History and Geography

Antiquity Through the Sixteenth Century It is likely that humanity has always suffered from acute infections of the middle ear and attendant suppurative complications such as mastoiditis. Studies of 2,600-year-old Egyptian mummies reveal perforations of the tympanic membrane and destruction of the mastoid air-cell system. Evidence of suppurative destruction of the mastoid is also apparent in skeletal specimens from early Persian populations (1900 B.C. to 800 B.C.).

Hippocrates appreciated the potential seriousness of otitic complications and noted that "acute pain of the ear with continued high fever is to be dreaded for the patient may become delirious and die." Early in the Roman era, the Roman physician Aulus Cornelius Celsus observed that "inflammation and pain to the ear lead sometimes to insanity and death." The Arabian physician Avicenna related suppuration of the ear and mastoid with the brain, reasoning incorrectly that the ear discharge was caused by the brain disease. For centuries, middle-ear and mastoid infections producing discharges from the ear were considered virtually normal conditions because they occurred so frequently.

Although the seriousness of ear suppuration was appreciated much earlier, the concept of opening the mastoid to relieve infection did not occur until the sixteenth century. The great medieval surgeon Ambroise Paré was called to the bed of Francis II of France. Paré found the young king febrile and delirious with a discharging ear. He proposed to drain the pus through an opening in the lateral skull. The boy-king's bride, Mary, Queen of Scots, consented. However, the king's mother, Catherine de Médici, refused to let the surgery take place, causing Mary to lose her first husband and throne while she was only 18 years old.

Seventeenth Through Eighteenth Century Notable advances in understanding the pathophysiology of aural suppuration were made in the late seventeenth century. Joseph DuVerney wrote Traité de l'Organe de l'Ouie (1683), which is generally regarded to be the first monograph published on the subject of otology. It was the first book to contain an account of the structure, function, and diseases of the ear, whereas earlier works were devoted to purely normal otologic anatomy. In this work, DuVerney described infectious aural pathology and the mechanisms producing earache, otorrhea, and hearing loss. He was the first to describe extension of tympanic cavity infection posteriorly to the mastoid air cells to produce the characteristic symptoms and findings of mastoiditis.

Noteworthy contributions were made by Antonio Valsalva (1704), who still believed that aural suppuration was secondary to cerebral abscess formation and was not the primary lesion. He did, however, suggest a method for removing purulence from the ear. This procedure consisted of blowing out strongly while holding the mouth and nose firmly closed, thus forcing air to pass into the middle ear by way of the eustachian tube. He suggested this maneuver as a means of expelling pus in cases of otitis. Valsalva's student Giovanni Morgagni, in his great work On the Sites and Causes of Disease (1761), revealed postmortem evidence that demonstrated that aural suppuration was the primary source of lethal, intracranial abscesses.

In the early eighteenth century, Jean Petit of Paris performed what is generally believed to have been the first successful operation on the mastoid for the evacuation of pus. He demonstrated recovery "after the compact layer had been taken away with gouge and mallet." He stressed the need for early drainage of mastoid abscesses because of the potential for "accidents which may supervene and render the disease infinitely complicated and fatal."

S. Stevenson and D. Guthrie, in their History of Otolaryngology (1949), describe how, in 1776, a Prussian military surgeon apparently treated a painful, swollen, draining mastoid by removing a portion of the overlying mastoid cortex. The surgeon was probably unaware of Petit's work, and the authors quote him saying, "Perhaps this is no new discovery, but for me it is quite new."

Performance of the mastoidectomy operation suffered a setback when the procedure was performed on Baron von Berger, personal physician to the King of Denmark. The baron, hearing of the success of Petit and others, persuaded a surgeon to operate upon his mastoid to relieve tinnitus and hearing loss. The operation was performed before the importance of surgical asepsis was realized, and resulted in a wound infection. The baron died of meningitis 12 days later, and the mastoidectomy operation fell into disrepute until the middle of the nineteenth century.

France was one of the first countries to remove otology from the sphere of the general surgeon and to give it a place of its own. One of the first to specialize in this discipline was Jean Marie Gaspard Itard. Itard was a military surgeon in Paris who carried out extensive study of otologic physiology and pathology, and published a textbook on these subjects, Traité des Maladies de l'Orielle et de l'Audition, in 1821. He exposed many errors of his predecessors, particularly their opening of the mastoid cavity as a cure for deafness. Like Itard, Jean Antoine Saissy, a Parisian surgeon, was strongly opposed to puncturing the tympanic membrane for aural suppuration as recommended by his predecessors. Instead, he treated middle ear and mastoid suppuration by rinsing through a eustachian catheter. He described the technique in his Essai sur les maladies de l'oreille interne (1829).

In 1853, Sir William Wilde of Dublin - father of the poet Oscar Wilde - published the medical classic Practical Observations on Aural Surgery and the Nature and Treatment of Diseases of the Ear. In this publication he recommended incision of the mastoid through the skin and periosteum for fluctuant mastoiditis when symptoms and findings were life-threatening.

The nineteenth century saw the successful employment of ether in a surgical operation by William Thomas Green Morton in 1846 and the introduction of chloroform by James Young Simpson in 1847. These, coupled with bacteriologic discoveries made by Louis Pasteur and the work of Joseph Lister on antisepsis, the invention of the electric light by Thomas Edison, and the work of Rudolph Virchow in cellular pathology, had profound effects upon the development of otologic surgery for suppuration.

James Hinton, a London surgeon, and Hermann Hugo Rudolf Schwartze of Halle are credited with establishing the specific indications and method of simple mastoidectomy. This operation involved removal of the bony cortex overlying the mastoid air cells. The insight and work of Schwartze led to the first systematic account of the operation as a scientific procedure to be performed when specific indications were present and according to a definite plan. His rationale was so convincing that by the end of the nineteenth century, the operation had attained widespread acceptance and had overcome more than a century of prejudice against it.

In 1861 the German surgeon Anton von Troltsch had reported successful treatment of a case of apparent mastoiditis with a postauricular incision and wound exploration. He subsequently recognized that failure to address disease deeper within the middle ear recesses and mastoid invariably resulted in recurrence of otorrhea. In 1873 he proposed extensions of Schwartze's simple mastoidectomy to treat surgically these problematic areas.

Following a similar line of reasoning, Ernst von Küster and Ernst von Bergmann, in papers read before the German Surgical Society in 1889, recommended extending Schwartze's mastoidectomy procedures to include removal of the posterior wall of the external canal and middle ear structures "to clear away all disease and so fully to expose the source of the suppuration that the pus is nowhere checked at its outflow." This extended procedure became known as the radical mastoidectomy.

Prior to these remarkable advances in the surgical treatment of mastoiditis, the "mastoid operations" frequently failed because of delayed surgical intervention in cases in which infections had already extended beyond the mastoid process to involve intracranial structures. George Shambaugh, Jr., has noted that these patients died most likely despite, not because of, their mastoid operation (Shambaugh and Glasscock 1980). Many surgeons trained before 1870 were unable to absorb and practice Listerian doctrines, and this fact may have contributed to an overly conservative approach to surgical procedures. Properly indicated and performed, mastoidectomy for a well-localized coalescent infection proved to be extremely effective in removing the risk of serious complication from an abscess within the mastoid and in preventing continued aural suppuration. The addition of techniques for exteriorizing infectious processes in the less accessible apex of the temporal bone, as well as progress in making earlier diagnosis of mastoiditis, capped this important phase of otologic surgery for aural suppuration.

In many cases of chronic otorrhea treated with radical mastoidectomy, previous infection had destroyed the middle-ear sound-conducting system. Removal of the tympanic membrane and ossicular remnants was necessary in order to extirpate the infection completely. However, it soon became apparent that in a subset of cases of chronic otorrhea, the infectious process did not involve the inferior portions of the tympanic membrane or ossicular chain. In 1899, Otto Körner demonstrated that, in selected cases, the majority of the tympanic membrane and ossicular chain could be left intact during radical mastoidectomy, thus maintaining the preoperative hearing level.

In 1910 Gustav Bondy formally devised the modified radical mastoidectomy for cases in which the inferior portion of the tympanic membrane (pars tensa) and the ossicular chain remained intact. He demonstrated that the removal of the superior bone overlying infected cholesteatoma adequately exteriorized and exposed disease while preserving hearing. Despite the successful demonstration of this less radical approach in selected patients, otologic surgeons were slow to accept Bondy's procedure. Most likely, the preoccupation with preventing intracranial suppurative complications forestalled acceptance of this less aggressive approach. Shambaugh and others in America and abroad recognized the utility of the Bondy procedure, and it finally gained widespread acceptance by the 1930s.

A marked decline in the need for mastoid operations developed with the use of sulfanilamide and penicillin. The favorable results that were achieved with the use of these antibiotics in many cases encouraged their application at earlier stages of severe infections including mastoiditis. At first, otologic surgeons were hesitant to abandon the established surgical drainage procedures for mastoiditis, fearing that antibiotics would mask the clinical picture and lead to late complications. It soon became evident, however, that if antibiotics could be given before localized collections of pus were established, fewer complications requiring surgical intervention would result. Nonetheless, modern-day physicians have recognized that too low a dose of an antibiotic given for too brief a time, or the use of a less effective antibiotic in the early stages of otitis media, may indeed mask a developing mastoiditis.

Interest in hearing-preservation in conjunction with surgical treatment of chronic ear infections continued to grow. The German surgeons F. Zöllner and H. Wullstein share credit for performing the first successful repairs of the tympanic membrane using free skin grafting techniques in 1951. The ability to repair perforations of the tympanic membrane and seal the middle ear reduced the likelihood of persistent aural suppuration and associated mastoid and intracranial complications.

The emphasis on preservation and restoration of hearing in conjunction with the management of chronic ear infections has fostered the development of methods of ossicular reconstruction since the 1950s. Techniques in ossicular reconstruction are designed to simulate the middle-ear sound-conducting mechanism. Alloplastic prostheses made of polyethylene and Teflon and bioceramic materials have produced mixed results with respect to long-term hearing and prosthesis stability and acceptance.

The incus interposition technique of ossicular re construction was introduced by William J. House in 1966. C. L. Pennington and R. E. Wehrs are credited with refinement of this technique for reestablishing ossicular continuity between the tympanic membrane and the cochlea.

In 1954 B. W. Armstrong reintroduced a procedure, first suggested by Adam Politzer in 1869, to reverse the effects of eustachian tube dysfunction. The procedure entails a limited incision of the tympanic membrane and insertion of a tympanostomy tube. Theoretically, a functioning tympanostomy tube exerts a prophylactic effect by maintaining ambient pressure within the middle ear and mastoid and providing aeration and drainage of retained middle-ear secretions. Tympanostomy tubes appear to be beneficial in restoring hearing and preventing middle-ear infections and structural deterioration while in place.

This review of the historical development of otology reports an evolution in the understanding and management of aural infections. Interestingly, current principles of the surgical treatment of chronic ear infections recapitulate this evolution. The essential principles and objectives upon which modern surgical procedures are based are (1) removal of irreversibly infected tissue and restoration of middle-ear and mastoid aeration; (2) preservation of normal anatomic contours, and avoidance of an open cavity, when possible, by maintaining the external ear canal wall; and (3) restoration of the middle-ear sound-transformer mechanism in order to produce usable postoperative hearing.

The historical lessons learned by otologists underscore the importance of adequate surgical exposure and removal of irreversibly infected tissue followed by regular, indefinite postoperative follow-up in order to maintain a safe, dry ear.

John L. Kemink, John K. Niparko, and.

Steven A. Telian

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