History of Otosclerosis and Stapes Surgery

The current advancements in otosclerosis therapy cannot be fully appreciated without studying the history, rediscovery, and modification of a once-forgotten procedure. The evolution of stapes surgery can be best summarized into 4 noteworthy eras: the preantibiotic era (which was forgotten and then rediscovered), the fenestration era (mainstreamed by Julius Lempert), the mobilization era (led by Samuel Rosen), and the modern stapedectomy era (revived and revolutionized by John Shea). Each era is unique with its own challenges and ingenious techniques to overcome what used to be among the leading causes of deafness.

General history of stapedectomy

The article gives an overview of the historical development of stapedectomy beginning with Kessel in 1876. Then, from the beginning to the middle of the 20th century, surgery on the oval window became obsolete, opening the way for an era of fenestration operations until Shea in 1956 performed the first modern stapedectomy using a Teflon stapes replacement prosthesis. Since then, numerous surgeons worldwide have used this procedure with great success. Many of them have contributed towards progressively refining the surgical techniques, e.g. by changing the total removal of the footplate for the less traumatic small fenestra stapedectomy or stapedotomy.

Teaching stapes surgery

This paper is a review of concepts and methods presented as a tribute to a great pioneer and teacher, Harold Frederic Schuknecht. His book entitled Stapedectomy, published in 1971, is based on past experience of '6,200 stapedectomy operations over a period of 13 years' and on experience gained from teaching the procedure to numerous residents and fellows. His concepts are still valid and represent a solid base for teachers and students of this elegant but precarious procedure.

Evolution of stapedectomy prostheses over time

The history of stapedectomy prostheses started in 1956, when John J. Shea first described the microsurgical technique of the stapedectomy procedure in which an otosclerotic stapes was replaced with a prosthesis made of Teflon. Over the years, the evolution of the prostheses was influenced by the changes in the microsurgical technique, materials used and technical properties. The materials evolved from Teflon, metal, to plastic, and most recently to gold and titanium. While initially the diameter of the pistons used was 0.8 and 0.6 mm, from the 1970s onwards, it has been becoming even smaller in order to ease the procedure and reduce the risk of inner ear damage. Improvement was made in the way the prosthesis is fixed to the long incus process, resulting in different solutions like Teflon memory effect, platinum and gold band, titanium-gold clip prostheses or nickel-titanium alloy. Eventually, the most decisive factor for successful surgery is surgical experience with a specific type of prostheses and the expertise in the microsurgery technique.

History of osteogenesis imperfecta or brittle bone disease: a few stops on a road 3000 years long

The attested history of osteogenesis imperfecta began three thousand years ago and it continues down to the present day. Through the centuries, we find a dislocated mummy of a child of Ancient Egypt, a young Arab named Satib, a Viking prince known as "Boneless", a subject of Louis XIV with a broken skeleton and finally, in the 20th century, a young deaf mother with blue sclerotics and a jazz pianist unable to walk except on crutches... Without being exhaustive, this review of contrasting cases attests to the universality and to the permanency of this disease.

[30 years of stapes surgery]

This study reports the results of otosclerosis surgery performed during the past thirty years (1973-2002) in the ENT Clinic in Katowice. The authors present difficult anatomic relationships in the tympanic cavity which might have an influence on stapes surgery. Audiometric evaluation of 100 bilateral stapedotomies performed in 50 patients revealed that a small--hole stapedotomy is a safe technique and could be performed bilaterally. The group of 55 stapedotomies with stapedial tendon preserved was compared to the group of 55 stapedotomies with dissected tendon. SRT was better in the group where the tendon was preserved. In the group of 32 patients ABR before and after stapedotomy was recorded. The latency of V wave after the operation was reduced to the normal values what indicated a correct function of the ossicular chain postoperatively. In the group of 60 patients DPOAE prior and after stapedotomy was evaluated. Prior to the operation no signal of otoacoustic emission was registered, in 37 patients out of 60 the signal was present after the operation. DPOAE obtained postoperatively indicated successful ossicular chain restoration and inner ear function. Audiometric evaluation in reference to the group of 905 stapedotomies performed in years 1992-2001 showed that most of the patients were in group B--443/905 and C--402/905 according, in A group--60/905 according to Shambaugh. A-B gap < or = 10 dB was obtained in 469/905 (51.8%), the mean of the hearing threshold at 500, 1000, 2000 and 4000 Hz was 24.3 dB (+/- 8.3, med. 25.0) in A group and 32.0 dB in B and C group. The result of stapedotomy in reference to tinnitus based on the patients' subjective opinion. We may conclude that the key to the stapes surgery lies in the training and skillfulness of the surgeon using save small hole technique with stapedial tendon preservation to obtain the optimal physiologic function of the middle ear and to gain the best hearing results.

[A century in the history of chronic ear surgery]

Although some advocated surgery of the tympanic membrane and stapes as early as early as the end of the nineteenth century, it took a long time for widespread development. Mastoid surgery had just been born and was to be greatly improved over the next century. Preservation of the tympano-ossicular its later reconstruction gradually came into use with the creation of the tympanomeatal flap and the recent development of middle ear surgery, followed by posterior tympanotomy and myringoplasty, thus allowing closed tympanoplasty. Likewise, the ventilation tube, forgotten for more than half a century, has found an important place in the treatment of chronic otitis with a closed ear drum.

[Historical analysis of otosclerosis surgery]

In the present work main surgical techniques used along the history to solve hypoacusis caused by otosclerosis (opening of the timpani box internal wall, <<duramater aeration>>, puncture of cephalorachidium liquid, etc.) are studied. Those which have been more spread due to their results are analyzed in more depth (fenestration of the horizontal semicircular ductus, stapes mobilization and stapedectomy).

A personal history of stapedectomy

Aristotle has said the essential ingredient of tragedy is first hubris. Fame leads to the hubris that offends the gods, who send great punishment. This is so true in the history of stapedectomy. The three distinct eras of surgery for otosclerosis teach us a lot about what happens in science and in life. The first stapes era began in Europe, ahead of its time, and in those halcyon days before the turn of the century, the Belle Epoch, proceeded, uncorrected to its tragic extreme, and then was stopped suddenly, quite rightly, by the establishment. The fenestration era proceeded to an extreme, when its technical master Julius Lempert would allow no criticism or improvement in "his" one-stage endaural technique, however good, nor would he accept the new mobilization and stapedectomy operations, and he and it ended badly. The fact that Jenkins and Holmgren would make an opening in the lateral semicircular canal and then close it in the epitympanum, not open to the ear canal, to expect to improve hearing is amazing. Until Sourdille went to Stockholm and saw one closed fenestration operation performed by Holmgren and devised his "open to the ear canal technique," the closed fenestration operation was not reasonable. Then Sourdille came to New York City, and Lempert heard him speak and read and reread his publication and greatly improved on his operation. It was Lempert's one-stage endaural open operation that gave the fenestration operation the worldwide acceptance it gained. The second stapedectomy era began before the fenestration era ended with the accidental and originally unrecognized mobilization of the stapes by Rosen and my resurrection of stapedectomy. I realized in reading the literature of the past that stapedectomy was not necessarily fatal to the ear or the patient as was generally believed, and what was needed was to seal the oval window with a living elastic membrane and reconstruct the sound-conducting mechanism of the middle ear with a biocompatible implant prosthesis to make it successful. But for me, in 1955-1956, the "Zeitgeist" was finally right. I realized the stapes could be removed and covered the oval window with a vein graft, and Harry Treace made me a biocompatible implant prosthesis out of the newly discovered Teflon. For a new technology to be accepted, it must be much better than what it replaces, and stapedectomy was much better than fenestration. In the new microsurgical era of otology that began, improvements in the stapedectomy operation came from everywhere and were readily accepted. Stapedectomy has now become so successful, like many treatments in medicine, the problem has now largely disappeared. If the measles virus is the cause of the growth of the otosclerotic focus, as it seems to be, then vaccination against measles eventually will eliminate the hearing loss of otosclerosis completely. What the history of stapedectomy reveals is the truth of the quotation from Ecclesiastes, "There is nothing new under the sun." Progress is only made when the Zeitgeist is right, by someone who puts together the truths of the past with the new discoveries of the present.

[Evolution of the operative technique. The rigid system stapedectomy]

In our Clinic, from 1987 up to 1993, 296 patients suffering from otosclerotic disease underwent stapedotomy, either using a classical or modified technique. The Authors reported the almost total disappearance of post-operative vertiginous symptomatology and a very good functional recovery; they believe that the placing of the prosthesis before disjointing the stapes, thereby allowing operation on a rigid structure, helps reduce labif1nthine traumatism. Moreover, stapedotomy with inversion of surgical times requires only a 24-hour hospitalization, with obvious advantages both for patient and clinic.

Statistical analysis of otosclerosis surgery performed by Jean Marquet

The early and long-term hearing results of 1,681 primary otosclerosis operations performed by the same surgeon, Jean Marquet, were reviewed retrospectively and analyzed with very strict statistical standards. Significantly better short- and long-term results were achieved with the stapedotomy technique compared to total stapedectomy, mainly at the higher frequencies (4 and 8 kHz) important for speech discrimination. Whatever technique was used to open the footplate (micropick, microdrill, or laser), no statistical audiometric difference could be found. The results were equal whether or not the stapedial tendon was preserved. Perioperative problems like pronounced oozing, difficult anatomic relationships, and accidental perilymph aspiration could affect hearing at higher frequencies. The calibrated hole technique was equally as good as conventional oval window sealing in sealing of the fenestra to prevent fistula. The stapedotomy technique was found the safest, having fewer complications.

Stapedectomy--past and present

Surgical technics for bypassing ankylosis of the stapes in the management of otosclerosis gradually evolved; modifications were prompted by problems which were revealed by the ongoing audits carried out by earlier surgeons. Auditing of performance must remain an integral part of any otologist's work. The natural history of otosclerosis should be taken into account so that a patient may be fully informed of treatment alternatives available. Stapedectomy will remain a most effective operation which can be recommended with confidence, provided the surgeon has acquired the skill to perform it properly. It is now accepted that many ear, nose and throat surgeons are neither physically nor temperamentally capable of this task and should not perform stapedectomy.

Thirty years of stapes surgery

The modern stapedectomy with prosthesis insertion and living oval window seal, like the modern cataract extraction with lens replacement, is now performed, very much the same, throughout the world. I have reviewed the evolution of stapes surgery during these last thirty years and tried to gain some agreement for several important facts about otosclerosis and several basic principals of stapes surgery. While a well-performed stapedectomy can eliminate the conductive component, the sensorineural hearing loss continues and, in about one-third, will progress till the patient, after age 65, must return to a hearing aid. A piston prosthesis gives the best hearing results: 0.6 mm diameter, when half the footplate is removed and a living oval window seal interposed, and 0.6 mm diameter when a small opening is made in the footplate obliterated by otosclerosis. I prefer a teflon prosthesis to stainless steel because it can be altered by the surgeon at operation, and vein as an oval window seal. I have presented a rare group of patients who develop facial palsy 5-1/2 days after uncomplicated stapedectomy, of whom all recover quickly and completely. I am confident that progress will continue to be made in the understanding of otosclerosis, and the performance of stapes surgery, but in these last thirty years we have made a good beginning.

CO2 laser stapedotomy: is it practical?

The argon laser has been described as an instrument capable of performing stapedotomy for otosclerosis. Because of the possibility of cost ineffectiveness and damage to the saccule using the argon laser, this study was undertaken to ascertain the possibility of using the CO2 laser for stapedotomy. the operation was done on seven cats, and the resulting histopathologic findings were studied. Stapedotomy was also performed with the CO2 laser on human cadaver temporal bones to measure temperature changes in the vestibule and to develop guidelines for the laser's use in humans. The authors' results indicated that the CO2 laser can be used effectively and safely in cats and should be considered for human use.

History of stapedectomy

The history of stapedectomy dates back to the late 19th century. Although otologists 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.

Management of the stapes footplate with special reference to otosclerosis

The history of the description of otosclerosis is presented in detail, beginning with Toynbee in 1857, together with the development of the surgical treatment beginning with Kessel in 1876. The prominent European and American contributors to this development are presented, with emphasis on the evolution of thinking with regard to surgical treatment as new information became available and new instruments were invented.

Otosclerosis-past and present

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