Douglas D. Backous, MD
February 6, 1992
The history of stapedectomy is one of near discovery, condemnation, reintroduction and refinement. Prior to the twentieth century poor lighting and magnification, nonstandardized audiometry, and a lack of understanding of the middle ear conduction mechanism plagued early researchers. Procedures concentrated on either partial or total removal of the tympanic membrane and ossicles. Mobilization of the stapes, described by Miot and later by Blake, would eventually be condemned by the otologic world. Siebenmann, in 1900, capped the early era of stapes surgery by stating, “Clinical experience teaches that all endeavors at mobilization of the stapes in otosclerosis are not only useless but often harmful.”
Between 1900 and 1952 attempts at fenestration of the horizontal semicircular canal came to the spotlight. Results were reported as excellent but temporary. Microscopy and rotating drills were introduced. In 1929 the American Otologic Society commissioned a committee to compile a resume of all literature concerning otosclerosis up to 1928. The result included a 700 page, two volume document covering histology of the otic capsule, heredity, audiology, and treatment of otosclerosis.
Successful surgery for hearing restoration truly began with Lempert’s fenestration operation. Rosen, a student of Lempert, serendipitously discovered that footplate mobilization improved hearing immediately in a patient with otosclerosis. He continued to refine his mobilization procedure until Shea, his student, reopened the era of stapedectomy in 1956. Shea developed the modern technique of footplate mobilization, soft tissue grafting of the oval window, and ossicular replacement.
Shea is also credited with the first stapedotomy, performed on a young girl in 1960. A 6 millimeter stapedotomy with piston insertion and soft tissue packing provides equally improved hearing with less risk for damage to inner ear structures. Higher frequency hearing is preserved better with stapedotomy.
Robinson summed up the stapedectomy/stapedotomy debate best by declaring the “best” procedure is the operation which provides the individual surgeon with a predictable and safe outcome along with improved hearing to levels consistent with current otologic standards.
Depletion of the pool of patients with otosclerosis occurred during the “golden age” of stapes surgery throughout the sixty’s and early seventies. Increased numbers of trained otolaryngologists and improved hearing amplification further contribute to an overall limited exposure in modern practice and residency. Stapedectomy is the second least performed procedure in American residency, as shown by Harris and Osborne in 1990.
The issue of training residents to do successful stapedectomy first appeared in the literature in 1983. Chandler and Rodriguez-Torro revealed a 62% closure of the air-bone gap to within 10 dB in resident cases, well below the 90-95% standard expected of practicing otologists. Five studies of results from training programs have since revealed results ranging from 64%-82% closure to within 10 Db in training programs. Of interest are the results of Shapira, et al. Their residents, in Israel, did stapedectomy in all four years of training. Results during the first two years of residency compared with American programs. During the second two years, however,results approached and often equaled those of staff. These findings further emphasized the critical importance of adequate numbers of procedures to insure acquisition of competence.
Solutions to the problem of numbers of cases include increased observation of otologic procedures with correlation in the temporal bone laboratory. Residents should display competence in surgery for chronic middle ear disease prior to attempting stapedectomy. Finally, all procedures should be supervised by senior otologic staff and one consistent technique used. For physicians in practice, batching stapedectomies into groups with review of needed skills in the temporal bone lab followed by consecutive case completion and review of results could provide valuable feedback in regard to outcome and maintenance of required skills.
In summary, stapedectomy has a fascinating history. Had Rosen not been open-minded to his first accidental mobilization, more delay in technique development was inevitable. The best procedure is surgeon dependent varying with individual skills and experience. Otosclerosis is now at a steady incidence making increased work in the temporal bone laboratory mandatory for both the acquisition and maintenance of required skills in footplate manipulation.
A 68-year-old white male presented with a fifteen year history of progressive hearing loss. He had the most difficulty hearing in small group conversations. He denied tinnitus, dizziness, otalgia, or chronic middle ear infections. He did admit to a long history of loud noise exposure. Past surgical and medical histories were unremarkable. Weber exam showed localization to the right. Audiometry revealed normal to moderate sensorineural and severe to moderate conductive loss in the right ear with absence of acoustic reflexes. The left ear had mild to moderate sensorineural loss with normal acoustic immittance measures. Speech intelligibility scores were within the normal range bilaterally. The patient underwent right middle ear exploration, stapedectomy, with perichondrial grafting over the oval window and insertion of a standard well Robinson prosthesis.
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