History of stapes surgery
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History of Stapes Surgery
The history of stapes surgery is one of the most dramatic narratives in surgical medicine - a field that was declared dead by the medical establishment, then resurrected and transformed within a single generation.
1. The Pre-History: Valsalva and Early Anatomists
The foundation was laid in 1704 when Antonio Maria Valsalva first identified stapes fixation as a cause of hearing loss. Over a century later, in 1841, Joseph Toynbee dissected 1,659 temporal bones and found 39 cases of stapes fixation linked to deafness. By 1893, Adam Politzer published histological studies identifying otosclerosis as the underlying pathological cause - abnormal bone growth fixing the stapes footplate to the oval window.
- Cummings Otolaryngology, p. 2781; ACTA Ital review 2024
2. First Surgical Attempts and Their Abandonment (1876-1900)
Kessel, in 1876-1879, was among the first to attempt stapes mobilization to relieve conductive hearing loss. Other early surgeons attempted similar operations, some even performing rudimentary stapedectomies.
Then came a catastrophic setback. At the 1900 International Congress of Otology, leaders of the specialty united in condemning surgery for deafness as "not only useless, but dangerous to life." The rejection was total:
- By 1919, Sir Charles Ballance's Surgery of the Temporal Bone made no mention of any operation to improve hearing.
- In 1930, Kerrison's Diseases of the Ear devoted less than a page to the topic, concluding that these operations "mentioned for their place in otologic history are quite obsolete today."
- Shambaugh Surgery of the Ear, p. 796
3. The Fenestration Era (1911-1952)
Despite this hostile climate, a few surgeons persisted:
Bárány (1911), Jenkins (1912), and Holmgren (1914) resumed operations on otosclerosis with "considerable courage in the face of this concerted opposition." Holmgren's key contribution was demonstrating that by careful aseptic technique, a semicircular canal could be opened safely to achieve temporary hearing improvement.
Nylén (1921), a young assistant in Holmgren's clinic, made a pivotal contribution: he was the first to use a monocular operating microscope in ear surgery during a radical mastoidectomy. Holmgren immediately recognized the advantage and adopted a binocular operating microscope for his otosclerosis operations - giving birth to otologic microsurgery.
Sourdille (1924-1937) observed Holmgren's work and returned to France, devising his multi-stage procedure called the tympanolabyrinthopexy - creating a fistula in the horizontal semicircular canal and covering it with a skin flap from the meatus. For the first time, permanent hearing improvements in otosclerosis were documented.
In 1937, Sourdille lectured at the New York Academy of Medicine, which prompted Julius Lempert to apply the technique. Lempert used the endaural approach (rather than postauricular) with a dental drill to create his one-stage fenestration operation - a major simplification. In 1938, G. Shambaugh Jr. became Lempert's first pupil and went on to perform over 5,000 fenestration operations. He further innovated by introducing the operating microscope, continuous irrigation, enchondralization, and a diamond drill for constructing the fenestra - achieving lasting hearing improvements in 80% of fenestrations.
- Shambaugh Surgery of the Ear, pp. 796-797
The key limitation of fenestration surgery was that it bypassed the fixed stapes entirely by creating a new window into the lateral semicircular canal, requiring a permanently open mastoid cavity and maintenance. It also did not fully restore normal hearing thresholds.
4. Stapes Mobilization: A Return to the Oval Window (1953)
In 1953, Samuel Rosen of New York accidentally rediscovered stapes mobilization while testing the stapes for fixation during a fenestration procedure and found that simply freeing the stapes restored hearing immediately. He reintroduced stapes mobilization as a surgical goal in its own right. This fundamentally shifted the operative target from the semicircular canal back to the oval window area.
Results were promising in the short term but recurrence of fixation was common, as otosclerotic bone re-anchored the stapes in most patients over time. The procedure was nonetheless a critical conceptual and anatomical stepping-stone.
5. The Stapedectomy Revolution: John Shea (1956)
On May 1, 1956, John J. Shea Jr. of Memphis performed the first modern stapedectomy - completely removing the stapes and replacing it with a Teflon replica of the stapes connected to a vein graft over the oval window. This was the procedure that changed everything.
Initially considered dangerous by the surgical community, the technique became the new standard by the 1960s. Key subsequent developments in the stapedectomy era:
- Schuknecht (1960) developed a steel-wire loop prosthesis, improving reliability.
- Plester proposed partial footplate removal, further refining technique.
- Zöllner and Wullstein (1955-1960s) contributed concepts of tympanoplasty and ossicular reconstruction, including connecting the incus to the oval window in stapedectomy cases.
- The vein graft was soon supplemented and sometimes replaced with perichondrium or fat tissue seals.
- Cummings Otolaryngology, p. 2781; Shambaugh Surgery of the Ear, p. 797
During the 1960s and 1970s, stapes surgery reached its peak volume. Surgeons like Harold Schuknecht at Massachusetts Eye and Ear Infirmary (Harvard) reportedly performed over 20,000 stapedectomies as the backlog of unoperated cases was worked through.
6. Stapedotomy: The Small-Fenestra Technique (1970s-1980s)
A refinement of stapedectomy came with the concept of stapedotomy - rather than removing the entire footplate, a small fenestra (0.6-0.8 mm) is drilled or perforated into the footplate, and a piston-type prosthesis is inserted through it. Key advantages:
- Preserves the footplate as a protective barrier to the inner ear
- Reduces risk of perilymphatic fistula
- Lowers the rate of sensorineural hearing loss (SNHL) and post-operative vertigo
- More stable long-term hearing outcomes
Guilford and others popularized the small-fenestra technique in the USA. The shift from stapedectomy to stapedotomy became the dominant trend from the 1980s onward, and most otologists today prefer stapedotomy whenever feasible.
7. The Laser Era (1980s-Present)
The introduction of laser technology into stapes surgery was another landmark. The CO₂ laser, KTP (potassium titanyl phosphate) laser, and argon laser have all been applied to:
- Precisely create the small fenestra in the footplate
- Divide the stapedial tendon and crura without mechanical trauma
- Reduce bleeding and the vibration transmitted to the inner ear during footplate penetration
Laser stapedotomy has been associated with reduced inner ear trauma in selected hands.
8. Endoscopic Stapes Surgery (2000s-Present)
The most recent phase of evolution is the adoption of endoscopic ear surgery (EES) for stapes procedures. The endoscope provides a wide-angle, high-magnification view of the oval window niche with a single-handed technique, often through a purely transcanal approach without any incision. While depth perception is reduced compared to the binocular microscope, endoscopic stapedotomy is now practiced in specialized centers and offers improved visualization of the oval window anatomy.
- ACTA Ital 2024 review
Summary Timeline
| Year | Surgeon | Development |
|---|---|---|
| 1704 | Valsalva | Identified stapes fixation causing deafness |
| 1841 | Toynbee | Linked stapes fixation to deafness in 1,659 temporal bone dissections |
| 1893 | Politzer | Histological identification of otosclerosis |
| 1876-1879 | Kessel | First stapes mobilization attempts |
| 1900 | International Congress of Otology | Surgery for deafness condemned |
| 1914 | Holmgren | Semicircular canal fenestration (temporary results) |
| 1921 | Nylén/Holmgren | First use of operating microscope in ear surgery |
| 1924 | Sourdille | Tympanolabyrinthopexy - first permanent improvements |
| 1938 | Lempert | One-stage endaural fenestration operation |
| 1940 | Shambaugh Jr. | Microscope + diamond drill for fenestration; 80% success |
| 1953 | Rosen | Reintroduction of stapes mobilization |
| 1956 | John Shea | First stapedectomy with Teflon prosthesis |
| 1960 | Schuknecht | Steel-wire prosthesis |
| 1970s-1980s | Guilford et al. | Small-fenestra stapedotomy |
| 1980s | Various | Laser-assisted stapedotomy |
| 2000s+ | Various | Endoscopic stapes surgery |
The arc of stapes surgery reflects a broader truth in medicine: transformative advances often require surgeons willing to persevere against institutional consensus. From Holmgren's defiance of the 1900 condemnation to Shea's "dangerous" Teflon prosthesis, each breakthrough came from those willing to challenge received wisdom.
- Shambaugh Surgery of the Ear, pp. 795-797
- Cummings Otolaryngology Head and Neck Surgery, p. 2781
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