the fenestra's r e m a i n i n g o p e n and remarked that closure, if it occurs, is rare past six months. He also cited a 2 per c e n t incidence of severe complications and listed these as labyrinthine damage, infection, meningitis, a n d facial paralysis. Before leaving the 1940s, one other m i d d l e ear operation introduced then should be d i s c u s s e d , not because of its merit in restoring hearing, but because its surgical approach was a f o r e r u n n e r of modern stapedectomy. In 1946, L e m p e rt published his results "8 of t y m p a n o s y m p a t h e c t o m y performed in 15 patients to treat vertigo. Lempert first explained his research into the matter. During fenestration operations, he u s e d Zeiss magnifying lenses to examine the p r o m o n t o r y in 100 patients who complained of tinnitus. In all
HILLEL
Fiftystapes removed from fresh cadavers with the footplates fixed in cement. Rosen used this arrangementto pracrice palpation of the capitulum. [Reprinted with permission from Rosen.:"}
Figure 3.
100 patients, he found either a normal or, occasionally, an enlarged tympanic plexus. Lempert also e x a m i n e d the promontory in 60 patients who h a d no tinnitus and found total absence of the t y m p a n i c p l e x u s . He p e r f o r m e d tymp a n o s y m p a t h e c t o m y procedures in 15 patients who complained of severe vertigo, and recorded results that showed complete resolution of the s y m p t o m s of tinnitus in ten of the 15 patients. Lempert's presentation of his surgical technique of t y m p a n o s y m p a t h e c t o m y described a nondestructive approach to the middle ear by elevating an a n n u l a r flap in conjunction with preservation of the tympanic membrane. THE MODERN ERA OF MIDDLE EAR SURGERY
The era of contemporary middle ear surgery began with Dr. Samuel Rosen. In the late 1940s, Rosen ~'J was in practice at Mt. Sinai Hospital in New York City. Also in New York City was the Endaural Hospital, Julius Lempert's private hospital, where he did his fenestration procedures. The Endaural Hospital was also where Lempert c o n d u c t e d his six-week fenestration course for ear surgeons and, in addition, was the location of the Lempert Otolagic Society and the Lempert Research Foundation. In 1947, Rosen studied with Lempert. He then r e t u r n e d to Mt. Sinai to become a well-known fenestration surgeon. Rosen also had learned L e m p e r t ' s t y m p a n o s y m p a t h e c t o m y procedure and e x p a n d e d on it to develop a new operation for M~ni~re's disease2 ~ In 1952, Rosen was demonstrating a fenestration operation for Dr. Franz Altmann of Vienna. After removing the incus and cutting between the head and neck of the malleus, Rosen palpated the stapes and saw that it moved. Rosen knew that a mobile stapes would cancel the perilymph wave from the fenestra and realized that, in this patient, the fenestration operation would not be
of much benefit. Because of the removal of the ossicular chain, Rosen felt compelled to complete the procedure and, as expected, the patient had a poor result. Altmann admitted that this experience had occurred at least once to him too, and Rosen became convinced that palpation of the stapes before fenestration was necessary. He recalled his abandoned operation for M6ni~re's disease and realized that the same approach that he had used for it would expose the head of the stapes for palpation. He first experimented by glueing 50 stapes to a board (Fig. 3) and palpated the capitulum of each to be sure that in all stapes the crura are rigid so as not to allow movement of the capitulurn and mimic a mobile footplate. 'a' Rosen went on to do a preliminary stapes palpation in his next six candidates for fenestration, and published his results in 19522' Three of the six had fixed stapes so he accepted them for fenestration. Rosen felt that two patients had partially mobile stapes and chose not to operate on them. The sixth patient claimed that after Rosen palpated his stapes, he could hear everything. Rosen's paper was very reserved. It emphasized the recommendation of palpating the stapes before f e n e s t r a t i o n , a n d c a s u a l l y remarked that loosening the stapes might be of benefit. (Rosen's description of the event in a film ~'-'with Howard House and John Shea, and in Rosen's autobiography, is rather dramatic, however.) Rosen described his palpation of the patient's stapes. Unsure whether it had moved, he pushed it a little harder until he was sure it moved. Disappointed that he would be unable to help this man, Rosen asked for the suction, and the patient stated that he now heard everything. The patient went on to tell of a metal instrument that had hit a bucket a few rooms down the hall, and Rosen recalled the sound that he had ignored because it was so familiar. Rosen asked him whether he could hear, and the patient replied, " S u r e . "
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Figure 4. Eight-ounceweight suspended from the neck of the stapes to determinepressure required to fracturethe neck of the crura. This apparatus formed another of Rasen's experiments to determine the characteristics of the normal stapes. (Reprintedwith permission from Rosen.a3)
American Journal af Otolaryngalogy 138
Rosen was concerned that the response was the reply of a hopeful patient who had anticipated his doctor's obvious first question, so Rosen asked him the famous egg question, "Do you like your eggs scrambled or fried? . . . . Oh, I prefer them scrambled," was the reply. The patient's hearing remained good, and reluctantly Rosen allowed him to return home to Wisconsin. The patient dutifully called every two weeks and reported normal hearing. At the end of each call, he would ask Rosen when he could have the other ear done. Rosen delayed because he had to have time to determine what had happened. Rosen began night work in a basement on cadavers he had illegally purchased from the diener of a medical school. Once or twice, he narrowly escaped disclosure. One example of the difficulty he had with his research occurred at his summer home in Katonah, where he practiced at night on summer weekends. One morning the police arrived to investigate, telling of a witness who had seen Dr. Rosen with parts of human bodies. There had recently been two murders in the area, and they were there to investigate. Rosen s h o w e d them his cadaver heads, ex-
plained his work, and, somewhat reluctantly, the police drove off. Rosen had special instruments made by Fred Grafrath and practiced incessantly. He developed his touch by lying awake in bed pushing the tip of his instruments through apple peels held on his thumb, considering it a success only when he could push the tip through the peel without its being f e l t b y his t h u m b b e n e a t h . Rosen learned to curet the scutum for more exposure, and did experiments on the stapes. He demonstrated the strength of the stapes with wires and weights (Fig. 4).3s He might have been assured of the stapes' incredible strength if he h a d read Blake's text where Blake describes turning the heads of two patients by pulling on the stapes when attempting stapedectomy. '~ When Rosen had finished his experiments, he scientifically proceeded with a second patient. Fortunately, his second patient was also one of the three per ten in w h o m mobilization was possible. Rosen took the care to obtain irrefutable independent audiologic documentation for his patients. In May 1953, he presented his first five patients who had undergone mobilization at the Medical Society of the State of New York. ~ He then began a persistent battle to overcome the resistance of his colleagues who claimed that the Rosen procedure existed, but was dangerous, and caused permanent nerve damage to the unfortunate victim. Rosen's liberal political beliefs were implicated as his work was proclaimed to be part of what critics called his communist proclivities. Rosen went abroad and presented his data to Sir Terrence Cawthorne, the leading otologist in England. Warmly received by Cawthorne, Rosen attempted to mobilize the stapes of one of Cawthorne's patients. Again, fortune was with him, for this patient was also one of the three per ten who had a stapes that could be mobilized. Cawthorne's high opinion of Rosen accompanied the pioneer back to New York, and Rosen was on his way to educating American otologistsY 4 The early events of acceptance of Rosen's work in the United States have been summarized by Dr. Victor Goodhill (personal communication): A Los Angeles otolaryngologist, Dr. George Frankel, who had otosclerosis went to see Dr. Rosen and was operated on by him. A mobilization apparently was successful on Dr. Frankel. He in turn began to perform mobilizations in the Los Angeles area. Shortly thereafter Dr. Rosen placed two long-distance telephone calls, one to Dr, George Shambaugh and the other to me. He told us both of his difficulties with the otologic fraternity in New York City and the problems at some of the hospitals where he was allowed to operate because of a good deal of opposition to his
HILLEL mobilization procedures. Dr. Shambaugh and I agreed to come to New York specifically for the purpose of examining Dr. Rosen's patients otologically and audiometrically, personally, preoperatively, observing the surgical procedure, and then doing independent postoperative examinations and audiograms without the use of technicians. I believe Dr. Shambaugh and I spent about ten to 14 days in New York at that time on this project. Both of us very definitely saw some substantive improvements in hearing in patients we examined and observed. Dr. Shambaugh returned to Chicago and I returned to Los Angeles. I was sufficiently impressed with this experience that I began to perform stapes mobilizations as soon as I returned. To the best of my knowledge, therefore, the first stapes operations performed in California were perfermed by Dr. Frankel and I followed him. My colleagues soon joined me. Within a few months Dr. Eugene Derlacki, Dr. Shambaugh's associate at that time, came to visit me in Los Angeles and observed a number of my cases. He was sufficiently impressed that when he returned to Chicago both he and Dr. Shambaugh began to do stapes mobilization in the Chicago area. E d w a r d (Edmund) Fowler d e v e l o p e d the anterior c r u r o t o m y t e c h n i q u e a'5 of stapes mobilizat i o n for cases in w h i c h there was a simple focus of otosclerotic p l a q u e fixing the footplate. Rosen b e g a n to scratch holes in the t h i c k e n e d plaques to enable him to mobilize an otherwise inoperable stapes. With these techniques, stapes mobilization became a 50 to 60 per cent successful proc e d u r e rather t h a n a 30 per cent successful procedure. John Shea also came to N e w York to study w i t h Rosen, and at Rosen's insistence, went to s t u d y in Vienna, w h e r e there was a more available s u p p l y of cadavers. Shea r e t u r n e d and, in 1956, r e o p e n e d the era of s t a p e d e c t o m y with a skin graft to cover the o p e n oval window. 36 His first prosthesis was based on extensive studies by h i m and an engineer w h o h a d t h o r o u g h l y investigated the stress lines of a h u m a n stapes. Shea, in the film with House and Rosen, laughed about his first belief that the prosthesis must look like a h u m a n stapes a6 (Fig. 5). In 1958, Shea s7 described the operative t e c h n i q u e of modern-day s t a p e d e c t o m y and i n t r o d u c e d the use of the vein graft in conjunction w i t h a p o l y e t h y l e n e strut as the ossicular replacement. Mobilization had b e c o m e the preliminary to the Lempert fenestration and the stapedectomy p r o c e d u r e rapidly replaced both of its immediate a n c e s t o r s . In the 1950s a n d all t h r o u g h the 1960s, thousands of stapedectomies were being p e r f o r m e d o n all t h e p r e v i o u s l y u n t r e a t e d otosclerotic ears. Since Shea's r e d i s c o v e r y , the stapedectomy p r o c e d u r e has been constantly refined, and the r e s u l t s h a v e i m p r o v e d . M e a n w h i l e , as the
Figure 5. An early stapes prosthesis designed by John Shea and his engineer. (Reprinted with permission from Shea.~") backlog of otosclerotic patients has diminished, there has been a decrease in the n u m b e r of such procedures being performed, and the stapes ope r a t i o n is b e c o m i n g a rare one for m a n y otolaryngologists. An interesting note in the h u m a n aspect of the history of stapedectomy is the life of Julius Lempert, after the work of Sam Rosen and John Shea. Rosen, in his autobiography, describes a great admiration for Lempert's talents, but tells of a rather sad ending to the relationship. In 1956, Rosen had a poster exhibit at the American Medical Association meeting. He left the exhibit during a recess a n d w h e n he c a m e back, he saw Lempert staring at it from about 20 feet away. Rosen approached him a n d tried to induce h i m to walk to the exhibit and allow Rosen to show it to him. "He stood there, saying not a word. His hands thrust into the side pockets of his jacket, his eyes seemingly looking right t h r o u g h me. It was as if he had h e a r d nothing, seen nothing. Then abruptly he turned and walked away quickly." As late as 1959, Lempert published an article s8 entitled "Principles used in the development of modern temporal bone surgery." He discussed the history of ear surgery, and again spoke of the success of the Lempert fenestration. He concluded his article with some words about stapes mobilization: It does not seem reasonable to assume that the great surgeons of that period [late 1800s] . . . would have abandoned the use of a technique which initially seemed to offer so much . . . . Given a group of outstanding ear surgeons and any technique for possible improvement of hearing, is it not logical to assume that if the procedure offered even limited success, it would have been tried?... As of this writing, no one has attempted to explain this historical anomaly. Although there are many accounts of the clinical success of the procedure since its reintroduction five years ago, there is yet a complete dearth of convincing evidence which would justify its use on fundamental surgical principles . . . . Mobilization of the stapes, as practiced today, is a destructive, nonsurgical orthopedic procedure with complete disregard for the
Volume 4 Number 2 March 1983
139
HISTORY OF STAPEDECTOMY b i o l o g i c a l and p h y s i o l o g i c a l factors u p o n w h i c h m a i n t e n a n c e of t h e i m p r o v e m e n t w i l l d e p e n d .
COMMENT It is clear that in the 1880s there were some isolated results that were as dramatic as Sam Reson's first mobilization. These few patients were the cause of as much excitement for their physicians as were Dr. Rosen's. The difference between the 1880s and the 1950s lay in the understanding of the middle ear transformer and the availability of audiometry as a diagnostic tool. In the 1890s, the excellent results in the few patients were not reproducible. None knew what had caused the return of hearing, and no one could accurately measure the patients' hearing before or after surgery. The ossicular chain was not understood. Most of all, because of these shortcomings, the true otosclerotic patient was not always the one w h o h a d the attempted stapes mobilization. Therefore, the operation was doomed to bad repute, and with its abandonment came the essential abandonment of middle ear reconstructive surgery. Stapedectomy, an operation discovered ahead of its time, became dormant for the half century needed for otologists to discover the principles to harness it.
References
American Journal of Otolaryngolagy 140
1. Blake C: Middle ear operations. Trans Am Otol Sac 512:306, 1982 2. Shambaugh G: Surgery of the Ear. Philadelphia, W. B. Sounders, 1967 3. Toynbee i: Case of complete bony ankylosis of the stapes to the fenestra ovalis. Trans Pathol Sos London 4:253, 1853 4. Kessel J: Ueber die Durchschneidung des Steigbugelmuskels beim Menschen Arch Ohrenheilkd 8:321, 1874; 11'.199, 1876; 12:237, 1877, as abstracted from Bellucci R: Repair and consequences of surgical trauma to the ossicles and oval window of experimental animals. Trans Am Oral Sac 1958 5. Baracz R: Die Exzisien des Trommeifells sammt Hammer bei Sklerose der Paukenschleimhaut. Wien Mad Wochenschr 37:290, 1887 (as described in Otosclerosis ~1 6. Otosclerosis. American Otologic Society, 1929 7. Lucae A: Uabet operative Entfernung des Trommelfells und der beiden grosseren Gehorknochelchen bei Sklerose de Paukenschleimhaug. Arch Ohrenheilkd 22'.233, 1885 [as described in Otosclerosis") 8. Boucheron E: La mobilisetion de i'etrier et son precede operatoine union, Mad Paris 46:412, 1888 (as described in Otosclerosis G) 9, Miot C: De la mobilisetion de l'etrier. Rev Laryngol :[0"49, 83,145,200, 1690 (as described in Shambaugh~ and Otosclerosis s)
10. Blake C: Stapedectomy and other middle ear operations. Trans Am Otol Sac 5:464, 1891-1893 11. Jack F: Further observations on removal of the stapes. Traus Am Otal Sac 1893 12. Jack F: Remarks on stapedectomy. Trans Am Otol Sac 6:102, 1893 13. Grunert K: Was Konnen wir van der operativen Entferhung de Steigbugels bei Steigbugel-Vorhofankylose zum z w e k der Horrerbesserung e r h o f f e n ? Arch Ohrenheilkd 41:294, 1896 (as described in Otosclerosis ~) 14. Blake C, Reiks H: Surgicat Pathology and Treatment of Diseases of the Ear. New York, D. Appleton & Co., 1906 15. Politzer A, as quoted in Lempert J: Principles used in the development of modern temporal bone surgery. Arch Otolaryngol 69:515, 1959 16. Heine: Operations of the Ear. New York, William Wood & Co., 1908 17. Faraci G: Importanza acustica e funzgionale della mobilizzazione della statta; risultati di una nuova serie di operazioni. Arch Ital Oral 9:209, 1899 (as described in Otosclerosis 6) 18. Alderton HA: Trephining of the stapedial footp[ate for otitis media sclerosa. Trans Am eta( Sac 4(1):60, 1899 19. Noltenius: Zur Frage der operativen Behandlung der Stapesankylese. Verh Dtsch Otol Ges 7:173, 1899 (abstracted in Otosclerosid ~) 20. Passow H, in Panse R: Discussion. Verh Dtsch Otol Ges 6;141, 1897 (as described in Otosclerosis ~) 21. Floderus B: Bidrag till stigbygelankylosens operativa radikalbehandlung. Nard Mad Arch 32:1, 1899 (as described in Shambaugh 2 and Otosclerosis ~) 22. Jenkins GJ: Otosclerosis: certain clinical features and experimental operative procedures. Trans XVII Int Congr Mad 16:609, 1913 (as described in Shambaugh '2 and Otosclerosis") 23. H o l m g r e n G: Some experiences in the surgery of otosclerosis. Acta Otolaryngol 5:460, 1923 24. Sourdille M: New techniques in the surgical treatment of progressive deafness from otosclerosis. Bull NY Acad Mad 13:673, 1.937 25. Lempert ]: h n p r o v e m e n t of h e a r i n g in cases of otosclerosis. Arch Otolaryngol 28:42, 1938 26. Shambaugh G: The surgical treatment of deafness. Ill Mad I, February 1942, p 104 27. House H: What can be done for the deafened today. Calif Western Med 63:3, 1945 28. Lempert J: Tympanosympathectomy. Arch Otolaxyngol 43:199, 1946 29. Rosen S: The Autobiography of Dr. Samuel Rosen. New York, Alfred Knopf, 1973 30. Rosen S: Surgery in Meniere's disease: a new operation which preserves the labyrinth. Ann Otol 60:657, 1951 31. Rosen S: Palpation of the stapes for fixation. Arch Otolaryngol 56:619, 1952 32. Rosen S, House H, Shea J: Film discussion. Los Angeles, Ear Research institute 33. Rosen S: Mobilization af the stapes to restore hearing in etosclerosis. NY State J Mad 53:2650, 1953 34. Rosen S: Results of mobilization of fixed stapedial footplate in otosclerottc deafness. JAMA 161:595, 1956 35. Goodhill V, Shea J, Derlacki E, Schuknecht H, Fowler E, Juers A, House H: Otosclerosis symposium. Arch Otolaryngol 71;246, 1960 36. Shea J: The operation for the mobilization of the stapes in otosclerotic deafness. Laryngoscope 66:729, 1956 37. Shea J: Fenestration of the oval window. A n n Otol 67:932, 1958 38. Lempert J: Principles used in the development of modern temporal bone surgery. Arch Otolaryngol 69:515, 1959