The Fenestration Era

Otosclerosis is a fairly common disease, being found, histologically, in 10% of the human temporal bones. But the abnormal bone formation that characterizes the disease causes hearing losses in only one tenth of the persons that have inherited the disease, which means that only 1% of the population has hearing loss caused by otosclerosis.

What happens in these persons is that the stapes is fixed by the abnormal bone formation, causing what we call a conductive deafness. The person does not hear well because a significant part of the sound energy does not reach the receptor cells of the inner ear. It is like the cataract in the eye: the opaque lens does not allow all of the light to reach the receptor cells in the retina.

The stapes fixation was described by Valsalva in 1704. A famous English otologist, Joseph Toynbee, made a detailed description the stapes fixation in 1841, but felt that this was caused by infections. It remained for Adam Politzer to describe the histologic features of otosclerosis, showing that the stapes fxation was caused by abnormal new bone formation.

In the late 19th century some otologists attempted to restore the hearing of patients with otosclerosis by operating on the stapes. The first stapes mobilization operations were performed in 1875 by Kessel, followed by Boucheron and Miot in 1888. The first stapedectomies – surgeries for stapes removal – were performed in 1892 by Blake and in 1893 by Jack.

But these operations had many complications, including complete deafness, meningitis, and death. Therefore, this early stapes surgery was abandoned. Famous otolaryngologists of that time, like Siebenmann, Politzer, and others expressed their firm opinion that these operations should not be performed.

In 1913, Jenkins first described a different type of surgery, which he called fenestration. It  consisted of the creation of a fenestra (a window) in the vestibule or in the lateral semicircular canal, thus establishing a new way for the sound waves to reach the perilymph of the inner ear. He operated on two patients that had a significant hearing improvement, but this hearing gradually declined. Robert Bárány opened the posterior semicircular canal in several patients, in 1914, without being able to obtain a persistent hearing gain.

Gunnar Holmgren, in Sweden, began his studies of the fenestration surgery in 1916, confirming that the creation of a labyrinthine “fenestra” (window) did actually improve hearing, but the closure of this window by new bone formation was the serious problem of this technique.

Maurice Soudille, in Paris, was the man that made the fenestration operation feasible. He visited Holmgren in 1924 and began his attempts to improve the technique, creating a fenestra on the lateral semicircular canal and covering it with a tympanomeatal flap. His surgical procedure was complex, being performed in two stages.  His early cases were operated in 1932. 

Maurice Sourdille
Sourdille presented his technique in New York and one of the members of the audience was Julius Lempert, who became very interested in the procedure. Lempert perfected the technique, making it a one-stage operation. In 1938 he reported 18 well succeeded cases in 23 operations and continued to improve his technique. 
Julius Lempert

Thus began the fenestration era.

Lempert gave courses on fenestration surgery, and had many important disciples, that came from many different countries, to learn the technique. I personally knew Theodore Walsh, in Saint Louis, Howard House, in Los Angeles, George Shambaugh Junior, in Chicago, Ion Simpson Hall, from Edinburgh, Ermiro de Lima and José Kós, in Rio de Janeiro. The operation was performed by a small number of highly specialized otologic surgeons, and was not taught to otolaryngological residents.

But Lempert did not care for hearing tests. He just asked the patients whether they were hearing better. 

Theodore Walsh, on returning to the Washington University in Saint Louis, asked Hallowell Davis, at the Central Institute for the Deaf – at walking distance from the Department of Otolaryngology – to establish the audiological parameters for indication and evaluation of the results of the operation. George Shambaugh Junior, in Chicago’s Northwester University, did the same. Their studies actually provided a more scientific status for the procedure and established the introduction of audiology in the field of otology.

The follow-up of the fenestration patients was easy to perform. The patients were asked to return once a year, and they really came, because their mastoid cavities had to be cleaned (this does not happen in stapes surgery, the patients with good results seldom come back for long-term control).

When I arrived in Saint Louis in 1958, Dr. Walsh was performing five fenestrations each week; this number decreased only in 1961. His results were excellent. One of his disciples, my late friend Jack Hough, told me that he considered Dr. Walsh as the very best of the fenestration surgeons. I believe that I watched Dr. Walsh perform hundreds of fenestrations. I am sure that I could perform it very well, but I did not perform it in any patient.

Because then came the stapes surgeries. While fenestration created a new way for the sound to reach the inner ear, now the idea was to repair the normal way for the sound to get in. 

It began with the stapes mobilization operations. When the stapes moved easily, the results were very good. But then the otologic surgeons devised different maneuvers and began to use miniature chisels to break the otosclerotic bone and achieve the mobilization in a larger percentage of cases, and in this situation the stapes often got fixed again after a variable amount of time.

And then came stapedectomy and stapedotomy, and the fenestration operation was totally abandoned.

Bill House once told me that the fenestration operation would be abandoned even if the stapes surgery had not been developed. In the fenestration operation the middle ear ossicles do not work (actually the incus was removed during the procedure), so all of the patients, even the ones with very good results, had some residual hearing loss. And in the 1950's the hearing aids became better, so that the use of hearing aids would provide hearing levels that would be better than those of the fenestration operation. Stapedectomy and stapedotomy, however, result in better hearing than the use of hearing aids.

I have mentioned in some papers concerning the cochlear implants that otology is a conservative field and tends to reject the new techniques that are proposed. The fenestration operation, as well as Julius Lempert, were intensely antagonized at first. As were the stapes surgery techniques. As were the operations for acoustic tumors and the cochlear implants. But in all of these examples, in time the procedures were accepted, showing that progress can be slowed, but it cannot be detained.

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