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.
Case Presentation
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.
Bibliography
Alford BR. Residency program length and structure. Otolaryngol Head Neck Surg 1983;91:1228-230.
Alford BR. Chance favors the prepared mind. The Crowe Lecture, Johns Hopkins School of Medicine, October 2, 1986.
Bailey HA, Pappas JJ, Graham SS. Small fenestra stapedectomy technique: reducing risk and improving hearing.
Otolaryngol Head Neck Surg 1983;91:516-519.
Benecke JE. Editorial. Am J Otol 1990;11:78.
Chandler JR, Rodriguez-Torro OE. Changing patterns of otosclerosis surgery in teaching institutions. Otolaryngol Head
Neck Surg 1983;91:239-245.
Coker NJ, Duncan NO, Wright GL, Jenkins HA, Alford BR. Stapedectomy trends for the resident. Ann Otol Rhinol
Laryngol 1988;97:109-113.
Conrad GJ. Collective stapedectomy (an approach to the numbers problem). J Laryngol Oto 1990;104:390-393.
Cummings CW, Fredrickson JM, Harker LA, et al. Otolaryngology-Head and Neck Surgery, Vol. IV. St Louis, Toronto:
C. V. Mosby Company, 1986:1095-3113.
Engel TL, Schindler RA. Stapedectomy in residency training. Laryngoscope 1984;94:768-771.
Farrior B. Contraindication to the small hole stapedectomy. Ann Otol 1981;90:636-639.
Farrior JB. Stapedectomy for the home temporal bone dissection laboratory. Otolaryngol Head Neck Surg 1986;94:521-
525.
Fisch U. Stapedotomy versus stapedectomy. Am J Otol 1982;4:112-117.
Fisch U. Tympanoplasty and Stapedectomy. New York: Theime-Skatton Inc. 1980:57-67.
Glasscock MF, Shambaugh GE. Surgery of The Ear, 4th ed. Philadelphia: WB Saunders, Co., 1980:389-418.
Gristwood RE. The surgical concept for otosclerosis. Adv Oto-Rhino-Laryngol 1988;39:52-64.
Jerger SJ, Jerger JJ. Auditory Disorders: A Manual for Clinical Disorders. Boston: Little, Brown and Company, 1981:131-
136.
Handley GH, Hicks JN. Stapedectomy in residency – the UAB experience. Am J Otol 1990;11:128-130.
Harris JP, Osborne E. A surgery of otologic training in US residency programs. Arch Otolaryngol Head Neck Surg
1990;116:342-344.
Hillel AD. History of stapedectomy. Am J Otolaryngol 1983;4:131-140.
Hughes GB. The learning curve in stapes surgery. Laryngoscope 1991;101:1280-1284.
Igarashi M, Guilford R, Alford BR. Bilateral vein graft stapedectomy. Acta Otolaryngol 1970;69:9499.
Rosen S. The Autobiography of Dr. Samuel Rosen. New York: Knopf, 1980:48-68.
Levin G, Fabian P, Stahle J. Incidence of otosclerosis. Am J Otol 1988;9:299-301.
Levenson MJ, Bellucci RJ, Grimes C, et al. Otosclerosis surgery in a resident training program. Arch Otolaryngol Head
Neck Surg 1987;113:29-31.
Levy R, Shvero J, Hadar T. Stapedotomy technique and results: ten years’ experience and comparative study with
stapedectomy. Laryngoscope 1990;100:1097-1099.
McGee TM. Comparison of small fenestra and total stapedectomy. Ann Otol 1981;90:633-635.
Manu P, Lane TJ, Matthews DA. How much practice makes perfect? A quantitative measure of the experience needed to
achieve procedural competence. Med Teacher 1990;12:367-369.
Marquet J, Creten WL, Van Camp KJ. Considerations about the surgical approach in stapedectomy. Acta Otolaryngol
1972;74:406-410.
Moon CN. Stapedectomy, connective tissue graft and stainless steel prosthesis. Laryngoscope 1968;78:798-807.
Murrant NJ, Gatland DJ. Temporal bone laboratory training for stapedectomy. J Laryngol Otol 1989;103:833-834.
Robinson M. Panel on stapes surgery – total footplate extraction in stapedectomy. Ann Otol 1981;90:630-632.
Robinson M. Is there a “best” stapedectomy technique for the general otolaryngologist? Ear Nose Throat J 1989;68:221- 224.
Rosen S. Palpation of the stapes for fixation. Arch Otolaryngol 1952;56:610-5.
Shapira A, Ophir D, Marshak G. Success of stapedectomy performed by residents. Am J Otolaryngol 1985;6:388-391.
Shea JJ. Fenestration of the oval window. Ann Otol Rhinol Laryngol 1958;67:932-51.
Shea JJ. Thirty years of stapes surgery. J Laryngol Otol 1988;102:14-19.
Schuknecht HF. Editorial-Training in otolaryngology. Arch Otolaryngol 1979;105:57.
Smyth GDL, Hassard TH. Eighteen years experience in stapedectomy-the case for the small fenestra operation. Ann Otol
Rhinol Laryngol 1978;87:3-36.
Vernick DM. Stapedectomy results in a residency training program. Ann Otol Rhinol Laryngol 1986;95:477-479.
Vernick DM. Who operated on Max? Ear Nose Throat 1988;67:125.
Weir N. Otolaryngology: An Illustrated History. London: Butterworth, 1990:203-212.