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Microsurgery of the Middle Ear for Otosclerosis
MICROSURGERY
OF THE MIDDLE EAR FOR OTOSCLEROSIS Ruby Tomlinson Sanches, R.N.
For untold centuries, deafness has been an diction of the human race. In Biblical days the prophet Isaiah spoke of the day when “the deaf shall hear words”1 and “the ears
Mrs. Sanches, a native of North Carolina, received her nurse’s training at the Scranton
State Hospital School of Nursing (Pennsylvania). She received post-graduute training in operating room nursing at New York Polyclinic Hospital and has taken courses at both Columbia and New York Universities. She is the supervisor of the Ear Operating Rooms at the New York Eye and Ear Infirmary in New York City. Mrs. Sanches is National Treasurer of the AORN, a member of the Executive Committee, and Chairman of the Committee o n Budget and Finance. As an active member of the New York Chapter, she is also Chairman of the By-Laws Committee.
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of the deaf shall be unstopped.”2 Deafness is found in people of all ages and
is prevalent throughout the world. Reliable statistics indicate that more than 18 million people in the United States, including three million children, suffer from some degree of hearing loss. 3 Defective hearing is considered the number one physical impairment4 in adults in this country. Otosclerosis, the subjeot of this paper, is alone responsible for 35 to # per cent of all those who are acoustically handicapped.6 Otosclerosis is a destructive disease. Since it is painless, the destruative action may progress for many years before the patient is aware of it. Its etiology, however, is still unknown. Otosclerosis is a process whereby new bone formation occurs in the bony labyrinth of the otic oapsule (middle ear). This process almost always begins on and around the foot plate of the stapes, causing it to become fixed
59
Fig. 1 Sagitall section of temporal bone showing the relationship of middle ear and inner ear structures. Note the otosclerotic bone formation. (Otologic Diagnosis and Treatment of Deafness, Myers, D., Schlosser, 1.D., and Winchester, R. A.: Clinical Symposia, 14:39, 1962.)
in the oval window, trapped like a peanut in brittle candy. When this occurs the foot plate can no longer vibrate freely and therefore is unable to transmit sound waves to the nerve of hearing. As the disease gradually progresses the foot plate becomes more firmly fixed and the hearing loss gradually increases. (Figure 1.) Bilateral involvement is the most common situation but in a small percentage of cases the deafness is unilateral and may remain so. It is a disease which is not bound by age limits and often becomes manifest after puberty and during pregnancy.6 The deafness usually reaches its peak during the fourth or fifth decade of life. The disease appears about twice as often in women as in men and there seems to be evidence that
60
heredity plays an important causative part. The white race is more susceptible to otosclerosis than the Negro race,? and among the Mongolian race it is quite rare. Indications are that the city dweller suffers greater hearing loss and with more frequency than those living in less urban areas.
HISTORY Stapes surgery has become the fruition of the dream to restore hearing to the patient plagued with otosclerosis. Very crude attempts at mobilizing the stapes date back to the late 1800’s. The extremely discouraging results of the pioneers in this field may have been due to poor light, inadequate magnification, and the complications of ever-present infection in the pre-antibiotic era. As a re-
AORN Journal
sult of these failures, the stapes was held to be inviolate and the technique was abandoned. Other methods for attempting to improve hearing surgically were sought. In 1924, Mr. Maurice Sourdille in France developed an operation in two stages for otosclerotic deafness. In Dr. Sourdille's technique, a small window was made in the horizontal semi-circular canal. Through this window sound was transmitted to the cochlea, resulting in improved hearing. In 1938, Dr. Julius Lempert in New York developed that technique into a one-stage fenestration operation. Over the years, Dr. Lempert added many variations in technique until he was able to obtain lasting hearing improvement in about 78 per cent of his cases. Basically, the fenestration operation consists of making an endaural incision, followed by mastoideotomy, resection of part of the head of the malleus and the incus, and fenestration of the lateral semi-circular canal. This technique by-passes the otosclerosis at the oval window, and sound is conducted through this new window or nov ovalis. This operation gained wide acceptance as the best surgical approach to otosclerosis until the rediscovery of stapes mobilization in 1952 by Dr. Samuel Rosen of New York City. In attempting to evaluate the suitability of the patient for fenestration surgery, Dr. Rosen developed a technique to test the fixation of the stapes in the oval window. One day, while employing this technique, Dr. Rosen applied pressure to the stapes and his patient suddenly announced his increased ability to hear. At that moment, Dr. Rosen had mobilized his first stapes and by so doing re-kindled an interest in this most fascinating sphere of otologic surgery. Since 1952, stapes surgery has become the most widely accepted approach to the correction of otosclerotic deafness.8 There are many causes of deafness or impaired hearing and many surgical procedures
July-Aug 1965
employed in an effort to improve or restore hearing. However, this paper deals only with the surgical procedures used in the treatment of otosclerosis, especially as conducted at the New York Eye and Ear Infirmary.
DIAGNOSIS Diagnosis of otosclerosis is dependent on a history of gradual rather than sudden hearing loss. Physical examination of the patient reveals an essentially normal external ear, canal and tympanic membrane. Audiological testing of the patient is the best means of arriving at an accurate diagnosis. It indicates the type of deafness, as well as the degree of improvement in hearing to be expected after surgery, We prefer to screen that patient by audiological testing, with several tuning forks of different pitch, before testing audiometrically. When the vibrating tuning fork is held close to the ear of a patient with normal hearing, he can hear it for a longer span of time than when the fork is moved so that' the handle is placed directly against the mastoid bone. The reverse is true of the patient with the otosclerotic deafness. The audiogram shown in Figure 2 is the result of audiometric testing which indicated the preoperative hearing levels and the hearing improvement gained by stapes surgery. Bone conduction, indicated in the audiogram by the symbol 7, is essentially normal, which means that the cochlea is not involved. PSYCHOLOGICAL PREPARATION
OF THE PATIENT The patient mu& be prepared, psychologically, to accept the facts relative to the operation. His consent for operation should be an informed consent. He should be acquainted with all the facts concerning the known dangers, the risks involved and the failures, as well as the degree of potential success of any procedure the surgeon may employ.9
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125
250
500
1000
2000
4000
8000
10
NORMAL 10
20 30 40
50 60
70 80
RECEI! THIprsI). - SPE€C+l p~~-op......-40 DB.
*......
.I
90 100
- ,
-I
5 DB.
----L
110
ROSEN
Fig. 2 Audiogram indicating the preoperative and postoperative hearing levels.
A paragraph from the Archives
Otolaryngology illustrates this need: “Never b e fore have so many patients with otoeclerosis been willing to accept the procedures that we are offering them today to improve their hearing. The unprecedented publicity regarding these operations in the newspapers, magazines, radio and television has left the impression in the minds of most people that the operation is infallible.”lO In each succeeding year, useful hearing is restored to more deaf ears than in any other preceding year in human history. However, there are still patients who experience no improvement. Otologist’s reports indicate that the hearing is improved in approximately 85 per cent of all the patients undergoing stapes surgery; and that it is unchanged in about 10 per cent; in 5 per cent the hearing is worsened and the patient may be left with almost total deafness. This misfortune is more common following total stapedectomy than from other procedure.
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of
PREOPERATIVE ORDERS The preoperative orders include a complete blood count, urinalysis, and determination of the bleeding and clotting time. An antibiotic such as tetracycline with nystatin 250 mgm is given every six hours. A barbiturate is given 1% hours preoperatively, followed by meperidine 50 mgm one-half hour later. Since this surgery is performed under local anesthesia, most surgeons request that dentures be retained by the patient. Male patients should be advised to have a haircut prior to admission, and female patients should be advised to have a shampoo because they will not be permitted to do this for three or four weeks following surgery.
PREPARATION OF THE PATIENT A preliminary prep is done on the operative ear approximately eight hours prior to surgery. Shaving the hair around the ear is usually unnecessary but a thorough cleansing of the operative field is obligatory. The
AORN Journal
auricle and periauricular areas are scrubbed with pHisoHex and water and a sterile dressing is applied. During the preliminary prep the canal is not entered. Every effort should be made to make the patient comfortable before surgery begins and he should be told of the importance of keeping his head in the position fixed by the surgeon. Various devices may be utilized to assist him in maintaining that position. We use the “headrest” which is available commercially for fixing the head, and also a “dough-nut” and foam rubber pillows which we have made for this purpose. If none of these are available, rolled towels or small sandbags will suffice. The use of these is determined by the surgeon’s preference. After the patient is positioned on the operating table the dressing is removed. A small amount of vaseline may be applied with a tongue blade to any stray wisps of hair, about an inch from the hair line, around the operative field of female patients. The entire field is prepped with an antiseptic of the surgeon’s choice. Tinted antiseptics have a tendency to discolor the outer membrane of the ear drum. Therefore, the colorless or untinted solutions are used.
DRAPING The head may be draped with either the plastic surgical sheet or the conventional head drape. In the latter instance, the drape is composed of two small sheets placed under the patient’s head at the same time, and brought down to the nape of the neck. The outer one is allowed to fall down over the end and sides of the table. The inner one is brought up around the patient’s head, above the operative ear, and fastened securely with a towel clip. It is important that all the hair be caught inside the head drape and covered. The instrument tray (the Mayo stand) is placed about two inches above the patient’s cheek, just anterior to the operative ear. A large double thickness sheet is draped over
July-Aug 1965
Fig. 3 Arrangement of furniture with the patient in position for surgery on the right ear,
the patient from the chin downward and over the feet. The instrument tray and stand are both covered with a double thickness sheet and towel. Three folded towels are placed around the operative ear to form a triangle and the fenestrated sheet is placed on last. Since the surgeons at our Infirmary operate with the patient’s face away from them, the instrument tray serves a twofold purpose. It is utilized to keep the drapes off the patient’s face as well as to hold instruments. This affords space for the patient to breathe freely and for the circulating nurse to care for him. The possibility of contaminating the operative field is lessened should the patient require medication or oxygen during the procedure, or if the patient becomes nauseous. Also, the face may be observed for twitching when the surgeon is working close to the facial nerve. EQUIPMENT AND INSTRUMENTS The physical set-up of the room is de-
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termined by which ear is to be operated on. The operating table is turned around and the patient is placed on it with his head at the foot. Inasmuch as the surgeon sits to do this particular operation he needs knee-room, and by turning the table this is accomplished. The operating microscope provides the necessary illumination and magnification for stapes surgery. Much of the unsuccessful surgery in the earlier era of this procedure was due to lack of the services provided by the microscope. This is a precision instrument, however, and in order to make use of its maximum potential it must be carefully handled and properly maintained. Since the Infirmary is a teaching institution, one or more persons usually observe these procedures. Therefore, the side viewing arm is a standard part of the microscope and is in use most of the time. (Figure 3.) The stockinette covers are designed with a sleeve on each side to accommodate the arm when it is changed from one side to the other. (In the July-August, 1W, AORN Journal, Mary R. Wilson, R.N., gave an excellent description and guide for making stockinette covers for the microscope in her article, “The Role of the Operating Room Nurse in Microsurgery of the Ear.”) An electric drill and burs may be needed during the stapes surgery procedure. They should be sterile and available, ready for use should this need arise. The Jordan-Day high speed drill with an angulated handpiece is preferred by some surgeons while the smaller Shea drill is used by others. Small burs, sizes 3-0 or 4-0, can be used with either of these drills. Both of these drills can be autoclaved, therefore, they present no problem in sterilization. However, the drills and burs must be thoroughly cleaned, dried, checked, and lubricated after each procedure in order to give optimum service. Adequate suction is imperative in this procedure. The operative field is so small that even one drop of blood can obliterate the view.
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Many of the instruments that are used in middle ear surgery are extremely delicate and require meticulous microprecision construction and maintenance. The set, as is used at the Infirmary, (Figure 4) includes the following instruments: 1. Three oval window picks, straight, 30degree angle, and 90-degree angle. 2. Four picks, two dull points, two sharp points. 3. Two angled picks. 4. Inca1 stapedial joint knife. 5. Two Rosen curettes, fine. 6. Sickle knife. 7. Lancet knife. 8. Two knife curettes, Rosen, large and small. 9. Triangle knife, Rosen.
AORN Journal
Fig. 4 The instruments needed to perform surgery of the middle ear. The set includes a suficient number of instruments to meet the needs for the various procedures of stapes surgery. See accompanying tezt for identification of instruments.
10. Two bayonet elevators, strong curve, and light curve. 11. Two drum elevators, right and left. 12. Three elevators, fine, medium, and strong. 13. Double end curette, Fowler. 14. Four scissors, straight, curved right, curved left, and upturned. 15. Two cup forceps, large and small. 16. Two forceps, serrated jaws, fine and very fine. 17. Non-serrated forceps, Wullstein. 18. Four ebony aural specula of varying sizes.
19. Lempert aural speculum. A nasal speculum or an aural speculum patterned after
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20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
the nasal speculum is often substituted for the Lempert speculum. Strut guide. Two crurotomy saws, Guilford-Wright, right and left. Three calipers, House, sizes 4, 41/, and 5mm. Two tympanic hooks, h e r s , angled up and angled down. Three hand foot plate instruments, Larkin, trephine, penetrator, and perforator. Chisel, 2mm. Mallet, Heerman. Tuning fork, Hartman. Wire crimper forceps, Schuknecht. Wire closure forceps, McGee.
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30. 31. 32. 33.
Speculum holder, Shea. Suction tubes, size 18, 20, 22, and 24. Cut-off adaptor, House. Rubber tubing with metal adaptor at each end. One adaptor fits into the cutoff, the other fits into the tubing from source of suction. 34. Syringe, finger control, Luer-lok. 35. Needles, gauge 20 x 1% inches for withdrawing xylocaine, gauge 26 x 1% inches for injesting. 36. Syringe, tuberculin, for injecting the local anesthesia. 37. Handle, Heermann, and assorted sizes foot plate chisels and gouges. 38. “C” press with two disks for pressing grafts. 39. Wire bending die, Schuknecht. 4Q. Stitch scissors. These fine pointed scissors are used primarily for cutting wire for prosthesis. 41. Two scissors, small, straight and curved for dissecting grafts. 42. Tissue forceps, fine tooth, for grafts. 43. Four hemostats, mosquito, for grafts. 44. Knife handle #3 with blade #15. Stainless steel wire gauge 35 is also included for making prosthesis. The instruments for specific procedures will vary in accordance with the preferences of the surgeon. The nurse, however, mu& know the steps of the operation, the instruments needed for each, the functions of the instruments, and the proper method of cleaning and sterilizing them. It is also important that she have some knowledge of the cost of these delicate and expensive instruments. The manner in which they are handled and cared for will determine their long range cost and serviceability.11 In order for the surgical nurse to fulfill her duties as a member of the team, she must have a basic understanding of the anatomy and physiology of the hearing mechanism; and since microsurgery of the middle ear is one of the newer procedures, she plays an im-
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portant role in this phase of her duty and responsibility to the surgeon and the patient.
OPERATIVE PROCEDURE After the ear has been prepped and draped, an aural speculum is placed into the external meatus. Four injections are made into the external canal skin (superiorly, inferiorly, anteriorly, posteriorly), allowing time for the solution to infiltrate down to the tympanic membrane. Because of its narrow circumference, a tuberculin syringe is used to afford better vision to the sites of injection. The solution for anesthesia consists of one part adrenalin chloride (strength 1 :1000), to seven part xylocaine (2 per cent). One to two cc. is usually sdicient to anesthetize the operative field and produce adequate hemostasis. The canal skin is incised from 11 to 6 o’clock on the right side, and from 1 to 5 o’clock on the left side, and the posterior canal wall is incised about 6 to 7 millimeters from the ear drum. The inner portion of the incised skin is then peeled down to the ear drum, and the skin and ear drum are c a r e fully elevated together and reflected forward. At this point the middle ear structures come into view. (Figure 5.) The chorda tympani nerve which lies close t o the canal wall often obstructs the view of the stapes. If possible it should be pushed aside without traumatizing it. However, it is often necessary to cut the nerve in order to see the entire stapes. Sometimes trauma to or severing of this nerve causes disagreeable postoperative effects. The chorda tympani is the principal nerve of taste to the anterior two-thirds of the tongue. In addition to a lack of taste, the patient may experience some dryness of the mouth, or a bitter metallic taste. These symptoms may disappear after a period of months, but may last longer.12 To further improve visualization, a chisel or curette may be used to remove one or two millimeters of bony posterior canal wall.
AORN Journal
Fig. 5 Exposure of otosclerotic middle ear. Top of ear is at left of the illustration. (Otologic Diagnosis and Treatment of Deafness, Myers, D., Schlosser, W . D., and Winchester, R. A.: Clinical Symposia, 14:39, 1962.)
When exposure is complete, a view of the incus, stapedial tendon, incudostapedial joint, and crus of the stapes will be obtained. This is the standard method of approach to expose the stapes. What is done from this point can vary widely from surgeon to surgeon. However, one of three procedures, or variations of these procedures will be employed. They include: 1) stapes mobilization, 2) partial stapedectomy, and 3) total stapedectomy with prosthesis and fat or vein graft, or a gelfoam plug. We will briefly describe these in the order in which they are listed. In the stapes mobilization technique, an instrument called a stapes mobilizer is placed against the anterior neck of the stapes and pressure is gently but firmly applied. If otosclerosis at the foot plate of the stapes is not extensive, this maneuver may mobilize the stapes and result in restoration of hearing.
In successful mobilization, marked improvement in hearing is often dramatic. New postoperative otosclerotic formation, however, can cause the stapes to re-fix with a recurrence of hearing loss. If this postoperative formation does not occur, the hearing gain should be permanent. When the stapes cannot be mobilized with ease, and the focus of otosclerosis is anterior, a partial stapedectomy is attempted. With a curved crurotomy scissors, the anterior crus is sectioned, the foot plate is fractured, and a portion of the anterior crus and foot plate are removed, as indicated in Figure 6. The posterior portion of the foot plate is mobilized forward into the center of the oval window. This results in a mobile portion of the stapes which is able to transmit sound without interposition of an artificial prosthesis. We are thus utilizing the patient’s own stapes in such a manner as to obviate the
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Fig. 6 Anterior otosclerosis. Resection of anterior crus and mid foot plate fracture resulting in partial stapedectomy including the otosclerotic focus. (Stapes Surgery for Otosclerosis by Victor Goodhill, M.D. by permission of Harper & Row, Publishers, Inc.)
necessity of placing foreign material into the oval window. This method seems to reduce the risk of further hearing loss, as compared to the total stapedectomy procedure where the entire stapes with the foot plate is removed. However, in some cases there is so much disease of the stapes that it must be removed in toto and an artificial prosthesis is introduced. Many types of grafts have been utilized in the stapedectomy procedures. Most frequently used are a small segment of vein, usually taken from the dorsum of the hand, or fat taken from the ear lobe. However, other grafts such as conjunctiva, mucosa, and connective tissue have also been successfully transplanted.13 These tissues may be used as a flat graft over the oval window with a strut placed between the incus and the graft. Or a “plug” of vein, fat or gelfoam may be attached to a stainless steel wire and placed in the oval window. The free end of the wire is bent into an incomplete circle and hung (like a coat hanger) over the long process of the incus. (Figure 7.) A new
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membrane forms over the oval window and in time the graft tissue is partially or completely replaced by fibrous tissue. The results of this procedure may be excellent. However, after such total stapedectomies, the incidence of severe cochlear loss is higher than in any other procedure.14 After the surgery has been completed and the surgeon is satisfied that good contact is being made with the middle ear, the operative wound is closed. All the blood is carefully suctioned from the operative field and the skin flap is replaced to its normal position. The folds are gently smoothed with a flap elevator. A small strip of surgical rayon is placed over the incision to splint the flap. No suturing is required. The canal is packed with small cotton balls. These are replaced by a pledget of cotton in the external meatus before the patient is discharged from the hospital. POSTOPERATIVE CARE Since these procedures are performed under local anesthesia, the patient is returned directly to his room. He is cautioned
AORN Journal
against blowing his nose. By so doing, infection could be transmitted from the mouth into the middle ear via the eustachian tube. Also, pressure in the middle ear could displace the prosthesis and delicate grafts, and nullify the entire procedure. He should remain in bed until he is free from the effects of the preoperative medication or vertigo. If there is postoperative vertigo, Dramamine 50 mgm is given every three hours, as necessary. Rarely is pain severe following stapes surgery. Codeine grains I, or meperidine 50 mgm, is usually sufficient to keep the patient comfortable. Regular diet is prescribed and lavatory privileges are resumed the same day of operation. The patient is usually discharged the day following surgery. He is advised to return to the physician’s office in a week for postoperative evaluation. After one week the incision is usually sufficiently healed that no packing or dressing is required. A pledget of cotton may be placed in the canal to protect it from dust, sudden changes in temperature, or loud noises. The patient should be advised to avoid getting water in the external auditory canal for a few weeks, and should also avoid traveling to high altitudes or flying for approximately thirty days. If the patient desires surgery on the opposite ear, he is usually advised to wait for two months or longer. In the event of reankylosis following mobilization of the stapes, audiometric testing and re-evaluation must be made before revision surgery can be planned. This requires a period of several months and possibly a year.l6 COMPLICATIONS Complications following middle ear surgery are infrequent. However, they do occur and may be serious. Meningitis and labyrinthitis are the most serious complications. A few fatalities have been reported.
July-Aug 1965
Fig. 7 Fat graft in position over the oval window with stainless steel wire connection to the incus. (Stapes Surgery for Otosclerosis by Victor Goodhill, M.D. by permission of Harper & Row, Publishers, Inc.)
Fortunately, they are rare. Facial paralysis, both transient and permanent, have been encountered but only infrequently. Labyrinthine degeneration causing permanent cochlear deafness has become more frequent with the increased number of stapedectomies being performed. This is a problem facing otologists, and serious attention must be directed to the physiology labyrinthine penetration with its multiple biochemical and immunologic problems.16 Other complications, such as otitis media, vertigo, which may be persistent and of lasting duration, and cerebrospinal otorrhea, may cause the patient much pain or discomfort but they are not considered serious unless further complications arise from them.
CONCLUSION No one should be enticed into believing that each new procedure provides the one magical formula which will solve every problem in surgery of the middle ear, even with the most concentrated effort to achieve better and better results. An orderly succession of techniques, from the simpler to the more complex, offers the maximum safety and the greatest possibility for success.1 7
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In the last two decades, however, otologists have made such impressive strides in surgery of the middle ear and have opened up so many avenues of study and research that even greater hope is now offered to the hard of hearing than ever before. In contemplating the possibilities, one is tempted to believe that we really may be approaching the era referred to by the prophet Isaiah
when he predicted that “the ears of the deaf shall be unstopped.” The author wishes to express sincere appreciation to Dr. Samuel Rosen for his assistance in preparing this paper. Dr. Rosen is a consultant surgeon at the New York Eye and Ear Infirmary where he operates frequently. The contribution made by Dr. Rosen to stapes surgery is known the world over. W e are very fortunate in having had his help. Much credit is also due Dr. Floyd Gusack whose efforts in the initial preparation o f the manuscript were invaluable.
REFERENCES 1. Isaiah, King James edition of Bible, Chapter 29, Verse 18. 2. Isaiah, King James edition of Bible, Chapter 35, Verse 5. 3. Release from the Deafness Research Foundation, New York, March 24, 1965. 4. “Deafness-A World of Hush,” Medicine at Work, Pharmaceutical Manufatcurers Association, June, 1964, p. 3. 5. Myers, David, Schlosser, Woodrow D. and Winchester, Richard A., Clinical Symposia Otologic Diagnosis and the Treatment of Deafness, Ciba Pharmaceutical Company, Summit, New Jersey, 14:39, 1962, p. 65. 6. Jackson & Jackson, Diseases o f the Nose, Throat and Ear, 2nd edition, W. B. Saunders Company, Philadelphia and London, 1959, pp. 485-514. 7. Havener, Saunders and Bergersen, Nursing Care in Eye, Ear, Nose and Throat Disorders, The C. V. Mosby Company, Saint Louis, Missouri, 1964, p. 284. 8. Kobrak, Heinrick G., The Middle Ear, The University of Chicago Press, Chicago, 1959, pp. 123-158.
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9. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,” J.A.M.A., Vol. 178, 1961, p. 96. 10. Hough, J.V.D., “Surgical Treatment of Otosclerosis,” Archives o f Otolaryngology, Vol. 77, American Medical Association Publication, 1963, pp. 118-119. 11. Wilson, Mary, “The Role of the Operating
Room Nurse in Microsurgery of the Ear, “AORN Journal, Vol. 2, #4, 1964. 12. Goodhill, Victor, Stapes Surgery for Otosclerosis, Paul B. Hoeber, Inc. (Medical division of Harper & Brothers), New York, 1964, p. 148. 13. Ibid. 14. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,” J.A.M.A., Vol. 178, 1961, p. 96. 15. Goodhill, Victor, Stapes Surgery for Otosclerosis, Paul B. Hoeber, Inc. (Medical division of Harper & Brothers), New York, 1964, p. 146. 16. Ibid. p. 147. 17. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,’’ J.A.M.A., Vol. 178, 1961, p. 96.
AORN Journal
OF THE MIDDLE EAR FOR OTOSCLEROSIS Ruby Tomlinson Sanches, R.N.
For untold centuries, deafness has been an diction of the human race. In Biblical days the prophet Isaiah spoke of the day when “the deaf shall hear words”1 and “the ears
Mrs. Sanches, a native of North Carolina, received her nurse’s training at the Scranton
State Hospital School of Nursing (Pennsylvania). She received post-graduute training in operating room nursing at New York Polyclinic Hospital and has taken courses at both Columbia and New York Universities. She is the supervisor of the Ear Operating Rooms at the New York Eye and Ear Infirmary in New York City. Mrs. Sanches is National Treasurer of the AORN, a member of the Executive Committee, and Chairman of the Committee o n Budget and Finance. As an active member of the New York Chapter, she is also Chairman of the By-Laws Committee.
J u l y - A ~ g1965
of the deaf shall be unstopped.”2 Deafness is found in people of all ages and
is prevalent throughout the world. Reliable statistics indicate that more than 18 million people in the United States, including three million children, suffer from some degree of hearing loss. 3 Defective hearing is considered the number one physical impairment4 in adults in this country. Otosclerosis, the subjeot of this paper, is alone responsible for 35 to # per cent of all those who are acoustically handicapped.6 Otosclerosis is a destructive disease. Since it is painless, the destruative action may progress for many years before the patient is aware of it. Its etiology, however, is still unknown. Otosclerosis is a process whereby new bone formation occurs in the bony labyrinth of the otic oapsule (middle ear). This process almost always begins on and around the foot plate of the stapes, causing it to become fixed
59
Fig. 1 Sagitall section of temporal bone showing the relationship of middle ear and inner ear structures. Note the otosclerotic bone formation. (Otologic Diagnosis and Treatment of Deafness, Myers, D., Schlosser, 1.D., and Winchester, R. A.: Clinical Symposia, 14:39, 1962.)
in the oval window, trapped like a peanut in brittle candy. When this occurs the foot plate can no longer vibrate freely and therefore is unable to transmit sound waves to the nerve of hearing. As the disease gradually progresses the foot plate becomes more firmly fixed and the hearing loss gradually increases. (Figure 1.) Bilateral involvement is the most common situation but in a small percentage of cases the deafness is unilateral and may remain so. It is a disease which is not bound by age limits and often becomes manifest after puberty and during pregnancy.6 The deafness usually reaches its peak during the fourth or fifth decade of life. The disease appears about twice as often in women as in men and there seems to be evidence that
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heredity plays an important causative part. The white race is more susceptible to otosclerosis than the Negro race,? and among the Mongolian race it is quite rare. Indications are that the city dweller suffers greater hearing loss and with more frequency than those living in less urban areas.
HISTORY Stapes surgery has become the fruition of the dream to restore hearing to the patient plagued with otosclerosis. Very crude attempts at mobilizing the stapes date back to the late 1800’s. The extremely discouraging results of the pioneers in this field may have been due to poor light, inadequate magnification, and the complications of ever-present infection in the pre-antibiotic era. As a re-
AORN Journal
sult of these failures, the stapes was held to be inviolate and the technique was abandoned. Other methods for attempting to improve hearing surgically were sought. In 1924, Mr. Maurice Sourdille in France developed an operation in two stages for otosclerotic deafness. In Dr. Sourdille's technique, a small window was made in the horizontal semi-circular canal. Through this window sound was transmitted to the cochlea, resulting in improved hearing. In 1938, Dr. Julius Lempert in New York developed that technique into a one-stage fenestration operation. Over the years, Dr. Lempert added many variations in technique until he was able to obtain lasting hearing improvement in about 78 per cent of his cases. Basically, the fenestration operation consists of making an endaural incision, followed by mastoideotomy, resection of part of the head of the malleus and the incus, and fenestration of the lateral semi-circular canal. This technique by-passes the otosclerosis at the oval window, and sound is conducted through this new window or nov ovalis. This operation gained wide acceptance as the best surgical approach to otosclerosis until the rediscovery of stapes mobilization in 1952 by Dr. Samuel Rosen of New York City. In attempting to evaluate the suitability of the patient for fenestration surgery, Dr. Rosen developed a technique to test the fixation of the stapes in the oval window. One day, while employing this technique, Dr. Rosen applied pressure to the stapes and his patient suddenly announced his increased ability to hear. At that moment, Dr. Rosen had mobilized his first stapes and by so doing re-kindled an interest in this most fascinating sphere of otologic surgery. Since 1952, stapes surgery has become the most widely accepted approach to the correction of otosclerotic deafness.8 There are many causes of deafness or impaired hearing and many surgical procedures
July-Aug 1965
employed in an effort to improve or restore hearing. However, this paper deals only with the surgical procedures used in the treatment of otosclerosis, especially as conducted at the New York Eye and Ear Infirmary.
DIAGNOSIS Diagnosis of otosclerosis is dependent on a history of gradual rather than sudden hearing loss. Physical examination of the patient reveals an essentially normal external ear, canal and tympanic membrane. Audiological testing of the patient is the best means of arriving at an accurate diagnosis. It indicates the type of deafness, as well as the degree of improvement in hearing to be expected after surgery, We prefer to screen that patient by audiological testing, with several tuning forks of different pitch, before testing audiometrically. When the vibrating tuning fork is held close to the ear of a patient with normal hearing, he can hear it for a longer span of time than when the fork is moved so that' the handle is placed directly against the mastoid bone. The reverse is true of the patient with the otosclerotic deafness. The audiogram shown in Figure 2 is the result of audiometric testing which indicated the preoperative hearing levels and the hearing improvement gained by stapes surgery. Bone conduction, indicated in the audiogram by the symbol 7, is essentially normal, which means that the cochlea is not involved. PSYCHOLOGICAL PREPARATION
OF THE PATIENT The patient mu& be prepared, psychologically, to accept the facts relative to the operation. His consent for operation should be an informed consent. He should be acquainted with all the facts concerning the known dangers, the risks involved and the failures, as well as the degree of potential success of any procedure the surgeon may employ.9
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125
250
500
1000
2000
4000
8000
10
NORMAL 10
20 30 40
50 60
70 80
RECEI! THIprsI). - SPE€C+l p~~-op......-40 DB.
*......
.I
90 100
- ,
-I
5 DB.
----L
110
ROSEN
Fig. 2 Audiogram indicating the preoperative and postoperative hearing levels.
A paragraph from the Archives
Otolaryngology illustrates this need: “Never b e fore have so many patients with otoeclerosis been willing to accept the procedures that we are offering them today to improve their hearing. The unprecedented publicity regarding these operations in the newspapers, magazines, radio and television has left the impression in the minds of most people that the operation is infallible.”lO In each succeeding year, useful hearing is restored to more deaf ears than in any other preceding year in human history. However, there are still patients who experience no improvement. Otologist’s reports indicate that the hearing is improved in approximately 85 per cent of all the patients undergoing stapes surgery; and that it is unchanged in about 10 per cent; in 5 per cent the hearing is worsened and the patient may be left with almost total deafness. This misfortune is more common following total stapedectomy than from other procedure.
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of
PREOPERATIVE ORDERS The preoperative orders include a complete blood count, urinalysis, and determination of the bleeding and clotting time. An antibiotic such as tetracycline with nystatin 250 mgm is given every six hours. A barbiturate is given 1% hours preoperatively, followed by meperidine 50 mgm one-half hour later. Since this surgery is performed under local anesthesia, most surgeons request that dentures be retained by the patient. Male patients should be advised to have a haircut prior to admission, and female patients should be advised to have a shampoo because they will not be permitted to do this for three or four weeks following surgery.
PREPARATION OF THE PATIENT A preliminary prep is done on the operative ear approximately eight hours prior to surgery. Shaving the hair around the ear is usually unnecessary but a thorough cleansing of the operative field is obligatory. The
AORN Journal
auricle and periauricular areas are scrubbed with pHisoHex and water and a sterile dressing is applied. During the preliminary prep the canal is not entered. Every effort should be made to make the patient comfortable before surgery begins and he should be told of the importance of keeping his head in the position fixed by the surgeon. Various devices may be utilized to assist him in maintaining that position. We use the “headrest” which is available commercially for fixing the head, and also a “dough-nut” and foam rubber pillows which we have made for this purpose. If none of these are available, rolled towels or small sandbags will suffice. The use of these is determined by the surgeon’s preference. After the patient is positioned on the operating table the dressing is removed. A small amount of vaseline may be applied with a tongue blade to any stray wisps of hair, about an inch from the hair line, around the operative field of female patients. The entire field is prepped with an antiseptic of the surgeon’s choice. Tinted antiseptics have a tendency to discolor the outer membrane of the ear drum. Therefore, the colorless or untinted solutions are used.
DRAPING The head may be draped with either the plastic surgical sheet or the conventional head drape. In the latter instance, the drape is composed of two small sheets placed under the patient’s head at the same time, and brought down to the nape of the neck. The outer one is allowed to fall down over the end and sides of the table. The inner one is brought up around the patient’s head, above the operative ear, and fastened securely with a towel clip. It is important that all the hair be caught inside the head drape and covered. The instrument tray (the Mayo stand) is placed about two inches above the patient’s cheek, just anterior to the operative ear. A large double thickness sheet is draped over
July-Aug 1965
Fig. 3 Arrangement of furniture with the patient in position for surgery on the right ear,
the patient from the chin downward and over the feet. The instrument tray and stand are both covered with a double thickness sheet and towel. Three folded towels are placed around the operative ear to form a triangle and the fenestrated sheet is placed on last. Since the surgeons at our Infirmary operate with the patient’s face away from them, the instrument tray serves a twofold purpose. It is utilized to keep the drapes off the patient’s face as well as to hold instruments. This affords space for the patient to breathe freely and for the circulating nurse to care for him. The possibility of contaminating the operative field is lessened should the patient require medication or oxygen during the procedure, or if the patient becomes nauseous. Also, the face may be observed for twitching when the surgeon is working close to the facial nerve. EQUIPMENT AND INSTRUMENTS The physical set-up of the room is de-
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termined by which ear is to be operated on. The operating table is turned around and the patient is placed on it with his head at the foot. Inasmuch as the surgeon sits to do this particular operation he needs knee-room, and by turning the table this is accomplished. The operating microscope provides the necessary illumination and magnification for stapes surgery. Much of the unsuccessful surgery in the earlier era of this procedure was due to lack of the services provided by the microscope. This is a precision instrument, however, and in order to make use of its maximum potential it must be carefully handled and properly maintained. Since the Infirmary is a teaching institution, one or more persons usually observe these procedures. Therefore, the side viewing arm is a standard part of the microscope and is in use most of the time. (Figure 3.) The stockinette covers are designed with a sleeve on each side to accommodate the arm when it is changed from one side to the other. (In the July-August, 1W, AORN Journal, Mary R. Wilson, R.N., gave an excellent description and guide for making stockinette covers for the microscope in her article, “The Role of the Operating Room Nurse in Microsurgery of the Ear.”) An electric drill and burs may be needed during the stapes surgery procedure. They should be sterile and available, ready for use should this need arise. The Jordan-Day high speed drill with an angulated handpiece is preferred by some surgeons while the smaller Shea drill is used by others. Small burs, sizes 3-0 or 4-0, can be used with either of these drills. Both of these drills can be autoclaved, therefore, they present no problem in sterilization. However, the drills and burs must be thoroughly cleaned, dried, checked, and lubricated after each procedure in order to give optimum service. Adequate suction is imperative in this procedure. The operative field is so small that even one drop of blood can obliterate the view.
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Many of the instruments that are used in middle ear surgery are extremely delicate and require meticulous microprecision construction and maintenance. The set, as is used at the Infirmary, (Figure 4) includes the following instruments: 1. Three oval window picks, straight, 30degree angle, and 90-degree angle. 2. Four picks, two dull points, two sharp points. 3. Two angled picks. 4. Inca1 stapedial joint knife. 5. Two Rosen curettes, fine. 6. Sickle knife. 7. Lancet knife. 8. Two knife curettes, Rosen, large and small. 9. Triangle knife, Rosen.
AORN Journal
Fig. 4 The instruments needed to perform surgery of the middle ear. The set includes a suficient number of instruments to meet the needs for the various procedures of stapes surgery. See accompanying tezt for identification of instruments.
10. Two bayonet elevators, strong curve, and light curve. 11. Two drum elevators, right and left. 12. Three elevators, fine, medium, and strong. 13. Double end curette, Fowler. 14. Four scissors, straight, curved right, curved left, and upturned. 15. Two cup forceps, large and small. 16. Two forceps, serrated jaws, fine and very fine. 17. Non-serrated forceps, Wullstein. 18. Four ebony aural specula of varying sizes.
19. Lempert aural speculum. A nasal speculum or an aural speculum patterned after
Julv-Aug 1965
20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
the nasal speculum is often substituted for the Lempert speculum. Strut guide. Two crurotomy saws, Guilford-Wright, right and left. Three calipers, House, sizes 4, 41/, and 5mm. Two tympanic hooks, h e r s , angled up and angled down. Three hand foot plate instruments, Larkin, trephine, penetrator, and perforator. Chisel, 2mm. Mallet, Heerman. Tuning fork, Hartman. Wire crimper forceps, Schuknecht. Wire closure forceps, McGee.
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30. 31. 32. 33.
Speculum holder, Shea. Suction tubes, size 18, 20, 22, and 24. Cut-off adaptor, House. Rubber tubing with metal adaptor at each end. One adaptor fits into the cutoff, the other fits into the tubing from source of suction. 34. Syringe, finger control, Luer-lok. 35. Needles, gauge 20 x 1% inches for withdrawing xylocaine, gauge 26 x 1% inches for injesting. 36. Syringe, tuberculin, for injecting the local anesthesia. 37. Handle, Heermann, and assorted sizes foot plate chisels and gouges. 38. “C” press with two disks for pressing grafts. 39. Wire bending die, Schuknecht. 4Q. Stitch scissors. These fine pointed scissors are used primarily for cutting wire for prosthesis. 41. Two scissors, small, straight and curved for dissecting grafts. 42. Tissue forceps, fine tooth, for grafts. 43. Four hemostats, mosquito, for grafts. 44. Knife handle #3 with blade #15. Stainless steel wire gauge 35 is also included for making prosthesis. The instruments for specific procedures will vary in accordance with the preferences of the surgeon. The nurse, however, mu& know the steps of the operation, the instruments needed for each, the functions of the instruments, and the proper method of cleaning and sterilizing them. It is also important that she have some knowledge of the cost of these delicate and expensive instruments. The manner in which they are handled and cared for will determine their long range cost and serviceability.11 In order for the surgical nurse to fulfill her duties as a member of the team, she must have a basic understanding of the anatomy and physiology of the hearing mechanism; and since microsurgery of the middle ear is one of the newer procedures, she plays an im-
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portant role in this phase of her duty and responsibility to the surgeon and the patient.
OPERATIVE PROCEDURE After the ear has been prepped and draped, an aural speculum is placed into the external meatus. Four injections are made into the external canal skin (superiorly, inferiorly, anteriorly, posteriorly), allowing time for the solution to infiltrate down to the tympanic membrane. Because of its narrow circumference, a tuberculin syringe is used to afford better vision to the sites of injection. The solution for anesthesia consists of one part adrenalin chloride (strength 1 :1000), to seven part xylocaine (2 per cent). One to two cc. is usually sdicient to anesthetize the operative field and produce adequate hemostasis. The canal skin is incised from 11 to 6 o’clock on the right side, and from 1 to 5 o’clock on the left side, and the posterior canal wall is incised about 6 to 7 millimeters from the ear drum. The inner portion of the incised skin is then peeled down to the ear drum, and the skin and ear drum are c a r e fully elevated together and reflected forward. At this point the middle ear structures come into view. (Figure 5.) The chorda tympani nerve which lies close t o the canal wall often obstructs the view of the stapes. If possible it should be pushed aside without traumatizing it. However, it is often necessary to cut the nerve in order to see the entire stapes. Sometimes trauma to or severing of this nerve causes disagreeable postoperative effects. The chorda tympani is the principal nerve of taste to the anterior two-thirds of the tongue. In addition to a lack of taste, the patient may experience some dryness of the mouth, or a bitter metallic taste. These symptoms may disappear after a period of months, but may last longer.12 To further improve visualization, a chisel or curette may be used to remove one or two millimeters of bony posterior canal wall.
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Fig. 5 Exposure of otosclerotic middle ear. Top of ear is at left of the illustration. (Otologic Diagnosis and Treatment of Deafness, Myers, D., Schlosser, W . D., and Winchester, R. A.: Clinical Symposia, 14:39, 1962.)
When exposure is complete, a view of the incus, stapedial tendon, incudostapedial joint, and crus of the stapes will be obtained. This is the standard method of approach to expose the stapes. What is done from this point can vary widely from surgeon to surgeon. However, one of three procedures, or variations of these procedures will be employed. They include: 1) stapes mobilization, 2) partial stapedectomy, and 3) total stapedectomy with prosthesis and fat or vein graft, or a gelfoam plug. We will briefly describe these in the order in which they are listed. In the stapes mobilization technique, an instrument called a stapes mobilizer is placed against the anterior neck of the stapes and pressure is gently but firmly applied. If otosclerosis at the foot plate of the stapes is not extensive, this maneuver may mobilize the stapes and result in restoration of hearing.
In successful mobilization, marked improvement in hearing is often dramatic. New postoperative otosclerotic formation, however, can cause the stapes to re-fix with a recurrence of hearing loss. If this postoperative formation does not occur, the hearing gain should be permanent. When the stapes cannot be mobilized with ease, and the focus of otosclerosis is anterior, a partial stapedectomy is attempted. With a curved crurotomy scissors, the anterior crus is sectioned, the foot plate is fractured, and a portion of the anterior crus and foot plate are removed, as indicated in Figure 6. The posterior portion of the foot plate is mobilized forward into the center of the oval window. This results in a mobile portion of the stapes which is able to transmit sound without interposition of an artificial prosthesis. We are thus utilizing the patient’s own stapes in such a manner as to obviate the
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Fig. 6 Anterior otosclerosis. Resection of anterior crus and mid foot plate fracture resulting in partial stapedectomy including the otosclerotic focus. (Stapes Surgery for Otosclerosis by Victor Goodhill, M.D. by permission of Harper & Row, Publishers, Inc.)
necessity of placing foreign material into the oval window. This method seems to reduce the risk of further hearing loss, as compared to the total stapedectomy procedure where the entire stapes with the foot plate is removed. However, in some cases there is so much disease of the stapes that it must be removed in toto and an artificial prosthesis is introduced. Many types of grafts have been utilized in the stapedectomy procedures. Most frequently used are a small segment of vein, usually taken from the dorsum of the hand, or fat taken from the ear lobe. However, other grafts such as conjunctiva, mucosa, and connective tissue have also been successfully transplanted.13 These tissues may be used as a flat graft over the oval window with a strut placed between the incus and the graft. Or a “plug” of vein, fat or gelfoam may be attached to a stainless steel wire and placed in the oval window. The free end of the wire is bent into an incomplete circle and hung (like a coat hanger) over the long process of the incus. (Figure 7.) A new
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membrane forms over the oval window and in time the graft tissue is partially or completely replaced by fibrous tissue. The results of this procedure may be excellent. However, after such total stapedectomies, the incidence of severe cochlear loss is higher than in any other procedure.14 After the surgery has been completed and the surgeon is satisfied that good contact is being made with the middle ear, the operative wound is closed. All the blood is carefully suctioned from the operative field and the skin flap is replaced to its normal position. The folds are gently smoothed with a flap elevator. A small strip of surgical rayon is placed over the incision to splint the flap. No suturing is required. The canal is packed with small cotton balls. These are replaced by a pledget of cotton in the external meatus before the patient is discharged from the hospital. POSTOPERATIVE CARE Since these procedures are performed under local anesthesia, the patient is returned directly to his room. He is cautioned
AORN Journal
against blowing his nose. By so doing, infection could be transmitted from the mouth into the middle ear via the eustachian tube. Also, pressure in the middle ear could displace the prosthesis and delicate grafts, and nullify the entire procedure. He should remain in bed until he is free from the effects of the preoperative medication or vertigo. If there is postoperative vertigo, Dramamine 50 mgm is given every three hours, as necessary. Rarely is pain severe following stapes surgery. Codeine grains I, or meperidine 50 mgm, is usually sufficient to keep the patient comfortable. Regular diet is prescribed and lavatory privileges are resumed the same day of operation. The patient is usually discharged the day following surgery. He is advised to return to the physician’s office in a week for postoperative evaluation. After one week the incision is usually sufficiently healed that no packing or dressing is required. A pledget of cotton may be placed in the canal to protect it from dust, sudden changes in temperature, or loud noises. The patient should be advised to avoid getting water in the external auditory canal for a few weeks, and should also avoid traveling to high altitudes or flying for approximately thirty days. If the patient desires surgery on the opposite ear, he is usually advised to wait for two months or longer. In the event of reankylosis following mobilization of the stapes, audiometric testing and re-evaluation must be made before revision surgery can be planned. This requires a period of several months and possibly a year.l6 COMPLICATIONS Complications following middle ear surgery are infrequent. However, they do occur and may be serious. Meningitis and labyrinthitis are the most serious complications. A few fatalities have been reported.
July-Aug 1965
Fig. 7 Fat graft in position over the oval window with stainless steel wire connection to the incus. (Stapes Surgery for Otosclerosis by Victor Goodhill, M.D. by permission of Harper & Row, Publishers, Inc.)
Fortunately, they are rare. Facial paralysis, both transient and permanent, have been encountered but only infrequently. Labyrinthine degeneration causing permanent cochlear deafness has become more frequent with the increased number of stapedectomies being performed. This is a problem facing otologists, and serious attention must be directed to the physiology labyrinthine penetration with its multiple biochemical and immunologic problems.16 Other complications, such as otitis media, vertigo, which may be persistent and of lasting duration, and cerebrospinal otorrhea, may cause the patient much pain or discomfort but they are not considered serious unless further complications arise from them.
CONCLUSION No one should be enticed into believing that each new procedure provides the one magical formula which will solve every problem in surgery of the middle ear, even with the most concentrated effort to achieve better and better results. An orderly succession of techniques, from the simpler to the more complex, offers the maximum safety and the greatest possibility for success.1 7
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In the last two decades, however, otologists have made such impressive strides in surgery of the middle ear and have opened up so many avenues of study and research that even greater hope is now offered to the hard of hearing than ever before. In contemplating the possibilities, one is tempted to believe that we really may be approaching the era referred to by the prophet Isaiah
when he predicted that “the ears of the deaf shall be unstopped.” The author wishes to express sincere appreciation to Dr. Samuel Rosen for his assistance in preparing this paper. Dr. Rosen is a consultant surgeon at the New York Eye and Ear Infirmary where he operates frequently. The contribution made by Dr. Rosen to stapes surgery is known the world over. W e are very fortunate in having had his help. Much credit is also due Dr. Floyd Gusack whose efforts in the initial preparation o f the manuscript were invaluable.
REFERENCES 1. Isaiah, King James edition of Bible, Chapter 29, Verse 18. 2. Isaiah, King James edition of Bible, Chapter 35, Verse 5. 3. Release from the Deafness Research Foundation, New York, March 24, 1965. 4. “Deafness-A World of Hush,” Medicine at Work, Pharmaceutical Manufatcurers Association, June, 1964, p. 3. 5. Myers, David, Schlosser, Woodrow D. and Winchester, Richard A., Clinical Symposia Otologic Diagnosis and the Treatment of Deafness, Ciba Pharmaceutical Company, Summit, New Jersey, 14:39, 1962, p. 65. 6. Jackson & Jackson, Diseases o f the Nose, Throat and Ear, 2nd edition, W. B. Saunders Company, Philadelphia and London, 1959, pp. 485-514. 7. Havener, Saunders and Bergersen, Nursing Care in Eye, Ear, Nose and Throat Disorders, The C. V. Mosby Company, Saint Louis, Missouri, 1964, p. 284. 8. Kobrak, Heinrick G., The Middle Ear, The University of Chicago Press, Chicago, 1959, pp. 123-158.
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9. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,” J.A.M.A., Vol. 178, 1961, p. 96. 10. Hough, J.V.D., “Surgical Treatment of Otosclerosis,” Archives o f Otolaryngology, Vol. 77, American Medical Association Publication, 1963, pp. 118-119. 11. Wilson, Mary, “The Role of the Operating
Room Nurse in Microsurgery of the Ear, “AORN Journal, Vol. 2, #4, 1964. 12. Goodhill, Victor, Stapes Surgery for Otosclerosis, Paul B. Hoeber, Inc. (Medical division of Harper & Brothers), New York, 1964, p. 148. 13. Ibid. 14. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,” J.A.M.A., Vol. 178, 1961, p. 96. 15. Goodhill, Victor, Stapes Surgery for Otosclerosis, Paul B. Hoeber, Inc. (Medical division of Harper & Brothers), New York, 1964, p. 146. 16. Ibid. p. 147. 17. Rosen, Samuel, “Assessment of Techniques of Stapes Surgery,’’ J.A.M.A., Vol. 178, 1961, p. 96.
AORN Journal