|Year : 2015 | Volume
| Issue : 2 | Page : 340-345
The story of progress of otology
KS Gangadhara Somayaji
Department of ENT, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||16-Dec-2015|
K S Gangadhara Somayaji
Department of ENT, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gangadhara Somayaji K S. The story of progress of otology
. Arch Med Health Sci 2015;3:340-5
| Introduction|| |
History is always fascinating to read. The story of how things were discovered, the way good and bad about them were learnt, and how the past knowledge and skills was used in the invention of newer things is never boring to read. History is not just a narration of events of the past; it is a science by itself, written with an art. Knowledge of the history makes us cleverer and wiser. Every medical field has its own history and otorhinolaryngology is not an exception. This article tries to cover the major sequence of events and the progress made in the field of otology, a subspecialty dealing with the diseases of the ear.
It is only in the early 20 th century that we saw the evolution of otorhinolaryngology prior to which, the specialty was studied as otology and laryngology separately. Early otologists were considered as surgeons and the laryngologists as physicians.  Recent advances in the field has now divided the specialty into subspecialties. However, otology is still the most important part of the ear, nose, and throat (ENT) curriculum in any university. The main reason for otology to remain in the forefront is its fascinating history and the scope for advanced learning. In this article, an attempt has been made to take the reader through the progress made in the field of otology from the time of its evolution to the present era. For easy reading, the historical aspects have been discussed from the earliest time of its development, century-wise, to the present era.
| Earlier Times|| |
The term otology is derived from the Greek word "Óus." Descriptions of the ear are available in the prehistoric age, before 4000 BC.  Ebers Papyrus, one of the most famous medical papyri, described the clinical problems associated with ear and Edwin Smith Papyrus gave the description of the temporal bone injuries.  Ebers and Brugsch papyri described otitis media as "fire in the heart of the ear" and its treatment with honey. , Hippocrates, the father of medicine, at around 400 BC had given the description of tympanic membrane and mastoid air cells. He had also given the description of acute and chronic otitis media as the causes of deafness.  Empedocles (504-443 BC), a Greek philosopher, described the cochlea, which he called "ko΄cloV," referring to a seashell of the Mediterranean region.  Aristotle (384-322 BC) created a theory on hearing, which postulated that the inner ear was a resonating chamber that vibrated in response to sound.  His theory persisted unchallenged till Cotugno demonstrated the inner ear has only fluid in the 18th century.
In the first century AD, Rufus of Ephesus gave the present anatomical names to parts of the external ear. Galen, (130-200 AD) the personal physician of the Roman Emperor Marcus Aurelius, described the auditory nerve. He, however, thought that it originated in the middle ear.  Galen was also known for the medical and surgical treatments of many ear conditions.
| Middle Ages|| |
The results of a dissection by Vesalius of Padua, Italy performed in 1543 contributed to the anatomical knowledge of the middle ear including oval and round windows, malleus, and the incus.  Filippo Ingrassia (1510-1580), a native of Sicily, described the stapes in 1546.  Later, Bartolomeo Eustachi (1520-1574) described the Eustachian tube, semicircular canals, and cochlea [Figure 1] and wrote the earliest book on the anatomy of the ear. He suggested blowing out strongly while holding the mouth and nose closed, forcing air to pass into the tympanum by way of the Eustachian tube as a treatment of deafness.  Gabriele Fallopius (1523-1562) gave a description of the fallopian canal, tympanum, vestibule, and the cochlea  [Figure 2]. Du Verney, personal physician of the French royal family, published a book with impressive drawings of the inner ear anatomical structures [Figure 3]. He showed that the Eustachian tube was not an avenue of breathing but provided the source of air into the middle ear.  He, however, thought that the inner ear was filled with air.  He was at that time called the father of otology.
Later in the 18 th century, Italians dominated the scene. Antonio Mario Valsalva, (1666-1723) dissected more than 1,000 human heads and gave a description of the anatomy of the middle ear.  Giovanni Battista Morgagni (1682-1771) suggested that brain abscess could occur secondary to otitis media. Meckel in 1777 suggested that the labyrinth may contain fluid and not air as suggested by DuVerney.  Later, Domenico Cotugno (1736-1822) of Naples, Campania, Italy described the perilymph and Antonio Scarpa (1747-1832) [Figure 4] of Modena, Province of Modena, Italy and Pavia, Lombardy, Italy gave the description of endolymph. 
The 19 th century witnessed major progress in otology. Anatomical descriptions of the structures continued while the treatment options became broader based on anatomical knowledge. Ashley Cooper in 1801 performed the first myringotomy for earache secondary to middle ear infection. The first specialty hospital for diseases of the eye and ear was established in London, England in 1805 by John Cunningham Saunders.  In Germany, Johannes Müller started pioneering work in experimental auditory physiology. He coined the term "cholesteatoma" for the pathology associated with chronic otitis media. Helmholtz described middle ear physiology in 1868, based Du Verney's work.  He also gave a description of the impedance matching mechanism in the middle ear. The microscopic structures of the inner ear were first described by an Italian microscopist, Alfonso Giacomo Gaspare Corti in 1851. Later in 1892, Retzius gave a description of hair cells and their innervation by auditory nerve fibers. 
Hermann Von Helmholtz (1821-1894, [Figure 5]) started working on the biomechanics of the ear and described the mechanical coupling of sound from the tympanic membrane to the oval window. He also interpreted the analysis of sound in the inner ear. In 1861, Prosper Ménière described the classic triad of the disorder that has his name: Periodic vertigo, hearing loss, and tinnitus. He said that the disease is an inner ear disorder and not a brain-related illness as believed earlier.  Joseph Toynbee, a London-based clinicopathologist, (1815-1866) played a pioneering role in understanding the middle ear diseases. He dissected more than 2,000 temporal bones to correlate microscopic pathology with the patient's symptoms. He invented the otoscope and wrote books on the treatment of ear diseases. In 1857, he published a catalogue of his collection, which was kept in the Museum of the Royal College of Surgeons. However, this was destroyed during the war in 1941.  He discovered that the stapes footplate ankylosis was the main cause of deafness in the cases he studied.
Subsequently, in the latter part of the 19th century, otologists concentrated on surgical treatment for various ear diseases. Politzer described procedures such as politzerization and myringotomy for the treatment of serous otitis media in his atlas of otoscopy in 1865. Kessel, in 1878 performed the first surgery for otosclerosis. He tried to mobilize the stapes and in some cases, removed it. However, the procedure did not gain popularity as a majority of the patients lost their hearing or developed infection. Later, the promontory was trephined and the opening covered with a mucoperiosteal flap. No lasting improvement was obtained, and often the hearing was made worse.  A contemporary was Sir William Wilde, who was an ophthalmologist and an otologist, in the United Kingdom. His name is still associated with the postaural incision - Wilde's incision used for mastoid exploration.  Wilde recommended that the incision be at least 2.5 cm long and be made when "the mastoid process enlarges or even in the presence of a slight floating sensation."  Von Troltsch, Professor of Otology in the University of Wurzberg, has been credited with popularizing ear surgery in Germany; he motivated his student Hermann Schwartz to standardize the procedure and define the standard indications for mastoid exploration. 
As the infections of the ear were among the most common causes for the morbidity and hearing loss during that time, a lot of people started doing different procedures for the same. The first myringoplasty was performed by Emil Berthold in 1878. Jean Louis Petit (1674-1750) is said to have performed mastoidectomy for chronic ear infections much before Schwartze performed simple mastoidectomy in 1873. In 1883, Politzer described the pathophysiology of otosclerosis. Later in 1912, Siebenmann proposed a new term "otospongiosis" for the same. Ernst Kuster and Ernst Von Bergmann, both general surgeons, did a first radical surgery for extensive middle ear disease.  Kuster defined the indications for mastoidectomy and advocated the removal of the posterosuperior wall of the external acoustic meatus. In 1890, Emanuel Zaufal and Ludwig Stacke standardized the radical mastoidectomy procedure. Following these procedures, the patients lost their hearing even though the ears became dry.  In 1893, Sir William MacEwan established the concept of the suprameatal triangle, also called the MacEwan triangle as a landmark for mastoid exploration. Gustave Bondy (1870-1954), an Austrian surgeon, popularized the modified radical mastoidectomy in 1910 wherein both the disease clearance and hearing reconstruction were achieved. 
Toward the end of 19th century, with the reduction in infectious diseases, the focus of research gradually moved toward hearing and deafness. Prior to the 19th century, tests of hearing were mostly affected either through the human voice or various mechanical devices such as a watch, tuning fork, or whistles. There were also other instruments such as Politzer's acumeter, Galton's whistle, which emitted tones > 6000 Hz, and Struycken-Schaefer's monochord - A kind of violin to assess the upper limit of hearing but these were less frequently employed.  John Shore invented the tuning fork; however, it was used for hearing tests by Sir Charles Wheatstone (1802-1875) Later, Ernst Heinrich Weber (1795-1878), Adolf Rinne (1819-1868), and Dagoberg Schwabach (1846-1920), all from Germany described the tuning fork tests that bear their names.  The first audiometers appeared after the key invention of the induction coil and telephone. The audiometer was discovered in 1879 by David Edward Hughes (1831-1900) and Benjamin Ward Richardson (1828-1896). 
| Transition to The Present Era|| |
Sir Alexander Fleming's discovery of the antibacterial effects of penicillin had a big influence on the infective conditions of the ear, which nearly eliminated the need for the radical surgeries. Great technological advances and discovery of technically precise instruments and equipment also contributed to the better outcome of surgical procedures in the early 20 th century. Otology and laryngology merged to form otolaryngology. More importance was given to organ conservation and hearing preservation. The need for accurate hearing assessment with audiometers in sound-treated rooms was also stressed. In 1922, Fletcher and Wegel introduced the audiometric examination for screening patients with hearing loss. In 1934, Schuster measured the middle ear impedance with the tympanometer. Simultaneously, efforts were made to amplify hearing with external devices. Thanks to the invention of the telephone by Graham Bell (1847-1922) in 1876, Ferdinand Alt could build the first amplifying prosthesis in 1900. He called it microtelephone, built from an amplifier and a coal microphone. However, it was not very popular because of its large size. 
Meanwhile, with better anatomical knowledge, surgeons started exploring deeper areas. In 1901, Perry, a Scottish physician, performed a vestibular nerve section for Meniere's disease. Total labyrinthectomy was described for the same by F.H. Quix in 1912.  In 1912, Kisch described a procedure for the closure of tympanic membrane perforation for the first time. In 1914, Bαrαny received the Nobel Prize because of his work on vestibular apparatus physiology and pathology.  Meanwhile, another Nobel laureate, George Von Bekesy (1899-1972, [Figure 6]) observed with a stroboscope that sound generated traveling waves along the cochlea. Using pure-tone stimuli, he found that each point along the cochlear partition vibrates at a frequency equal to that of the stimulus. The resulting pattern of vibration appears as a wave traveling from the base to the apex. 
As a part of advancements in plastic surgery as related to otology, Gillies in 1920 used cartilage in remodeling the framework in cases of pinna reconstruction. Developments in the neuro-otology front witnessed the discovery of pathophysiology of Meniere's disease by Hallpike and Cairns in 1938.  Hallpike later established a neuro-otology clinic and along with Dix, popularized the Dix Hallpike test used to diagnose benign paroxysmal positional vertigo. The biggest advancement that influenced the development of micro ear surgery was the introduction of the monocular operating microscope by Carl Nylen, a Swedish person, in 1921.  In 1932, Balance and Duel introduced the facial nerve decompression technique in the middle ear for facial nerve paralysis. In 1938, Julius Lempert performed one-stage fenestration procedure on the lateral semicircular canal in patients with otosclerosis. In 1940, Boettcher introduced the electrical burr for mastoid surgery. 
In 1953, Zeiss Optical Company in the USA, introduced modern microscopic ear surgery with the development of the binocular microscope. Tympanoplasty, aiming at clearing the disease from the middle ear, with reconstruction of hearing mechanism and repair of tympanic membrane emerged in the early 1950s through the work of Wullstein and Zollner. Rosen reintroduced the technique of stapes mobilization for the treatment of otosclerosis and John Shea Jr. performed the first stapedectomy in 1955. Around the same time, neuro-otology saw great development both in Europe and North America through the works of Ugo Fisch and Bill House.  William House described the first case of cholesteatoma in the middle ear cleft, seen through the intact tympanic membrane. The pioneering work of William House contributed toward the successful removal of cerebellopontine angle tumors with the use of microscopes.  House introduced the middle cranial fossa approach, which made hearing preservation possible in intracanalicular neuromas and Fisch popularized the intratemporal facial nerve decompression. 
With reduction in infectious diseases, deafness and tinnitus happened to be the most annoying symptoms in patients visiting otology clinics. This scenario stimulated research on cochlear implants. The knowledge that cochlear electrical stimulation produced hearing had existed since many years. The Italian scientist, Alessandro Volta, who invented the electrical battery had already performed experiments placing metal plates in his ears and connecting them to electricity in 1800 and reported listening sounds similar to that of boiling water. However, his experience was not pleasant. Two French pioneers, Djurno and Eyries, in 1957 laid the foundation for cochlear implantation. However, it was William House who popularized the implant program and performed the first implantation in 1961. 
Further research in the field of neurophysiology led to the discovery of the electrical potential of cochlea, brainstem, and cerebral cortex. In 1967, Sohmer and Feinmesse recorded the electrical activity of the human brainstem in response to a stimulus. In 1968, Aran and Le Bel in Bordeaux, Aquitaine, France, described electrocochleography. In 1970, Jewet, Romano, and Wilinston described the wave pattern in brainstem-evoked response audiometry.  In 1978, Kemp discovered otoacoustic emissions (sounds produced by the outer hair cells), which opened up the avenue for screening newborn babies for deafness. 
Progress in the field of audiology saw the introduction of hearing aids. The first hearing aid was created in the 17 th century. It was however, based on simple nonelectric technology. The first electric hearing aid was created in 1898. Digital hearing aids were available by 1996.  Disadvantages and lack of social acceptance of the hearing aids led to the discovery of bone anchored devices and middle ear implants.
The introduction of endoscopy into the middle ear opened up the avenue for minimally invasive ear surgery. Mer et al. described the endoscopic picture of middle ear in 1967.  Thomassin et al. developed endoscopic techniques to reduce recurrence rates in cholesteatoma surgery.  Magnan et al. popularized the use of endoscopes in cerebellopontine angle surgery. 
The frontier of skull base surgery started linking up with otology, thanks to the works led by House and Fisch. Diagnostic imaging, especially magnetic resonance imaging (MRI) scanning, has improved our understanding of the functional aspects of the auditory system. Image-guided surgery, neuromonitors, lasers, radiofrequency, and sterotactic surgeries have added to the creativity of contemporary otologists.
This is only a glimpse into the progress of otology over the centuries. Certain details might have been missed and few have been left out due to constraints of space. For further detail on the history of otology, the readers are requested to refer to the excellent works of Stevenson and Guthrie,  Weir,  and Pappas. 
| The Future|| |
The future of research in otology is linked to the research in the field of molecular genetics. The focus has shifted from infectious diseases to deafness. Many deafness-related genes have been identified by genetic engineering technology, and stem cells have been used in the repair and regeneration of hair cells.  Developments in tissue engineering and gene therapy have helped in the prevention of deafness. With the development of advanced equipment such as endoscopes, best quality microscopes, and precise instruments, fiberoptic light source and other gadgets have opened up the avenue for more surgical options and better results.
Developments in the field of immunology have helped in the management of conditions such as serous otitis media and neonatal meningitis through the development of vaccines, thereby reducing the incidence of deafness.  Similarly, a lot of research is being undertaken to improve the rehabilitation of the deaf through advances in cochlear implants, middle ear implants, bone anchored hearing devices, semi-implantable hearing devices, and brainstem implants. 
Otology, in spite of the advances, has remained a medical-surgical specialty. In the future, the advances in immunotherapy, gene therapy, tissue engineering, robotic surgery, and others may lessen the hands-on experience with which we are familiar. However, this will benefit patient care and reduce the hospital stay. The future generation of otologists needs to be flexible and adapt to such changes.
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Conflicts of interest
There are no conflicts of interest, direct or indirect, involved.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]