Otology's past, present, and future

In this article, we examine the foundations of otology and the development of the field and then make some predictions about its future.

Otology's Past

As we step into a new millennium and reflect on new directions for the practice of otology, it behooves us to look back at the past and follow the evolution of this subspecialty since the dawn of recorded medical history.

Health and Religion: Priest Healers

Ear-related problems and their management were recorded in the earliest medical manuscripts. Several medical papyri have been found in tombs and other archaeologic sites in Egypt. Unfortunately, most of these were fragmented. One of the most famous medical papyri, the Ebers Papyrus, which was found complete, deals with 250 clinical problems. It includes sections on the ears, nose, tongue, gums, and teeth.1

The Ancient Egyptians were interested in knowledge of human anatomy as shown in their practices of the art of healing. They even applied this knowledge in their well-developed practice of mummification. For example, they reached through a well-planned small hole that they made in the cribriform plate to evacuate the brain of the deceased from the cranial cavity.2 Similarly, other internal organs were removed and kept in separate jars. It is mind boggling to think how such procedures were done without proper modern illumination or equipment. For the most part, these practices were driven by strong religious and spiritual convictions that governed all aspects of people's lives.

Discussions of the tympanic membrane, the auricles, and even what could be the eustachian tube are found in many papyri and tablets. Many ear ailments were treated with poultices and powders and alcohol-- containing solutions (wine with honey). These included treatment for deafness, ear discharge, pressure in the ears, and earache (Ebers and Brugsch papyri). Descriptions of cases of otitis media as a "fire in the heart of the ear" are found in the Brugsch Papyrus.3,4

There are even descriptions of what seems to be the earliest forms of ear or mastoid surgery. In the Ebers Papyrus, one reads

What is done to treat effluency which is sent out from an ear if it exudes from its interior like ka [dirt] of efflucency, because it flows over with humour like paste-water, then thou shalt go round it with a khept [knife] to the limits of all that decays in it thou shalt prepare for it, oil, honey, seed-wool are placed within it and applied as a fillet of linen and is bandaged there with until it is healed.3

The Edwin Smith Papyrus (which is thought to have been written by Imhotep, who built the first step pyramid for King Zoser, c. 2800 BC) describes several cases of ear injury and differentiates between those that are treatable and the deadly ones involving deeper structures. It even includes the first description of closing an ear wound with stitching and special dressing. Another case in the same papyrus describes hyperacusis associated with some ear or temporal bone injury.5

This period is striking for its view of unity of soul and body. The priests were the healers and had the secrets of the art. Certainly, medical practice at that time was relatively quite primitive and at times mixed with superstition and even magic. The clever priests, however, showed a great deal of attention to detail in describing disease symptoms. They developed an array of fine surgical instruments including knives and tweezers that are now on display in museums around the world. It is not surprising that the ear, being such an important organ of communication, should occupy an important place in that art, which, as primitive as it may seem, had certainly developed to a great extent. Otology was being born when human civilization was in its cradle.

It is quite conceivable that similar developments occurred in other places in the ancient world such as Assyria, Babylon, Persia, India, and China. We may just not have been as fortunate as to find records of their advances in this area from such early times as we were to find the medical papyri.

From Soul to Mind: The Foundation of Medicine

To the contrary of the preceding epoch, Greek physicians did not necessarily come from the ranks of the religious clergy. Medicine was married to philosophy rather than religion, and scientific thinking was emerging. The great pioneers of ancient Greece thus laid the foundation for modern medicine. Some of the aphorisms of Hippocrates describe and deal with issues like deafness and vertigo. It is believed that he was the first to describe the tympanic membrane.6 Galen is thought to have been the first to treat chronic ear disease by removing diseased tissue through a postauricular incision. This, however, is disputable, especially in light of some descriptions in the Ebers Papyrus.3 He applied medications to the external auditory canal to treat otitis. He removed foreign bodies from the ear using probes, forceps, syringes, and hooks. He discouraged occluding the external auditory canal in the treatment of otorrhea.6

The scope of this article will not allow us to go into details about the development of otology. The Middle Ages saw the transmission of Greek medicine to the West. During this period, the Arabs also emerged as a leading civilization. Rhazes (860-932 AD), a prominent Arabic physician, used alum in wine to treat draining ears.7

Up until the sixteenth century, the progress of medicine in general had been a relatively slow process marked with brief leaps made by a few dedicated, hard-working pioneers. There was also a great deal of witchcraft and quackery, generally due to widespread ignorance, that prevailed up to and throughout the Middle Ages.

Modern Art and Science

The Renaissance brought great anatomists like Vesalius of Padua, who was the first to describe malleus and incus; Eustachius (c. 1510-1574), who studied the auditory tube, which now carries his name, and who was the first to describe its bony and cartilaginous portions; and Falloppio, who described the facial canal.

The seventeenth and eighteenth centuries witnessed the development of great scientific progress. During this time, specialization evolved, and the first textbooks dedicated to the ear appeared. Valsalva, who wrote one of these texts in which he described the cochlear scalae, emerged as one of the most brilliant physicians of this era. He was also the first to describe ankylosis of the stapes footplate.8 Carlos Mondini described cochlear dysplasia, and Antonio Scarpa described the membranous labyrinth. Santorini described the auricular muscles and the incissura. It is worth mentioning that the Ancient Egyptians placed great emphasis on the incissura and showed it in many of their papyri and mural carvings.9

The birth of modern otology as a specialty occurred in France in the nineteenth century, fueled by the advancement in anatomic knowledge along with the discovery of eustachian tube catheterization. Again, the greatest advances in this early era were in the area of the anatomy and physiology of the ear. These included the description of the microstructure of the cochlea, the organ of Corti, and the otoconia.10

Nevertheless, sound knowledge of ear pathology was lacking at that time, and many "quacks" treated ear-related ailments aggressively, without formal medical training and did more harm than good.6 Joseph Toynbee vowed to rescue otologic surgery4 and dissected 2000 temporal bones. He was thus able to correlate ear pathology such as ankylosis of the stapes with clinical presentation of ear disease.11 During that time, Adam Politzer in Vienna emerged as one of the most prominent otologists. He was the first to describe otosclerosis as a separate pathologic entity. The late ninteenth century also saw famous otologists whose names are well known to all otolaryngologists today, such as Fredrick von Troltsch, Herman Schwartze, Moritz Trautmann, and Frederic von Bezold.

On the neuro-otology front, Prosper Meniere in the mid-nineteenth century was the first to attribute episodic balance disturbances to disordered labyrinthine function rather than cerebral congestion.12 The pathology of the disease was not understood until Hallpike and Cairns, in 1938, described the pathologic changes of endolymphatic hydrops in temporal bone sections of two Meniere's disease patients who had died of cerebellar hemorrhage following eighth nerve section that was performed by Hugh Cairns.13 In the same year, Kyoshino Yamakawa reported on the pathologic changes in a Meniere's patient.14

Hallpike later perfected the bithermal caloric test introduced by Ba ranay and established an internationally renowned neuro-otologic clinic. With Margaret Dix, he later published their famous positioning test for the diagnosis of benign paroxysmal positional vertigo.15

Modern Technology: The Big Leap

The discovery of antibiotics had the greatest influence on medical practice in the early twentieth century. This also coincided with great technological advances that followed the industrial revolution of the late nineteenth century. It was only then that the major shift occurred in many areas including otology, from ablative crude surgery to relatively more refined reconstructive surgery. It is this change that has continued to evolve ever since, and we have seen organ preservation and reconstruction prevail as a major physiology in modern surgical practices. By far the biggest advancement that influenced the development of modern otologic surgery was the introduction of the monocular operating microscope by Carl Nylen in the early 1920s. Microsurgery of the ear, however, did not become possible until Zeiss Optical produced the binocular microscope in 1953.

The Irony of War

Like many aspects of our modern civilization, the greatest advances in otology in the twentieth century were brought about by World War II.The combination of rapid technological development and the competition between the two sides was behind many major accomplishments in science and medicine. Tympanoplasty emerged in the early 1950s through the work of Wullstein16 and Zolner,17 as well as other German otologists. Similarly, John Shea Jr. performed the first stapedectomy in 1955 and presented his work a year later in Montreal.18 He eliminated the need for the much more extensive fenestration procedure developed by the great Julius Lempert less than two decades earlier. Around the same time, neuro-otology saw similar development both in Europe and in North America. Both Ugo Fisch in Switzerland and Bill House in the United States have contributed greatly with their innovative techniques to the progress of neuro-otologic surgery. Among their many accomplishments, House introduced the middle cranial fossa approach, which made hearing preservation possible in intracanalicular neuromas,19 and Fisch developed and popularized intratemporal facial nerve decompression.20 It is certainly worth mentioning that as minor as it may seem, the development of the pressure-equalizing tube by Armstrong21 is probably the most useful achievement in modern otology considering its impact on the health and well-being of a great number of children around the world.

This is only a glimpse into the development of otology over the centuries, and it is by no means complete. Our hope was to shed some light on the dedication and great achievements of the people who devoted their lives for the progress of knowledge in this great specialty and the service of humanity. For further detail on the history of otology, the reader is referred to the excellent works by Stevenson and Guthrie,6 Weir,4 Pahor,22 and Pappas.23

The Present: An Unprecedented Pace of Progress

The twentieth century has seen the fastest pace of development in human history, and it continues to get faster and faster. Electronic and computer technology has changed our lives in ways nobody could ever imagine. What seems to be far-fetched today may soon be outdated and obsolete. The stunning evolution of information technologies has certainly surpassed our wildest imagination and made remote access a reality. We are only seeing now the tip of the iceberg, and it seems that the chain reaction of progress that was set off is moving with a breathtaking speed that will be impossible to control. Similar to e-commerce and Internet shopping, remote access of medical information has also become a reality. Similarly, remote surgery is now developing in many fields, and very soon precision otologic procedures will be performed by remote access with the use of advanced miniature robotics based on newer versions of Aesop, Hermes, and Zeus, which are already in use.24 This technology can also be voice operated, making it all the more user friendly. In the same manner, surgical training will very soon be exclusively done by virtual computer-based models, which will be able to simulate the operating room experience with a great deal of perfection.

In the field of neuro-otology, gene linkage studies helped identify the gap junction protein, connexin-26, thought to be responsible for a fairly common form of Mediterranean nonsyndromic deafness.25,26 This will hopefully help in the early identification of this problem. Whether gene therapy in early childhood will be the answer for this entity remains to be seen. Stereotactic nerve cell transplantation will evolve to be the treatment of choice for the majority of patients with neural hearing loss and tinnitus. The potential role of neurotrophins such as NT3 and neuronal cytokine transforming growth factor NTG3 in preventing neuron loss is presently under investigation.27 It has several applications, including the prevention of cochlear damage and in cochlear implantation. The technology of cochlear implants has progressed significantly in the last decade. Very soon, the new generation will be available with implantable microphones. These will also include sensitive sensors able to respond to tympanic membrane and ossicular chain movement.27

Very soon, otology will be the parent of many subspecialties including molecular neuro-otology, transplantation neuro-otology, and conductive stereotactic reconstructive surgery. But as we advance and subspecialize, is it going to be possible for us to continue to see patients as whole beings and be able to listen and communicate effectively with them? Or is the trend now gearing otologists to be technology-based super-- specialists who are only able to hone into a very restricted area of human health and well-being?

Otology's Future

Prediction is very hard, especially when it's about the future.

-Yogi Berra

Yogi Berra is correct. Although we may think that we know otology, the events in the greater world at large (yes, there is one) will have a profound impact on otology. Will there be nuclear destruction or economic upheaval? Will antibiotic resistance increase so that bacteria kill us all? Will there be famines? Will the Blue Bombers ever win the Grey Cup? No one knows these answers, but we can guess. We assume that future political and economic situations will generally remain similar to today's. If not, all bets are off.

It has been said that the future is not predictable. This is not true. Not only can the future be predicted, it can be controlled-partly. The future results from today. What we do today determines our future. If the specialty of otolaryngology does no research, other specialists will manage otolaryngologic problems. Infectious disease physicians will treat otitis media and other infections. Oncologists or general surgeons will treat head and neck cancer. All doctors will evaluate and treat dizziness with methods that are anecdotal and unscientific.

Otology has undergone many revolutions in the past 100 years, and there is no reason to think that the same will not happen in the next century. In this article, we consider otology topics to imagine what an otologist might have been thinking about in 1900, and then imagine what will be on the horizon in 2100. If we find our tongue in our cheek at times, well, what is the harm?

It is likely that the rate of medical progress will slow, but hype will conceal that. The reasons for this slowing of pace are as follows:

1. Financial-the costs of doing research are increasing.

2. Restrictions-there are increasing rules and committees restricting research, demanding money for their "work." This punishes investigators.

3. Supply-the fraction of physicians and researchers interested in otology is dropping.

4. Practical-it will be increasingly difficult to attain expert knowledge in any field.

Next let us consider the past and future of some current otologic problems.

Otitis Media

At the last turn of the century, ear infections were an important cause of death. Physicians could do little but watch as intracranial abscesses and meningitis developed. Surgery and anaesthesia were crude. Antibiotics were not available. Pollutants such as horse dung littered the streets in large cities. We have progressed. Today, our pollution is elevated to the atmosphere, so the respiratory tract bears the burden.

The most significant advance in otology in the last 100 years was the introduction of antibiotics. Prior to that, the specialty of otolaryngology was basically ear infections. When antibiotics became available, some thought that otolaryngology as a specialty would cease to exist.

In the future, antibiotic resistance will increase, and the number of new antibiotics that drug companies can come up with will be exhausted. This will not matter much because alternative therapies for infections will be developed. Pathogens will be replaced environmentally by genetically engineered bacteria that overgrow them or viruses that destroy them. These replacement organisms will be designed so that some simple compound will eradicate them if the need arises. For treatment, electrical stimulation techniques that open some ion channels in bacteria and viruses will be available. Admission to hospital to treat infection will not be needed.

Middle ear disease will encompass treatments for local immunity, ciliary function, and mucus quality in addition to the pressure-equalizing function of the eustachian tube. Otologists will chuckle at the current notion that failure of eustachian tube pressure equalization causes all ear infections. Our lives depend on quality mucus, and its understanding will increase so that otologists will evolve away from being surgeons. In fact, surgery as we know it will not be needed. For those rare diseases that are not treated by drugs or other means, physical removal will be accomplished by intelligent robots and smart catheters, often under video feedback, so that full general anaesthesia will rarely be needed.

Dizziness

In the previous century, evaluation and treatment of dizziness were anecdotal and unscientific. The main reason for this is that dizziness is a symptom that can occur with almost any pathologic process. The need for science in dizziness was realized, but most of the scientific, quantitative methods did not turn out to be clinically meaningful. The observation that nystagmus had something to do with dizziness and the caloric response resulted in the electronystagmogram. Wonderfully complex mathematical models of rotary testing and the relationship between eye movements and movement were proposed but met with limited clinical acceptance. Interest in vestibular dysfunction is waning, so it is likely that vestibular practice will not improve much.

Devices

Of all otologic devices, the cochlear implant must be considered the most interesting advance, but progress will be limited. There are two reasons for this pessimistic statement. First, the technology may be reaching its limit in stimulating nearly dead neurons. Second, the use of neurotrophins and other techniques that will cause the growth of hair cells will replace the cochlear implant. Hearing aids have become quite sophisticated, and there is no reason to think that they will not continue to improve.

Tinnitus

Tinnitus has been troublesome for clinicians. As life expectancy has increased, the proportion of patients with bothersome tinnitus has increased over the last 100 years. Although many treatments have been proposed, none are widely successful. We do not understand the pathophysiology or treatment of tinnitus. This should change in the next 100 years, with treatments that are highly selective for particular neurons.

Sensorineural Hearing Loss

Presbyacusis and sensorineural hearing loss have become more common than conductive hearing losses. The introduction of antibiotics in the 1930s and development of tympanostomy tubes in the 1950s have almost eliminated the long-term complications of otitis media.

There will likely be more progress in treating disorders that relate to mitochondrial deoxyribonucleic acid (DNA) because, unlike the major genome, these "little genomes" can be ablated. Presbyacusis and congenital hearing loss may be treatable. Patients with the latter may not agree to treatment as our experience with congenitally deaf persons and cochlear implants has shown.

New Techniques

Of course, new techniques such as application of electromagnetic energy in special ways should help many disorders in the next 100 years.

How about the genome? There is currently great excitement about cracking the code of life. Some investigators believe that they have decoded the human genome, so the cure for genetically based diseases is imminent. They are naive and must be watched. To be sure, the understanding of the genetic basis for disease will increase, but the application will fall short of current expectations.

There are two reasons for this pessimistic view about the genome findings. The first is the experience of other great discoveries that start off with a flourish of excitement and optimism and then fall when reality bites back. The second reason that the genome will disappoint some is that its complexity is underestimated. Gregor Mendel published his sweet pea findings in 1865. It has taken 135 years for us to come to where we are now. Will we be able to learn enough to routinely apply gene therapy in the next 100 years? Not likely. According to an article in Scientific American, about 1100 scientists have worked for more than 10 years to sequence the 3 billion DNA base pairs that represent about 100,000 genes in the human genome.1 Now, we have an idea what we have. We do not know how to control it or what unexpected effects these gene manipulations have. One hundred years is not enough time.

At the turn of the previous century, the treatment of ear diseases was radically different from what became available in the last century. Although the future of otology is bright, otologists will be using radically different treatments than we know today. For clinicians, the message is to keep current and understand the background material.

References

References

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