MASS EYE & EAR - 200TH ANNIVERSARY

Mass Eye and Ear 200th Anniversary Herbert Silverstein MD, FACS

Mass Eye and Ear 200th Anniversary Herbert Silverstein MD, FACS Silverstein Institute President Ear Research Foundation

Why I Love Mass Eye and Ear Herbert Silverstein MD, FACS Why I LOVE MEE

WHY I LOVE MASS EYE AND EAR

Sixty-one years ago, I walked into MEE as a first-year resident applicant. MEEI was considered one of the best hospitals to train for otolaryngology. I never thought it possible to be accepted there. And no way that I could envision I would be standing here at the 200th anniversary celebration.

Sixty-one years ago SixtySixty I walked into the Mass Eye and Ear Infirmary No way I could have imagined being here for the 200th year celebration of the MEE

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Gene Myers who was one year ahead of me at Temple U medical school advised me to apply to MEEI where he was training. I was ready to go to Temple U for my residency with Gene’s Father, David Myers who was head ENT Dept there.

WHY I LOVE MASS EYE AND EAR

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My father was a professor of neurology at Temple, he encouraged me to do research while in Med school. I studied the vestibular system in cats.

Alexander Silverstein M.D.

Medical Family • My father was Neuropsychiatrist and professor at Temple University Medical School • Was always interested in research and encouraged me to pursue research

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I felt so honored to be accepted by Dr. Harold Schuknecht as a resident. Especially because I was 1.5 hours late for my interview. I got lost driving around Boston. Fortunately I had a successful interview and we had research using cats in common.

Harold Schuknecht, MD

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HFS was a world class histopathologist and author of three additions of Pathology of the ear.

Harold Schuknecht, MD • Chief of Otolaryngology, Mass Eye and Ear Infirmary, 1961 1961--1987

• World class histopathologist • Author of three editions of PATHOLOGY OF THE EAR 8

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He invented the fat wire prostheses for otosclerosis. He was a great teacher, surgeon and mentor. He always called me Herbie.

Harold Schuknecht, MD

• Invented fat wire prosthesis • Great teacher, surgeon, and mentor • Always called me Herbie 9

I owe my career mainly to Gene Myers, he was a mentor and friend who coached me through med school and residency. He tried to prevent me from making mistakes and screwing up.

Gene Myers, M.D. •Friend and mentor

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I was always interested in research and development.

I always liked to find the best and improved ways of doing things.

• I was always interested in research and development

I searched for ways to do procedures easier, using a more direct approach that was effective.

Three Principles of Innovation

•Easier •Direct approach • •Effective

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Dr. Schuknecht encouraged me to do research while in residency. He said, “Herbie I want you to be an expert in Meniere’s disease, and want you have a lab to do research on inner fluids which I think has something to do with the disease process. Here is $5000 to get started until you get an NIH grant. Also, Herbie it is very important that you make a contribution to science.” I had a research fellow and a technician to manage while being a fulltime resident.

• HFS encouraged me to do research • He offered me a lab to study inner ear fluids • Gave me $5000 • Herbie I want you to be expert in Meniere's disease • Very important to make contribution to science • I had a research fellow and technician

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Mike Paparella knew Sigur Rauch of Dusseldorf Germany and said I had to learn microchemical techniques from him. HFS sent me to Germany for three weeks to Sigur Rauch to learn how to analyze small samples of inner ear fluid.

The picture can't be displayed.

Mike Paparella M.D., F.A.C.S.

I worked till 10 or 11PM many nights and developed the diagnostic labyrinthotomy procedure or inner ear tap where we took inner ear fluid from patients’ to help diagnose acoustic neuroma.

Diagnostic Labyrinthotomy

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We could diagnose acoustic neuroma because there was a high perilymph protein concentration vs Meniere’s disease that had high potassium levels because of the endolymphatic hydrops. This was before MRI and CT scans.

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One day I was doing experiment on a cat trying to simulate a Meniere’s vertigo attack by putting endolymph type of fluid in the inner ear. HFS theory was that a rupture in the inner ear caused a flooding of perilymph space with high potassium endolymph that caused the vertigo attack in Menieres disease. The cat developed nystagmus like a Meniere’s attack. I was so excited that I ran to the private offices where HFS was seeing patients and interrupted him and said you have to come to the lab and see what I did. And he left patients and came with me to the lab up four floors .

Vertigo experiment in CAT • Put endolymph like fluid into cat inner ear • Developed Meniere like vertigo • Interrupted HFS while seeing patients and asked him to come to lab

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The energy at the MEEI was intense. Constantly looking for better ways to improve patients’ quality of life.

Energy at MEE was Intense

•To make quality of life better for patients As a first-year resident with Roger Lindeman a second year resident.

Roger Lindeman M.D.

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We developed the arrow tube which was one of the first flanged tubes to aerate the middle ear in chronic serous otitis media. The tube was designed to stay in place for months.

Serous Otitis Media “Arrow Tube” with Roger Lindeman

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At the same time, I developed an anesthetic of the Tympanic membrane which was pontocaine base powder dissolved in alcohol which we still used today for myringotomies.

Anesthetic of Tympanic Membrane • Pontocaine base power dissolved in alcohol • Worked for several hours • Still used today for myringotomy and PE tube

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Danny Miller who was surgeon at MEEI had residents on his service. Dr Schuknecht told the us that residents were supposed to be doing a significant portion of the surgery on private patients. Danny was doing a tympmastoid and after several hours he left the room, and turned it over to his associate.

Danny Miller M.D. • Surgeon MASS EYE and EAR

Tom Klein. I didn’t get to do anything during the case and complained bitterly to Dr Klein while he was kicking me under the table. Little did I know that the scrub nurse was Dr Millers personal nurse. Well, she went back to Danny and told him what I said. From then on Danny black balled me until Gene Myers who was Danny’s favorite saved me and Danny then let me start doing procedures again.

Tom Klein M.D.

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Sunday school was a great part of the residency training.

Gene was doing monkey business, training monkeys on Sunday and discovered by accident that Dr Schuknecht was looking at temporal bone slides on Sunday morning with his research fellows. Gene invited himself to the teaching sessions and told me to come also. We had a great time looking at slides trying to correlate the clinical picture and the pathology. At lunch time HFS would take us to the union Oyster bar. Where he would smoke a large cigar.

Sunday School • Studying Temporal bone histopathology with fellows and HFS

These were the golden years of otology and helped shape my career.

Golden Years of Otology

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Other People who helped mold me were Dick Gacek and Bill Montgomery, Mike Paparella and Nelson Kiang.

Dick Gacek was two years ahead of me in residency. He was a great teacher and researcher. After residency he went into the private offices with HFS and Monty. When House did the first cochlear implant I said this was the most important breakthrough in our specialty. Dick responded with buzz, buzz, buzz. We had an altercation about the importance of the cochlear implant.

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One day I asked Nelson a research question. He said sure I will see you here at 3 am. Of course I went there at three AM. Nelson Kiang PhD

My fellow residents were Joel Bernstein, MD, who was very interested in research, and we did many projects together. Joel went into private practice in Buffalo. Charlie Gross, MD became a professor at University of Virginia.

John Knowles, MD went to Vermont to practice. Peter Van Orman, MD went into private practice in a Boston suburb.

Residents 1966

• Joel Bernstein, M.D. • Charles Gross, M.D. • Peter Van Orman, M.D. • John Knowles, M.D.

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When I finished residency I was obligated to enlist in the Army for 2 years. But I was able to keep the research lab going at MEEI going while I was serving in Hawaii. After two years I came back to join the private office for three years.

After Residency

• Army 2 years • Kept MEE research lab going • Back MEE for three years

During my teaching years at MEE, I had the pleasure of taking KJ Lee a resident through his first tympanoplasty.

KJ was first to use computer punch cards to do clinical research. I knew then that KJ would be a leader in our field.

K.J. LEE and Bill Clinton

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Then I joined Gene Myers at U of P for three years. Gene got the chairmanship of University of Pittsburg and wanted me to join him.

Joined Gene Myers • University of Penn • •Had research lab • 3 years

At Penn, I met Jeff Harris, MD who was a medical student and told him to go MEE for his training. Look at what a great career he has had.

Jeff Harris M.D., F.A.C.S.

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In 1973, I decided to retire from academic medicine at 38 and move to Sarasota, Florida.

1973 • Herb retired at 38 from academic medicine to Sarasota

HFS was appalled by my choice and said what’s a Sarasota. Never heard of it. And you are no longer my favorite son. He wouldn’t speak to me for years.

• Dr. Schuknecht was appalled at my decision • What's a Sarasota??

• Would not speak to me for years 35

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I won back his respect after I invited him to be guest of honor at the first Neurological Surgery of the Ear meeting in Sarasota 1977.

Won Back HFS Respect • Made him guest of Honor at first Neurological Surgery of the Ear Symposium in Sarasota 1977

HFS surprised me at my 20th anniversary party of being in Sarasota by coming to roast me. He had details of my entire career.

HFS Surprised me 20th anniversary party

of my move to Sarasota He roasted me.

Remembered every detail of my life.

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When moving to Sarasota I was not welcomed by the ENT physicians, they told me that another ENT was not needed in this small town. But If I did come, I would be on my own with no coverage.

• Local ENT physicians said I was not needed, not wanted, and told to move on • No coverage 38

I had no money, an old corvette, and one suitcase.

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There was no place to rent but I found a 1000 sq ft storage closet in an ortho office that I renovated. The Bank lent me $100,000 on my signature. I took call 24/7. Somehow I persevered but retirement didn’t work out so well.

Started practice in Sarasota 1974 • No space to rent • Found 1000 sq ft closet to renovate into office • Borrowed $100,000 from bank • Took call 24/7 • Persevered

This was my first office, only kidding My First Office 1974

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I started the non-profit organization, the Ear Research Foundation in 1979. This was the original 1000 sq ft building.

Ear Research Foundation 1979

Our mission was doing Research into finding better ways to treat hearing loss and vertigo, Education of physicians and the public and community service taking care of indigent patients.

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This our 49th fellow Allan Young who is in practice in Las Vegas.

The Clinical fellowship program began in 1983, and this year we celebrated 50 fellows trained and 50 years in practice in Sarasota.

Clinical fellowship started 1983 • 50 fellows trained in Otology/ Neurotology • 50 years in practice •50 Sarasota

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This is the Schuknecht conference room with pictures of the 50 fellows.

Here are the fellows at recent 50-50 celebration.

50-50 Celebration

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This is the 30,000 sq ft Si building we built in 2003.

Silverstein Institute Occupied Feb 21, 2003

This is a 3-D picture of the building.

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Now after 50 years Gene and I are back together endowing chairs at MEE.

After 50 years

•Gene Myers and Herb Silverstein endowed chairs at MEE Gene recently visited me at Silverstein Institute.

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MEEI launched my career, and gave me the foundation to develop new treatments and surgical procedures.

Some of which I would like to show you now.

MEEI Launched My Career

Gave me foundation to develop new treatments and surgical procedures For long term middle aeration, the SPAT silicone tube was designed to go thru the bone of the ear canal into the middle ear. This procedure was patented and is still being used today.

Long-Term Middle Ear Aeration LongLong

• SPAT tube patented 1968 • Silicone rubber

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Drawing of procedure Transosseous SPAT tube Long--Term Middle Ear Aeration Long

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Picture of tube in place in Dr Wazen’s patient

SPAT Tube Through Scutum Right Ear

Dr. Jack Wazen’s patient 2017

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Training young docs to do surgery near the facial nerve prompted me to improve the Gaza facial nerve stimulator to a facial nerve monitor.

Facial Nerve Monitor 1985

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There was a Sensor attached to the face.

Mechanical Pressure Sensor

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A SACS device that electrifies the drill to help identify the facial nerve when drilling close to the facial nerve.

SACS Device to Electrify Drill

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I was doing a biopsy of a posterior fossa tumor through the retrolab approach which is going into the posterior fossa between the labyrinth and lateral sinus. I noticed the I could see the eight nerve easily and the Retrolab Vestibular neurectomy was born. This approach was improved when we entered the post fossa behind the lateral sinus. 250 procedures were done. This stopped the vertigo attacks and preserved hearing in many patients.

Vestibular Neurectomy (Right Ear) 1977

Meniere's disease Relieve Vertigo Preserve Hearing

250

procedures done

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The rt. vestibular nerve is being cut

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The nerve separates after transection

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Dr Norrell a neurosurgeon and I organized the first Neurological surgery of the Ear meeting in 1977 where 50 neurosurgeons and 250 oncologists came together. After that meeting we had five meetings every other ear. At that time Neurosurgeons didn’t think much of ENT physicians.

Team Approach to Skull Base Surgery • Organized first skull base conference in 1977 • Held five bi bi-annual Neurological bi-annual surgery of the ear conferences 62

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Dr Norrell had significant impact in creating the team approach to skull base surgery. At first he wanted to stop me from doing any neurotologic procedures because I was invading his turf.

Horace Norrell M.D.

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• Dr. Horace Norrell had significant impact creating team approach in neurotologic surgery 64

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In fact, Dr Norrell cancelled my first middle fossa vestibular neurectomy. The next day, he checked me out with DR Ojemann at Mass General, and Dr Langfitt at U of Penn. They told him don’t stop Silverstein, he is qualified to do neurotologic procedures. After that he let me do the procedure that he cancelled and we became a team for 25 years, and wrote many papers.

Dr. Norrell Cancelled My First Middle Fossa Vestibular Neurectomy • He checked me out at Mass General and Penn • Silverstein qualified to do neurotologic procedure’s • We became a team for 25 years • Wrote many papers

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In 1996, I developed the MicroWick to allow patients to self-instill medications into the inner ear for one month.

It Is used with Dexamethasone ear drops 4mg/cc in Meniere’s disease to reduce symptoms of pressure, tinnitus and vertigo. It is also used for Sudden deafness along with oral Prednisone.

MicroWick for Continuous Perfusion of Inner Ear 1996

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A picture of the MicroWick in place

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I developed the Laser Stamp procedure for minimal Otosclerosis at the fistula antefenestrum that didn’t require a prosthesis. I asked HFS if it would last and he said yes if you pick the right cases.

LASER STAMP

• For minimal otosclerosis of the anterior footplate • No prosthesis needed • 75 cases done

Laser probe performing Anterior crurotomy LASER STAMP

• Bend laser probe tip 30 30° • Vaporize anterior crus • May need to do by feel

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Laser transection of the anterior portion of foot plate. if the otosclerosis is confined to fissula antefenestrum the stapes becomes mobile. If it is fixed we enlarge the opening and place a prosthesis.

LASER STAMP Linear laser stapedotomy:: stapedotomy anterior one onethird of footplate 70

I developed cartilage reinforcement of the round window for SSCD. The results are being presented at upcoming AAO in Miami.

Superior Semicircular Canal Dehiscence SSCD

• The round window reinforced by tragal cartilage and perichondrium

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Also developed a surgical procedure to reduce hyperacusis by temporalis Reinforcement of the Round and Oval windows.

Surgery For Hyperacusis • Temporalis Fascia Reinforcement of the Round and Oval Window

There are four types of sound hypersensitivity.

Hyperacusis, recruitment, Misophonia, and phonophobia.

The surgery is designed only for hyperacusis.

Four Types of Sound Hypersensitivity 1. Hyperacusis 2. Recruitment 3. Misophonia 4. Phonophobia

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Hyperacusis is a condition where a person cannot tolerate normal sounds. They become anxious and avoid places like the movies, restaurants and sporting events. It often affects their quality of life, 6 - 17% of population are affected. Noise trauma in history 62% Hyperacusis • A condition where a person can not tolerate normal sounds • They become anxious and avoid places like the movies, restaurants and sporting events • Often affects their quality of life • 6 - 17% of population affected • Noise trauma in history 62%

Their loudness discomfort level LDL is below 90Db. Normal LDL is 90-100Db Treatment: is using ear plugs, tinnitus retraining therapy (TRT), cognitive therapy. Non surgical treatment may not be effective.

Hyperacusis • Uncomfortable loudness level (LDL) below 90dB Normal LDL 9090-100 dB • Treatment: ear plugs, tinnitus retraining therapy (TRT), cognitive therapy, long term treatment • Results are variable and may not be effective

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Cause often unknown Noise trauma in 62% Cochlear trauma SSCD Perilymph fistula Adverse reaction to medication Hypermobility of stapes - new finding Causes of Hyperacusis • Often unknown • Noise trauma 62% • Cochlear trauma • SSCD • Perilymph fistula • Adverse reaction to medication • Hypermobility of stapes - new finding

Possible mechanism of Hyperacusis Impaired neuroplasticity in noise suppression.

Hypersensitivity of the cochlea to sound.

Hypermobility of Stapes.

Possible Mechanism of Hyperacusis • Impaired neuroplasticity in noise suppression • Hypersensitivity of the cochlea to sound • Hypermobility of Stapes

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Temporalis fascia is shown reinforcing the round window Reinforcement Round Window RW Reinforced

Temporalis fascia is shown reinforcing oval window.

Reinforcement Oval Window

OW Reinforced

Reinforcement Oval Window OW Reinforced

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Results divided into two discomfort groups. Moderate discomfort to sound with LDL above 70dB, 52 patients.

And High discomfort to sound with LDL below 70dB, 21 patients.

Results

Divided patients into two loudness discomfort level (LDL) groups: • 52 LDL Group above ( > 70dB)

Moderate discomfort to sound

• 21 LDL Group below( < 70 dB)

High discomfort to sound

In the moderate discomfort group 81%, are happy with the result and would recommend the surgery. The result lasted in many patients.

Post-op PostPost op Improvement Moderate discomfort LDL Group >70 dB: • 80.8% would recommend surgery • 72.9% stated improvement lasted • Follow up 1 – 6 years

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In the high discomfort group only 47% would recommend the surgery.

Post-op PostPost op Improvement High discomfort LDL Group <70 dB

••47.6% 47.6% would recommend surgery

To improve the results in the high discomfort group we are now enhancing the amount of fascia for reinforcement.

Present Study • Enhanced reinforcement of oval and round window • Patients with LDL<70dB (high discomfort)

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Extra temporalis fascia is placed over the reinforced windows.

Enhanced OW fascia

Fascia is then placed beneath the posterior tympanic membrane.

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The results in last 4 of 5 patients have been encouraging.

Results Enhanced Reinforcement

• Four of five patients have had good results

In the last patient LDL went from 65 pre op to 95 post op.

PRE LDL 65dB

Post LDL 95 dB

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Well this is my story. I have enjoyed the specialty of Otology/neurotology and never felt it was work. I feel honored to have had the privilege of training 50 fellows and counting, and contributing to science as I was ordered to do by HFS. All this has improved the quality of life for many patients.

This is My Story

• Have enjoyed specialty of Otology/Neurotology • Training fellows • Making contributions to science • Improving quality of life for patients

And owe my success to the training I received at MEE.

OWE MY SUCCESS TO • TRAINING RECEIVED AT MEE

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This is why I LOVE MEE.

WHY I LOVE MASS EYE AND EAR

Thank you

Thank You

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