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H i s t o r y o f O t o s c l e ro s i s an d

Stapes Surgery
a, b c
Ronen Nazarian, MD *, John T. McElveen Jr, MD , Adrien A. Eshraghi, MD, MSc

KEYWORDS
 Stapes  Otosclerosis  Stapedectomy  Stapedotomy  Fenestration  Lempert
 Rosen  Shea

KEY POINTS
 The study of otosclerosis dates back to as early as 1704 with the research of Antonio
Maria Valsalva.
 Stapes surgery was first described by Johannes Kessel in 1876, but fell into disrepute in
1899 due to concerns of patient safety at the time.
 Julius Lempert’s ingenious single-stage fenestration operation became the mainstream
method to indirectly treat Otosclerosis in the 1930s to 1950s.
 John Shea rediscovered and modernized the stapedectomy procedure in 1956.
 Modern stapes surgery is still evolving, but studying the history, rediscovery, and modifi-
cation of otosclerosis therapy is essential for appreciating advances in medicine today
and in the future.

INTRODUCTION

The current advancements in otosclerosis therapy cannot be fully appreciated without


studying the history, rediscovery, and modification of a once-forgotten procedure.
The study of otosclerosis dates back to as early as 1704 with the research of
Antonio Maria Valsalva1 (Fig. 1). Valsalva, who was Professor of Anatomy in
Bologna, is credited with first describing stapes fixation as a cause of hearing
loss. His meticulous postmortem dissections of a deaf patient in 1704 revealed fix-
ation of the stapes as the cause of hearing loss. The dissections were performed in
the Anatomical Theater of the Archiginnasio in Bologna, Italy (Fig. 2). In 1841, Toyn-
bee’s publication firmly established the link between deafness and stapes fixation.
He dissected 1659 temporal bones and found stapes fixation in 39. He concluded
that “osseous ankylosis of the stapes to the fenestra ovalis was one of the common
causes of deafness.”

Disclosure: The authors have nothing to disclose.


a
Osborne Head and Neck Institute, 8631 West 3rd Street, Suite 945E, Los Angeles, CA 90048,
USA; b Carolina Ear Institute, Carolina Ear and Hearing Clinic, Raleigh, NC, USA; c University
of Miami Ear Institute
* Corresponding author.
E-mail address: Nazarian@ohni.org

Otolaryngol Clin N Am 51 (2018) 275–290


https://doi.org/10.1016/j.otc.2017.11.003 oto.theclinics.com
0030-6665/18/ª 2017 Elsevier Inc. All rights reserved.
276 Nazarian et al

Fig. 1. Antonio Maria Valsalva. (Data from https://wellcomecollection.org/works/yhyxsfk3


under a Creative Commons Attribution 4.0 international license.)

In 1873, Schwartze described a reddish hue on the cochlear promontory of patients


with active otosclerosis (Schwartze sign).2 This active hyperemic stage with increased
vascularity was later named otospongiosis by Siebenmann. It was assumed by Toyn-
bee and others that chronic inflammatory mucosal changes in the middle ear resulted
in secondary ankylosis of the stapes.3 However, in December, 1893, some 52 years
later, Adam Politzer (Fig. 3) described the histologic findings in 16 cases of stapes fix-
ation. His findings indicated that the deafness, which had been attributed to chronic
interstitial middle ear catarrh with secondary stapes fixation, was really due to a pri-
mary disorder of the labyrinthine capsule.4 He referred to this pathology as otoscle-
rosis. His findings were initially published in 1894 in Zeitschrift Für Ohrenheilkunde

Fig. 2. The dissections of Valsalva were performed at the Anatomical Theater of The Archi-
ginnasio in Bologna, Italy.
277

Fig. 3. Adam Politzer. (Data from https://wellcomeimages.org/indexplus/image/V0027026.


html under a Creative Commons Attribution 4.0 international license.)

and then translated into English and published a few months later in the Archives of
Otology. Despite both of these publications, Politzer’s views, although histologically
verified, were slow to catch on. It took almost half a century for Politzer’s principles
to gain universal acceptance.
It is not known exactly when the first attempts to mobilize the stapes were carried
out; however, in 1842, Prospere Ménière reported the case of a patient who was
able to temporarily improve his own hearing by tapping the stapes directly with a small
gold rod.5 Some cite this as the first attempt at stapes mobilization.
The ensuing evolution of stapes surgery can be best summarized into 4 noteworthy
eras: the pre-antibiotic era (which was forgotten and then rediscovered), the fenestra-
tion 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 a leading cause of deafness (Fig. 4). It is extremely worthwhile,

Fig. 4. Frederick L. Jack. (From Tange RA, The history of otosclerosis treatment. Amsterdam:
Kugler Publications; 2014; with permission.)
278 Nazarian et al

educational, and entertaining to study all 4 of these eras as they bear timeless lessons
for any physician with an interest in expanding and advancing medicine.

THE PRE-ANTIBIOTIC ERA

The first era of stapes surgery entailed some of the boldest surgical advancements,
which were soon abandoned due to concerns of long-term efficacy and patient
safety. Johannes Kessel6 is considered the first to describe stapes surgery in
1876. He was under the mistaken opinion that the hearing loss associated with
otosclerosis was caused by increased pressure in the inner ear fluids. He theorized
that by removing the stapes, he could relieve that pressure. Before testing his hypoth-
esis on humans, he removed the columella (stapes equivalent) from 2 pigeons. He
was able to demonstrate that opening of the oval window did not necessarily result
in destructive damage to the inner ear as was generally feared. Based on this exper-
imental investigation in pigeons, he performed stapes mobilizations and also stapes
removal in humans.
In 1878, Kessel7 reported on the procedure in which he would incise the posterior
part of the tympanic membrane, separate the incus from the stapes, and then attempt
to mobilize the stapes by applying pressure to its head in various directions. When this
was not successful, he would remove the stapes. He continued to publish similar re-
ports throughout his career, demonstrating that transtympanic stapes mobilization
and stapedectomy is an effective method for the improvement of hearing in stapes
ankylosis.8
The German otologists Schwartze9 and Lucae,10 also carried out stapes mobili-
zation and removal of the stapes. In 1890 and 1888, the French otologists Miot11
and Boucheron12 reported their experience with patients who had undergone a
similar procedure, respectively. Hearing improvement was achieved in 74 cases
out of 126 stapes mobilizations. In 1890, Miot11 reported his successful results
with 200 stapes mobilizations in a series of 5 articles. These results and techniques
were very similar to the ones that Samuel Rosen would publish more than 60 years
later.
In the United States, at the Massachusetts Eye and Ear Infirmary, C.J. Blake13
(1892) and Frederick L. Jack14 (1893) performed mobilization and removal of the
stapes. The usual method of treatment was to approach the middle ear cavity via tym-
panic membrane incision rather than a reflection of a tympanomeatal flap. Illumination
was poor and it is unlikely that any proper magnification was used. They reported that
patients experienced improved hearing as the tympanic membrane healed over the
oval window niche. At that time, no attempts were made to seal the oval window or
to reconstruct the ossicular chain. Jack15 also reported a particularly interesting
case in which a patient who had a double stapedectomy maintained good hearing
10 years later. He described how the tympanic membrane had retracted in the healing
process and created a moveable membrane over the oval window. This description
became lost in the literature only to be found again over a century later by John
Shea, convincing him that stapes surgery should be revisited.
In many of the patients who were operated on in Europe and the United States,
hearing improvement was often temporary, sometimes lasting only for a period of
days to weeks. Although not widely published, there is speculation that some patients
experienced grave complications, which included labyrinthitis, meningitis, and even
death.16 The discovery of penicillin did not occur until 1928, and it is likely that these
complications arose due to the absence of antibiotics as a prophylactic measure dur-
ing and after surgery.
History of Otosclerosis and Stapes Surgery 279

Because of its short-term hearing improvement and probable morbidity, this


early form of stapes surgery fell into disrepute. In 1899, it was heatedly criticized
by some of the leading otologists of the time, Politzer, Siebenmann, and Moure,
at the 6th International Otology Congress in London. During this meeting, stapes
surgery was declared “useless, often mutilating, and dangerous.” They went on
to say, “The question of surgical therapy for otosclerosis was interred with great
pomp at the 1894 International Conference in Rome. There is no reason to revive
it.”16 In 1900, Johannes Kessel was publicly censured for unscrupulousness. He
resigned from his position in Jena in disgrace. Embittered, he retired from all scien-
tific work.
The eager and bold first steps for stapes surgery had come to a sudden end. A
movement to indirectly treat otosclerosis without manipulating the stapes was soon
to begin, and surgery on the stapes would not be attempted again for more than
half a century.

THE FENESTRATION ERA

Because surgical operations on the actual fixed stapes were considered too
dangerous, surgeons began to use detour approaches to the inner ear using “third-
window” fenestration techniques.
Passov (1897) and Floderus (1899) both proposed the idea of a fenestration along
the promontory or vestibular labyrinth,16 but it did not become fully established until
1913 when Jenkins17 described a “fenestration of the lateral semicircular canal.”
In the early 1920s, Gunnar Holmgren18,19 (Fig. 5) inadvertently made an opening in
the lateral semicircular canal while removing infection from the mastoid. He covered

Fig. 5. Gunnar Holmgren. (From Hamberger C. Gunnar Holmgren (1875–1954). Arch Otolar-
yngol 1968;87(2):214–8; with permission.)
280 Nazarian et al

the area with mucoperiosteum and, to his surprise, the patient was able to hear better
for a short while. With the new use of the operating microscope, Holmgren devised a
three-staged “closed” fenestration operation on the lateral semicircular canal through
a postauricular incision. The 3 stages would take place over a period of a few months,
and he was able to achieve modest and limited results mainly because of infection or
early closure of the fenestration due to bony regrowth.
In 1924, Maurice Sourdille20 (Fig. 6) of Nantes, France visited Holmgren and
observed a “closed fenestration” operation and realized the shortcoming of Holmg-
ren’s “closed” technique. Sourdille modified this operation and was the first to
develop the fenestration of the lateral semicircular canal toward the outside in a
three-stage “open” operation in which the fenestra would remain exteriorized instead
of buried in a postauricular incision.16 In 1937 he was able to produce a long-lasting
hearing improvement in 64% of 109 operated patients with his tympanolabyrintho-
pexie. Sourdille would teach his operation to many otologists, including Juan Tato,
who returned to Buenos Aires and performed the first fenestration operation in the
new world in 1934.21
In 1937, Sourdille was invited to address the Otolaryngology Section of the New
York Academy of Medicine. Julius Lempert (Fig. 7) was in the audience and, after
Sourdille’s presentation, he invited Professor Sourdille to dinner. Sourdille would later
recall that during the dinner Lempert plied him with questions on details of the oper-
ative procedure. By combining what he had learned from Sourdille’s three-stage post-
auricular operation with his own endaural techniques, Lempert was able to develop a
new “single-stage” endaural fenestration operation just 3 months after the fateful
dinner meeting. Lempert’s single-stage operation quickly supplanted Sourdille’s
three-stage procedure worldwide.

Lempert’s Legacy
In 1938, Julius Lempert22 finally published his ingenious modification of the fenestra-
tion operation that made the procedure into a single-staged surgery. The story of
Julius Lempert is worth special attention because it teaches lessons in facing adver-
sity, perseverance, and the consequences of not adapting to change.
Lempert was born in a Jewish ghetto in Poland, where his parents escaped a deadly
sweep by a Cossack troop when he was just 4 years old. In search of a better life, the
Lemperts fled their village and eventually relocated to the Lower East Side of New
York City.23 Lempert worked several street jobs starting at a young age but eventually
finished high school and applied to medical school. Due to family finances and Jewish

Fig. 6. (A) Maurice Sourdille. (B) Post-operative photo of a patient who underwent the
fenestration operation by Sourdille in 1929. (Courtesy of F. Legent, France.)
History of Otosclerosis and Stapes Surgery 281

Fig. 7. Julius Lempert. (From Lustig L. Anesthesia, antisepsis, microscope: the confluence
of neurotology. Otolaryngol Clin North Am 2007;40(3):415–37, with permission; and
Shambaugh GE, Glasscock ME. Surgery of the ear. 3rd edition. Philadelphia: W.B. Saunders;
1980, with permission.)

quota systems24 among first-tier medical schools at that time, Lempert was admitted
to Long Island Medical College, which was considered a third-rate medical school.23
Lempert developed a strong interest in otolaryngology; however, chances of accep-
tance into this field from a third-tier medical school at that time were nearly impossible.
Lempert decided to continue his pursuit of otolaryngology training by shadowing otolar-
yngology surgeons across New York. He visited operating rooms at Bellevue Hospital,
Columbia, Cornell, Manhattan Eye and Ear, and New York Eye and Ear. Lempert would
overstay his visits at these hospitals, eventually being asked to leave each and to never
return.23
Lempert opened his own office and mailed announcements to all doctors in New
York, stating boldly that he would return 50% of all his fees for any referrals of otolar-
yngology surgical cases.23 Although facing scorn from other surgeons, Lempert
quickly became one of the busiest otolaryngology surgeons in the city. By 1927, Lem-
pert performed more than 1500 mastoid operations and hundreds of other otolaryn-
gology surgeries. In 1928, Lempert published his first article in the Archives of
Otolaryngology describing his new technique for performing the endaural mastoidec-
tomy in contrast to the traditional postauricular approach.
Lempert was inspired by both Sourdille and Holmgren to develop his famous single-
stage endaural fenestration operation. Sourdille’s famous talk at the Otolaryngology
Section of the New York Academy of Medicine and Lempert’s visit to Holmgren at
the Karolinska Institute in Stockholm both played vital roles in the development of
his new procedure. Just like Sourdille, Holmgren received Lempert’s visit to Stock-
holm in a generous, unguarded way, showing him all the details and unresolved obsta-
cles of the fenestration procedure.23 Holmgren encouraged Lempert to continue his
282 Nazarian et al

research in Vienna, where autopsies were mandatory, thus giving Lempert an ample
supply of cadavers to explore the fenestration technique. In Vienna, Lempert devised
a method to convert Holmgren’s three-stage procedure into a single-stage operation.
He called this new operation the fenestration nov-ovalis.23
Lempert returned to New York and began performing his single-stage fenestration
operation for advanced otosclerosis. The results of the operation were well-received
by his patients but not by most surgeons at the time, who did not believe that Lempert
was qualified or credible in performing such an operation.
Lempert’s surgical tools also were not conventional. He was the first surgeon to use
the dental drill instead of the chisel and mallet to dissect the mastoid. Other ingenious
techniques included the use of magnifying loops and a customized headlight for illu-
mination. Although ahead of his time, his unusual surgical techniques raised many
eyebrows, and he was even asked to relinquish his privileges at a hospital where he
operated. With the success of his current practice and increasing antipathy from his
counterparts, Lempert ended up opening his own surgical institution, which he named
the Endaural Hospital.23
Because he was never formally trained in otolaryngology, Lempert could not present
at, or even be a member of, any otologic societies or professional organizations. In
1938, he was given the opportunity to publish his novel procedure in the Archives of
Otolaryngology.22 Most of his sample of 23 patients demonstrated successful results,
and his article would later be recognized as a landmark paper for fenestration surgery.
The single-stage endaural approach to fenestration was a significant improvement
over Sordille’s three-stage approach. The hearing results were consistent: more
than 50% of patients noted hearing gains to 20 to 25 dB. However, at the time of pub-
lication, Lempert’s work continued to draw skepticism from most ear surgeons.
Samuel Kopetzky, an ear surgeon and former president of the American Otological
Society (AOS), realized the revolutionary nature of Lempert’s single-stage fenestration
operation and approached Lempert to see if he can observe, present, and acknowledge
Lempert’s work at the AOS upcoming meeting in Atlantic City that was to be held on
May 6th, 1938. Meetings of the AOS were open to all doctors, but membership was
by invitation only and limited to those considered to be among the professional elite
of otologic surgeons. Lempert was thrilled by the prospect that his work would be finally
legitimized by a leading ear authority and in the presence of the elite among otologists.25
Lempert spent many hours trying to teach Kopetzky every step of the procedure so
that he could present it at the upcoming meeting. Kopetzky submitted his request to
present at the upcoming AOS meeting, but members of the AOS council had heard
rumors that Kopetzky may not be the actual surgeon behind the subject of the pro-
posed presentation. Dr Harris Mosher, who was president of the AOS and an
outspoken critic of Lempert’s work, asked Dr Hoople to investigate this before the
meeting.
Hoople made arrangements to observe Kopetzky perform the procedure. In the first
case, Kopetzky was the surgeon on record and Julius Lempert was the young assis-
tant. Kopetzky was just about to make the initial incision when he received an emer-
gency phone call, requiring his services at another hospital. He informed Hoople that
his assistant, Dr Lempert would complete the operative procedure. A few weeks later,
Hoople again made arrangement to observe Kopetzky but similar events occurred,
with Lempert performing most of the procedure. Hoople reported his findings to Dr
Mosher and the AOS council.
Kopetzky presented his paper on May 6, 1938 to the AOS. To Lempert’s disap-
pointment, Kopetzky never mentioned Lempert’s name throughout the presentation.
Dr Mosher presided over the meeting and, armed with the data provided by Hoople,
History of Otosclerosis and Stapes Surgery 283

allowed no discussion. He immediately rose and pounded his gavel. An emergency


meeting of the AOS council was held in Mosher’s suite and Kopetzky was interro-
gated. Despite his disapproval of Lempert, Mosher was more bothered that
Kopetzky broke his professional code of ethics. At the emergency meeting, the
council voted to expel Kopetzky from membership in the AOS.26 Lempert’s profes-
sional career was finally vindicated. Lempert was given sole credit for the paper,
“Improvement of Hearing in Cases of Otosclerosis,” published in the Archives of
Otolaryngology in 1938.
Lempert’s single-stage fenestration technique became the mainstream operation
for otosclerosis. He organized temporal bone courses twice a year to teach his oper-
ation to other surgeons. There was no way to know that, soon, an accidental rediscov-
ery of a once forgotten procedure would reemerge and render Lempert’s fenestration
surgery obsolete. Lempert could never allow himself to transition from his fenestration
procedure to stapes mobilization or stapedectomy, and lost everything as the fenes-
tration operation gave way to these procedures. Lempert would eventually die alone,
feeble-minded in a nursing home in 1968.

THE MOBILIZATION ERA

Samuel Rosen (Fig. 8) was the first to describe stapes mobilization after nearly half a cen-
tury. Rosen was the fourth of 5 children of a peddler. He lived in a poor section of Syra-
cuse, NY. His brothers and sisters paid his tuition at Syracuse University.27 Originally, he

Fig. 8. Samuel Rosen. (From House HP. The evolution of otosclerosis surgery. Otolaryngol
Clin North Am 1993;26(3):330; with permission.)
284 Nazarian et al

studied law but switched to medicine. After his training, he decided to meet Lempert to
learn the fenestration technique and eventually became a successful otolaryngologist.
Rosen performed Lempert’s fenestration operation; however, his modification to the
surgery was that he would check for the mobility of the stapes to ensure it was fixed
before proceeding to a semicircular canal fenestration.28 In 1952, Rosen developed,
almost by accident, the operation that would make him famous around the world.
During a routine procedure, Rosen accidentally mobilized the stapes while tapping
on it to check for fixation. The patient, who was awake during the procedure, began to
notice sound coming from the operating room next door.28 Astonished, Rosen prac-
ticed the procedure on cadavers several times before trying it again on an actual pa-
tient. His surgery began to gain global attention but, similar to Lempert’s early
struggles, wide skepticism ensued.
Rosen’s procedure was performed under local anesthesia and involved a transcanal
approach. Patients had immediate results on the operating room table and the recov-
ery period was quick. The surgery was relatively simple when compared with Lem-
pert’s fenestration operation and was easy to teach.
In 1955, the AOS invited both Lempert and Rosen to present their work in the same
session. During the discussion, it became obvious that Lempert did not approve of his
former student’s new mobilization technique. Howard House was in the audience and,
as recorded in his biography, recalled how Lempert’s attack on Rosen was similar to the
blind hostility that Lempert himself had experienced earlier in his own career: “The bril-
liant innovator seemed unable to accept the inexorable nature of progress in science
that comes as practitioners seek different ways to deal with medical problems.”29
Similar to Holmgren and Lempert, Rosen continued to perform his own invented
operation throughout his career. The shortcoming of the mobilization procedure
was that many patients would refixate shortly after the operation. Rosen would
often take patients back for revision mobilization surgery. After more than half a
century, stapes surgery was finally reestablished. A movement to fine-tune and pre-
serve stapes mobility was already underway, and Rosen was soon to experience
the consequences of failing to embrace and adapt to change.

THE STAPEDECTOMY ERA

John Shea (Fig. 9) was only in his thirties when he first described the stapedectomy
procedure. Shea was trained in the techniques of both Lempert and Rosen in the
1950s. In 1953, Shea visited Rosen who recommended that he to go to Vienna to
study at the First Ear Clinic to practice mobilization of the stapes on the abundant
cadaver material available there.21 While serving as a clinical fellow in Vienna, he
stumbled across the early literature of stapes surgery from the late 1800s, including
the report by Frederick L. Jack of a double stapedectomy patient in 1892. Jack’s
long-lost report described how the patient was still hearing, even 10 years after sta-
pedectomy, most likely due to the tympanic membrane healing over the oval window
and creating a mobile membrane. After reading the paper, Shea had realized the sig-
nificance of Jack’s procedure, and that it must be possible to remove and replace an
otosclerotic stapes with a prosthesis.21 In collaboration with the engineer Treace, he
created a stapes prosthesis made of the then newly discovered biocompatible ma-
terial Teflon (Fig. 10). In a female patient with otosclerosis, after removal of the sta-
pes and covering of the oval window with subcutaneous tissue, he used this Teflon
stapes prosthesis for the first time on May 1, 1956, with complete success.30,31
At the time of Shea’s discovery, the complete removal of the stapes was
still considered very dangerous and was forbidden. Many surgeons were still
History of Otosclerosis and Stapes Surgery 285

Fig. 9. John Shea. (Courtesy of Shea Ear Clinic; Memphis, TN.)

critical of the stapes mobilization technique. Nevertheless, Shea collaborated


with Howard House to discuss his newly discovered procedure during a
question-and-answer session at the First Symposium on Stapes Mobilization at
the annual Triological Society meeting in May 1956. Howard House was to be

Fig. 10. John Shea’s Teflon stapes prosthesis. (Courtesy of Shea Ear Clinic; Memphis, TN.)
286 Nazarian et al

the moderator of the session, and so they formulated a plan. Knowing the trouble
that both Lempert and Rosen had gone through to overcome their critics, House
decided that Shea would be the last person to be called for questions on
that day.28 As planned, Shea was called last and presented the results of his tech-
nique. At the end of Shea’s comments, House immediately hit the gavel, indicating
that time was up and there was no time for further questions.28 Members from the
audience were furiously rising to criticize Shea’s comments; however, the plan
worked and Shea’s presentation was included in the published transcripts of the
meeting.
Shea formally presented another 89 stapedectomy cases the following year at the
Second Symposium on Stapes Mobilization in 1958. Within a decade, Shea’s stape-
dectomy procedure became the standard operation for the treatment of otosclerosis.
In the 1960s, thousands of hearing-impaired patients with otosclerosis were treated
with great success. After the Teflon stapes, Shea used a hollow polyethylene tube
and then a piston made entirely of Teflon.16 In 1960, Schuknecht32 developed a steel
wire-adipose tissue prosthesis to address both the need to seal the vestibule and to
reconstruct the ossicular chain.
The complete removal of the footplate is now reserved for only select cases. As the
stapedectomy procedure evolved, various methods to remove just a portion of the
footplate were devised. Eventually, the procedure was modified so that only a small
fenestration was created through the footplate. An even less invasive, implantless pro-
cedure was described by Silverstein33 for select patients who may benefit from
removal of only the fixed anterior footplate while maintaining ossicular continuity via
the posterior crus.
Modern stapes surgery is still evolving, and the laser has become the tool of choice
to create an opening in the footplate that is small enough to fit a piston prosthesis and
reduce injury to the vestibule. The footplate fenestration of the stapedotomy proced-
ure is now a distant reminder of the days of Holmgren’s and Lempert’s semicircular
canal fenestration (Fig. 11).

DISCUSSION

Otosclerosis is among the most fascinating diseases in otology. The evolution of


its treatment so far, the revival of a once forbidden and forgotten surgery, its intel-
lectual challenges, and the ingenious techniques for improving its surgical treatment
make otosclerosis a subject for continuous clinical research and an inspiration to all
(Fig. 12).
The path to the current treatment of otosclerosis with stapedotomy has been
tortuous. Many of the pioneers were ridiculed, and some, such as Johannes Kessel,
were forced to resign their positions. Other pioneers, such as Holmgren, Lempert,
and Rosen, could not accept change and became obsolete. These histories bear les-
sons in overcoming professional adversity, but also the consequences of unremitting
triumph. In the end, a young man, Dr John Shea, who, with the help of a politically
savvy older man, Dr Howard House, enabled stapes surgery to return to its rightful
place in the treatment of otosclerosis.
As we continue to review the current and future trends of medicine and surgery,
we must also remember the past, as old and forgotten knowledge may serve as
the candle to enlighten the dark mysteries we face today. In the same context, sci-
entists, clinicians, and surgeons must embrace change. As Howard House once
told Julius Lempert, “Change is constant, and happy are those that can change
with it.”
History of Otosclerosis and Stapes Surgery
Fig. 11. A timeline of advancements in otosclerosis therapy.

287
288
Nazarian et al
Otosclerosis and Stapes Surgery: Major World Influences
1841 1923
London, UK Sweden
Joseph Toynbee Gunnar Holmgren
established the link between Three-stage “closed”
deafness and stapes fixation fenestration operation

1876
1892 Germany
Boston, USA Johannes Kessel
Frederick L. Jack First to describe
Published report of double stapes surgery
stapedectomy patient with
preserved hearing after 10 y 1893
Vienna, Austria
1938 Adam Politzer
New York, USA Described histologic findings
Julius Lempert of stapes fixation as
1952
Single-stage “otosclerosis”
New York, USA
“fenestration nov-ovalis” Samuel Rosen
Rediscovery of
stapes 1704
mobilization Bologna, Italy
operation
Antonio Maria
1956 Valsalva
1924
Memphis, USA 1934 First described stapes
Nantes, France
John Shea Buenos Aires, Argentina fixation as a cause of
Maurice Sourdille
Rediscovery of Jack’s paper and hearing loss
Juan Tato Three-stage “open”
first stapedectomy using Teflon First fenestration operation fenestraon operaon
prosthesis in the New World

Fig. 12. World map: major contributors to otosclerosis therapy.


History of Otosclerosis and Stapes Surgery 289

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