- Non-surgical, minimally-invasive procedure performed by an interventional radiologist
- Involves the selective occlusion of blood vessels by purposely introducing emboli
Therapeutic applications in ENT
- Pre operatively for vascular tumors to occlude blood supply
- Occlude arteriovenous malformations (AVMs)
- Cerebral aneurysm
- Uncontrollable epistaxis
- Surgical hemorrhage
- ABC Maxilla, mandible
- Glomus tumors
- Carotid body tumors
- Maxillary artery
- Specific branch of maxillary artery
- Under LA
- Access to the organ in question is acquired by means of a guidewire and catheter(s) entered thru femoral artery
- Position of the correct artery or vein supplying the pathology in question is located by digital subtraction angiography (DSA)
- These images are then used as a map for the radiologist to gain access to the correct vessel
- Artificial embolus used is usually one of the following
- Coils – Made of platinum or stainless steel with Dacron wool tails which induces clot
- Polyvinyl alcohol Particles 50-1200 um in size
- Gelfoam à temporary, dissolve in approx.. 5 wks
- Detachable balloon
- Once the artificial emboli have been successfully introduced, another set of DSA images are taken to confirm a successful deployment.
- In case occlusion of internal carotid artery is planned then collateral circulation to brain must be first tested by Endovascular Balloon Occlusion Test (Mata’s test) to prevent stroke
- Minimally invasive
- No scarring
- Minimal risk of infection
- No or rare use of general anesthetic
- Faster recovery time
- High success rate compared to other procedures
- Preserves fertility and anatomical integrity
- User dependent success rate
- Risk of emboli reaching healthy tissue e.g. CVA, limb ischaemia
- Increased chances of recurrence in JNA
Father of Modern Otology
(for more interesting topics, visit www.nayyarENT.com )
The Julius Lempert story occurred in the early part of the 20th century. It would be an impossible accomplishment in the 21st century. The son of Mischa and Anna Lempert, Julius was born in Lublin, Poland, on July 4, 1891. Not much is known about the boy’s early years.
Most accounts start at age 13 when Julius joined a student protest march, was arrested by the police, and thrown in prison. Mischa moved the family to New York City on May 30, 1905 due to the unrest in Poland. They would have been from the Polish middle class whereas most Russian and Polish immigrants were peasants. Mischa published a Yiddish newspaper and settled the family on Delancey Street on the Lower East Side of Manhattan. Julius’s father died at age 35 and Anna took over the running of the paper. Julius had three sisters, Rose, Hanna, and Belle. Belle was Julius’s favorite.
Anna was partial to Julius and doted on him, often ignoring her daughters. All four children walked across the Brooklyn Bridge to school. Julius was a small child and his adult height was barely five feet four inches. He worked around his neighborhood doing odd jobs to add to the family’s finances. Since he was so diminutive, he was often the brunt of bullies. To walk through the tough neighborhoods he would pay for protection.
He grew up with a set of friends who eventually became famous entertainers. Among them was Billy Rose, the songwriter-Broadway producer whose first wife was Fannie Brice (Funny Girl). Lempert was friends with Brice as well as Claudette Colbert, Danny Kaye, and Florenz Ziegfelt of the Ziegfelt Follies.
In 1913, Julius went directly from high school to Long Island Medical School, as in those days college was not a requirement. Unfortunately, at that time, the school was considered a class C institution (3rd rate) and that prevented Julius from obtaining an internship. Without an internship it was impossible for him to enter a residency program for specialization. That meant he would always be considered a general practitioner. Somewhere along the way he decided he wanted to become an ear, nose, and throat specialist. Since he was not eligible for a residency, this presented a major problem. His solution was to visit the different programs in the city as an observer. He would go to the clinics and watch over the shoulders of the doctors as they saw patients. He also went to surgery and observed operations.
In 1919, Julius became an American citizen. He continued to visit the Manhattan Eye and Ear Infirmary, Mount Siani, Columbia, and NYU residency programs. By 1924 he had worn out his welcome all over the city and was asked not to return to any of these institutions. Bitter and disillusioned, he opened an office near Greenwich Village. Then he sent an announcement to every physician in Manhattan and the Boroughs stating that he would send half of any fee he collected back to the referring doctor. While this was frowned upon by the medical profession, he immediately became the busiest ENT surgeon in the city. In those days the specialty of ear, nose, and throat consisted on removing tonsils and adenoids, sub-mucous resection of a deformed nasal septum, and radical mastoid procedures for chronic and acute infections of the ear. Julius would perform hundreds of operations a day.
He practiced assembly-line surgery. He would seat patients around the walls of a huge room and have an assistant inject the tonsils with a local anesthetic. Then Julius would follow behind the assistant and remove the tonsils and adenoids. His financial worries were over as he began to make enormous amounts of money. He purchased a Cadillac limousine and was chauffeured around Manhattan. Since he was a fee-splitter, the other ENT specialist would have nothing to do with him. His friends were all in show business. He was making so much money that he began to back Broadway plays and musicals, increasing his wealth.
In 1930, Lempert married Florence (Flo) Kennedy of the Ziegfeld Follies. She was six feet tall. Anna never accepted Flo as a daughter-in-law because she was Irish. Julius and Flo’s son, Mischa, was born in 1932. While shunned by most surgeons, Julius was allowed to operate at the Manhattan Eye and Ear.
In 1929, mastoid surgery was routinely performed using a mallet and gouge. This was a crude method that had been handed down from the 19th century. The rate of complications was high. Facial nerves were severed and hearing destroyed in a high percentage of cases. Julius decided that it would be better to open the mastoid with a dental drill rather than a mallet and gouge. The head nurse of the operating room was horrified. She went to the chief of surgery and Lempert was asked to leave the operating room. Another surgeon finished the surgical procedure. Ironically, all mastoid procedures today are performed with variations of the dental drill. Since he was not allowed to operate in any of the cities’ hospitals, Julius decided to open his own near Lenox Hill Hospital. He called it the Lempert Institute of Endaural Surgery . Lempert filled the institute with countless original oil paintings, some worth thousands of dollars. He continued to enjoy a busy practice and began to gravitate to more and more ear procedures. He did hundreds of mastoid operations.
There are two basic surgical incisions used to expose the mastoid process of the ear: the post-auricular incision made behind the pinna and the endaural made in the ear canal. Julius wore a specially designed headlight for illumination. All other surgeons continued to use the overhead light of the operating room which was inadequate for most procedures. Julius also wore magnifying loops so he could see well. The loop and headlight were the precursors of the modern day operating microscope used by many different specialties.
Otosclerosis à During the early part of the 20thcentury, this diagnosis resulted in the recommendation of a hearing aid. These instruments were very large and unsightly. There were surgeons in Europe who were beginning to perform surgical procedures to improve hearing in patients with otosclerosis. Rather that attack the fixed stapes, they chose to make an opening in the lateral semi-circular canal of the inner ear balance system. This exposed the fluids of the inner ear to outside sound waves. In 1922, Holmgren (Sweden) performed a series of these cases with success using an operating microscope and sterile technique. Before Holmgren’s work, most surgeons felt to open the inner ear would result in total deafness and possibly meningitis. Holgremn performed his surgical procedure in three stages. Sourdille (France) was impressed with Holmgren’s work and simplified the operation by completing it in two steps. Sourdille reported his cases in the United States in 1937. Lempert was in the audience and was impressed by what he heard. Lempert went on to develop what was known as the one stage fenestration of the lateral semi-circular canal and began having exceptionally good results. In the late 1930s, no U.S. surgeon was performing any type of surgery for otosclerosis. Stories began to circulate around New York City about Lempert’s success with fenestration. In 1938, Lempert reported 23 cases of hearing restoration. The first prominent U.S. otologist to observe Lempert was George Shambaugh, Jr. of Chicago. He went to Manhattan for that purpose in late 1938. Soon there was a constant stream on ear surgeons visiting Lempert.
The demand became so great that Lempert instituted a temporal bone course in order to train his visitors. Lempert gave two courses a year at a cost of two thousand dollars. Temporal bone courses continue to be offered at various clinics and universities today. The students would work in the lab and observe Lempert in the surgical suite. At the end of each day, Lempert and Flo would take the doctors to the 21 Club for dinner. After eating, Julius handed out fine Cuban cigars. As the group filed out of the restaurant, Lempert would ask all the employees of the establishment (chiefs, waiters, hat-check girls) to line up and he’d pass out twenty dollar bills. This was at the height of the Great Depression.
Two prominent New York surgeons, Freisner and Kepitske were still recommending hearing aids for their patients with otosclerosis. As stories of Lempert’s success reached them, Kepitske decided to visit Lempert. He was so impressed with what he saw that he suggested the two of them report the work at an upcoming meeting of the American Otological Society. The AOS was and remains the senior organization representing ear surgeons and membership is by invitation. Kepitske presented Lempert’s work as his own, never mentioning Lempert. Julius was in the audience at the time. Dr. Mosier was the chief of service at the Massachusetts Eye and Ear Infirmary and a member of the Council of the AOS. A notorious anti-Semitic, he nonetheless took it upon himself to call an emergency meeting of the Council. The governing body of the AOS demanded that Dr. Kepitske appear before them that evening. The Council threw Dr. Kepitske out of the AOS on the spot.
In 1940, Leonard Firestone (Firestone Tire Company) went to see Lempert because he’d been diagnosed with otosclerosis. Julius confirmed the diagnosis and stated that he could improve Mr. Firestone’s hearing. Lempert’s method of establishing a fee depended upon the individual’s annual income. Lempert would refer the patient to his secretary who would set the fee. When she asked Mr. Firestone what his annual salary was, he told her it was none of her business. At an impasse, the poor woman didn’t know what to do. Mr. Firestone solved her problem by saying that he would pay twenty-five thousand for the operation and if it was successful, he would up it to a total of one hundred thousand and donate it to a charity of Lempert’s choosing. The operation was immensely successful and the donation was used for the founding of the current Deafness Research Foundation.
Julius’s son, Mischa, died of leukemia in 1942. Flo and Julius became depressed and Flo began to drink heavily. In 1948, Anna Lempert died at age 82. Even though Lempert never had an official ear, nose, and throat residency, he was given his credentials by the American Board of Otolaryngology. He became a member of the American Academy of Ophthalmology and Otolaryngology and the Triologic Society.
One of the most famous surgeons in New York City at the time was a man by the name of Samuel Rosen. He came to visit Julius Lempert on numerous occasions. The two men were like oil and water. Lempert disliked Rosen from the moment they first met. When Rosen wanted to watch Lempert operate, Julius would try to block his view. By the early 1950, Rosen had developed a procedure known as the stapes mobilization operation in which the surgeon lifted the eardrum and placed an instrument on the stapes bone, then broke it free so that the patient heard immediately. This procedure was done through the ear canal and was much less of an operation than the fenestration. It could be performed under local anesthesia. Rosen was becoming famous for his operation. Unfortunately, most patients had a re-fixation of their stapes within a few months resulting in a return of their hearing loss.
Then in the late 1950s, John Shea Jr. of Memphis, Tennessee, boldly removed the stapes and replaced it with a plastic strut over a vein covering the open oval window. His results were outstanding and withstood the test of time. Faced with competition from Rosen and Shea, Lempert refused to recognize either operation. His practice suffered and he was forced to sell his hospital. He moved into a small office on 5th Avenue in 1961. He continued to perform fenestrations, but the stapedectomy procedure of Shea was far superior and patients gravitated to surgeons who could perform that operation.
By 1962, Lempert was in trouble with the Internal Revenue Service. He slowly slipped into a deep depression followed by an early form of dementia. He was institutionalized in 1963 and died on December 14, 1968. A memorial service was held for him on January 5, 1969. Almost all of the surgeons whom Lempert trained came to honor their mentor. The list of surgeons who were influenced by Lempert is impressive. Most went on to become famous in their own right and trained a whole generation of young otologist.
George Shambaugh, Jr. was one of Lempert’s first students. He was associated with Northwestern University in Chicago and authored a classic text on surgery of the ear. It is still in print.
Howard House trained with Lempert in 1940. Dr. House founded the famous House Ear Clinic and the House Research Institute in Los Angeles. He trained numerous young doctors over the years and his younger brother, William F. House, developed the first Cochlear Implant.
Tom Rambo of the “Rambo Procedure” practiced with Lempert before Lempert began to deteriorate. He like all of Lempert’s students gravitated to the stapedectomy operation of Shea.
Gordon Hoople became the chief of service at John Hopkins University. Shirley Baron developed a successful otologic practice in San Francisco and was associated with the University of California in that city.
Philip Meltzer worked at the Massachusetts Eye and Ear Infirmary and trained many residents in the principals of ear surgery. Richard Bellukei was associated with the Manhattan Eye and Ear Infirmary and was an inventive surgeon who developed several surgical instruments that still bear his name.
Harry Rosenwasser worked in New York City and was the first surgeon to describe the glomus tumor of the middle ear. Michael Kos was the residing otologist at the University of Iowa in Iowa City. Two research doctors who worked closely with Lempert were Merle Lawrence and Dorothy Wolf. Both of these individuals made countless basic science discoveries related to the ear.
Julius Lempert’s contributions to otology were numerous. He developed the one stage fenestration operation for otosclerosis and proved it was safe to operate on the inner ear to improve hearing. He introduced the dental drill for mastoidectomy. As a precursor to the operating microscope, he employed a bright headlight and magnifying loops so he could see well. Lempert shared his knowledge and trained a whole generation of temporal bone surgeons, many of whom trained the next generation. He made some of the first motion pictures of ear, nose, and throat surgery and was instrumental in the founding of the Deafness Research Foundation. Julius Lempert received many awards. He was given the Award of Merit of the American Otological Society although never admitted to the organization. He won the Gold Metal Award of the American Medical Association, an honorary M. D. from the Karolinska Institute in Stockholm, and the Royal Order of Vasa Knighthood First Class bestowed by the King of Sweden. He became a fellow of the New York Academy of Science. The Brazilian government awarded him the Cruzeiro do Sul and the International College of Surgeons bestowed the Edwon and Hanna Speidel Award. He was given a citation by the United States Department of Defense and made an Honorary Fellow of the Society of Military Otolaryngologists.
This poorly trained physician went on to become the most famous otologic surgeon in the world, and was written up in many newspapers and magazines such as the Reader’s Digest. Patients from the United States and Europe traveled to his hospital for treatment. What makes Lempert’s story unique are the many obstacles he had to overcome to reach the status of world-renowned otologist. He went to a third-rate medical school and had no formal training in the diagnosis and treatment of ear, nose, and throat problems. He was basically a general practitioner. He was Jewish in an era of rampant anti-Semitism. He had no financial backing, was dirt poor, and jumpstarted his practice by splitting fees.
Yet, by any measure, he was the father of modern otology.