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.

The Stapes Prosthesis: Past, Present, and Future.

Since the original carved Teflon stapes over vein graft, stapedectomy prostheses have undergone evolution. Prostheses shapes, materials, and surgical techniques for placement have reflected advances in biomaterials and surgical tools. The variability in prostheses has reflected alternative techniques of stapedectomy and stapedotomy and differing strategies for attachment to the incus. Although many iterations of stapes prostheses have been proposed, excellent results can be achieved with various prostheses designed to rest on tissue grafts in stapedectomy techniques or pass through the footplate in stapedotomy techniques when used by surgeons experienced with technique details specific to the selected prosthesis.

Historia del estribo en el Río de la Plata hasta mediados del siglo XX / The history of stapedius in the River Plate until mid 20th century

El estribo, último descubrimiento óseo, fue hallado en forma accidental por Philippi Ingrassia en 1546. Constancius Varolio, en 1531, describió por primera vez el músculo del estribo. Antonio María Valsalva encontró la anquilosis estapedio vestibular en la necropsia de un sordo profundo en 1704 y asimismo hizo mención a los líquidos laberínticos.A mediados del siglo XIX, Joseph Toynbee realizó estudios microscópicos sobre 2.000 temporales y describió con precisión la enfermedad que años después Adam Politzer llamaríaotosclerosis. Este mismo autor y casi todos los grandes otólogos de fines del siglo XIX procedieron a continuación a condenar las operaciones sobre el estribo, léase las movilizaciones de Ernest Mach y Johannes Kessel y la estapedectomía de Frederick Jack. Enel siglo XX, la perseverancia de Maurice Sourdille, alumno de los suecos Gunnar Holmgren y Carl Olof Nylen, creadores de la microscopía otológica, llevó la fenestración a algunos éxitos luego de más de diez años de esfuerzos. A continuación y muy rápidamente, Julius Lempert y George Shambaugh modificaron la técnica e impulsaron la apertura laberíntica en un solo tiempo, con mejores resultados. Samuel Rosen, de Nueva York, redescubrió la movilización en 1952 y cuatro años después John Shea, de Memphis, Tennessee, hizo lo mismo con la estapedectomía. En el Río de la Plata, la primera mención académica sobre el tema osicular correspondió a Pedro Belou, que a lo largo de 20 años de penosas disecciones (1912-1931) publicó finalmente un excelente Atlas de anatomía del oído. Martín Castro Escalada también debe ser recordado por su tesis primacial de 1914 acerca deldesarrollo del aparato auditivo en los mamíferos. Por último, dos grandes latinoamericanos, Mario Rius de Uruguay y Juan Manuel Tato deArgentina, enseñaron en esta región del mundo los estudios anatómicos y desarrollaron las destrezas quirúrgicas que llevaron a la Escuela Otológica Rioplatense a su actual nivel deexcelencia.

The stapedius, the last bone discovered was found by accident by Philippi Ingrassia in 1546. In 1531 ConstanciusVarolio had described the stapedius muscle for the first time. Antonio María Valsalva found stapedio-vestibularankylosis at the necropsy of a profoundly deaf person in 1704 and he also mentioned the existence of labyrinthine liquids. During the mid 19th Century, Joseph Toynbee conductedmiscroscope studies on over 2,000 temporal muscles and he accurately described the disease Adam Politzer would later call otosclerosis. This same author and almost all great otologists of late 19th Century were against stapedial surgery - see initiatives by Ernest Mach y Johannes Kessel and stapedectomy by Frederick Jack. In the 20th Century Maurice Sourdille, a disciple of Swedish Gunnar Holmgren and Carl Olof Nylen, founders ofmicroscopic otologic surgery, achieved certain success in fenestration after over ten years of efforts. Soon after, Julius Lempert and George Shambaughmodified the technique and fostered the opening of the labyrinth in a single time surgery, what resulted in a betteroutcome. Samuel Rosen, in New York rediscovered this re-positioning in 1952 and four years later John Shea, formMemphis, Tennessee also rediscovered stapedectomy. In the River Plate, the first academic reference to ossicularissues was made by Pedro Belou, who finally published an excellent Atlas on the earÆs anatomy after twentyyears (1912-1931) of hard dissections.We also need to remember Martín Castro Escalada due to his primacy thesis of 1914 on the development of thehearing system in mammals. Last, two great Latin Americans, Mario Rius from Uruguay and Juan Manuel Tato from Argentina taught in the area of the world the anatomic studies and developed surgical skills that led the River Plate School of Otology to its current level of excellence.

O estribo, último osso a ser descrito, foi encontrado acidentalmente por Philippi Ingrassia em 1546. ConstanciusVarolio, em 1531, descreveu pela primeira vez o músculo do estribo. Antonio Maria Valsalva encontrou a anquilose estapedio vestibular na necropsia de um homem com umasurdez profunda em 1704 e também fez menção aos líquidos do labirinto. No século XIX, Joseph Toynbee realizou estudos microscópicos sobre 2.000 temporais e descreveu com precisão a doença que anos depois Adam Politzerdenominaria otoesclerose. Este mesmo autor e quase todos os grandes otologistas do fim do século XIX condenavam as operações sobre o estribo, como se pode observar na leitura das mobilizações de Ernest Mach e Johannes Kessel e na estapedectomia de Frederick Jack. No século XX, a perseverança de Maurice Sourdille, alunodos suecos Gunnar Holmgren e Carl Olof Nylen, criadores da microscopia otológica, fez com que a fenestração fosse bem sucedida depois de mais de dez anos de esforços. Em seguida e rapidamente, Julius Lempert e GeorgeShambaugh modificaram a técnica e propuseram abrir o labirinto no mesmo momento, com melhores resultados.Samuel Rosen, de Nova York, redescobriu em 1952 a mobilização e quatro anos depois John Shea, de Memphis, Tennessee, a estapedectomía.No Rio da Prata, a primeira menção acadêmica sobre o tema ossicular foi feita por Pedro Belou, que depois de 20anos de penosas dissecções (1912-1931) finalmente publicou um excelente Atlas de anatomia do ouvido. Martín Castro Escalada também deve ser recordado por sua tese de 1914 sobre o desenvolvimento do aparelho auditivo em mamíferos. Por último, dois grandes latinoamericanos, Mario Rius do Uruguai e Juan Manuel Tato da Argentina, ensinaram nesta Região estudos anatômicos e desenvolveram destrezascirúrgicas que fizeram com que a Escola Otológica do Rio da Prata chegasse ao seu atual nível de excelência.

[History of endaural surgery]. / Historia chirurgii wewnatrzusznej.

History of the endaural mastoid surgery and the development of this approach to the temporal bone begins with the first paracentesis, which is the oldest endaural operation of the middle ear. Prior to the invention of the ear mirror paracentesis was a difficult operation. In 1885 Kessel reported endaural radical ear surgery. A great inconvenience is the narrow operative field within the external auditory meatus. It influenced the surgeon to extend the incision posteriorly into the auricle. In 1930 Heermann H. described antero-superior extracartilaginous endaural incision.

Phylogeny of the stapes prosthesis.

OBJECTIVE: To create the first ever stapes prosthesis phylogenetic tree for the evolution of the stapes prosthesis. STUDY DESIGN: Retrospective literature review, personal interviews. SETTING: University Medical Center. PATIENT: Not applicable. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Construction of a stapes prosthesis phylogenetic tree with branches capable of including all stapes prostheses. RESULTS: One hundred five different stapes prostheses were reviewed, starting with the first-ever prosthesis used in the first stapedectomy and continuing up to the present time. The stapes prosthesis family tree contains 4 main branches that allow for categorization of all the commercial prostheses currently used. Many examples of atavistic prostheses, single surgeon use, and dead-end characteristics exist. CONCLUSION: An overview of the complicated phylogenetic tree for stapes prostheses gives great perspective to the history of stapedectomy and insights into many characteristics that are useful for designing new stapes prostheses.

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.

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.

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.

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.

Importancia del láser en la técnica quirúrgica de la otosclerosis y sus resultados / Importance of laser in the surgical technique of otosclerosis and its results

Los autores plantean la utilización del láser en la cirugía. Se revisa la literatura, en la que se encuentran autores que nos hablan de las ventajas que supone la utilización de este instrumento. También se recogen nuevas tendencias en la cirugía del estribo. Se plantea la enseñanza de la cirugía de la otosclerosis, con diferentes criterios. Se refuerza la idea de que es dificil mejorar los rendimientos auditivos, ya que los que se obtienen con técnicas clásicas son excelentes, pero si que se mejora la comodidad y se disminuyen los riesgos

The authors bring up the matter of the usefulness of laser in otosclerosis surgery. They set out some advantages of laser utilization. A bibliografic review is done and some important authors are found explaining the advantages of this instrument. Some new tendencies on stapes surgery are presented. Teaching on otosclerosis surgery problems are stated, with some different criteria. The idea that improvement of audiologic results in stapes surgery is not easy is strengthened, because the results obtained with the classic techniques are excellent, but some of these methods increase the surgical comfort and reduce the potential risks to the patient

[30 years of stapes surgery]. / 30 lat chirurgii strzemiaczka.

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]. / Un siècle d'histoire de la chirurgie d'otite chronique.

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]. / Análisis histórico de la cirugía de la otosclerosis.

In the present work main surgical techniques used along the history to solve hypoacusis caused by otosclerosis (opening of the timpani box internal wall, <>, 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.