The otomicroscope has become na indispensable tool for the most of the operations performed upon the temporal bone today in every part of the world. Like so many of the major inovations that have profoudly influenced medical and surgical techniques, microsurgery went through a period of controversy, verging on active opposition, before it came into full bloom, making possible the development and perfection of new techniques that have entirely revolutionized the speciality of otology.
In 1921, Maier and Lion made their classical observations of endolymph movements in the living pigeon, using a low-power microscope. This prompted Calr-Olof Nylén, them a young assistant in the clinic headed by Gunnar Holmgren, to desing a microscope with higher magnification wich could be used for distinguishing details invisible to the naked eye during ear operations. Such an instrument was particularly needed for the experimental and clinical study of labyrinthine fistulas which formed the basis of Nylén's doctoral thesis.
Nylén's first microscope was monocular. Zeiss had already manufactured a binocular microscope used by ophthalmologists to inspect the cornea and anterior chamber of the eye, as well as for use as a low-power dissecting microscope. In January 1922, Nylén reported his experiences with the monocular operating microscope at meeting of the Swedish otolaryngologic Society, and again in Paris in July of the same year, before the Tenth International Congress of Otology. His chef, Gunnar Holgren, head of University Clinic in Stockholm, immediately recognized the advantages of magnification in certain types of surgery. By adding a ligth source and support suitable for the operating theater to the Zeiss binocular microscope, Holmgren stressed its usefulness for thorough removal of cholesteatoma from remote areas, and for removing "diseased bone from the most easily damage organs such as the membranous labyrinth." Holmgren went further and suggested that in cases of nonsuppurative middle-ear disease and otosclerosis hearing might be retored "by drilling away the capsule of the labyrinth between the fenestra ovalis and rotunda to expose the membranous labyrinth, covering the artificial labyrinthine window by a flap." One could also construct an artificial labyrinthine window in one of the semicircular canals, covering it in the same way."
Early, between 1910 and 1922, Bárány had operated upon a number of patients with otosclerosis by making fenestrae into the labyrinth, with inicial favorable results, but always eventual closure of the fistula, as a result of witch he finally abandoned the procedure. Holmgren, with his new binocular otomicroscope, now resumed this work with vigor and enthusiasm, operating upon a large number of patients, and studying in the experimental animal with Engstrom methods of preventing bony closure of the fenestra. Like Bárány before him, however, Homlgren continued to experience the same eventual discouraging results: loss of the hearing gain due to closure of the fenestra.
In 1938 there ocurred two significant developments that changed the course of otologic surgery. The advent of antibiotic treatment of ear infections had nearly aliminated the need for mastoid surgery for acute middle ear infections and at the same time reduced the risk of postoperative infection and the dread intracranial complications. In 1938 Lempert described his one-stage fenestration operation, utilizing the technique of Sourdille of covering the fistula in the horizontal semicircular canal with a tympanomeatal skin flap. Earlier Sourdille, stimulated by his visit to Holmgren in 1924, had demostrated that such a skin flap applied do a horizontal canal fistula helped to prevent regrowth of bone and closure of the fistula. Neither Sourdille nor Lempert adopted Holmgren"s operating microscope, but instead used a binocular opthalmic loupe for creating the fistula in the horizontal canal.
In 1940 Shambaught first applied a binocular operating microscope to Lempert's one stage fenestration operation. The improved results due to better ability to construct a fenestra free from bone fragments led him to employ the operating microscope with continuous irrigation to help to wash away bone dust as a routine. Meanwhile, Cawthorne, in London, had begun to use na operating microscope for operations upon facial nerve, while Simpson-Hall in Edinburgh has been using a similar instrument for Sourdille-type operations for otosclerosis.
Fo more than a decade the influence of Lempert, who continued to use a loupe for magnification, predominated and the operating microscope was used at first by comparatively few otologic surgeons, among them Sullivan in Toronto for facial nerve and fenestration operations, Brown Farrior in Tampa, Guilford in Houston for fenestration surgery. Then, between 1952 and 1958, the dormant bud of microssurgery burst into full bloom. In Germany Zöllner and Wullstein adopted the operating microscope as na essencial tool for their ingenious and revolutionary concepts of tympanoplasty, Rosen, not knowing of the early and nearly forgotten work upon the stapes of Miot and Blake and Jack had happened upon stapes mobilization. Shambaugh quickly recognized the advantages of the operating microscope for operations upon the stapes, and with this instrument his associate, Derlacki, and Heerman in Germany simultaneously and independently developed microchisels for mobilizing the fixed foot plate. Menwhile, Jongkees, at the Fifth International Congress of otolaryngology in Amsterdam, had demostrated the new otomicroscope of Zeiss, the first complete operating microscope designed primarily for operations upon the ear. The final step in the evolution of otosclerotic surgery was taken by Shea in 1958, using the Zeiss operating microscope to extract the entire foot plate of the stapes. Today stapedectomy under the operating microscope has virtually replace all other operative procedures for otosclerotic fixation of the stapes, while tympanoplasties, facial nerve decompression and, in repair, middle ear tumor removals, and, in fact nearly every type of operatin upon temporal bone today employs this instrument for part or all the procedure.
Neurosurgeons have traditionally been conservative in the use of magnification in their work. Just as the influence of Lempert retarded the widespread adoption of the operating microscope for fenestration surgery, it is likely that the dominance of Cushing in the neurosurgical field may have retardedits use in neurosurgery. Certainly the translabyrinthine approach for tumors within the internal acustic meatus, first suggested many years ago by Panse, and employed by Quix, was efectively impeded by the pronouncement of Cushing that "no method [of removing na acoustic neuroma] is more difficult or more dangerous." The final application of microsurgery to otology is transtemporal bone microsurgery removal of early acoustic neurinomas. In many hundreds of operations by William House and his associates, and in addicional operations being done elsewhere, the advantages to the patient of this method in reduce mortality and lessened morbidity have been abundantly demostrated. This history of microsurgery must not end without mention of Hamberger's pioneer work in the transnasal microsurgical remove ot the pituitary. This and the work of Willian House, have paved the way for usefulness of the operating microscope for many neurosurgical procedures. Microsurgery is beginning to find a place in vascular surgery and in some ophthalmic operations. The future of microsurgery begun by Nylén in 1921, and bursting into full flower scarcely one decade ago, is so promising that we can say that, except in otology where it has grown into maturity, the surface has hardly been scratched.
C.O.Nylén after his initial contribution of the monocular operating microscope, found himself unable to continue to develop this instruments in the clinic of his chief, where tradition and custom dictate that chief alone could carry out the new and still experimental otosclerosis surgery. As a result, Nylén turned his attention toward oto-neurology and puzzling problem of positional nystagmus. Soon he was appoited professor and head of the Department of Otolaryngology at the University of Upsala, succeding Bárány. There he continued his work on the vestibular apparatus until his retirement.
Nylén was na enthusiastic and talented tennis player who entered the Olympics with King Gustav of Sweden as his partner. Since it was considered unseemly for king to compete, King Gustav played under a pseudonym of Mister X. A coronary occlusion ended the tennis career of Nylén, but did not end his interest in his family and in medicine. Today, at the age of 77, Nylén, the father of microsurgery, continues to enjoy summers far out in the archipelago of Stockholm. The last summer he sailed with his son Bengt,a plastic surgeon, in his son's boat Catarina III, winner of last year's International Atlantic Race. He still regrets that he was unable to pursue his original wish to develop and work with a binocular operating microscope in otosclerosis surgery.