The History of Otologic Surgery at Mayo Clinic, 1883 to ... · The earliest beginnings of otology at Mayo Clinic can be traced to Dr William Worrall Mayo, who was born in Eccles,

HISTORICAL VIGNETTE

The History of Otologic Surgery at MayoClinic, 1883 to PresentMatthew L. Carlson, MD

From the Department ofOtorhinolaryngologyeHead and Neck Surgery,Mayo Clinic, Rochester,MN.

F or the past 130 years, Mayo Clinic inRochester, Minnesota, has maintainedan active, uninterrupted otologic prac-

tice with activities that are well documentedand preserved through the Mayo Clinic His-torical Archive. This historical narrative fo-cuses on the development of the modernsurgical subspecialty of otology from theperspective of a single tertiary academic cen-ter and highlights the importance of contin-uous innovation and reinvention withinmedicine and surgery. Source material forthis report comprised the annual reports tothe Mayo Clinic Board of Governors, theMayovox newsletter, the illustration archivesof the Mayo Clinic Division of Creative Me-dia, staff biographies, curriculum vitae,memoirs, full-text journal articles, andbook publications. The interested reader isencouraged to reference “The History ofOtorhinolaryngology at Mayo Clinic,”1

which provides relevant historical contextwith separate but complementing material.

THE EARLY YEARSThe earliest beginnings of otology at MayoClinic can be traced to Dr William WorrallMayo, who was born in Eccles, a smalltown neighboring Manchester, UnitedKingdom, on May 31, 1819.2,3 Notably, Wil-liam Worrall Mayo came from a lineage ofgreat physicians and scientists, includingHerbert Mayo (1796-1852), who first accu-rately described the separate sensory andmotor function of the fifth and seventh cra-nial nerves (Figure 1).4,5 In 1845, WilliamWorrall Mayo immigrated to the UnitedStates and secured a position as an assistantpharmacist in New York but soon migratedwestward, where he obtained 2 separatemedical degrees at Indiana Medical College

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and University of Missouri MedicalSchool.3,6

During the following 10 years, WilliamWorrall Mayo and his growing family trav-eled to several cities in Minnesota in searchof steady work before finally settling inRochester to serve as the medical examinerfor draftees during the Civil War. Notably,William Worrall Mayo’s oldest son, WilliamJ. Mayo (“Will”) received his medical degreein 1883 from the University of Michigan un-der Dr George E. Frothingham, professor ofophthalmology and otology.6,7 His secondson, Charles H. Mayo (“Charlie”) completedhis medical doctorate at Northwestern Uni-versity in 1888 and shortly after graduationacquired whooping cough requiring 6months of medical leave. During this time,Charlie spent several formative months inEurope observing otorhinolaryngologic pro-cedures under several eminent surgeons ofthe time.7,8

The timing of the Mayo brothers’ educa-tion was auspicious because they completedtheir training only decades after Sir WilliamWilde of Ireland described the postauricularincision with removal of the mastoid cortexfor the treatment of acute suppurativemastoiditis, only years after HermanSchwartz and his assistant Adolf Eysellreviewed the surgical indications and tech-nique of cortical mastoidectomy using malletand chisel in place of the trephine andtrocar, and near the same time that theradical mastoidectomy was described byKüster, Stacke, and Zauful.9-11 The Mayobrothers’ early exposure to ear surgery dur-ing this pivotal time in the field of otologyprovided them with a unique surgical skillset that was immediately put to work afterreturning to Rochester to join their father’sgrowing practice.

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MAYO CLINIC PROCEEDINGS

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In just the third entry in his extensive575-article bibliography, William J. Mayopublished an account of a 33-year-old manpresenting with suppurative otomastoiditis.The patient was initially treated with myrin-gotomy and cortical mastoidectomy using agimlet and dental drill.12,13

“Chloroform was administered, the mas-toid process freely exposed by incision,and a small quantity of fetid pus foundbeneath the periosteum. The temporalbone for some distance was rough, andthe periosteum dissected up by this pus.With an ordinary gimlet I opened the mas-toid process to a depth of 3/4 inch. The re-lief was immediate and improvementmarked. On the fifth day the opening inthe [mastoid] process was enlarged withthe dental engine, which was done rapidlyand perfectly” (Supplemental Appendix1, available online at http://www.mayoclinicproceedings.org).

Published in 1886, this was among theearliest accounts documenting use of theelectric drill to perform mastoidectomy,occurring only 20 years after its inventionand at least 30 years before Julius Lempertwas credited with popularizing its use in oto-logic surgery.14 In a similar account pub-lished 5 years later, in the second entry ofa 413-item bibliography, Charles H. Mayoreports caring for a 17-year-old womanwith mastoiditis and epidural abscess whowas treated via mastoidectomy and abscessdrainage.15

“Complaining of more or less headache,she was again taken with severe pain inthe left ear, and during the followingnight had three spasms, epileptoid incharacter. The next day the ear againbegan discharging, and she returnedhome, where she remained about tendays before coming to the hospital. Dur-ing this time she suffered from increasingphotophobia and intense pain in andbehind the left ear, loss of memory, andcold sweats.. The mastoid was openedwith a gouge chisel, and pus found inthe cells, at a depth of 1/4 inch. With abone curette a sinus leading into the

Mayo Clin Proc. n February 201

antrum was enlarged, and also a sinusleading upward to a small space betweenthe dura mater and skull, evacuating inall about 1 gram of pus. The openingwas drained and kept open for threeweeks, when it was allowed to heal..All headache was relieved, and the sup-puration from the ear ceased in a fewdays. The photophobia passed away, butwas followed the first few days by a par-tial paralysis of the right external rectus,existing about a week.” (SupplementalAppendix 2, available online at http://www.mayoclinicproceedings.org)

ERA OF SPECIALIZATIONEarly on, Will and Charlie saw the impor-tance of dividing surgical cases betweenthemselves to meet high clinical demandsand to cultivate specialized clinical skills.Will was primarily involved in abdominaland gynecologic surgery, and Charlie concen-trated on head and neck surgery, neurosur-gery, and orthopedic surgery.6,7 Thus,Charles H. Mayo should be considered thefirst otologic specialist at Mayo Clinic.

After completion of Saint Marys Hospitalin 1889, 21 new staff were hired in responseto the exponential growth in annual surgicalcase volume. Specific to the field of otologywere the additions of Gertrude B. Granger(1898-1914), who assisted Charles H. Mayoin the treatment of diseases of the ears,nose, throat, and eyes; Carl Fisher (1909-1917) as the section head of ophthalmologyand otology; and Donald Guthrie (1906-1909), an intern and second assistant toCharles H. Mayo.6,12 With the increasingnumber of specialty staff, the number of oto-logic procedures tripled between 1910 and1916 (Figure 2).6

By 1917, the practice had grown largeenough to justify apportionment of spe-cialty care to individual divisions. On July1, 1917, the Section of Otolaryngologyand Rhinology was inaugurated and HaroldI. Lillie was assigned chief, where he servedin this capacity for 34 years (Table).6,7 Lilliereceived his graduate medical training un-der the instruction of Roy Bishop Canfieldat the University of Michigan. Notably,Roy Canfield was a house surgeon at the

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FIGURE 1. Dr Charles H. Mayo with a portrait of Dr Herbert Mayo duringhis visit to Middlesex Hospital Medical School in June 1925. Reproducedwith permission from the W. Bruce Fye Center for the History of Medicine,Mayo Clinic, Rochester, Minnesota.

HISTORY OF OTOLOGIC SURGERY AT MAYO CLINIC

Massachusetts Charitable Eye and Ear Infir-mary and subsequently assistant surgeon tothe Manhattan Eye and Ear Hospital beforehis appointment as clinical professor at theUniversity of Michigan. Although he pub-lished on many subjects, Harold Lillie’sprimary interest was in the prevention andtreatment of otitis media and relatedcomplications.

EVOLUTION OF THE SPECIALTYBefore the introduction and widespreadavailability of antibiotics after World WarII, ear, nose, and throat specialists were pri-marily engaged in the treatment of infectiousand inflammatory conditions of the head andneck, including acute tonsillitis, otomastoi-ditis, and sinusitis. As a result of the signifi-cant volume of infectious disease and theacute need for timely intervention, the Sec-tion of Otolaryngology and Rhinologylargely forfeited treatment of head and neckcancer and functional surgery to other sec-tions. During this era, intracranial complica-tions of otitis media and sinusitis werefrequent causes of patient morbidity andmortality. As a result, radical external ap-proaches to the ear and sinuses werecommonly performed to exteriorize and con-trol advancing infection (Figures 3 and 4).16

The introduction of “chemotherapy” forthe medical treatment of infectious diseasein the 1930s significantly transformed thework of the otologist.17 The first report ofsulfonamide was made in the Mayo ClinicDepartment Annual Reports in 1939, peni-cillin in 1942, and streptomycin in1945.16,17 As a result of this development,most cases of acute infection could be effec-tively managed with medical therapy, andsurgery was mainly reserved for recalcitrantacute and chronic infections.17

Coinciding with the introduction ofeffective antibiotic drug therapy were severalkey technological developments in the fieldof otology. The first commercial vacuumtube audiometer in the United States wasintroduced in 1922 by Bell Telephone Labs,called the Western Electric 1A.7,18 Thatsame year, the illuminated binocular opera-tive microscope was first adapted to otologic

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surgery by Gunnar Holmgren while pioneer-ing lateral canal fenestration surgery forotosclerosis.19 The refinement of electricand air-driven drills with cutting and dia-mond bur assortments occurred betweenthe 1920s and the 1940s.14,20 Interestingly,despite the distinct advantages offered bythe operating microscope in otologic sur-gery, many US surgeons did not adopt itsuse for several decades secondary to signifi-cant limitations, including narrow field ofview, short working distance, poor illumina-tion, large size, and poor maneuverability.19

For example, Julius Lempert and MauriceSourdille commonly resorted to binocular2x to 4x loupe magnification. Similarly,although operating loupes had been widelyused since the 1940s at Mayo Clinic, it wasnot until 1959 that the operating microscopefirst became a standard part of otologic sur-gery with the introduction and greateravailability of refined operating microscopesystems.19,21 Notably, otologists were

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192011 12 13 14 15 16 17 18 19 21 22 23 24

Operations on ear in hundreds

Total operations in thousands

Years

FIGURE 2. Early surgical caseload of operations of the ear compared with the total surgical volume from 1890 to 1924. Reproducedwith permission from Sketch of the History of the Mayo Clinic and the Mayo Foundation. Philadelphia, PA: WB Saunders; 1926:46,chart 17.


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the first surgeons to use the operatingmicroscope, with several other specialtiesadopting its use shortly thereafter, includingophthalmology, neurosurgery, and oralsurgery.19

Also during this time, many requisite ad-vances in general anesthesia took place thatallowed for increasingly complex surgeriesto be performed with greater patient toler-ance and safety.9 Recall that the use of ether,nitrous oxide, and chloroform were origi-nally pioneered in the 1840s. However, itwas not until the late 1920s that intravenousanesthetics such as thiopental would bebecome available, and even later until


nonflammable, nontoxic inhalation anes-thetics were developed. In the 1929 annualreport to the Mayo Clinic Board of Gover-nors, the developments in general anesthesiawere noted: “The use of intratracheal anes-thesia has supplanted rectal anesthesia andthe use of amytal. This is a step forwardparticularly in the radical paranasal sinus op-erations. There has been a great improve-ment in the methods of administration ofanesthetics.”16

OTOSCLEROSISThe success of antibiotic drug therapypermitted otolaryngologists to shift focus




FIGURE 3. Illustration from 1925 demonstrating the technique of trans-mastoid drainage of an otogenic temporal lobe abscess from acute sup-purative otitis media, a relatively common occurrence in the pre-antibioticera. Reproduced with permission from the W. Bruce Fye Center for theHistory of Medicine, Mayo Clinic, Rochester, Minnesota.

TABLE. Otologists of the Department of Otorhino-laryngology, Mayo Clinic, Rochester, Minnesota,1917 to Present

Emeritus/active (MD) Years

Harold I. Lillie 1917-1953

Bert E. Hempstead 1921-1950

W. Berkeley Stark 1925-1934

Henry L. Williams 1934-1963

Kinsey M. Simonton 1937-1970

O. Erik Hallberg 1942-1970

Henry A. Brown 1942-1974

D. Thane R. Cody 1963-1987

Jack L. Pulec 1963-1969

George W. Facer 1970-2000

Thomas J. McDonald 1972-2007

Stephen G. Harner 1973-2003

Charles W. Beatty 1982-2018

Colin L.W. Driscoll 1999-Present

Brian A. Neff 2005-Present

Matthew L. Carlson 2012-Present


from prevention and treatment of life-threatening infection to functional surgery.This transition was most appreciable inthe early years of modern otology with themanagement of otosclerosis and Ménière dis-ease (Figure 5). Following the seminal workof Adam Politzer and Joseph Toynbeedescribing the condition and underlyingpathophysiology of otosclerosis, severalinnovative surgeons began performing pro-cedures of the stapes footplate with theintent of hearing restorationdJohannes Kes-sel in Gras with stapes mobilization in 1878,and Blake and Jack with stapedectomy in1892 and 1893, respectively.22,23 However,at the turn of the century, several eminentleaders in the field of otology, includingPolitzer, Bacon, Siebenmann, and Denker,denounced stapes footplate surgery giventhe attendant risks of sensorineural hearingloss and meningitis. In 1924, Harold I. Lillieremarked, “It is quite evident that the treat-ment of the stapes fixation type deaf personis futile. There are certain exceptions to this,but they are few.” Three years later, while ac-counting for the declining annual patientclinical volume, Lillie surmised that“another factor which may have influenced


the registration in this service is that inanswering inquires from patients who aretroubled with deafness, we have not urgedthem to come for treatment.. Little ornothing can be done to benefit them andnaturally they are disappointed for havingspent their time and money; they are liableto be dissatisfied.”16

In place of stapes footplate surgery, pio-neering ear surgeons, including George Jen-kins in the United Kingdom, GunnarHolmgren in Sweden, Maurice Sourdille inFrance, and Julius Lempert in New York,established and refined the technique oflateral semicircular canal fenestration forthe treatment of otosclerosis.22,23 In 1943,Dr Henry L. Williams attended a 5-weektemporal bone course with Julius Lempertto acquire skill in single-stage lateral canalfenestration surgery and address this signifi-cant clinical need in Rochester.17 Because ofthe implications of inner ear infection, it wasnot until the following year that Williamsbegan performing this procedure. In 1944he performed 10 cases with good outcomes,and in 1945 it was said that “as a result of anarticle appearing in the Readers Digest lastFebruary, hundreds of patients presentedthemselves for operations [at Mayo Clinic];

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FIGURE 4. Illustrations from 1926 depicting a case of thrombophlebitis of the left sigmoid sinus.Reproduced with permission from the W. Bruce Fye Center for the History of Medicine, Mayo Clinic,Rochester, Minnesota.


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patients with deaf mute children to personseighty odd years old.”17 In 1946, Drs KinseyM. Simonton, O. Erik Hallberg, and John C.Lillie also visited Lempert in New York forinstruction on lateral canal fenestration.Figure 6 outlines the dramatic upsurge inthe number of labyrinthine fenestration op-erations that were performed by the sectionbetween 1945 and 1948 to address the

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SurgerySurgery for otitis media

0%

FIGURE 5. Change in otologic surgical case distribution1925 and 1975.


significant backlog of patients with un-treated otosclerosis.

The first stapes mobilization performedat Mayo Clinic was in 1955, 2 years afterSamuel Rosen had revisited the stapes mobi-lization procedure of Kessel.17,22 After this,the first vein plug “stapedoplasty” (stapedec-tomy) was performed in 1959, 3 years afterDr John J. Shea Jr first performed this

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Vestibular surgery for otosclerosis

at Mayo Clinic in Rochester, Minnesota, between




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FIGURE 6. Change in otosclerosis surgical casedistribution at Mayo Clinic in Rochester, Min-nesota, between 1940 and 1975.


procedure on a 54-year-old housewife onMay 1, 1956.17,23 Although the techniquesof stapedectomy varied significantly acrossthe country, initially a tantalum wire(0.005 in, 36 gauge) attached to a vein graftplug taken from the dorsal hand waspreferred by otologists at Mayo Clinic.24 Af-ter several years, the technique was alteredto incorporate a connective tissue plugattached to a stainless steel wire designedby Schuknecht. Only in cases of obliterativedisease was a Shea Teflon piston or the stain-less steel piston designed by McGee used.The success of this surgery brought great de-mand, with an average of 220 primary stape-dectomy surgeries performed each year atMayo Clinic for the following decade.17 Asseen elsewhere, over time there was agradual decline in the number of stapedec-tomy procedures performed as the backlogof patients with advanced disease dwindled,and possibly from widespread measles vacci-nation.23 In 1965, 234 stapedectomies wereperformed, and this decreased to 112 in1975 and to 61 in 1985.25,26

MÉNIÈRE DISEASENear the same time that lateral canal fenes-tration was introduced, surgery for Ménière


disease received increasing attention. If a pa-tient failed dietary salt modifications as out-lined by Furstenberg, Lashmet, and Lathropor desensitization to histamine as recom-mended by Shelden and Horton, surgicalintervention was considered.27-29 Beforethis, retrosigmoid craniotomy with vestib-ular nerve section, popularized by WalterDandy, was one of the only surgical meansfor treating medically refractory vertigo.30

Secondary to the higher risk of surgery andinconsistent results, otologic surgeons,including Cawthorne, Portmann, Wright,and Day, sought alternative measures forsurgical treatment.31-33 First described in1943 by Day, the first 11 labyrinthotomy op-erations were performed at Mayo Clinic in1946, followed by 25 the following year.33

The Day operation was described as a simpleyet technical procedure performed through amastoid exposure with lateral canal labyrin-thotomy and application of weak diathermycurrent to the membranous labyrinth.17

This procedure was described as highlyeffective and low risk, with the potential topreserve residual hearing. Over time, thetransmastoid labyrinthectomy, firstdescribed by Cawthorne in 1943, was usedwith greater frequency.32

Although endolymphatic sac surgery forthe treatment of Ménière disease was firstdescribed by Georges Portmann in 1926, itwas several decades before it became morewidely adopted by centers in the UnitedStates.34 The first endolymphatic sac surgerywas performed in 1965 at Mayo Clinic, with32 cases the first year and an average of 18cases per year during the following 5 years.17

At this same time, Dr Thane Cody of MayoClinic described a novel surgical treatmentfor Ménière disease.7,17 Dr Izhak Fick, fromSouth Africa, had visited Rochester in 1967to attend the first international symposiumon Ménière disease.35 It was at this confer-ence that Fick described his pick sacculot-omy procedure for Ménière disease, and itwas from this collaboration that Cody devel-oped the tack procedure. This operationinvolved implanting a tack prosthesis intothe vestibule that would decompress thesaccule during hydropic episodes.36 In this

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FIGURE 7. The Cody tack procedure (automatic repetitive sacculotomy)for surgical treatment of Ménière disease. A and B, Placement of a tackprosthesis through the anterior footplate. C, With endolymphatic hydrops,the dilated saccule will contact the sharp tack and decompress the mem-branous labyrinth. D, After tack placement, a small fat graft is placed toreduce the risk of perilymphatic fistula. From Mayo Clin Proc.37 Reproducedwith permission from the W. Bruce Fye Center for the History of Medicine,Mayo Clinic, Rochester, Minnesota.


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surgery, a 1.0- to 1.9-mm stainless steel tackwas introduced via a transcanal stapedec-tomy approach using a magnetic probethrough the anteroinferior aspect of the foot-plate (Figure 7).38 In reviewing the first 290cases, Cody reported that vertigo was satis-factorily controlled in 79% of patients andhearing was improved or maintained ingreater than 60%.39 Given its success, theCody tack procedure was the most commonsurgical procedure performed for Ménièredisease at Mayo Clinic until a change inprosthesis manufacturers in the 1980s ledto its disappearance. Between 1965 and1985, 664 tack procedures were performedin total.25,26

A final notable contribution to the treat-ment of Ménière disease was the earlyobservation that certain aminoglycosidescarried ototoxic effects. As noted in the1945 Annual Report of the Section: “Dr.H.A. Brown has encountered a side effect


in the general use of streptomycin in that itaffects unfavorably the ear endorgan. Nosuitable explanation is available yet.”17 Sub-sequently, in 1964 it was documented that“Dr. Vrabec’s project done under Dr. Cody’sdirection produced a very valuable piece oforiginal research dealing with the concentra-tion of antibiotics in the perilymphatic fluidsof the labyrinth. The results indicate thereason for Streptomycin toxicity to the laby-rinth.”17 These early findings laid thegroundwork for the gentamicin injectionused today. That same year, Simonton andCody40 published their results of corticoste-roid therapy for the treatment of sensori-neural hearing loss.17

CHRONIC EAR DISEASEIn the pre-antibiotic era, the priority of oto-logic surgery was control of infection, andaural surgeons largely disregarded thethought of middle ear and tympanic mem-brane reconstruction for hearing improve-ment, particularly in patients withrecurrent acute or chronic infection.41

Furthermore, during this era, technologieswere primitive, audiological testing wasonerous and inaccurate, and the diseasedear was frequently left wasted by severeacute and chronic otitis media.

Between 1930 and 1970, surgery foracute and chronic ear disease evolveddramatically. Before the 1940s, radical mas-toidectomy was used nearly exclusively atMayo Clinic given its ability to reliably erad-icate disease and create a “dry and safe ear.”Because of the poor hearing outcome associ-ated with radical mastoidectomy, severalgroups in the early 1900s began to exploremore conservative mastoid approaches, leav-ing an intact and undisturbed tympanicmembrane and ossicular chain whenfeasible. Although several descriptions werepublished, the classic modified radical mas-toidectomy described by Bondy in 1910 isthe only lasting relic from these earlyyears.10 At the time of description, however,conservative mastoid surgery was out offavor, and it was not until the late 1930sthat Mayo Clinic and other centers in theUnited States considered the Bondy




FIGURE 8. Transcanal views of the right middle ear. A, The long andlenticular processes of incus are absent. A double loop wire prosthesis hasbeen used to unite the handle of malleus and the head of the stapes. B, Thelenticular process of incus is missing. A double loop wire prosthesis hasbeen used to unite the long process of incus and the head of the stapes.From Mayo Clin Proc.37 Reproduced with permission from the W. Bruce FyeCenter for the History of Medicine, Mayo Clinic, Rochester, Minnesota.


mastoidectomy a viable alternative to radicalmastoidectomy in select patients.41 Also dur-ing this time there was a change in the oper-ative incisions used. Before 1940, surgery forchronic ear disease at Mayo Clinic was per-formed through a standard postauricularincision. However, when endaural surgerywas popularized for lateral canal fenestrationby Lempert, endaural approaches for chronicear disease were used with greater frequencybecause it was believed that the incisioninherently made the middle ear more acces-sible.41,42 The postauricular incision was stillwidely used for extensive cholesteatoma,otogenic complications such as lateral sinusthrombosis, labyrinthectomy, and other op-erations in which the middle ear was notaccessed.

The 1950s and 1960s marked a secondsignificant turning point in the surgicaltreatment of chronic ear disease as outlinedin O. Erik Hallberg’s 1958 publication “Op-erations on the Middle Ear and Mastoid:Changing Aspects of Treatment in ChronicActive Disease.”41 Reflected in the casenumbers, obliterated cavity and intact canalwall surgeries were gaining favor given pa-tient preferences for avoiding an open cavityand demand for better hearing outcomes.41

During this decade, 740 classic modifiedradical and radical mastoidectomies wereperformed at Mayo Clinic e with nearly aneven distribution between the two.21 By1955, several of the surgeons were experi-menting with intact bridge mastoidectomyin select patients, a forerunner to the refinedintact canal tympanomastoidectomy popu-larized by House and Sheehy in the 1960s.By the 1960s, intact canal wall was usedwith greater frequency at Mayo Clinic. A1977 publication by Cody and Taylor re-ported that from 1963 to 1969, 40% of mas-toid operations were open cavity, 19% wereobliterated cavity, and 41% were intact canalwall operations.43

As Thane Cody outlined in a 1969 publi-cation in Mayo Clinic Proceedings, duringthis year there were 3 primary discoveriesthat drove the success of myringoplastyand tympanoplasty: (1) Wullstein’s descrip-tion of denuding the remnant tympanic


membrane and placement of a postauricularskin graft on the lateral surface in 1950; (2)Austin and Shea’s report of freshening theedges of the perforation and placing a veingraft medial to the remnant drum, supportedby absorbable gelatin sponge, in 1961; and(3) Storrs’ description of temporalis fasciause for tympanic membrane reconstructionthat same year, which proved more durablethan the former 2 techniques.37

Regarding restoration of the middle earsound-conducting mechanism, a variety ofmethods using autograft and homograftincus interposition and synthetic substrateswere devised.21,37,44,45 A favored method ofthe surgeons at Mayo Clinic in the 1960swas the use of a double loop wire prosthesis,where various defects, such as a long processof incus to head of stapes or head of malleusto head of stapes, could be reconstructed(Figure 8). In patients with an absentmalleus and incus with an intact stapessuprastructure, a myringostapediopexy wascommonly used with satisfactory results.37

In subsequent years, the incus interpositionand use of cartilage was used with increasingfrequency given lower rates of extrusion.Over time, improvements in titanium alloysand growing concerns over viral and priondisease transmission with allographic mate-rial led to a transition to manufactured mid-dle ear prostheses.46 Despite significant

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KEYBOARD

FREQUENCY

MID

DLE

C

64 72 80 85 96 107

120

128

144

160

171

192

213

240

256

288

320

341

384

427

480

512

576

640

683

768

853

900

1024

1152

1280

1365

1536

1707

1920

2048

2048

2308

2560

2731

3072

3413

3840

4096

5120

5461

6144

6827

7680

8192

F E E D D C C C B B

.138

.109

.088

.078

.327

.267

.214

.188

.150

.122

.107

.085

.069

.054

.510

.401

.325

.286

.228

.187

.148

.129

.101

.082

.073

.232

.189

.150

.131

.103

.084

.067

.057

.047

.037

.032

.026

.021

.018

.015

.187

.149

.130

.101

.082

.072

.057

.045

.037

.032INSTRUMENT

SETTING

NORMALHEARING

THRESHOLD

LEFTO

PATI

ENT

HEA

R-IN

G R

EAD

ING

RIGHTX

NO. RADIOEAR - AUDIOMETER:

RADIOEAR - MUSIC: VOICE:AUDIOMETER-2A:

PERCENT LOSS INSPEECH RANGE

EARLEFT

RIGHT

AUD. MUSIC

45 50 60 60 65 65 70 75 80 80 80 85 85 90 90 95 95 95 100

100

100

100

100

100

100

110

110

110

110

110

115

120

110

110

100

100

100

100 95 95 95 90 85 85 75 70 65 65 55 55

NORMALHEARING

20100

102030405060708090

100110120130

CURVES = NORMAL THRESHOLD MINUS PATIENT

+

–

20100

102030405060708090

100110120130

+

-

SEN

SATI

ON

UN

ITS

TOTAL LOSS OF SERVICEABLE HEARING

SPEECH RANGE · TO COMPUTE PERCENTAGE LOSS IN THIS RANGE MULTIPLY AVERAGE LOSS IN SENSATON UNITS BY OB

HEARING READING. E.A.MYERS & SONS, PGH, PA

FIGURE 9. Audiogram worksheet intended for use with the Radioear dual audiometer type DO-25. The Radioear dual audiometertype DO-25 was supplied to Mayo Clinic in 1930 and was capable of reproducing the tones and half-tones of the piano. In addition tothese tonal frequencies, the audiometer integrated a phonograph for measuring the level at which music was heard and a microphonefor testing speech recognition.7,48 Reproduced with permission from the W. Bruce Fye Center for the History of Medicine, MayoClinic, Rochester, Minnesota.


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strides in prosthesis development, consistentsatisfactory air-bone gap improvement re-mains an elusive goal in otologic surgeryeven today, particularly with total ossicularchain reconstruction.

AUDIOLOGYAlthough Harold Lillie had experimentedwith objective measures to quantify hearinglevels as early as 1924, hearing acuity wasstill commonly assessed using imprecisemethods such as the whispered voice, watchtick, and tuning fork examination into theearly 1940s.17,47 For example, 6 tuning forkswere commonly used for gross audiometrictesting at octave intervals between 128 and


4096 Hz. Air and bone conduction thresh-olds were estimated using the Schwabachtest, where the difference between the pa-tient’s and the examiner’s thresholds weremeasured in seconds, and the Rinne test,where the difference in patient thresholdsfor air conduction and bone conductionwere examined via tuning fork.18 A cumber-some Radioear dual audiometer (E. A. Myers& Sons) was acquired by Mayo Clinic in1930 but was rarely used for clinical pur-poses because of the impractical design(Figure 9).7,48 At this same time, the dutyof vestibular testing was transferred to theresident physicians. Bithermal caloric testingwas performed using water irrigation at 95�F





and 101�F for 60 seconds, and the period ofnystagmus was timed.7 After a period of rest,rotational testing was performed in the hor-izontal and vertical planes. After the patientwas turned 10 revolutions, the resultingnystagmus was once again timed.

Beginning in the 1940s, the need forimproved audiovestibular diagnostic testingbecame increasingly apparent as the demandfor otosclerosis and vestibular surgery rosesteeply.17 Initially a graduate nurse, Mar-garet Thomas, began serving as an audiomet-rist, devoting 2 to 3 hours daily.7,17 Duringthis time, a General Electric 6-A audiometerand, subsequently, 2 Maico audiometerswere acquired for clinical audiometrictesting.7,48 Despite significant controversyin the otology field about the requirementfor a noise-insulated room for testing,Mayo Clinic chose to move forward withconstruction of a custom-built dedicatedsoundproof booth in 1947.17 The benefitsof dedicated testing facilities were soon real-ized, and 7 additional prefabricated soundsuites were installed in 1966.17 At a timewhen the field of audiology was still veryyoung, Williams presented to the Board ofGovernors a plan to establish an “audio-metric and hearing advice unit” in 1948. Ul-timately, after considerable deliberation,LeRoy D. Hedgecock, PhD, was hired asthe first dedicated consulting audiologist atMayo Clinic in 1949.7,48 Hedgecock servedas the head of the Department of Audiologythrough 1971, and during this time hetrained a complement of proficient audiolo-gists and audiometric technicians.48 Beforejoining Mayo Clinic, Hedgecock worked asa speech pathologist at Indiana Universityand the University of Minnesota from 1944to 1949. As a result of his previous experi-ences, Hedgecock introduced speech pathol-ogy to the Clinic practice in 1949 andspecialized in this field until JosephineSimonson, MA, Fredric L. Darley, PhD, andArnold E. Aronson, PhD, were appointedspeech-language pathologists in the Depart-ment of Neurology approximately 6 yearslater.7 After 1950, differential ice water calo-rics were used, and an observer would re-cord the presence, direction, and intensity


of induced nystagmus.7 Electronystagmogra-phy was first used in 1964, when Dr JackPulec converted a Swedish electrocardio-gram machine to detect corneal retinal po-tentials based on Nils Henriksson’s thesison electrical analysis of eye movements innystagmus in 1956.35 An apparatus wasdevised through the department of engineer-ing for administering alternate binauralbithermal calorics, a technique first reportedby Fitzgerald and Hallpike in 1942.49

Also during this time, between 1964 and1966, were the notable contributions ofThane Cody to the development of auditoryevoked myogenic and cortical potentials, pre-cursors to modern-day auditory brainstemresponse and vestibular evoked myogenic po-tential testing.50-52 In 1965, Cody and Bick-ford found that the intensity of pure toneswhen the scalp vertex response disappearedoffered an objective and accurate method ofassessing auditory levels in awake patientsor when in a moderate to deep sleep.53,54

Cody called this test cortical audiometry.55

These studies were performed approximately5 years before Jewett and Williston werecredited with describing the human auditorybrainstem response signature in 1971 and de-cades before vestibular evoked myogenic po-tentials were first used clinically.18,52

Together with Terry Griffing, MS, a clin-ical audiologist who joined the audiologystaff on June 1, 1959, Hedgecock developedand validated a screening test for the Minne-sota Preschool Survey of Vision and Hearing,the Verbal Auditory Screening for preschoolChildren (VASC), which gained widespreadadoption.17,56 The early success of the audi-ology program led to formal establishment ofthe Section of Audiology in the Departmentof Otolaryngology in 1972.17 By this time,the newly formed division was already per-forming 13,000 audiograms and 1800 elec-tronystagmography tests annually. In 2001the Section of Audiology was formallyrenamed the Division of Audiology.48

NEUROTOLOGYAlthough otology remains the focus of thisreport, the history of otologic surgeryat Mayo Clinic would not be complete

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FIGURE 10. Illustration from 1934 depictingwide suboccipital craniectomy for resection of aleft-sided vestibular schwannoma using thetechnique of piecemeal intratumoral debulkingfollowed by capsule dissection. Reproducedwith permission from the W. Bruce Fye Centerfor the History of Medicine, Mayo Clinic,Rochester, Minnesota.


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without reference to the co-development ofneurotology and modern lateral skull basesurgery. The Mayo Clinic Department ofNeurosurgery is one of the oldest and largestneurosurgical programs in the country.57

Before the 1960s, vestibular schwannomasurgery remained largely within the purviewof the Department of Neurosurgery, per-formed exclusively through a suboccipitalapproach (Figure 10).58 Dr Jack Pulec wasthe first fellowship-trained neurotologist tojoin Mayo Clinic. Before joining the staff in1964, Pulec completed fellowship trainingat the Otologic Medical Group in LosAngeles during the time when Drs WilliamHouse and William Hitselberger wererefining the subtemporal middle fossa andtranslabyrinthine approaches for vestibularschwannoma resection with the aid of theelectric drill and operative microscope(Figure 11).59-61 After his fellowship, Pulecwas eager to establish a similar collaborationbetween the neurotologist and the neurosur-geon, believing that patients would benefitfrom the combined expertise of these com-plementing specialties.35 During the 5 yearsthat Jack Pulec was on staff he collaboratedwith several key members of the neurosur-gical department, including Dr Albert


Rhoton Jr. Through this collaboration,several seminal papers on microanatomy ofthe facial nerve and posterior fossa microsur-gery were completed.62,63 Jack Pulec had avery strong interest in facial nerve tumorsand compiled the largest series of thetime.64,65 He also first described the com-bined mastoidemiddle cranial fossaapproach for removal of facial nerveschwannomas.64

This strong partnership between neuro-tology and neurosurgery toward treatmentof skull base disease, in particular vestibularschwannoma, has strengthened over theyears through collaborations with severalkey neurosurgical colleagues, including DrAlbert Rhoton Jr, Edward R. Laws Jr,Michael J. Ebersold, and, currently, DrsMichael J. Link and Jamie J. Van Gompel.Mayo Clinic was the third center in theUnited States to install a Leksell GammaKnife unit for radiosurgery in 1990, and itcurrently remains one of the few centers toequally employ radiosurgery, microsurgery,and conservative observation for the approx-imately 150 new vestibular schwannomaconsultations performed each year. Mostrecently, in February 2018 the Departmentof Otorhinolaryngology received approvalfrom the Accreditation Council for GraduateMedical Education for a fellowship programin neurotology and lateral skull base surgery.

COCHLEAR IMPLANTATIONAlthough there have been a variety ofnotable accomplishments in the field of otol-ogy in the past century, in recent years thespecialty has been primarily defined by inno-vations in the surgical treatment of sensori-neural hearing loss. Before the invention ofcochlear implants, patients with advancedbilateral deafness from congenital, sudden,or progressive sensorineural deficits wereleft with no hope of aural rehabilitation.Cochlear implantation marks one of thegreatest modern technological innovationsnot only within the specialty but also in allof medicine, as deafness remains the onlysense that can be dependably restored.

The modern period of otologic surgery atMayo Clinic was inaugurated by the first




FIGURE 11. Illustrations from 1967 depicting the translabyrinthine approach for resection of a left-sidedvestibular schwannoma. Reproduced with permission from the W. Bruce Fye Center for the History ofMedicine, Mayo Clinic, Rochester, Minnesota.


cochlear implant surgery performed atRochester Methodist Hospital on December17, 1982, by Dr George Facer.48 Most ofthe early cochlear implant surgeries used asingle electrode placed at or just throughthe round window membrane. During thesefirst years, the number of cochlear implantsurgeries performed was sparse because pa-tient benefit was largely restricted toenhanced lip reading, voice modulation,and recognition of limited environmentalsounds, while open set speech recognitionwas uncommon.

On November 26, 1984, the first single-channel cochlear implant system wasapproved by the Food and Drug Administra-tion for adults with bilateral profound postlin-gual deafness. Subsequently, in October 1985the first multichannel cochlear implant wasapproved in the United States. Single-channeldesigns were soon replaced by multichannelcochlear implants after witnessing the benefitsof improved spectral perception and open setspeech recognition. Over time, candidacycriteria have expanded and now include


children and adults with greater degrees of re-sidual hearing.66

More recently, cochlear implantation hasdemonstrated benefit even in subgroups ofpatients with retrocochlear pattern hearingloss, a condition that has traditionally beenconsidered a contraindication to implanta-tion. Mayo Clinic continues to be a leadingcenter for cochlear implant research inneurofibromatosis type 2 and auditory neu-ropathy.67-69 In the most recent years, theuse of cochlear implantation for the treat-ment of single-sided deafness and intractabletinnitus has become a major focus of atten-tion.70 Since the first cochlear implant sur-gery was performed at Mayo Clinic in1982, cochlear implantation has remained amajor focus of the department. The 1000thcochlear implant was performed on August30, 2013, and each year more than 150 pa-tients undergo implantation.

CONCLUSIONThis historical account serves to commemo-rate a formative period in the history

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of otologic surgery at Mayo Clinic and toremember the contributions of our predeces-sors. This narrative also illustrates the impor-tance of continuous innovation and discoveryto ensure the growth and advancement of ourspecialty. From the treatment of life-threatening complications of acute suppura-tive otitis media in the pre-antibiotic era tothe management of profound sensorineuralhearing loss in more recent years, the historyof otology has been marked by innovation,driven by a force of dedicated physician-scientists.

ACKNOWLEDGMENTSWe thank Nicole M. Tombers, RN, Depart-ment of Otolaryngology; Nicole L. Babcock,W. Bruce Fye Center for the History of Med-icine; Emily J. Christopherson, HistoricalUnit; and Brenda S. Lindsay, Division ofBiomedical and Scientific Visualization, allat Mayo Clinic, for their assistance withacquiring historical documents and illustra-tions relevant to this article.

SUPPLEMENTAL ONLINE MATERIALSupplemental material can be found online athttp://www.mayoclinicproceedings.org. Sup-plemental material attached to journal articleshas not been edited, and the authors take re-sponsibility for the accuracy of all data.

Potential Competing Interests: Dr Carlson is a consultantfor MED-EL GmbH.

Correspondence: Address to Matthew L. Carlson, MD,Department of OtolaryngologyeHead and Neck Surgery,Mayo Clinic, 200 First St SW, Rochester, MN 55905([email protected]).

REFERENCES1. Carlson ML, Olsen KD. The history of otorhinolaryngology at

Mayo Clinic. Mayo Clin Proc. 2017;92(2):e25-e45.2. Braasch WF. Early Days in the Mayo Clinic. Springfield, IL: Charles

C Thomas; 1969.3. Keys TE, Key JD. An overlooked tribute for Dr. William Worrall

Mayo. Minn Med. 1984;67(7):375-378.4. Bradley J. Matters of priority: Herbert Mayo, Charles Bell and

discoveries in the nervous system. Med Hist. 2014;58(4):564-584.

5. Carlson ML, Bradley J, Van Gompel JJ, Tubbs RS. The disputeddiscovery of facial and trigeminal nerve function: revisiting thecontributions of Herbert Mayo and Charles Bell. Otol Neurotol.2017;38(9):1376-1381.


6. Mayo Clinic. Sketch of the History of the Mayo Clinic and theMayo Foundation. Philadelphia, PA: WB Saunders Co; 1926.

7. Mayo Historical Unit. MHU 0670: Simonton, KM. Otolaryn-gology and Head and Neck Surgery at the Mayo Clinic 1885-1970. General and Staff Memoir Collection. Box 13; Folder243. W. Bruce Fye Center for the History of Medicine. MayoClinic, Rochester, MN.

8. Mayo CH. Medicine in retrospect. Ann Otol Laryngol. 1928;37:206.

9. Lustig LR. Anesthesia, antisepsis, microscope: the confluence ofneurotology. Otolaryngol Clin North Am. 2007;40(3):415-437, vii.

10. Mawson SR. Surgery of the mastoid: the first centenary. Proc RSoc Med. 1975;68(6):391-395.

11. Sunder S, Jackler RK, Blevins NH. Virtuosity with the mallet andgouge: the brilliant triumph of the “modern” mastoid operation.Otolaryngol Clin North Am. 2006;39(6):1191-1210.

12. Mayo Clinic. Physicians of the Mayo Clinic and the Mayo Founda-tion. Minneapolis: University of Minnesota Press; 1937.

13. Mayo WJ. Mastoid abscess: opening of mastoid cells. NorthwestLancet. November 15, 1886.

14. Mudry A. History of instruments used for mastoidectomy.J Laryngol Otol. 2009;123(6):583-589.

15. Mayo CH. A contribution to cerebral surgery: report of twocases. Northwest Lancet. 1891;xi:59-60.

16. Mayo Historical Unit. MHU-0002: Annual Report to the Boardof Governors. Box 072; Subgroup 02; Series 03, Subseries 07;Folders 016-048. W. Bruce Fye Center for the History of Med-icine. Mayo Clinic, Rochester, MN.


18. Olsen WO. A historical perspective of hearing tests of periph-eral auditory function. J Am Acad Audiol. 1990;1(4):209-216.

19. Mudry A. The history of the microscope for use in ear surgery.Am J Otol. 2000;21(6):877-886.

20. Moberly AC, Fritsch MH. The evolution of mastoidectomy andtympanoplasty. Laryngoscope. 2010;120(suppl 4):S213.

21. Cottrell RE, Pulec JL. Modified radical and radical mastoidec-tomy: long-term results. Laryngoscope. 1971;81(2):193-199.

22. Beales PH. Otosclerosis: past and present. J Roy Soc Med. 1979;72(8):553-561.

23. Shea JJ. A personal history of stapedectomy. Am J Otol. 1998;19(5 Suppl):S2-S12.

24. Cody DT, Simonton KM, Hallberg OE, Hedgecock LD. Stape-dectomy for otosclerosis: an analysis of results. Mayo Clin Proc.1965;40(10):740-744.



27. Shelden CH, Horton B. Treatment of Ménière’s disease withhistamine administered intravenously. Proc Staff Meet MayoClin. 1940;15:17.

28. Furstenberg A, Lashmet F, Lathrop F. Meniere’s symptom com-plex: medical treatment. Ann Otol Rhinol Laryngol. 1934;43:1034-1046.

29. Williams HL. The medical treatment of Meniere’s disease. ArchOtolaryngol. 1955;62(6):573-578.

30. Dandy W. The surgical treatment of Meniere’s disease. SurgGynecol Obstet. 1941:421-425.

31. Altmann F. Surgical treatment of Meniere’s disease. Laryngo-scope. 1949;59(10):1045-1067.

32. Cawthorne T. The treatment of Meniere’s disease. J LaryngolOtol. 1943;58:363-371.



mailto:[email protected]




33. Day K. Labyrinth surgery for Meniere’s disease. Laryngoscope.1943;53:617.

34. Portmann G. Vertigo-surgical treatment by opening the saccusendolymphaticus. Arch Otolaryngol. 1927;6:309-319.

35. Brookler KH, Rubin W, Claussen C, Shulman A. In memoriam:Jack L. Pulec. Int Tinnitus J. 2004;10(1):8-12.

36. Cody DT, Simonton KM, Hallberg OE. Automatic repetitivedecompressionof the saccule in endolymphatic hydrops (tack oper-ation): preliminary report. Laryngoscope. 1967;77(8):1480-1501.

37. Cody DT. Reconstruction of the transformer mechanism of themiddle ear. Mayo Clin Proc. 1969;44(4):232-251.

38. Cody DT. The tack operation. Arch Otolaryngol. 1973;97(2):109-111.

39. Cody DT, McDonald TJ. Tack operation for idiopathic endolym-phatic hydrops: an update. Laryngoscope. 1983;93(11):1416-1418.

40. Simonton K, Cody TD. The effects of corticosteroids on certaincases of sensori-neural hearing loss. Paper presented at: Pan-American Congress of Otolaryngology and Broncho-Esophagology; Bogota, Columbia 1964.

41. Hallberg OE. Operations of the middle ear and mastoid: chang-ing aspects of treatment in chronic active disease. Cal Med.1958;89(2):101-106.

42. Lillie HI, Simonton KM. The mastoid incision; endaural or post-auricular? Surg Clin North Am. 1949;29(4):1093-1096.

43. Cody D, Taylor W. Mastoidectomy for acquired cholestea-toma: long-term results. In: McCabe BF, Sade J, Abramson M,eds. Cholesteatoma: First International Conference. New York,NY: Aesculapius Publishers Inc; 1977:337-351.

44. Cody DT, Taylor WF. Tympanoplasty: long-term hearing re-sults with incus grafts. Laryngoscope. 1973;83(6):852-864.

45. Pulec JL. Symposium on tympanoplasty, I: homograft incus.Laryngoscope. 1966;76(8):1429-1438.

46. Martin AD, Harner SG. Ossicular reconstruction with titaniumprosthesis. Laryngoscope. 2004;114(1):61-64.

47. Lillie H, Kranz F. A quantitative study of hearing with andwithout cotton plug prosthesis in the middle ear. Ann Otol Rhi-nol Laryngol. 1924;33:458-471.

48. Olsen WO, Rose DE, Hedgecock LD. A brief history of audi-ology at Mayo Clinic. J Am Acad Audiol. 2003;14(4):173-180.

49. Fitzgerald G, Hallpike CS. Studies in human vestibular function,1: observations on the directional preponderance (“nystagmus-bereitschaft”) of caloric nystagmus resulting from cerebral -le-sions. Brain. 1942;65(2):115-137.

50. Cody DT, Jacobson JL, Walker JC, Bickford RG. Averagedevoked myogenic and cortical potentials to sound in man. TransAm Otol Soc. 1964;52:159-176.

51. Townsend GL, Cody DT. The averaged inion response evokedby acoustic stimulation: its relation to the saccule. Ann Otol Rhi-nol Laryngol. 1971;80(1):121-131.

52. Zhou G, Cox LC. Vestibular evoked myogenic potentials: his-tory and overview. Am J Audiol. 2004;13(2):135-143.


53. Cody D, Bickford R. Cortical audiometry: an objective methodof evaluating auditory acuity in man. Mayo Clin Proc. 1965;40:273-287.

54. Cody DT, Klass DW, Bickford RG. Cortical audiometry: an objec-tive method of evaluating auditory acuity in awake and sleepingman. Trans Am Acad Ophthalmol Otolaryngol. 1967;71(1):81-91.

55. Cody D. Assessment of the newer tests of auditory function.Ann Otol Rhinol Laryngol. 1968;77(4):686-705.

56. Griffing TS, Simonton KM, Hedgecock LD. Verbal auditoryscreening for preschool children. Trans Am Acad OphthalmolOtolaryngol. 1967;71(1):105-111.

57. Spinner RJ, Al-Rodhan NR, Piepgras DG. 100 years of neuro-logical surgery at the Mayo Clinic. Neurosurgery. 2001;49(2):438-446.

58. MacCarty CS. Acoustic neuroma and the suboccipitalapproach. Mayo Clin Proc. 1968;43(8):576-579.

59. Hitselberger WE, House WF. Transtemporal bone micro-surgical removal of acoustic neuromas: tumors of the cer-ebellopontine angle. Arch Otolaryngol. 1964;80:720-731.

60. Pulec JL, House WF. Transtemporal bone microsurgical removalof acoustic neuromas: facial nerve involvement and testing inacoustic neuromas. Arch Otolaryngol. 1964;80:685-692.

61. Pulec JL, House WF, Hughes RL. Transtemporal bone micro-surgical removal of acoustic neuromas: vestibular involvementand testing in acoustic neuromas. Arch Otolaryngol. 1964;80:677-681.

62. Hall GM, Pulec JL, Rhoton AL Jr. Geniculate ganglion anatomyfor the otologist. Arch Otolaryngol. 1969;90(5):568-571.

63. Rhoton AL Jr, Pulec JL, Hall GM, Boyd AS Jr. Absence of boneover the geniculate ganglion. J Neurosurg. 1968;28(1):48-53.

64. Pulec JL. Facial nerve tumors. Ann Otol Rhinol Laryngol. 1969;78(5):962-982.

65. Pulec JL. Facial nerve neuroma. Laryngoscope. 1972;82(7):1160-1176.

66. Carlson ML, Driscoll CL, Gifford RH, McMenomey SO.Cochlear implantation: current and future device options. Oto-laryngol Clin North Am. 2012;45(1):221-248.

67. Breneman AI, Gifford RH, Dejong MD. Cochlear implantationin children with auditory neuropathy spectrum disorder: long-term outcomes. J Am Acad Audiol. 2012;23(1):5-17.

68. Carlson ML, Breen JT, Driscoll CL, et al. Cochlear implantation inpatients with neurofibromatosis type 2: variables affecting audi-tory performance. Otol Neurotol. 2012;33(5):853-862.

69. Carlson ML, Neff BA, Sladen DP, Link MJ, Driscoll CL.Cochlear implantation in patients with intracochlear andintralabyrinthine schwannomas. Otol Neurotol. 2016;37(6):647-653.

70. Sladen DP, Frisch CD, Carlson ML, Driscoll CL,Torres JH, Zeitler DM. Cochlear implantation for single-sided deafness: a multicenter study. Laryngoscope. 2017;127(1):223-228.

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The History of Otologic Surgery at Mayo Clinic, 1883 to ... · The earliest beginnings of otology at Mayo Clinic can be traced to Dr William Worrall Mayo, who was born in Eccles,