PERMANENT RESTORATION OF HEARING David Myers, M.D.

The surgery for the relief of deafness due to formed became fewer. Stapedectomy, i.e., the otosclerosis has come a long way. It is now removal of the stapes with the replacement of possible to help at least 90 per cent of patients the footplate by a graft of fat, vein, or Gel- deafened as the result of otosclerosis. The foam and the prefabricated stainless steel wire impetus for successful restoration of hearing surgically was given when Dr. Julius Lempert developed a one-stage fenestration operation in 1936. The fenestration operation was the only surgical procedure available in the years that followed until 1952, when Dr. Samuel Rosen carried out the mobilization of the stapes, a procedure which could be done through the ear canal trans-tympanically. This operation changed everything, and more and more patients were operated upon. The initial enthusiasm ran high, but many problems oc- curred; the stapes would refix or the stapes would be fractured at the initial surgery or even avulsed. Soon after, the otologic binocu- lar microscope became available and newer and more sophisticated operations were de- veloped. At one time, I counted thirty-six different technical variations of the initial sur-

is the operation of choice.

As more and more otologic surgeons de- veloped skill and experience in this type of surgery, it became possible to improve the percentage of results so that in carefully se- lected cases, we can help 94.5 per cent of those patients who have otosclerosis back to better hearing. Of a series of 364 patients, all of whom were operated upon and who were more than one year old, 312 or 94.5 per cent had their hearing improved. Twenty-two or 6.04 per cent did not improve, and 4 cases or 1.09 per cent had increased impairment. These results were obtained using the House technique of Gelfoam and prefabricated stain- less steel wire. With the use of the Schuk- necht fat and wire technique, of 338 cases, 312 cases or 92 per cent improved, 12 cases or 3 per cent did not improve, and 14 cases or

David Myers, M.D., is professor and chairman of the Drpartmrnt of Otolaryngology, Division of Grad- uate Medicine of tlie University of Pennsylvania Scliool of hledirine. Ile is also chief of Otolaryn- gology for the 1'1 esbytei ian-University of Pennsyl- vania hfedical Center. Dr. Myers directs the Otologic Research Institute. He has written extensively and has Iieen published widely in journals of otolaryn- gology and rhinology.

Dr. Myers is a Fellow of tlir American Otological Socic.ty, tlie Ainei ican Academy of Otology, Rhinol- ogy and Laryngology and the American College of Suigriins. Flr ha4 lrrtured to various medical soci- eties and at universities overseas and in the U. S.

careful otologic and audiologic evaluation. The audiologic tests should be performed in a sound treated room, so that careful measure- ments of air and bone conduction are made. After the diagnosis of otosclerosis is made, the surgical procedure is described to the patient and the possibilities and percentage of suc- cess or failure are related to the patient. It is important for the patient with otosclerosis to understand that not everyone can get his hear- ing back. Although the percentage of good re-

December 1967 61

Figure 1 . Normal middle ear, 162 magnification. The incus ( A ) , the posterior crus of the stapes ( B ) , and the stapedills tendon are visible.

Figure 2. The oval window area is completely obliterated by dense otosclerotic bone ( A ) . The incus is seen ( B ) .

sults is fastastically high, it is possible some- times for the hearing to get worse. Even though the percentage of complications is minute, still they do exist and the patient should know about it so that he can make his own decision as to whether he is willing to accept the risk. If the patient can not accept these chances of failure, albeit small, he should be advised to get a hearing aid.

Prior to surgery, the patient is also given a complete and thorough physical examina- tion. Usually they are asked to report to their family physician for an examination. The operation is carried out under local anes- thesia, but the patient receives intravenous sedation and is cared for by an anesthesiolo- gist, so that we are always certain that the patient is comfortable and in good condition. I t is possible to do this operation under gen- eral anesthesia without any change in tech- nique or in the final results. If the patient is apprehensive, we use a general anesthetic. In children with otosclerosis a general anesthetic also is used.

The technique which I employ at this time is the fat and wire technique of Schuknecht, or the Gelfoam and use of House wire. The

middle ear is carefully exposed and then a total stapedectomy is performed. After the removal of the stapes, a square of gelfoam is placed over the oval window and a stainless steel wire, 4.75 to 5.25 mm. long, is crimped onto the incus, and this projects into the middle of the oval window. In some cases a prosthesis is created using a small piece of fat from the ear lobe, around which is tied a stain- less steel wire.

Microscopic studies in animals and in post- mortem sections as well as observations in experimental animals, have shown that no matter which substance is used to close the oval window, whether it be fat, Gelfoam or vein, that the endosteal lining of the vestibule seals the inner ear. When fat is used, the fat does not remain as actual lipoid tissue, but the fibroareolar tissue of the fat remains loose and spongy, and the interstices of the lipoid tissue becomes filled with an amorphous myx- omatous tissue which is soft and mobile.

It can be stated that one of the most com- mon causes of a conductive deafness is oto- sclerosis. Otosclerosis is a disease of the tem- poral bone of unknown etiology, in which new bone is produced and which causes deaf-

62 AORN Journal

Figure 3. The otosclerotic footplate has been removed. Gelfoam ( A ) covers the oval window. The prefabricated wire ( B ) rests on the Gel- foam in the window.

ness by fixation of the stapes. The deafness due to otosclerosis can be helped by doing a stapedectomy with the application of a pros- thesis. This operation, however, is not a cure for otosclerosis. The patient still has otoscle- rosis, but in most instances there is no further bone growth by the time the operation is car- ried out. Actually, we are not curing otosclero- sis, but what we are actually doing is supply- ing the patient with an inside hearing aid in- stead of an outside one.

As far as complications are concerned, the most frequent complication that causes US

trouble is a non-specific, serous, non-suppura- tive labyrinthitis. When the stapes is removed

and the inner ear is exposed, a certain amount of trauma must result to the saccule and utricle. Even though the operation is per- formed very carefully, the absorption of blood, the small amount of suction, even minute sur- gical trauma sometimes sets up inflammatory reaction in the vestibule and the patient may become dizzy, and the hearing level decreases. As stated in our statistics, this happens less than just about one case out of a hundred. A good deal of this trauma can be eliminated by an experienced surgeon. The more adept one becomes in carrying out the operation, the less chance there is for trauma to the in- ner ear.

Another complication that may occur is the regeneration of bone. In my experience, this happens in less than 2 per cent of the cases. We can not tell by looking at it whether the otosclerosis lesion is still in an active grow- ing stage, and one has to accept this chance. Fortunately, it is a very infrequent complica- tion of the surgery and accounts for only a small percentage of the poor results.

This short review indicates the present status of otosclerosis surgery and would point out that this operation is one of the miracle oper- ations of this generation. Patients with oto- sclerosis can be helped back to better hearing in 94.5 per cent of cases and this is probably a permanent restoration of hearing, since we already have patients who were operated on ten years ago. What the ultimate outcome of the surgery will be, no one can really foretell, but we feel that if ten years have already elapsed and the patient maintains good hear- ing, it is very likely that this will continue.

1 don’t like these cold, precise, perfect people who, in order not to speak wrong, never speak at all, and in order not to d o wrong, never do anything.

Henry W a r d Beecher

December 1967 63