Otolaryngol Clin N Am

40 (2007) 415–437

Anesthesia, Antisepsis, Microscope:

The Confluence of Neurotology
Lawrence R. Lustig, MD
Division of Otology, Neurotology, and Skull Base Surgery,
Department of Otolaryngology - Head and Neck Surgery, University of California,
400 Parnassus Avenue, Suite ACC-746, San Francisco, CA 94143-0342, USA

The nineteenth century

Adam Politzer: the father of otology
The origins of otology are instrumental in understanding contemporary
neurotology, and no discussion of otology can ensue without appreciating
the contributions of Politzer. If one can rightly be called the ‘‘father’’ of
otology, he must be Adam Politzer (1835–1920). Without diminishing the
work of other great men during that time, such as Schwartze, Gruber,
and von Tröltsch, Politzer was the most charismatic leader of this newly
emerging specialty. Politzer’s missiondto establish a correlation between
the findings of his dissections and true clinical findingsdhad been realized
in part by Toynbee in London, Wilde in Dublin, and von Tröltsch in Wurz-
burg. None of these ear specialists had access to the tremendous wealth of
pathology offered by the Vienna General Hospital, however, which cared
for 3000 to 4000 patients at any given time [1]. In this setting, Politzer [2]
completely characterized a whole series of diseases previously grouped
under the vague heading ‘‘dry middle ear catarrh.’’ He was the first to define
panotitis, leukemia of the ear, and labyrinthine suppuration and established
that a cholesteatoma was related to an ingrowth of squamous epithelium.
His textbook, Lehrbuch der Ohrenheilkunde (Textbook of the Diseases of
the Ear and Adjacent Organs), originally published in 1878, was in its fifth
edition by 1908, had been translated into multiple languages, and was used
the world over as the standard of otologic practice. Politzer, along with his
colleague Joseph Gruber, had made Vienna the premier destination for
otologic training in the world at that time and had established otology as
a respectable specialty in its own right.

E-mail address: llustig@ohns.ucsf.edu

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
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416 LUSTIG

Resurrection of the mastoidectomy

The ‘‘mastoidectomy’’ was abandoned in the late 1700s and continued to
be shunned by the medical community until at least 1870 because of disas-
trous early attempts [3]. Herman Schwartze (1837–1900) (Fig. 1), in the late
1800s, is most credited with resurrecting the modern mastoid operation as
we know it today. Schwartze was born in 1837 in Neuhof, Germany, and
later studied in Berlin and Wurzburg, Germany. He was assistant at the
Anatomopathological Institute in Wurzburg anddlike many otologists of
his generationdwas a pupil of von Tröltsch. In 1859, he obtained his med-
ical degree and subsequently took a post as professor in Halle, Germany,
where he directed the Otological clinic at Halle University until his retire-
ment. Schwartze also was involved with helping to start the first journal ded-
icated solely to the ear, Archiv fur Ohrenheilkunde, in 1863 along with von
Tröltsch and Politzer. Schwartze eventually succumbed to a nervous condi-
tion of restlessness, vertigo, and delusions, dying of heart failure at the age
of 73.
It was Schwartze’s mentor, von Tröltsch, who was responsible for urging
Schwartze to fully develop a method of treatment for suppurative processes
of the temporal bone. In 1863, Schwartze and Eysell [4] published his ‘‘ep-
och-making’’ work on the indications for the mastoid operation and his suc-
cess with the use of specifically designed chisels and gouges (Fig. 2).
According to Whiting [5], an American otologist, in 1911, through this

Fig. 1. Schwartze, the creator of the modern mastoid operation the tympanic membrane found
in patients with otosclerosis.
 THE CONFLUENCE OF NEUROTOLOGY 417

Fig. 2. The Schwartze and Eysell mastoidectomy. (From Ballance C. Essays on the surgery of
the temporal bone. London: Macmillan, 1919; with permission.)

publication Schwartze had ‘‘.clearly enunciated the technical and symp-

tomatic principles upon which are based the steps of the modern mastoid
operation as performed to-day (sic), and however much we may modify
our practice the innovations result in a little more or a little less than
Schwartze’s operation.’’. Later, in 1889, Stacke, and subsequently, Zaufal
in 1890, described the radical mastoid operation [6].

Sir William Macewen: the first skull base surgeon

If one man can be named the first true skull base surgeon, then surely he
must be Sir William Macewen (Fig. 3). Once called the founder of neurosur-
gery by Cushing and Eisenhardt, and ‘‘the unfair surgeon’’ by others for his
exhaustive work ethic, leaving little behind for ‘‘.aftercomers to improve
or amend’’ [7,8], Macewen left behind a legacy that is still felt today. Mace-
wen was born in 1848 on the Scottish Island of Bute, the youngest of 12 chil-
dren. As the son of a master mariner, the young Macewen learned to use
tools and his hands at an early age. He joined the Glasgow Medical Faculty
in 1865 and began his surgical work at the same time that Joseph Lister per-
formed his epoch-making antiseptic research. Lister was Macewen’s premier
influence as a young faculty member and was instrumental in Macewen’s
pioneering work in surgical antisepsis.
In his now classic, Pyogenic Infective Diseases of the Brain and Spinal
Cord, Macewen [9] outlined his technique of treating otogenic intracranial
418 LUSTIG

Fig. 3. Sir William Macewen (1848–1924). He pioneered aseptic surgery of the brain and temporal
bone.

complications. His results were so extraordinary for the eradthey were un-
equaled until the era of computed tomographydand have been deemed
‘‘.nothing short of extraordinary’’ [10] and ‘‘.one of the most remark-
able books ever written on a neurosurgical subject’’ [11]. Certainly, one
can claim that it also is one of the most remarkable books ever written
on a neurotologic subject. In the monumental work, he described 94 cases
of intracranial infections and reported such extraordinary results as suc-
cessful evacuation of a brain abscess in 21 out of 22 cases (Fig. 4). As later
pointed out by Jefferson [12], Macewen may deserve the honor of having
written the first clear description of mastoiditis. Macewen reported on 54
mastoidectomies for infections confined to the middle ear and mastoid
and a separate listing of mastoidectomies in which there was extension
into the cranium. As a surgeon who was ‘‘.as familiar and at home oper-
ating on the head and brain, as a clinician educated by past experience to
recognize the signs of brain disease, and as an anatomist who had made
a special study of the ear, he was triply armed immediately to follow the
clues given him by the state of the patient or local extensions of the dis-
ease’’ [12]. For these reasons, Macewen must be considered the first true
skull base surgeon, equally versed in operations of the ear and brain and
the pathologic processes affecting both. It is, perhaps, because of Mace-
wen’s residence in Glasgow, some distance from the epicenter of British
medicine in London, that he felt that his accomplishments were unrecog-
nized during his lifetime [13].
 THE CONFLUENCE OF NEUROTOLOGY 419

Fig. 4. Illustrations from Macewen’s classic medical masterpiece, Pyogenic Infective Diseases of
the Brain and Spinal Cord. The illustration demonstrates two children with acute subperiosteal
squamo-mastoid abscesses.

In his later years, Macewen became an elder statesman of surgery. He

was president of the British Medical Association, president of the Interna-
tional Society of Surgeons, and was the surgeon to HM the King in Scot-
land. He was invited to become the chair of Surgery at the newly
established Johns Hopkins Medical School in 1889, but an agreement was
not reached and Halstead ultimately was appointed instead. Macewen
died after a severe case of pneumonia in 1924 at the age of 76 [8,14,15].

Victor Horsley and the birth of neurosurgery

It was not just otology that had defined itself as a unique subspecialty in
the latter half of the nineteenth century. Neurosurgery, the second pillar of
neurotology and skull base surgery, also saw its nascent beginnings during
this time. The National Hospital for Nervous and Mental Diseases, located
on Queen’s Square in London, is considered by most to be the birthplace of
neurological surgery. Although Macewen was clearly one of the stars of this
emerging field, his practice in distant Glasgow limited his influence among
his contemporaries. The National Hospital hosted such luminaries as
Charles-Édouard Brown-Séquard, John Hughlings Jackson, and Sir Wil-
liam Gowers, making it the center for neurologic studies in the world at
that time; however, the most famous surgeon to grace the hospital staff
also was credited with the founding of modern neurologic surgery: Sir Vic-
tor Horsley (1857–1916). A contemporary of Macewen’s, and also credited
with some of neurosurgery’s earliest successes, it was Horsley’s ‘‘.indefat-
igable physiological experimentation in addition to his clinical and patho-
logical experiments’’ that has led to his inclusion in neurosurgery’s
pantheon [10]. Horsley also was the first surgeon to devote most of his ef-
forts to neurosurgery. His contributions to neurosurgery included the first
420 LUSTIG

laminectomy for a spinal neoplasm, the first carotid ligation for aneurysm, the
first transcranial approach to the pituitary, pioneering intracranial trigeminal
nerve sectioning for neuralgia, and the use of bone wax to stem bleeding from
bone, to name but a few of his many accomplishments [16]. According to
Cushing [17], after Horsley was appointed surgeon to the ‘‘.National Hospi-
tal for the Paralyzed and Epileptic, Queen Square, the birth of modern neuro-
logic surgery may properly be assumed to have taken place.’’
Victor Horsley was present at what is widely considered the first modern
brain tumor surgery. In 1884, Godlee, at the Hospital for Epilepsy and Pa-
ralysis in London, operated on a tumor that had been diagnosed and local-
ized to the right motor cortex by the neurologist Bennett [13,18]. Although
brain tumors had been removed previously, Bennett’s localization of the tu-
mor and Godlee’s first use of the antiseptic technique during tumor surgery
made the case extraordinary. Using Bennett’s knowledge of neuroanatomy
and pathophysiology, Godlee was able to plan his craniotomy directly over
the tumor and easily removed the tumor, which turned out to be a glioma.
The patient survived the immediate operation, but succumbed to purulent
cerebritis a month later. The case is noteworthy for overcoming the third
most challenging obstacledfollowing anesthesia and asepsisdthat faced
the development of neurosurgery: tumor localization. With this obstacle
overcome, using the help of neurologists, such as Bennett, neurosurgical
advances accelerated. Godlee’s case also is noteworthy from the standpoint
of who attended the operation: the neurologist Hughlings Jackson and the
neurosurgeons Victor Horsley and David Ferrier; Joseph Lister (Godlee’s
uncle) was reported to be there as well [13].

Sir Charles Ballance: pioneering skull base surgeon

Along with Victor Horsley, Sir Charles Ballance (Fig. 5) was another of
the pioneering British neurologic surgeons. Neurotology and skull base sur-
gery also can claim Ballance as one of its instrumental founders, based upon
his landmark surgical advances within the temporal bone. Born in 1856 in
Middlesex, England, Ballance entered medical school in 1875 at St. Thomas’
Hospital in London. As one of the stars of his medical school class, Ballance
was taught by such eminent figures as Joseph Lister. Following his gradua-
tion, he traveled to Germany where he was taught by the leaders in medicine
at that time, including Virchow, von Bergmann, Schwartze, and Trendelen-
burg. Ultimately, and perhaps reluctantly, specializing in ear surgery, Bal-
lance returned to England where he was appointed Aural Surgeon at
St. Thomas’ Hospital in London. In 1891 he was appointed as Surgeon to
the National Hospital for the Paralyzed and Insane, Queen’s Square, where
he became a colleague of Horsley. Ballance ultimately ended up as Surgeon-
in-Charge of the Ear Department of St. Thomas’ Hospital [19,20].
Ballance’s accomplishments within the field of neurosurgery would be-
come legendary. He helped to advance the science of cerebral localization
 THE CONFLUENCE OF NEUROTOLOGY 421

Fig. 5. Sir Charles Ballance, a pioneering neurotologist and skull base surgeon. (From
Shambaugh GE, Glasscock ME. Surgery of the ear, 3rd edition. Philadelphia: W.B. Saunders,
1980; with permission.)

along with the neurologists David Ferrier, Charles Beevor, and Charles
Sherrington. He assisted Horsley in the first successful removal of an extra-
medullary spinal cord tumor; it is said that Ballance’s direction within the
operation probably led to its success [19]. In addition to these impressive ad-
vances are numerous groundbreaking contributions to neurotology and
skull base surgery. Ballance [21] was one of the first to popularize the radical
mastoidectomy for advanced middle ear infections and was one of the first
in England to advocate transmastoid drainage and ligation of the jugular
vein for an infected, thrombosed lateral sinus (Fig. 6). He improved the mas-
toidectomy by advocating lining the cavity with an epithelial graft, lowering
the prevalence of postoperative infection [22]. Although successful drainage
of cerebellar otogenic abscesses were reported first by Schwartze in 1887 and
later by Macewen in 1890, it was Ballance who first drained such an abscess
by cerebellar localization, rather than following the infection from the mas-
toid [23]. Ballance also devised a new method of gaining access to the cav-
ernus sinus in cases of otic infection spread [19]. Based upon these numerous
accomplishments, Ballance rapidly ascended to become the premier surgeon
in London for infectious diseases of the temporal bone.
As if these accomplishments were not enough, Ballance is credited with
the first successful complete removal of an acoustic neuroma, performed
422 LUSTIG

Fig. 6. Illustrations from Ballance’s masterpiece, Essays on Surgery of the Temporal Bone.
Shown are the intracranial pathways of spread of mastoid infection (A) and Ballance’s surgical
treatment of infectious sigmoid sinus thrombosis (B). (From Ballance C. Essays on the surgery
of the temporal bone. London: Macmillan, 1919; with permission.)

in 1894 [24,25]. Ballance [26] also attempted division of the auditory nerve
by way of a suboccipital approach for painful tinnitus. The operation also
was noted for its use of electrical and mechanical stimulation of the exposed
cranial nerves for clear auditory nerve identification. Although the opera-
tion was described as a success because ‘‘.the painful tinnitus had ceased,’’
the patient expired 1 year later. Additionally, Ballance performed landmark
studies on the facial nerve, Bell’s palsy, and facial nerve grafting.
It is clear that Ballance was one of the greatest neurotologic and skull
base surgeons in the history of the field. One of his landmark treatises,
Essays on the Surgery of the Temporal Bone, written in 1919 [27], continues
to have relevance, based upon his treatment paradigms, approach to tem-
poral bone disease, and historical review of otology and temporal bone
surgery.

Twentieth century
A tumor that helped defined a specialty: acoustic neuroma
It comes as no surprise that one of the most common tumors of the brain
has played a pivotal role in the development of neurotology and skull base
surgery. It also is not surprising that the surgeons who pioneered acoustic
neuroma surgery throughout the twentieth century are considered the
most influential surgeons of their era.
Although the first postmortem description of an acoustic neuroma was
made in 1777 by Sandifort of Leyden University [28,29], it was not until
nearly 200 years later that the first attempt was made at its removal. Encour-
aged by the success of Godlee’s operation using neurologic tumor
 THE CONFLUENCE OF NEUROTOLOGY 423

localization and aseptic technique in 1884 [18], several attempts were made
in the late 1800s to remove brain tumors that, following their removal, were
diagnosed as acoustic neuromas. The first reported unsuccessful case (the
patient died) of an acoustic tumor removal was by McBurney in 1891
[30]. Clearly, the influence of the London school of neurosurgery, led by
Horsley, had permeated New York by this time where McBurney was work-
ing, because in the report he described his use of tumor localization and its
influence upon diagnosis and surgery. The first successful suboccipital resec-
tions of an acoustic neuroma were reported by Balance [31], and shortly
after by Annandale [19].
Despite these early attempts and limited successes, mortality was high for
tumor surgery; dissection was by finger, and hemostasis was achieved by
packing. As reviewed by Jackler [32] at an international conference of neuro-
surgeons, the mortality for these operations was 78%, and most survivors
had serious disability; however, these statistics were changed radically by
the most influential neurosurgeon of the twentieth century, Harvey Cushing.

Harvey Cushing: the founder of modern neurosurgery

There is perhaps no one in the annals of neurologic surgery about whom
more has been written than Cushing, a man whose name is synonymous
with the field.
Born the youngest of 10 children in a long line of physicians, Cushing
followed his father, grandfather, great-grandfather, and great-great-
grandfather’s path into medicine. After an undergraduate education at Yale
University, he studied medicine at Harvard Medical School. Subsequently,
he went to Johns Hopkins University to train under the pioneering surgeon
Halsted, where he was exposed to the other medical icon of that era William
Osler. From Johns Hopkins and later at Harvard, Cushing literally revolu-
tionized the field of neurosurgery. He introduced the concept of meticulously
documented anesthesia records and the use of continuous intraoperative
blood pressure monitoring. He was perhaps the first surgeon to make regu-
lar use of the new technology of x-rays, including making the emulsions and
developing the films himself. He described the ‘‘Cushing response,’’ the
physiologic changes induced by an increase in intracranial pressure. He
performed pioneering work in balanced salt solutions that led to modern in-
travenous therapy. He pioneered transsphenoidal pituitary surgery. He
revolutionized surgical training by introducing canine surgery for medical
students. He radically improved intracranial hemostasis with the develop-
ment of surgical clips and electrocautery, and with it, drastically improved
surgical morbidity during neurosurgical procedures [13,33,34].
In addition to these ‘‘technical’’ advances, Cushing radically changed the
practice of surgery. Cushing insisted that surgeons take responsibility for
their own diagnoses and decisions to operate, rather than rely upon medical
physicians or neurologists [33]. It was Cushing who made fashionable
424 LUSTIG

meticulous, anatomically based surgical technique, rather than reliance

upon speed. Of course, this was made possible by his improved technical ad-
vances, such as hemostasis and insistence upon superior anesthesia. So per-
vasive was his instruction, that to this day, nearly all American-trained
neurologic surgeons can trace their legacy back to Cushing.
Cushing’s advances within the field of skull base surgery are equally mon-
umental, particularly with regard to the treatment of acoustic neuromas.
After realizing that the tumors could not be removed completely by current
standards, he advised intracapsular removal of the tumor and subtotal re-
section (Fig. 7) [35]. Combined with his other technical advances, this ap-
proach enabled Cushing [36] to reduce surgical mortality from near 90%
to 20%, as noted in his classic monograph, Tumors of the Nervus Acusticus
and the Syndrome of the Cerebello-Pontine Angle, published in 1917.
By the time 1920 rolled around, Cushing had redefined the specialty of
neurologic surgery, with its emphasis upon a strong foundation of neuro-
logic training. According to Greenblatt and Smith [34], ‘‘.with further

Fig. 7. Cushing’s technique of vestibular schwannoma tumor removal, leaving the tumor capsule
intact. (From Cushing H. Tumors of the nervus acusticus and the syndrome of the Cerebello-
Pontine angle. Philadelphia: W.B. Saunders, 1917.)
 THE CONFLUENCE OF NEUROTOLOGY 425

demonstration of his successes in training, in therapeutic results, and in re-

search productivity, the Cushing model became the world model.’’

Nyle´n, Holmgren, and the birth of the operating microscope

While Cushing was laying the foundations for modern neurologic surgery
in America, two unassuming Swedish surgeons were developing a technology
that ultimately revolutionized the fields of otology, neurotology, skull base
surgery, and neurosurgery.
The operating microscope evolved out of the optics of the microscope
originally pioneered by Robert Hooke and Antony van Leeuwenhoek in
the mid-1600s. Yet, it was the inherent constraints of ear surgery that
led to the development of a microscope uniquely suited to the operating
room. Otology and neurotology were uniquely poised for this transition
because of the difficulties imposed by the microscopic anatomy of the inner
ear, limiting what ear surgeons could do by unmagnified eyesight alone.
Further, with the development of improved anesthesia at the beginning
of the twentieth century, the need for more precise surgical technique
within otology, as championed by Cushing in neurosurgery, became
paramount.
Carl-Olaf Nylén was an assistant in the University Otolaryngology Clinic
in Stockholm under the chief Holmgren in the early 1920s. Prompted by
Maier and Lion’s [37] report of endolymph movements in the living pigeon
using a low-power microscope, Nylén began work on a higher-power micro-
scope that could be used during ear surgery. Such a device would have
direct relevance to Nylén’s primary clinical interest of study: labyrinthine
fistulas [38].
Nylén’s [39] first monocular microscope was developed by the Brinnell-
Leitz factory. Nylén later recalled his initial use of the microscope, ‘‘The
idea of using a larger magnification than had previously been employed, oc-
curred to me early in 1921 when I was experimenting with labyrinthine fis-
tula operations on temporal bone preparations from human beings and in
living animals.In November 1921 I used the Brinell microscope for obser-
vations and operations in two cases of chronic otitis with labyrinthine fistu-
las, and in one case with bilateral pseudo-fistula symptoms.’’ Nylén [40] later
modified the scope with the help of his friend and engineer Persson so it
could mount on the patient more easily. These results were reported in
1922 at the meeting of the Swedish Otolaryngologic Society and in Paris
in July of that same year.
Unfortunately, after his initial contribution of the monocular operating
microscope, Nylén found himself unable to continue to develop the instru-
ment in the clinic of his chief, Holmgren (Fig. 8) [41], where tradition and
custom dictated that the chief alone carried out the new, and still experimen-
tal, otosclerosis surgery, one of the primary applications of the new ‘‘otomi-
croscope.’’ Holmgren was already known for having introduced the
426 LUSTIG

Fig. 8. Holmgren is shown using a binocular operative microscope. (From Holmgren G. Oper-
ations on the temporal bone carried out with the help of the lens and the microscope. Acta
Otolaryngol 1922;4:383–93; with permission.)

operating loupes to ear surgery, and, thus, already had a substantial appre-
ciation for the need of magnification during these procedures. After seeing
his assistant Nylén use the operating microscope, Holmgren immediately
recognized the added advantages of the microscope over loupes during these
cases. Holmgren did not simply copy Nylén’s idea, he advanced it signifi-
cantly, and gave ample credit for the idea to his assistant. In one of his pub-
lications, he stated, ‘‘.following a good idea of my 1. Assistant surgeon
Dr. Nylén I tried a microscope and found the Zeiss binocular microscope
a very suitable instrument.’’ To the Zeiss binocular, ophthalmologic scope,
Holmgren [41] added a light source and support suitable for the operating
theater and began using it that same year, in 1922 (see Fig. 8). Compared
with Nylén’s monocular scope, Holmgren had developed an entirely new
and revolutionary binocular operating microscope.
In his initial description of the uses of the operating microscope in the
temporal bone, Holmgren [41] enthusiastically presaged its benefit in ear
surgery, stating that the advantages of using the microscope for radical op-
erations on otitis ‘‘.are indeed so obvious that no operator, who has had
experience of the lens will give it up when doing this operation.’’ Holmgren’s
words are prescient indeed, as any current otologic, neurotologic, skull base
surgeon, or neurosurgeon will attest! Additionally, Holmgren [42] used what
he termed ‘‘.a little circular cutting file, viz., one driven by a little electro-
motor of the type which is often used by dentists, armed with the very small-
est drills obtainable, which are sufficiently small to make it possible that
even very delicate bone operations can be carried out in the utmost safety
 THE CONFLUENCE OF NEUROTOLOGY 427

under the guidance of the eye.’’ This was perhaps the first application of the
drill for aural surgery and has to be regarded as a seminal event in the his-
tory of neurotology and skull base surgery.

Walter Dandy
At approximately the same time that Nylén and Holmgren were intro-
ducing the operating microscope to aural surgery, one of Cushing’s pro-
tégé’s was carrying on the transformation of neurosurgery started by his
mentor. Walter Dandy (1886–1946), perhaps Cushing’s most accomplished
student, was clearly responsible for ushering in the next great leap in neuro-
tologic, neurosurgical, and skull base surgery.
Passing up a Rhodes Scholarship to enter Johns Hopkins Medical
School, Dandy would go on to redefine the specialty of neurosurgery. After
graduating medical school, he was appointed by Halsted to surgery, and
spent his first year in the Hunterian Labs where Cushing was performing
his physiologic experiments. There the two giants developed a contentious
relationship almost from the start. At one point, Dandy accused Cushing
of not being ‘‘.a real scientist’’ [43]. Therefore, it is no surprise that
when Cushing left Johns Hopkins to take over the new neurosurgical de-
partment at Brigham Hospital in Boston in 1912, Dandy was not asked
to join the team [34].
If great minds truly do clash, then the squabbles between Cushing and
Dandy should come as no surprise. For as much as Cushing transformed
the landscape of neurologic surgery, Dandy [44] would nearly rival his
teacher’s accomplishments while at Johns Hopkins. Perhaps Dandy’s great-
est accomplishment came while he was still in his training years. In 1918, he
reported on ventriculography by the injection of air into the cerebral ventri-
cles. The impact upon the field of neurosurgery was enormous, for it allowed
the direct localization and size estimation of brain tumors for the first time.
According to Horrax [10], ‘‘It brought immediately into the operable field at
least one third more brain tumors than could be diagnosed and localized
previously by the most refined neurological methods.’’ One year later,
Dandy introduced pneumoencephalography.
Dandy’s [45,46] influence upon neurotology and skull base surgery was
equally profound. In 1917, he reported on the first successful total excision
of an acoustic neuroma. Whereas Cushing had advocated leaving the cap-
sule intact to minimize surrounding brain injury, bleeding, and facial paral-
ysis, Dandy recommended total excision (Fig. 9). This departure from his
former teacher’s doctrine reportedly left Cushing infuriated [43,47]. Subse-
quently, Dandy [48] championed the suboccipital approach for complete
acoustic neuroma resection with reports extending into the 1940s.
Dandy’s [49] influence upon neurotology and skull base surgery did not
end with his achievements in vestibular schwannoma resection; his impact
upon the treatment of Ménière’s disease was equally important. Although
428 LUSTIG

Fig. 9. Dandy’s technique of tumor excision. (From Dandy WE. Results of removal of acoustic
tumors by the unilateral approach. Arch Surg 1941;29:1026–33; with permission.)

Dandy stated that he initially began sectioning the whole VIIIth cranial
nerve for patients who had vertigo as early as 1912, he started selectively sec-
tioning the vestibular nerve beginning around 1930. By 1940, he published
the results of the operation in more than 400 patients who had Ménière’s
disease. Dandy was not the first to treat Ménière’s disease by dividing the
VIIIth cranial nerve; this honor probably belongs to Parry [50], who re-
ported on such a case using a middle fossa approach in 1902. Undoubtedly,
the primitive state of neurologic surgery at the time, the outcome of Parry’s
reported case (complete facial nerve paralysis), and the report of two other
deaths from similar attempts at relieving vertigo dissuaded others from try-
ing this treatment for some time. By the time of Dandy’s [51] report in 1941,
however, the procedure was far safer. As Dandy stated, ‘‘Ménière’s disease
can be permanently cured by division of the auditory nerve. This procedure
carries almost no risk to life. Up to the present time, I have performed 401
operations, with 1 deathdthe 358th caseddue to meningitis.’’

Terence Cawthorne and the rise of the transmastoid labyrinthectomy

Otologists of the 1930s and 1940s encountered a number of difficulties
when attempting to perform Dandy’s surgery, most obvious being the
 THE CONFLUENCE OF NEUROTOLOGY 429

unfamiliarity of neurosurgical anatomy [52]. As a result, a variety of oto-

logic operations were tried during this time to relieve patients of the severe
symptoms of Ménière’s disease, including injections of alcohol through the
horizontal canal or stapes footplate, electrocoagulation of the horizontal ca-
nal, or simply opening the labyrinth and suctioning the contents [53]. It was
the method of the British otologist Terence Cawthorne, however, that even-
tually became the new standard for treating Ménière’s disease in the 1940s
and 1950s: the transmastoid labyrinthectomy.
Cawthorne (1902–1970) was universally acknowledged as one of the
greatest ear surgeons in the mid-1900s [54]. While serving on the staff of
the National Hospital for Nervous Diseases and the Metropolitan Hospital
in England, he began studying labyrinthine vertigo intensively. In 1943,
Cawthorne [55] introduced a transmastoid labyrinthectomy as a means of
destroying the labyrinth and curing the symptoms of Ménière’s disease.
The appeal to the otolaryngologic community was immediate. The mastoid
operation was one that all otolaryngologists were familiar with already. As
amply noted in this historical review, the mastoidectomy had become
a widely accepted treatment for suppurative diseases of the ear and chronic
otitis media since the 1860s. By the 1940s, all otolaryngology training pro-
grams included the mastoidectomy as a basic part of resident training, prac-
ticed essentially as it is today. Modifying the mastoid operation to include
a labyrinthectomy was a simple step, and the transmastoid labyrinthectomy
quickly became the preferred method for treating patients who had
Ménière’s disease, surpassing the vestibular nerve section championed by
Dandy.

Neurotologic surgery advances in the 1930s and 1940s: Maurice

Sourdille, Julius Lempert, and the fenestration operation
Pioneering efforts to restore hearing to patients who had otosclerosis un-
deniably benefited the development of neurotology and skull base surgery.
For the operation to succeed, it required improvements in aural operative
technique and surgical microscopy, advances that ultimately were incorpo-
rated into neurotologic and skull base surgery. During the 1940s, two figures
were prominent in the development of an effective surgical treatment for
otosclerosis: Maurice Sourdille and Julius Lempert.
Although the lesser known of the two men, Maurice Sourdille’s impact
upon the surgical treatment of otosclerosis was perhaps nearly as equally
important. After studying at the University of Paris in 1911, he eventually
became a pupil of Lermoyez, one of the most prominent otolaryngologists
in France at that time. It was under Lermoyez’s tutelage that Sourdille de-
veloped his passion for hearing preservation surgery [56]. Following World
War I, Sourdille traveled to Sweden where he studied with Holmgren and
Barany. There he witnessed first-hand the spectacular, although often
short-lived, labyrinthine fenestration results with the microscope that
430 LUSTIG

Holmgren was achieving on patients who had otosclerosis. The high inci-
dence of deafness eventually led Barany and Holmgren to abandon the
procedure.
Sourdille recognized that the two principal drawbacks of Holmgren’s op-
eration were closure of the fistula and the risk for infection. After experi-
ments in the cadaver, Sourdille developed a three-stage procedure. He
decided that the horizontal canal was the most accessible, and he closed
the fistula with a thin cutaneous flap from the external auditory canal, which
came to be known as ‘‘Sourdille’s flap’’ [56]. Not only were his hearing re-
sults superior, the auditory improvement lasted. After Sourdille presented
his results to the French Academy of Medicine in 1929, word quickly spread
throughout Europe and the Americas, leading otologists and patients from
around the world to seek out Sourdille.
According to Glasscock, Lempert (Fig. 10) must be considered one of the
three most pivotal ear surgeons of the twentieth century and the father of
modern otologic surgery. According to Cawthorne [57], Lempert ‘‘.led
the renaissance of otologic surgery and of otology as a science, at the very
moment that antibiotics began to remove acute mastoid infections and their
dread complications from the surgeon’s scalpel to the family doctor’s pre-
scription pad.’’ His charm and charisma were legendary. Based largely
upon Sourdille’s technique, Lempert developed the endaural approach to

Fig. 10. Julius Lempert, the highly influential surgeon who popularized the fenestration oper-
ation for otosclerosis and performed pioneering neurotologic and skull base surgery. (From
Shambaugh GE, Glasscock ME. Surgery of the ear, 3rd edition. Philadelphia: W.B. Saunders,
1980; with permission.)
 THE CONFLUENCE OF NEUROTOLOGY 431

ear surgery [58], and popularized the drill in otologic surgery, as used by
Holmgren before him. According to Glasscock , his exposure of the carotid
artery during temporal bone surgery in 1938 was one of the seminal events
of skull base surgery development.
Lempert altered Sourdille’s technique into a single-stage procedure, ap-
plied his endaural approach, and used a dental burr to expose the horizontal
semicircular canal; however, in his subsequent descriptions of the technique,
Lempert failed to cite Sourdille’s prior work [56]. This did not seem to be the
first time that Lempert failed to cite earlier work that may have influenced
him. In Lempert’s original description of the endaural approach to the mas-
toid, he failed to cite Joachim Heermann, the German physician who had
first described the procedure [59].
Regardless of the controversy surrounding the primacy of the procedure,
Lempert’s one-stage fenestration operation rapidly took hold and revolu-
tionized otologic surgery in the United States. Surgeons and patients from
all over the world soon flocked to Lempert’s private office in New York,
while Sourdille slipped into relative obscurity.

Neurotologic surgical advances in the 1950s

Surgical advances in neurotology in the 1950s are remembered principally
for three advances: the stapedectomy operation, the modern tympanoplasty,
and the development of a microscope that revolutionized surgery. Of the
three, the development of the microscope is the most important, because
it directly enabled the other two advances.
Although several surgeons continued to use the microscope after
Nylén’s and Holmgren’s description, including Shambaugh, Cawthorne,
Tullio, and Simpson-Hall [38], there still was some general resistance to the
use of the ‘‘otomicroscope’’ for several reasons. First, there were cost is-
sues; these microscopes were custom built and were expensive. Second,
Lempert preferred the loupes for ear surgery along with a headlamp,
probably because of the microscope’s limitations, and his technique dic-
tated much of what was done in operating rooms of the United States
during the 1940s [60]. Lastly, there were the microscope’s technical limita-
tions, with a variety of unique designs [39]. Then in 1951, the Zeiss Com-
pany produced the OpMi-1 binocular dissecting microscope, also known
as the Zeiss-Opton, which incorporated many of the advances that had oc-
curred over the previous decade [39]. Of particular importance, the micro-
scope included illumination that entered the operative field through the
same objective as the operating surgeon was viewing. It also incorporated
variable magnification from 6 to 40 and an adequate working distance
of approximately 20 cm using a 200- or 250-mm lens, which was just
about ideal for ear surgery [39]. Although this microscope was not the
first, it was adaptable, affordable, and durable, all of which led to its en-
during success.
432 LUSTIG

Most of the development of Zeiss’s OpMi-1 was done in collaboration

with Wullstein and Zöllner during the development of their revolutionary
technique of tympanoplasty, or what they termed ‘‘plastic surgery of the
sound conducting apparatus’’ [61]. Following this work, the usefulness of
the microscope became obvious and was quickly adapted for nearly every
type of otologic surgery. Rosen [62] developed the stapes mobilization pro-
cedure, while Shambaugh, Derlacki, Heermann, House, and Shea simulta-
neously advanced and independently adapted it toward stapes surgery,
along with specially designed instruments for use under the microscope
[63–65]. According to Glasscock , ‘‘.it was Shea who made it a practical,
everyday instrument for performing otologic procedures.’’ This widespread
acceptance of the microscope during routine otologic surgery, as pioneered
by surgeons such as Shea, Cawthorne, Shambaugh, and Rosen, led directly
to the birth of an independent subspecialty: neurotology and skull base
surgery.

William House and the birth of modern neurotology and skull base
surgery
From the moment that William House (Fig. 11) applied the operating
microscope to acoustic neuroma resection, he faced an uphill battle. That
his prescience and perseverance led to his ultimate triumph over the

Fig. 11. William House, the ‘‘father’’ of modern skull base surgery. (From House W. Mono-
graph: transtemporal bone microsurgical removal of acoustic neuromas. Arch Otolaryngol
1964;80:597–756; with permission.)
 THE CONFLUENCE OF NEUROTOLOGY 433

neurosurgical establishment of the day has earned him a revered spot in the
pantheon of great ear surgeons.
After completion of his residency, William House joined his brother
Howard in a private otology practice in the flourishing Los Angeles of the
1950s. House soon developed an interest in the treatment of diseases of
the inner ear. It was House’s interest in sensorineural hearing loss from oto-
sclerosis, and the possibility of restoring hearing by drilling out the internal
auditory canal, that ultimately led him to attempt a middle fossa approach
[66]. After a series of experiments on cadavers in his local morgue, he at-
tempted the middle fossa approach using the operative microscope, along
with the neurosurgeon Kurze, on a patient who had cochlear otosclerosis
[67,68]. The patient did not regain hearing, nor did the two subsequent pa-
tients on whom the operation was attempted. According to House [66],
when he presented the operative approach at a symposium, he was publicly
ridiculed not only for the results, but for the approach itself.
It was several years later that House [69] revived the translabyrinthine ap-
proach to the cerebellopontine angle for resection of vestibular schwanno-
mas. House, along with William Hitselburger, introduced the operating
microscope and otologic surgical technique to neurosurgery. The operative
approach was immediately recognized for its import within the otolaryngo-
logic community. Dr. George Shambaugh, Jr wrote in the foreword to
House’s [70] highly influential 1964 monograph that his work was ‘‘.des-
tined to become a second milestone in the surgical approaches through
the temporal bone made possible and practical by microsurgical temporal
bone techniques.’’ In fact, the first milestone that Shambaugh was referring
to was Cushing’ [36] work nearly 50 years earlier. Shambaugh also noted in
his foreword the not-so-subtle manner in which House patterned his mono-
graph exactly as Cushing laid out his classic work in Tumors of the Nervus
Acusticus in 1917.
Despite the enthusiastic reception of the work within otolaryngology, the
opposition that House and Hitselberger faced from the neurosurgical com-
munity, who had traditionally cared for these tumors, was fierce [66]. The
squabble at House’s own institution ultimately was mirrored across the
country on numerous other hospital staffs as similar turf wars played them-
selves out between neurosurgeons and otologists. Soon, however, the advan-
tages of House and Hitselberger’s microscopic technique became obvious,
and the microscope quickly spread to other fields, including neurosurgery
itself. Otology and neurosurgery gradually came to realize that by combin-
ing their individual expertise toward the resection of vestibular schwanno-
mas, the ultimate benefactor was the patient. Once the acoustic neuroma
obstacle had been cleared, collaboration on resection of other skull base tu-
mors soon followed. Thus, one can argue convincingly that once the recon-
ciliation between neurosurgery and otology over acoustic neuromas had
occurred in the late 1960s and early 1970s, the field of skull base surgery
was born.
434 LUSTIG

House’s impact upon neurotology was profound. He went on to develop

additional, expanded approaches to the skull base, including the extended
middle fossa and transcochlear approaches. His pioneering work on co-
chlear implants was far ahead of its time, and again initially met with great
opposition from within otology’s own elite establishment [71]. As noted by
Glasscock , ‘‘Had William F. House not had such a strong personality, had
he not been so determined, then neuro-otology would not exist as we know
it today.’’

The creation of the American Neurotology Society

By the mid-1960s, the multitude of advances in the hearing, vestibular,
and neurosciences, as well as in otologic and skull base surgery, were stirring
the restive members of the American Academy of Ophthalmology and Oto-
laryngology. There was a concept of ‘‘neurotology’’ as an independent sub-
specialty that was slowly growing and gaining consensus. As recalled later
by Marcus [72], the growing array of diagnostic tests and surgical ap-
proaches, as well as advances in the basic understanding of the inner ear
and central nervous system, led Dr. Nicholas Torok and Dr. Marcus to
form ‘‘the Neurotology group.’’ On Sunday, November 14, 1965, during
the 70th Annual Meeting of the American Academy of Ophthalmology
and Otolaryngology at the Palmer House Hotel in Chicago, the Neurotol-
ogy Group presented its first program. The goals of the group were twofold:
to exchange and disseminate information about the physiology, pathology,
and clinical management of the sensorineural systems of audition and equi-
librium and to stimulate education and basic and clinical research relating to
these systems. As the Neurotology Group grew in numbers and influence, its
organizational work increased proportionately. To acknowledge its new sta-
tus, it became the American Neurotology Society in 1974. With its forma-
tion, neurotology can be said to have ‘‘officially’’ begun.

Summary
Contemporary neurotology and skull base surgery is the triumph of the
goals of the ‘‘Neurotology Group’’ that originally formed in 1965. In so
many more ways, however, neurotology and skull base surgery is the contin-
uation of a tradition of the pioneering spirit of the clinician, the surgeon,
and the scientist, often wrapped up in the same individual, dating back to
the Renaissance and beyond.

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