Otology and Neurotology - Past, Present and Future - II

Part II

During the 48th Brazilian Congress of Otorhinolaryngology there was a presentation named The Future of Otolaryngology. I decided to include in my list of blogs this slightly expanded version of my presentation. Some of the names mentioned here have been presented in other pages of this blog.

Ádám Politzer

Politzer is celebrated as a pioneer of modern otology in the History of Medicine. For many years he was the Professor of Otolaryngology of the University of Vienna and attracted many physicians from different countries, influencing and training thousands of otologists from all over the world.


He invented many medical instruments for the diagnosis and treatment of ear diseases. He created the ventilation tubes for the aeration of the middle ear after paracentesis and created the otoscope. He made the first observation that the middle ear ossicles vibrate to sound stimuli. 

Wladimir Michailowitsch Bechterew

An important Russian neurophysiologist, creator of the “objective psychology.” His experiments with the destruction of the vestibular labyrinth were the first descriptions of vestibular compensation.

Ernst Julius Richard Ewald

Ewald was a German physiologist, best remembered for his research of the vestibular system. “Ewald’s laws” are still fundamental in the study of the neurophysiology of the semicircular canals.

Robert Bárány

Robert Bárány is the father of Neurotology. Working at the Otological Clinic of Vienna University, Professor Ádám Politzer, he created the caloric tests for studying the labyrinthine function, perfected the rotatory tests and also made studies on the cerebellar function. He was well acquainted with the researches conducted by Flourens, Purkynĕ, Mach, Breuer and others, and made important contributions to the physiology and pathology of the labyrinth.

In 1914 he was awarded the Nobel Prize in Medicine for his work in Neurotology. He was still a prisoner of war when he received the news that he had won prize. He was released in 1916 and then went to Stockholm to receive his prize. On returning to Vienna, however, his Austrian colleagues accused him of plagiarism. This accusation was investigated by the Nobel Prize Committee, which found it groundless. It is interesting to quote Sigmund Freud’s comments on this episode: “The granting of the Nobel Prize to Bárány... has aroused sad thoughts about how helpless an individual is about gaining the respect of the crowd.”

Gunnar Holmgren 1875 -1954

A pioneer in Otology, Holmgren was the first Professor of Otolaryngology of the Karolinska Institute – the chair was created for him in 1912. For many years he was chairman of the Medical Nobel Committee. He has been honored with honorary membership in a large number of international scientific associations.

He was particularly interested in the surgical treatment of otosclerosis and, in 1936, demonstrated a successful case of the fenestration operation. His patients, however, heard well for a limited period of time, for the new fenestras eventually closed.

He founded the Acta Oto-Laryngologica and played an important part in liberating Robert Bárány, who was a prisoner of war in Russian, and offering him a chair at the University of Uppsala.

He was the first otologist to operate with a surgical microscope, devised by his disciple Carl-Olof Nylén.

Maurice Sourdille

Sourdille was a French otologist from the city of Nantes. He was inspired by the work of Bárány and Holmgren and by their use of the surgical microscope. During his visit to Stockholm, in 1924, he observed the closed fenestra operation of Holmgren and then developed his two-stage exteriorized fenestration operation, that was very successful. After the Paris Congress of 1935 devoted to the surgical treatment of otosclerosis, Sourdille made his surgical technique known to all the world.

Carl-Olof Nylén

In 1921 Nylén created the first surgical microscope, which was employed in ear operations both by himself and by Holmgren. He described the vestibular disorder that he named “vestibular neuritis” and classified the different types of gaze nystagmus. 

Julius Lempert

In 1937 Maurice Sourdille was invited to speak about the fenestration operation at the New York Academy of Medicine. Julius Lempert was in the audience and figured that he could perform the fenestration operation in only one stage, using his new endaural approach to the middle ear and mastoid. Not only he perfected the fenestration operation, but also popularized it, teaching his technique to a number of otologists all through the world.

Hallowell Davis

Dr. Davis was my professor of neurophysiology. He means a lot to me, in some way he inoculated in me the interest in otological and neurotological research. 

During his Harvard days, in the 1930̓s, he helped to develop electroencephalography. At the Central Institute for the Deaf his contributions to cochlear neurophysiology were many, including the discovery of the  summating potentials. He was also the father of electric response audiometry.

His book “Hearing”, written with the experimental psychologist S. S. Stevens and published in 1938, was reprinted by the Acoustical Society of America for being a perfect description of all of the research performed previously to its appearance. The word “Audiology” was coined by Dr. Davis.

I am very proud to have contributed a chapter for the book that his disciples wrote as a gift for his 80th birthday: “Hearing and Davis – Essays Honoring Hallowell Davis.” 

Charles Skinner Hallpike

Hallpike was an important British neurotologist. He perfected caloric tests, created maneuvers for diagnosing benign paroxysmal postural vertigo (BPPV), described endolymphatic hydrops

Hallpike and Nylén founded the Bárány Society, the most important international society of Neurotology.  

Fritz Zöllner and Horst Wullstein

Working independently, Zöllner in Austria and Wullstein in Germany, created “tympanoplasty” – the reconstruction of the middle ear. This opened a totally new field in otological surgery.

Georg von Békésy

He started as a telephone engineer and became an extraordinary researcher of the physiology of the cochlea He received the Nobel Prize in Medicine in 1961.

Harold F. Schuknecht

Besides being a practicing otologist, he dedicated much of his time to the pathology of the ear and built an important colection of human temporal bones. Among many other contributions, he discovered the etiology of BPPV. 

His book, “Pathology of the Ear”, is a masterpiece.

John Shea, Jr.

He recreated stapedectomy and made it become the standard surgical treatment for otoclerosis.

William F. House

Bill’s contribution to otology and neurotology was simply amazing. He was the father of Otoneurosurgery, creating surgical techniques that became standard procedures throughout the world. And he was also responsible for the progress of Neurosurgery.

But Bill’s greater contribution was the cochlear implant. At that time we were actually looking at the future. He was severely criticized by most otologists (as I also was, when I performed my first cochlear implant). And yet, so many deaf patients are now being helped.

The Cochlear Implant

This experimental unit was used for my first cochlear implant, performed at the Albert Einstein Hospital in São Paulo in 1977.

Jun-Ichi Suzuki and Naoaki Yanagihara

Prof. Suzuki (left) – a dear friend – was the Professor of Otolaryngology of the Teiko University School of Medicine, in Tokio, Japan. Prof. Yanagihara (right) was the Professor of Otolaryngology of the Ehime University School of Medicine in Ehime, Japan. To both of them we owe the development of the implantable hearing aids. Between them, in the photo, is my late associate Yotaka Fukuda, a
very dear friend who participated in all my cochlear implants and acoustic tumors for many years. Dr. Fukuda spent some time in Ehime with Prof. Yanagihara.

Michael Halmagyi

This Australian neurologist, with a group of excellent collaborators, developed the video head impulse test, making it possible to investigate the function of all semicircular canals. 

David Newman-Toker and David Zee

These American neurologists created an excellent nerotological diagnostic center at the Johns Hopkins University, in Baltimore.

Jorge Kattah

Prof. Kattah and I

A neuro-ophtalmologist with important contributions to neurotology. 

The Future

Genetics

The availability of the Human Genome changed the role of Genetics in Medicine. We expect to have genetically designed proteins and genetically designed medications in approximately five years.

Regeneration of Cochlear Cells

The word cochlea is associated with a spiral shape. It exists only in mammals. The reptiles and the birds do not have true cochleas, their hair cells are linearly disposed.

A reptile's cochlea

But the reptiles and the birds are capable of regenerating their hair cells when this becomes necessary. 

A bird's "cochlea"

For some reason - possibly the greater complexity of its structure - the cochlea of the mammals lost this capacity. We hope to find the genes and proteins related to hair cell regeneration, something that will probably take some 10 to 15 years.

Trunk cells have been inserted in cochleas and have been shown to survive, but do not differentiate into hair cells. But we may be able to find ways to use them as replacements for lost hair cells.

Specially designed cochlear implants may be used to deliver trunk cells, or genetically designed proteins, to different places in the cochlea.

"We do not the responsibility of previewing the future; but we have the obligation of making it possible."

Antoine de St. Exupéry