Historical Comments

16 Historical Comments

For many centuries, medical progress has been marked by technological revolution and conceptual evolution. Politzer’s 1913 review of the history of otology describes many of these developments. Since that time, there have been few objective and critical synopses of the various new approaches that have been developed for the optimal treatment of otosurgical diseases. All of today’s personal reviews of treatments are affected by the tremendous diversification of knowledge and by the individual scope of the literature cited. Despite these limitations, however, historical reports of this type are still of value. They explain how current situations and approaches have arisen, and they can encourage further progress. Methods that appear self-evident today may once have been thought heretical, dangerous, or even absurd. It must be admitted, too, that clinical research and surgical improvements tend to be based on at least three psychological forces: curiosity regarding as yet unknown principles or mechanisms, dissatisfaction with the results of accepted and routine methods, and pleasure in demonstrating that there is a better solution. In this context, it may be justified to present here a further reassessment of the beginnings of functionally oriented ear surgery and contemporary developments in the field, in order to outline the aims of the present book and underline once again the cogency of the approach I have termed “restitutional ear surgery.”

Functional ear surgery aimed at improving hearing undoubtedly began with fenestration of the lateral semicircular canal for the treatment of otosclerotic deafness (the technique developed by surgeons such as Holmgren 1923, Sourdille 1930, Lempert 1929, 1941, H.P. House 1948, Shambaugh 1949, Ombrédanne 1947). It was the introduction of the binocular operating microscope that opened the way to this field, in which it was possible for reproducible successes to be achieved. Before this period, a few pioneers such as Kiesselbach in Erlangen, Germany, (who first carried out surgery for congenital atresia to improve hearing) and Kessel (who carried out stapedectomies for different indications), had inevitably met with failure. It was logical that with the development of new instruments, efforts to imitate natural patterns advanced quickly. Stapes surgery, reestablishing direct physiological conduction of sound energy into the oval window, was a breakthrough in otosclerosis surgery made in the early 1960s–inaugurated by Shea, Portmann, Schuknecht, and H.P. House and with a subsequent tradition extending for more than 40 years.

The second wave of successful microsurgery of the ear, in this case for chronic otitis media, was initiated by H.L. Wullstein and F. Zöllner, as well as W. Moritz and others. They combined earlier good experience with skin grafting in radical cavities (O. Mayer 1916) and for myringoplasty (E. Berthold 1878) with systematic use of the residual ossicular chain. Free grafting of skin, split-skin grafting and temporalis fascia grafting became safe and routine procedures. A glance at the titles of their articles and monographs shows that the focus of interest for these authors was the potential for improving impaired hearing–and even in that period of radical surgery, it was in fact possible to preserve a diminished hearing ability. By contrast, however, the architecture of the middle ear spaces and the handling of the diseased lining mucosa remained of minor importance. Reconstruction procedures were aimed at achieving dry ears and at restoring hearing, but the formal results resembled those of the days of radical surgery. It was only in ears with limited pathology that both a posterior canal wall over a mastoid cavity and their lining mucosa were retained. Advanced granulation, and cholesteatomas in particular, were basically treated by forming a radical cavity and removing the diseased mucosa.

A good example of this attitude, which was certainly motivated by a fear of otogenous complications, which were an everyday risk in the 1930s and 1940s, is H.L. Wullstein’s 1968 monograph. Even at that time, removal of the lateral attic wall and posterior meatal wall was the usual response if a larger attic cholesteatoma, and particularly a mastoid cholesteatoma, was detected, or when there was a need to remove severely diseased, granulating, or swollen mucosa. Especially when the resulting mastoid cavity, open to the external auditory canal, was obliterated or at least flattened with a pedicled Palva flap, meticulous removal of the lining mucosa was required. The sketches in Wullstein’s articles make it clear that his type III–V ossicular reconstructions were synonymous with externalization of the retrotympanic spaces, implying closure of the internal middle ear ventilation system just above the oval niche. By analogy, fractures of the tegmen with epitympanic dural fistulas were also treated using a transmastoid approach for obliteration of the attic and antrum (Wullstein 1968, Figs. 228 and 229, p.345), with all the inherent functional disadvantages. Similarly extensive sacrifices of the normal anatomy of the middle ear are still widely practiced by otosurgeons today. The canal wall down technique is still popular for the management of cholesteatomas and for some options in glomus tumor operations, sometimes sacrificing a functioning middle ear unnecessarily. It is also a common practice to carry out thoughtless destruction of the middle ear mucosa with crude dissections and superfluous drilling. In a recent international discussion on the teaching of cholesteatoma surgery, there was almost unanimous agreement that generous bone removal for exposure of the matrix is mandatory, and that all cells below the cholesteatoma sac have to be drilled out (Charachon 1998). The current literature is also full of reports describing this type of strategy (Albu et al. 1998, Maassen et al. 1998, Merchant et al. 1998).

When I began to alter the endaural tympanoplasty operation by introducing the bridge technique (Wigand 1967, 1970) to allow reventilation throughout all the middle ear spaces, the principal idea was to promote internal drainage of this cell system. Restoring this natural self-cleaning mechanism appeared to be more logical and more easily feasible than total removal of all mucosal extensions below an obliterating flap. I have in fact observed frequent complications due to persistent infection in residual remote cells buried by muscle flaps or by alloplastic material in operations carried out at other institutions. A second motivation was the observation by Ingelstedt and his group that opening of the eustachian tube would be facilitated by larger air volumes in the middle ear, while small volumes may counteract the equalization of middle ear pressure (Ingelstedt and Örtegren 1963). A third reason for the innovation was a perception that reestablishing the new drum membrane within a natural framework at a physiological distance from the stapes footplate, guaranteed by the preserved bony bridge, would allow the reconstruction of a more effective sound-conducting ossicular chain, which at the same time would not be compromised as easily by adhesion as a lower stapes in the “shallow tympanic cavity.”

This threefold philosophy was of course supported by earlier hypotheses in the otological literature, and it became more and more generalized to serve as a guideline for other indications in subsequent years. The credit for this must go to a number of other authors who were also following the trend to abolish radical cavities, either by removing the posterior bony canal wall temporarily (Guilford 1960, Schnee 1964, Wehrs 1965), or by combining postauricular transcortical mastoidectomy with endaural tympanotomy, thus preserving the bony posterior meatal wall (Brunar 1958, Jansen 1958, 1963, 1968, Myers and Schlosser 1960, Smyth 1962). Known as the “closed technique,” the aim here was to restore the communication between the mastoid spaces and the tympanic cavity–and the surgery was to that extent restitutional. Later, S.R. Wullstein (1973) and Feldmann (1977) implemented the same principle of excising parts of the posterior canal wall and repositioning them after cleaning the attic and mastoid during a single intervention.

However, all of these procedures destroyed the outer mastoid wall, mastoid cortex, and mastoid mucosa to a considerable extent. Even contemporary videos and panel discussions show that the mucosal lining is generally sacrificed in operations for advanced otitis media and cholesteatoma. In relation to mucosa-conserving dissection techniques, standards have not changed considerably since the days of Wullstein’s monograph. The recommendations given in the present book are therefore somewhat heretical. The underlying philosophy of carrying out internal restoration of the tympanomastoid airways is logically connected to a preference for the endaural approach, as it avoids destroying the integrity of the mastoid walls. All of the “closed techniques” mentioned above are inconsistent to the extent that they destroy this ensemble. The endaural approach, inaugurated by Kessel (1878) for the radical mastoid operation, rediscovered by Lempert (1929) and Thies (1933), and later vigorously promoted by Heermann and Heermann (1964), respects the natural configuration of the external ear to a greater extent. However, it should be noted that also these authors carried out conventional mastoid and radical surgery using the endaural approach, their aim was not to achieve a reventilated mastoid.

For the surgical rehabilitation of microtic, severely deformed ears with congenital atresia, a shift took place from broad, ugly transmastoid excavations with crudely constructed aural imitations to endaural tympanoplastic approaches and to refined composite reconstructions of the pinna. Pioneers such as Converse (1950), Ombrédanne (1955), H.P. House (1948,1955), Mündnich (1957), Livingstone (1959), Miodonski (1959), and Denecke (1960) introduced microsurgery and plastic surgery into this field, but the aesthetic and functional results remained far from optimal. A period of resignation set in, and repair surgery was postponed until patients had reached adulthood, instead of being carried out in children. Only more recent efforts to achieve a more natural formal outcome have renewed interest in this type of surgical indication (Wigand 1978, Brent 1974, Jahrsdoerfer 1986).

Surgery in the ear-related skull base has also been substantially influenced by the trend in every discipline of surgery to modify approaches and ablative techniques to allow minimally invasive procedures. Looking back on operations carried out in the late 1960s on large glomus jugulare tumors, which required liters of transfused blood and produced large, visible defects—and which led to total deafness in every case—one can better appreciate the sophisticated techniques of combined bidirectional approaches and of gentle microsurgical handling of the facial nerve that are today’s standards. Considerable efforts have gone into identifying methods of preserving both as much of the natural structures as possible and the functions of the inner and middle ear, as well as the related cranial nerves. Restitutional ear surgery need not necessarily compromise oncological radicality—although admittedly it may from time to time come close to this boundary.

Another example of the evolution of functional skull base surgery is the change in contemporary methods of treating acoustic neuromas. At the end of the nineteenth century, when it became possible to diagnose infratentorial tumors, the suboccipital approach was tested, with the sole aim of offering palliative treatment to patients with a terrible and life-threatening condition. Sir Charles Ballance may have been the first surgeon to undertake such a risky operation; he exposed the petrous bone from behind, transdurally, and resected a solid tumor (Ballance 1907). As early as 1893, Guldenarm attempted the operation on two occasions, but the patients died in both cases. Krause (1903) popularized the suboccipital approach, which extended beyond the midline, with resection of the sigmoid sinus. Cushing (1917) tried to minimize the risks of intraoperative depression of respiration by enlarging the exposure to the contralateral side and to the foramen magnum, as well as by resecting the arch of the atlas and making an incision in the atlanto-occipital membrane. Cushing also favored carrying out incomplete tumor removal, with intracapsular debulking. Despite these and other efforts, the mortality rate at that time was as high as 80%, and postoperative morbidity was also high. Dandy (1925), who accomplished total tumor removal via the suboccipital approach, had an extremely low mortality rate (2.4%) in a series of 41 cases, but the overall figure was 22.1% (Revilla 1947). Olivecrona (1940), who succeeded in preserving facial nerve function, still had an overall mortality rate of 19.2%.

A long period followed during which considerable efforts were put into improving techniques in neurosurgery. Advances in antibiotic medication and general anesthesia helped, but it was only the use of the operating microscope that was able to reduce postoperative morbidity and bring the mortality rate down to almost zero. More recently, neuromicrosurgery has focused on achieving acceptable rates of postoperative facial nerve paresis. In particular, the principle of dissecting the facial nerve from medial to lateral has proved valuable. However, with the suboccipital approach, the inherent difficulty of identifying the facial nerve behind the tumor mass continues to lead to facial paralysis rates (House-Brackmann grades IV–VI) of 3–26% (Sterkers et al. 1994).

A considerable achievement in this area was the introduction by Rand and Kurze (1967) of microsurgery of the internal auditory meatus after resection of the posterior wall of the internal auditory canal. All neurosurgeons and otosurgeons who reported on the lateral suboccipital approach claimed to have observed many “medial” acoustic neurinomas that did not reach deep into the internal auditory canal. Preoperative magnetic resonance imaging may be able to image this type of tumor growth and help in selecting the approach.

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Jun 14, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Historical Comments

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