Modern surgical treatment of otosclerosis - Helda - Helsinki.fi

1 Introduction
Introduction
Otosclerosis is a disease of the otic capsule and middle ear ossicles. It is more common in
Caucasian populations. Histological incidence in Caucasians varies between studies from
3.4% to 13% (Guild 1944, Schuknecht and Kirchner 1975, Hueb et al. 1991, Declau et al.
2007). Histologically, alternating phases of bone formation and resorption occur. After
repeated cycles of remodelling, highly mineralized sclerotic bone is created. If a
stapediovestibular joint is invaded by the disease, a clinical picture of conductive hearing
loss is formed. Only about 10% of patients develop clinical otosclerosis with conductive
hearing loss with or without a sensorineural component (Menger and Tange 2003).
Valsalva was the first to describe hearing loss due to stapes ankylosis in 1704 (Politzer
1981, Hausler 2007). About 140 years later, Meniere described a patient whose hearing
was temporarily improved by tapping on the stapes with a small gold rod. In the late 19th
century, many surgeons have performed stapes mobilization. However, in 1899, at the 6th
international otology congress, leading otologists of the time proclaimed stapes surgery
useless, dangerous and unethical and banned the procedure (Shambaugh and Glasscock
1980, Hausler 2007). Thus, the development of stapes surgery halted for 50 years. During
these five decades, a fenestration operation for otosclerosis was performed. Passow
presented the idea of a third window that could be created in the promontory and covered
with tympanic membrane in 1897. It did not become common practise, but did evolve to
the one stage operation of semicircular canal fenestration described by Lembert in 1932.
In 1952, while performing Lembert's fenestration operation, Rosen accidentally mobilized
the stapes and rediscovered its positive effect on hearing. The advantages of stapes
surgery, as compared with fenestration, were a reduction in the time needed for immediate
recovery and the absence of a large postoperative cavity. Stapes surgery once again
became acceptable (Shambaugh and Glasscock 1980, Hausler 2007).
In addition to Rosen’s discovery, innovations in the early 20th century improved operative
results and made more advanced procedures possible. An important technical step forward
was the introduction of the electric head light and the surgical microscope (Shambaugh
and Glasscock 1980). Another large advance in medicine was the beginning of the clinical
use of antibiotics in the 1930s' (Huovinen and Vaara 2005).
The era of modern stapes surgery began in 1956, when Shea successfully removed stapes
and reconstructed the ossicular chain with a Teflon prosthesis after sealing the oval
window with a thin skin graft (Shea 1956). In 1958, Shea presented a technical note of
stapedectomy, where the oval window was sealed with vein graft and reconstruction was
performed with the posterior crus of stapes or with a polyethylene tube. This new state-ofthe-art
reconstruction of the ossicular chain was found to be far superior to the former
mobilization operations, and thus, became the standard. Many modifications of
stapedectomy have been developed using different sealing materials such as fat, fascia,
gelatin foam and perichondrium, and the prosthesis has been constructed with such
material as steel, tantalum, platinum and bone. Some methods were more prone to
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