The History of OHNS
“Study the past, if you would divine the future.” — Confucius
OHNS is an end of the 19th century born medical specialty. It is the congruence of otology and laryngology, rapidly associated with rhinology. It went through three chronological steps: construction in the second part of the 19th century, consolidation in the first part of 20th century and extension in the second part of the 20th and beginning of the 21st century. The first phase, construction, was marked by the foundation of the first OHNS hospital departments and university chairs, the organization of the first specific national and international congresses and the publication of the first OHNS journals and books. In 1875, “The close anatomical and pathological relations existing between the ear, the nose and the throat often render it necessary that diseases of those organs be treated by the same hand.” The second phase, consolidation, was particularly marked by the recognition of OHNS as a medical specialty and its obligatory teaching during medical studies. Special training was organized to obtain the title of OHNS specialist. Already in 1887, “Hardly any individual is capable of a complete mastery of the whole range of rhino-laryngology, and if otology be superadded the ground is so extensive, that without devoting his whole time and attention to these subjects over several years, no one can hope to be a scientific expert throughout such a large territory.” The third phase, extension, is marked by the introduction of highly technological improvements, and the progressive annexation of neighbouring areas in the head and neck region. This extension is considered by some observers as the result of the decline of the specialty because of the introduction of effective antimicrobial therapy in most of the OHNS infections. On the other hand, OHNS knowledge development is linked with various factors, which can be schematically separated into three extrinsic factors, i.e. societal (religion, hygiene, and politics), scientific (electronics, photography, microscopes, rod lens, and computers), and medical (dissections, pathology, anaesthesia, asepsis, antisepsis, bacteria, radiology, and antibiotics), and into intrinsic proper factors (instruments, surgical techniques, prosthesis, and implants). These factors impregnated different steps of the non linear development of OHNS. Of course the development of OHNS knowledge followed the classical chronology of Antiquity, Middle Age, Renaissance, Modern and Contemporary Times. However, to better understand this development, it is usefull to separate it into five partially layered “setting out”: bedside, anatomopathological, clinico-experimental, operative, and highly technological. The increase of knowledge becomes progressively exponential because all « settings out » also concomitantly progress. It conducted to a renewal of the subdivision of the specialty into otology, rhinology, laryngology, head and neck surgery, pediatric OHNS, otoneurology, facioplastic surgery, and phoniatry in the last decades of the 20th century.
Bedside setting out:
Bedside setting out corresponds to the antique history of medicine until the Renaissance when medical knowledge was only accessible at the patient’s bedside. The first medical writings found in Ancient Egypt, Mesopotamia, Ancient India, and China demonstrated that the symptoms were the diseases, such as painful tongue, face ecchymosis, ear which heard bad, ear which give water of decomposition, swelling in the throat, or exsudate in the nose. Anamnesis was a fundamental step in the comprehension of the disease. The physical examination was limited to external observation except inside the mouth. The treatments were purely empirical, based on remedies of vegetal, mineral and animal origin, for example: oil, fat, honey, sea salt, cumin, beer foam, date wine, boiled hedgehog’s thorns, rat head, fly specks, human bone, red ground ochre, mercury, copper, arsenic, and malachite. Some surgical gestures, mainly in relation with trauma, were used, such as sutures, digital reposition of the nose, and reconstruction of the lobes of the ear and nose with flaps. Extraction of foreign bodies from the ear, excision of the uvula, incision of throat abcess, and nose tamponade were also mentioned. The Ancient Greek world brought the concept that the diseases were not supernatural but had a natural origin based on the Hippocratic theory of the four humors, each one could be insufficient or excessive. Thus, it introduced new therapies based on purgation (emetics, clysters, bloodletting, and cupping), cauterisation, fumigation, modification of the ambiant environment, and diet. Another important concept which influenced OHNS until the Modern Times was the idea that defluxion of the ear and the nose were emonctories of the brain. The Roman world improved the humoral theory and added the concept of “disease of the parts”, i.e. organic origin of disease. Anatomy was very superficial and saw its first descriptions, mainly based on animal studies. Many new words were introduced to name different parts, notably for the auricle, the cartilage of the nose and larynx, and the muscles of the larynx. The hidden part of the ear was simply named “labyrinth”, and the wind pipe the “trachea-arteria”. Some surgical techniques were clearly exposed, such as the extraction of foreign bodies in the ear with a hook, earspoon, or “auricular clyster” (Celsus, 1st cent.), the ablation of nasal polyps with a special knife (Hippocratic school mentioned a sponge attached to a string passed into the nose, to forcibly draw the polyp from its attachment), the ablation of tonsils with a finger, or with a hook and a scalpel, and the section of the uvula. Since the 1st century BC, the opening of the trachea is clearly discussed under different appelations, such as “laryngotomy” (Asclepiades of Bythinia, 1st cent. BC), “cutting the larynx” (Galen, 2nd cent.), “incision of the arteria” (Aretius, 2nd cent.), or “pharyngotomy” (Antyllus, 3rd cent.). At the same time, the first pharmacopoea was published which listed more than 1000 remedies. The Middle Ages did not bring much innovation, except some surgical instruments and the idea that a kind of “cold which arises during spring when roses deploy their parfumes.” It is only in the 20th century that allergology began to be understood. Chauliac described the first known bivalve ear and nose speculum that he used with sun light in 1368.
Anatomopathological setting out:
Renaissance and early Modern Times (16th-18th centuries) opened new fields in medicine, mainly in anatomy and pathology. Human dissections were possible, thus leading to the progressive description of all the macroscopical parts of the body. The nasal turbinates, the four sinuses of the face with their orifices, the three ear ossicles, the tympanic cavity, the vestibule, the semicircular canals, the cochlea, the detailled anatomy of the larynx, and the cranial nerves are particularly described. Then the salivary glands are finely depicted (Malpighi 1666) with their respective excretory canals (Warthon 1656, and Stenon 1661). The saliva is demonstrated not to originate from the lymph but from these glands. A second step is made with the introduction of the simple microscope leading to the description of most of the details of the inner ear, and the confirmation that it is filled with fluid and not air as supposed since Antiquity. Physical examination enlarged with the detailed examination of the external auditory canal and the nostrils. Reconstructive surgery is advanced with the improvement of flaps, notably for the nose and the ears (Tagliacozzi 1597), and the use of prosthesis for the same parts (Paré 1585). Tracheostomy (Fienus introduced the term at the beginning of the 17th century) became an established operation, being performed with a vertical, horizontal or punctiform opening, associated with the placement of a canula. The advent of pathology and the understanding of the local lesions related to the disease made clear that defluxion of the nose (Schneider 1661) and the ears (Morgagni 1761) came from these respective parts and not from the brain. Antique surgeries are slightly improved and new ones are introduced: the opening of the maxillary sinus in the case of infection through three different routes: the canine fossa (Molinetti 1675), the tooth (Meibomius, Cooper 1707) and the nasal wall of the maxillary sinus (Jourdain 1765); the superficial opening of the mastoid area in the case of abscess as soon as fluctuation was felt with the trephine, or gouge and mallet, rugine or a perforator (Petit since 1736); the catheterization of the Eustachian tube first through the mouth (Guyot 1724) then through the nose (Cleland 1744) with a “silver tube” in the case of obstruction of “external and internal auditory passages”; and the perforation of the tympanic membrane “with a sharp, long, but small lancet”, in the case of deafness (Busson 1748, Cooper 1800). The deaf-mute children were no longer considered as “burdensome pariahs”, and their systematic education was of public concern and established with two main controversial approaches, i.e. oralism (Heinicke) and manualism (De l’Epée). In 1880, the oral method was recognized superior to the manual method. Nosologies are implemented to try to classify the different known diseases, thus introducing new terms, such as otitis and epistaxis. Otology began to be a separated topic with the publication of its own books, notably by Duverney in 1683, Valsalva in 1704 and Wildberg in 1795.
Clinico-experimental setting out:
The clinico-experimental setting out began at the beginning of the 19th century. It opened up a new approach in medical practice with the correlations of the bedside clinical symptoms and the lesions described during autopsy. Anamnesis became more orientated and more precise. A second, later step was added with the possibility of investigating in the laboratory the quality of the different liquids and secretions of the body, and also the microscopic structures of the tissues (biopsie). New techniques of examination with new definitive instruments were introduced to directly find these lesions. The funnel shaped speculum was definitively accepted, the laryngeal mirror first described by Garcia in 1855 and rapidly improved by Czermak and Türck, and the bivalve nasal speculum found its definitive shape. The main problem was the reflected illumination which having been natural became artificial in association with the hand, then mouth, and finally concave perforated frontal or head mirror. This latter mirror became the emblem of the OHNS specialist. The discovery of electricity allowed for direct light to be joined to the mirror. All the OHNS orifices were then visually and completely accessible. Despite the development of photography, these organs were not reachable, reason why the first published OHNS atlases contained only watercolour images drawn by the observer. With the development of the cell theory, anatomy was improved with the use of the compound microscope which led to the description of the ciliate cells of the organ of Corti and their supportative cells. It guided the reworking of the theories of hearing, notably by Helmholtz and his concept that different regions of the basilar membrane act as resonators for tones of different frequency. The following demonstration that most of the diseases were linked to cellular troubles and that the ear, nose and larynx have a similar cellular covering (i.e, respiratory mucosa) in most of their parts, lead to the concept of a common insight in the development of diseases. A clear relation was demonstrated directing the physicians to join together the care of the diseases of these organs and create the OHNS specialty. At the same time, physiological experiments began to be conducted to understand the functions of the OHNS organs. Flourens demonstrated, in cutting the semicircular canals of birds, that these inner ear structures participated in the balance system. Goltz went a step further in demonstrating that there is the balance system, and Breuer that a relation exists between the troubles of the system with nystagmus. In between, Menière described his famous disease associating vertigo, hearing impairment and tinnitus. Surgery did not really progress and remained very limitated. Some already described operations were demonstrated as being dangerous such as mastoidectomy. Other interventions became very popular, even if only discussed, such as catheterization of the Eustachian tube and artificial perforation of the tympanique membrane. Tracheostomy was well established and tonsillectomy began to be a routine operation with the introduction of a kind of guillotine, the “tonsillotome”, invented by Physick in 1828. This instrument saw various modifications up until Sluder in 1911.
Operative setting out:
Invention of aneasthesia with ether and chloroform in the 1840’s and the introduction of asepsis (sterilisation) and antisepsis (desinfection) in the 1860’s, opened a completely new surgical era with the possibility to operate for more than only a few minutes. In parallel, medications against pain became synthetized, thus rendering the post-operative care more successful and affordable by the patients. The discovery of bacteria as agents responsible for the development of infection was another important event. Surgeons were now able to extirpate diseased organs such as the larynx by Billroth in 1873, creating a definitive opening of the trachea in the neck ; to completely open all the cells of the mastoid process by Schwartze with hammer, cisels and gouges in the same year ; to endomucosally correct the deviation of the nasal wall with specially designed instruments (various surgeons, 1882) ; to practice endonasal corrective aesthetic correction of the nose (Roe 1887) ; to place a tube into the glottis (O’Dwyer, 1882) in case of infectious obstruction (diphtherai) ; to replace the guillotine technique of tonsillectomy by the “dissection technique”, the patient being placed on his back with a sandbag under his shoulders and with the head well extended ; or to reconstruct the face with various flaps in the 1920’s. O’Dwyer’s tube precluded the development of the orotracheal tube (Kuhn 1900, Magill 1920). Another important advance in OHNS was the recognition of the importance of the adenoids described by Meyer in 1868 in the development of middle ear infections. Removal of them quickly became a routine operation first with a kind of ring-knife and then with the curette. Concomitantly, local anaesthesia with cocaïne was introduced in 1884 by Jelinek. It opened a new field of “small” operations notably in the larynx and the nose. After the remarkable development of oesophagal and bronchial endoscopy during the last twenty years of the 19th century, endoscopy found its mark in the first two decades of the 20th century also becoming therapeutic. It was included in the domain of most of OHNS specialists. Very quickly, OHNS became a surgical specialty. New techniques were progressively depicted allowing more precise surgery, notably the different types of mastoidectomy (cortical, radical, and modified radical) and partial conservative surgery of the larynx. Mobilisation (notably of the stapes), and extraction of the ossicles were attempted, such as the skin grafting (“myringoplasty”) of perforation of the tympanic membrane (Berthold, 1878, Ely, 1878). With the expansion of the number of OHNS journals (31 OHNS journals were created, with more or less success in the 19th century, the first in 1864), these new techniques were rapidly made known by the specialists. Laboratory work allowed the recognition and the description of many diseases such as cholesteatoma and otosclerosis. Cholesteatoma is a term coined in 1838 by Müller because he was aware of the presence of cholesterin and fat in what he believed to be a fatty tumor. Three main theories were then discussed to explain the origin of this entity: metaplasia of mesenchymal cells (Virchow 1855), heterotopia, and epithelial migration (Habermann 1889, and Bezold 1890) of the external auditory canal epidermis into the tympanic cavity. In 1893, Politzer described a “circumscribed disease of the bony labyrinth capsule, leading to new bone overgrowing to the oval window and stapes, and finally leading to complete anchylosis of the stapes”, which he later named otosclerosis. The term otospongiosis was also added to name this disease (Siebenmann 1912). At the turn of the 20th century, two important discoveries modified the practice of OHNS: radiology and the carbon amplificator. Radiology allowed one finally to directly see inside the OHNS cavities of the face leading to the development of numerous different incidences to specifically analyse the ear and the sinus. The classical incidences of Schüller (1905), Cadwell (1906), Law (1913), Waters (1915), Stenvers (1917), Hirtz (1922), Mayer (1923), and Blondeau (1926) are rapidly described. Cancer development and evolution is better understood in the OHNS region, rendering the research of primary metastatis a full part in its diagnosis and treatment. Neck dissection was included in the surgical treatment. Radiotherapy (Roentgentherapy) was introduced such as radium therapy. Rapidly, radium therapy was stoped because of many side effects. Thanks to the development of the carbon amplificator, the first electric hearing aids were produced. The invention of the audiometer in the 1920’s opened a new era in the measurement of hearing levels. It took more than 20 years to definitively replace the voice, clock, acoumeter and different whistles used until this time. A standard method of collecting the results (audiogram) was introduced and accepted worldwide. In 1906 Barany developed the caloric reaction of the ear producing a reproductible nystamus correlated with the temperature of the installated water. He also invented the rotatory chair for the examination of patients suffering from vertigo. For all his work, he received the first OHNS Nobel Price in 1914. In 1925 Frenzel developed his special glasses allowing to easily observe the nystagmus. But it was only in the 1950’s that otoneurology really found its place in OHNS with the development of electronystagmography.
Highly technological setting out:
“With the use of sulfonamides and antibiotics we need no longer fear many of the major surgical procedures in otolaryngology.” The discovery and progressive use of antibiotics largely modified the surgical practice of the OHNS specialists in the 1940s and 1950’s. It also orientated research in the area of physiology and chemical understanding of the functions of organs. The number of mastoidectomies, openings of the sinus, and drainages of throat abcesses dramatically diminished. The scope of surgery became limited to the few cases not responding to antibiotic treatment and the specialty was questioned for its future. It introduced some pessimism leading to the conclusion that “Otolaryngologists have much to gain by thrashing out the problem calmly and deliberately rather than by ignoring it.” Nevertheless and fortunately the invention of the binocular microscope and rod lens endoscopes opened new surgical techniques and allowed an expansion of the classical surgical field to the surrounding structures such as skull base, lacrymal ducts, face and thyroid. Otolaryngology became otolaryngology, head and surgery. With the binocular microscope, it was then possible to reconstruct the tympanic membrane and the ossicles. Wullstein and Zöllner were the instigators of these tympanoplasties from 1952. Wullstein coined the German term “Tympanoplastik” to describe his various surgical techniques of reconstruction of the tympanic membrane and the middle ear sound-conducting mechanism, the goal being “one-step reconstruction of hearing”. He described five types of function in the extension of ossicular destruction. Numerous different materials were then used as grafts, and various surgical approaches were developed in function notably of the size and localization of the tympanic perforation and the extent of ossicular destruction. At the same time, the tympanostomy tube was reintroduced by Armstrong in 1954. It completely modified the treatment of serous otitis media. In fact, it was developed in the mid 19th century but was unsuccessful during this time. Mastoidal techniques were also modified with the systematical use of the air-driven drill associated with the suction system. With the first works of Shea in 1958, stapedectomy became possible, with the replacement of the stapes by a prosthesis which quickly found its classical piston-like form in the 1960’s. With the introduction of the first tomographies, the temporal region was more accessible to the surgeon and the internal auditory canal became a domain accessible to the ear surgeon. House and Fisch pioneered this lateral skull base surgery between the 1960’s and 1970’s. The microscope was also used in surgery of the larynx, associated with the development of new direct laryngeal tubes “in suspension” on the thorax of the patient. Kleinsasser played an important role in the development of this system in the 1960’s. Phonosurgery rapidly found its place with the introduction of many specific instruments and techniques. A revolution in the treatment of profound deafness was the invention of the cochlear implant by House. Inspired by the 1957 works of Djouro and Eyries, in 1961 House, placed an electrode directly in the cochlea to stimulate the endings of the auditory nerves. It unlocked a completely new approach in the treatment of deaf-mutism. It took more than 30 years of technical refinement by various teams before the device became accepted and used worldwide. It certainly represents the most important development of OHNS in the 20th century. The improvement of rod lens endoscopes in the 1960’s, notably by Messerklinger also introduced new surgical paths and techniques in nasal surgery. Everything was visually accessible and the systematical opening of ethmoidal cells became a routine operation. It also enlarged the field of work with the perfectionment of transnasal hypophysectomy, dacryorhinostomy, and frontal skull base surgery. These new endoscopes brought new possibilities in esophagoscopy and bronchoscopy, notably the development of various stents. These microscopicial and endoscopical surgical extensions of OHNS found a second great impulse with the invention of the CT scan and MRI in the 1970’s. All the fine anatomical and pathological details were recognizable, thus rendering surgery much safer and sure. It also allowed for the development of new less traumatic approaches in skull base surgery. The treatment of OHNS cancer entered a new era with the development of surgical reconstruction of the diseased part of the neck and face with local flaps such as the myocutaneous deltopectoral since 1965 (Bakamjian) ; transplants, such as the jejunum, and microvascular flaps such as the peroneal flap and the forearm flap. The concept of functional neck dissection was introduced. Radiotherapy became more precise, focalized, and associated with less side effects and chemotherapy found an important place in treatment. Head & neck tumor boards and concilia with all the competent physicians were progressively organized to find the best possible therapeutical solution. An international system of classification of cancers (TNM) was agreed in 1978 and became the standard in the description of the extension of the cancer. Cutting lasers (particularly CO2) were introduced at the turn of the 1980’s notably in the surgery of the vocal cords and for the ablation of superficial mucosal lesions. Other lasers (notably YAG) were used to desintegrate obstructive tumoral lesions in the bronchial tree and oesophagus or to cauterize bleeding chronical lesions in the nasal cavity. Computers, in the 1990’s, allowed for the development of a navigation-system of surgery, especially for endonasal surgery and lateral skull base surgery. The invention of transistors in 1948 and their progressive miniaturization allowed the production of new hearing aids placed behind and in the ear in the 1960’s which became much more acceptable by the person suffering from impaired hearing. The weight of these new devices was under 5 grammes. The digitalization of the treatment of the signal in the 1990’s gave a new impetus to their development. The comprehension of the physiology of the ear has been improved by the works of Bekesy who received the second OHNS Nobel Price in 1961. The physiology of the hearing system and neural encoding system then became a large field of research. In the 1960’s better comprehension of apnea and related sleep disorders opened a new area of competence for the OHNS specialist with the development of various surgical techniques and devices to improve the quality of air flux exchange through the naso-bucco-pharyngo-laryngeal passage. OHNS fundamental research became an indispensable support of this highly technological setting out. Ear, nose and throat diseases affect almost everyone at some point in their life, often in ways most people never expect. With the expansion of the field, many new issues of interest appear, in a collaborative and comparative effectiveness. Some of the main topics of interest are inner ear hair cell regeneration, biomechanics in hearing, genetics and hearing loss, auditory and vestibular implants, immune system and cancer, infection and cancer, risk factors in cancer development, cancer specific therapies, regeneration of respiratory mucosal cells, pathophysiology of smell and taste disorders, artificial voice organ, immunohistochemical and molecular analysis of OHNS tissues, tissue engineering (cartilage, bone, nerve, etc), computer modelling and robotics surgery. This high technological setting out is in perpetual expansion, with more or less success. The future looks really bright. The danger is that only the surgical technological aspect of the OHNS specialty is credited and considered, whilst putting the ethical and human aspects of medicine to one side in the face of progress. Further more, and for many people, a good OHNS specialist is a surgeon! OHNS is a multifaceted fascinating specialty, and to be effective, it must have all its different aspects joined together in a respectful, collaborative and constructive spirit. “Real generosity toward the future lies in giving all to the present.” (Albert Camus)