Operation for Removal of the Stapes

CLARENCE J. BLAKE
1892 Boston Medical and Surgical Journal  
The question of the removal of the stapes in the human subject with a view toan improvement in hearing is one which has been gradually approached both in this country and in Europe through observations upon the effect of operations in the middle ear undertaken for the purpose of increasing the mobility of the sound-transmitting apparatus or of removing such obstructions to the passage of the sound waves as might have occurred as the result of previous disease of tho middle ear. These operations
more » ... r. These operations have included, from a very early date, incisions of the membrana tympani, and its partial or entire removal, myringotomy, myringectomy, divisions of adhesions or folds, symcchtomy, plicotomy. tenotoiny of the musculus tensor tympani, and removal of one or all of the ossicula. The latter operation when done ih a case of suppurative disease of the middle ear, either because of existent caries of the ossicula themselves, or because their removal is necessary to permit access to the carious walls of the tympanic cavity and to facilitate drainage, comes under the head of an ordinary and Justifiable surgical procedure. In the case of non-suppurative disease of the middle ear with fixation of the ossieular chain, as the result of thickening of the investing membrane and of changes O O ES in the articulations and about, the insertion of the stapes the queBtion of surgical interference assumes a different aspect, since it includes the invasion of an aseptic cavity and indirectly the interference with an apparatus devoted not only to tho perception of sound but also to the maintenance of equilibrium, and is done, not because of an already existent surgical necessity, but with tho view to the improvement of a condition, and should not tlierefore bo undertaken without a full appreciation of its possibilities for botter or worse nor without complete antiseptic precautions. The removal of the membrana tympani, malleus and incus, as proposed by Kessel, an operation which has been much exploited in this country as a remedy for extreme deafness, vertigo and tinnitus auriuin in cases of non-suppurative disease of the middle ear, not only offers an unnecessary degree of violence to the middle ear but is unscientific in the sense that it leaves untouched that portion of the ossieular chain, the stapes, which has been justly denominated the key to tho labyrinth ; experience also indicates that the improvement in hearing in the eases so operated upon has been due, in the great majority of them, to the mobilization of the stapes incident to tho removal of the two largor ossicles rather than to tho removal of an obstruction presented by these bones themselves, for unless the stapes itself be mobile removal of the membrana tympani and the other ossicula must be in a measure ineffectual. The theoretical objection to interference with the stapes, on the ground that disturbance of iutra-labyrinthine pressure would result in moro or less disturbance of equilibrium, has at various times been met iu the past by practical experience at the bands of different observers in cases of mobilization of the stapes, and of accidental removal of the Stapes in the human subject, and recent experiments on the removal of tho columella in birds show that vertiginous symptoms are not evoked unless the labyrinth is unnecessarily interfered with. At the same time in performing the corresponding operation ou the human subject the question of the possible after-effect, in the more or less protracted vertigo should always bo considered. The operation of stapedectomy, to give it a distinctive name, or of incudo-stapedectomy, in case it is necessary to remove or displace both the incus and stapes is, under favorable circumstances, a very simple one, and easily performed under the necessary conditions of a good illumination, proper anatomical knowledge, and a trained sense of touch. The instruments need be but of the simplest, and such as are found in any ordinary aural clinic, namely, a paracentesis needle, an angular knife for division of the articulation of the incus and stapes, a small hook, preferably blunt, and a small pair of curved forceps, elaborations of these instruments being added according to the demand of individual cases or the choice of individual operators. The simplicity of the operation itself does not imply the permissibility of any lack of precaution as regards antisepsis or extent of the interference with the tympanic cavity, in both of theBe respects every care should be taken and the course of the operation as originally planned and as 1 have so far practised it may be briefly outlined as follows, it being understood that the ear to be operated upon has boon carefully tested as to its hearing power, and carefully examined with reference to the position of the membrana tympani and ossicula bo far as ascertainable and the external auditory canal thoroughly washed and scrubbed with a bichloride solution ou a cotton-tipped probe. The hands of the operator should be thoroughly washed and dipped in bichloride solution before the operation and in addition to the instruments aud a number of cotton-tipped probes, there should be provided a saturated solution of boric acid in alcohol and a two per cent, solution of cocaine sterilized, the former for dipping the instruments before using, and the latter for checking congestion and bleeding. The patient having previously been etherized, preferably in a sitting position, the incision of the membrana tympani ¡a made with a paracentesis needle from a point at the posterior border of the membrana tympani, and carried upward and forward closely following the periphery until the point of insertion of the posterior ligament of the short process of the malleus is reached, and is then carried downward along the border of that ligament and for a short distance down the manubriuin mallei, or if preferred may be made in the reverse direction, the flap so formed falling outward by its own weight and affording a clear view in the great majority of cases of the incudo stapedal articulation ; the advantages of this form of cut, the same which I have previously used in the operation for simple mobilization of tho stapes, in preference to either tho semilunar or the triangular cut, and which is a modification of that used by Miot, are evident on examination in the temporal bone of the relationship which the superior posterior periphery of the tympanic ring bears to the long axis of the fenestra ovalis when viewed from the centre of the auditory niealus, aud alBo on consideration of the fact that it affords a broad field for examination of the stapedal region and may be extended downward posteriorly to include the round The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. 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doi:10.1056/nejm189211171272001 fatcat:pdtnqz4fl5h7hhimhtmpj2iusy