Interview with William F. House M.D., Physician, Dentist, Father of Neurotology
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AO/Beck: Hi Dr. House. Thanks for your time today. Our last interview with you was about three years ago, in August of 2000.
House: Yes, it's been a while.
AO/Beck: If you don't mind, I'd like to explore your reflections and recollections, and perhaps go into a little more detail this time?
House: That's fine Doug. Please feel free to ask whatever you like.
AO/Beck: Let's start with college. What year did you start?
House: I started college the year Pearl Harbor happened, 1941. When Pearl Harbor was attacked, we all went out and signed up. I signed up for the Navy. The whole atmosphere was different at that time because of the attack. Everybody was geared up to go ahead and take care of it. I remember feeling like I'd sign up and the whole thing would be over in a couple of months. We were gonna teach them a lesson or two. That was the attitude at the time. I went to the recruiting office and the fellow at the desk said, You're in college aren't you? And I said, Yes, I am. He said, Well look, I'll sign you up for the reserves -- but for now, just go back to college. We don't have any boots, we don't have any tents, we don't have any guns and we don't have any ships. So there's nothing for you to do. Go back to college and we'll call you when we need you.
AO/Beck: And that was that? They never called during pre-dental?
House: Right - that's the way it was. They didn't call. I went back to Whittier College in California. I kept going to college and I started in pre-dental because my father was a prominent dentist. I had worked with him and I thought it would be great to become a dentist. So at that time, pre-dental was two years, we went to school summer and winter and I managed it in three semesters and a summer session, 60 credits. Nobody bothered me. I just went to school.
AO/Beck: Where did you go to dental school?
House: I was accepted into dental school at a couple of places, but I attended the University of California in San Francisco and graduated with a DDS in 1945. So I graduated from dental school 4 ½ years after high school.
AO/Beck: That really is amazing - particularly when compared to professional education today!
House: When I started dental school everybody in class was from an Army or a Navy program - except me. They said, Why aren't you in uniform? I said, Well -- nobody called me. They put me into a program called B12. Pretty soon I was on active duty as an apprentice seaman cadet and they sent me completely through dental school and paid all my expenses. The war ended just before I graduated from dental school and I married June between my junior and senior year. She was in nursing school at the time. I waited for her to get out of nursing school and then I took about nine months of surgery, and then the Navy called me for two years as a dentist.
AO/Beck: So they finally got you!
House: Yes they did. I was stationed up in Bremerton, Washington in a dental clinic for a year and a half and then on a Jeep aircraft carrier after that. Those carriers were built on the old Liberty Ship hulls. They put a top on them and they rolled like mad. It's just one big sail up there.
AO/Beck: It must have been amazing trying to do dentistry on one of those.
House: Yes, it was. But we weren't really at sea very much. I put in two years up there and later on I was assigned to a ship in San Diego.
AO/Beck: Okay. What year did you get out the Navy?
House: I got out in 1948.
AO/Beck: So for a couple of years you were actually a full-time dentist and officer?
House: That's right.
AO/Beck: And then when you got out of the Navy, did you practice dentistry?
House: No. My interest in oral surgery drove me to get a medical degree. It was apparent to me that if I wanted to do surgery, dental surgery was too limited in those days. I had been accepted to medical school before I put in my two years of active duty. I actually applied before I knew they were gonna make me go in for two years, and then after I got out of the Navy, they accepted me again to medical school. So I went for four more years to medical school and then another year of internship. I finished all that in 1953. I thought I was interested in being a maxillofacial surgeon but because of Howard's influence, as I watched him do otologic surgery during my residency, I became very interested in otology. The patients were very interesting and very grateful.
AO/Beck: Let me go back a moment just to be sure I understand. So your residency was in otolaryngology, but you were planning to become a maxillofacial surgeon?
House: Right. During the last part of my residency I had pretty much made up my mind to become an otologist, and I guess that must have been 1955 or 1956.
AO/Beck: At about that time fenestration was very popular and Dr. Howard House was doing an awful lot of them!
House: Yes, that's right, and John Shea came out with the stapedectomy in 1955.
AO/Beck: Was John Shea in Memphis at the time?
House: He was, but he came to Los Angeles and spent some time with Howard and I got to know him quite well. He was about my age. He had already finished his residency. Another thing that was personally influential during my residency was -- we didn't have microscopes. We did all of our work through what they called loops and a headlight. Howard found out about microsurgical techniques going on in Germany under Wolfstein and Zolner and he went over to observe. He ordered a microscope when he was in Germany and it was the first one imported into the USA.
AO/Beck: I've heard a few versions of this Dr. House -- was that the first microscope ever used in surgery in the USA?
House: Yes. As best we know, it was. To me, it was just an amazing thing to view what we could see with that microscope. I've compared it to the feeling when you walk along the rim of the Grand Canyon. It was awe-inspiring.
We saw all the structures so clearly with the microscope it was just fantastic, better than we had imagined.
AO/Beck: What was the first surgical application you used the microscope for?
House: Well at that time, Howard was doing stapes mobilizations through his otoscope. I first joined his practice in 1956 and I recall patients would we would mobilize the stapes with a needle, while viewing it through the otoscope. Of course, using the mircroscope made us better surgeons, and we got better results.
AO/Beck: I can't even imagine watching someone operate on the middle ear using only an otoscope! That is simply amazing. OK, so then in 1956 you joined Howard's otology practice in Los Angeles?
House: Right. He was very, very busy with fenestration cases. When stapes mobilization came out, he started doing those but the problem was that in a matter of a few weeks or months they would reaffix. When Shea came out with the stapedectomy, it was shocking to most people - intentionally taking out the stapes was a concept many people simply could not understand. There was tremendous controversy about that. John Shea came out and demonstrated the procedure and that was just about as I was beginning to practice otology.
AO/Beck: Were there a lot of complications back then? Specifically, did you see facial nerve problems or experience gushers or other problems while you were learning stapedectomy?
House: Well we didn't see gushers - they're so rare, but pretty soon there were a lot of reports about things like that. Jack Hough came out with a really great study on all the anomalies he saw during stapes surgery. The microscope opened all that up and knowledge increased dramatically.
AO/Beck: How many stapes would you have operated on, in a typical day on the OR, back in the late 1950s?
House: I was doing between four and six, two days per week. But Howard operated four or five days each week, and he operated Saturday morning as well.
AO/Beck: That's just incredible.
House: It was. He also had a lot of fenestration patients and I was taking care of a lot of those too.
AO/Beck: Was it common for fenestration patients to convert into stapedectomy patients?
House: Yes, many of them did. We began to convert them into stapedectomy, usually on the non-operated ear. I was taking care of a lot of fenestration patients, and they all had mastoid cavities and I had to clean them all the time. Many of those patients let me operate on their other ear because over time, I became acquainted with them.
AO/Beck: Did the patients ever say to you....I want to see the real Dr. House?
House: Oh yes. I was about 31 or 32 years old, and that happened pretty often. They knew and loved Howard and I was the new kid! Howard was doing so many stapes surgeries that we had patients lined up for him. There was a tremendous back log of stapes patients. It's important to understand that there were a lot of problems with fenestration. In fact, the dead ear rate was about 10%, so stapedectomy was welcomed by the patients and the surgeons!
AO/Beck: I had no idea the dead ear rate was that high with fenestration. What were the rest of the results like?
House: They were pretty good -- but we didn't operate unless the patients really met the guidelines. They had to be very good candidates or we wouldn't operate.
AO/Beck: Was it common to do bilateral fenestration -- or was that pretty unusual?
House: That was fairly unusual but there were cases like that now and then.
AO/Beck: I know that with stapes surgery, when you have somebody with bilateral otosclerosis and you operate on the first ear, the patient reports that the result is remarkable, day and night! But then, when you operate on the second ear it was more of a ho-hum thing, even if you hit a homerun and closed the air-bone gap, because they were accustomed to hearing well again. Was that true with fenestration?
House: Pretty much yes. For that reason it wasn't common to do the second ear because fenestration was a big deal. It was a week in the hospital, general anesthesia, an hour or hour and a half procedure, dizziness afterwards; it really was a big event.
AO/Beck: Did you do many fenestrations?
House: I did two fenestrations. It was the only operation I've ever done where I had 100% success - it worked fine. However, I just felt that it wasn't a good procedure because of all the other problems. Stapes surgery was just booming along, so I saw no reason to do any more fenestrations. The patients were under local anesthesia with the stapes procedure, and they would start to hear on the table and they'd say Oh my God! It was very exciting. We were very busy seeing otosclerotics, but very few of them had fenestration because of all the problems associated with it. So all of a sudden, once stapes surgery came around, there was an abundance of patients that were previously not suitable for fenestration, who were suddenly suitable stapedectomy candidates.
AO/Beck: I guess you and Dr. Howard must've trained hundreds of otologists. Did the possibility of having highly competent, House-trained competition ever present a problem for you? I recall stories of chairman from ENT-HNS departments who would train residents and fellows and they apparently had agreements that they couldn't practice within 25 or 50 miles.
House: That was very common. We didn't restrict people from practicing, and in fact, a few did set up their practices in Los Angeles. Some training sites wouldn't accept people from their own towns, but we felt that was not a good thing to do,
AO/Beck: I recall that the House group had a few names in the 1950s and 1960s. What was the first group name?
House: Some of the fenestration patients were very grateful for the care they received, and the patients set up the Los Angeles Foundation of Otology.
AO/Beck: The patients actually set that up?
House: Yes, they did it for Howard. Howard was so busy with stapes surgery; he turned over all the patients that came in for chronic ear surgery to me.
AO/Beck: So you were doing a lot of chronic ear surgery!
House: Yes, I got very interested in the whole thing because the radical cavities were so bad. One principle of infection management since time memorial was incision and drainage. That's what we did with radical mastoids. We opened everything up so it would drain and so it didn't back up into the brain. Before all that was worked out, in the late 1800's, brain abscess and fatality from ear infection was very real.
AO/Beck: In the early days of your practice, when patients had 80 or 90 dB sensorineural loss, or worse, what were the options? What did you tell them?
House: We fitted them with hearing aids as best we could. They were all body aids back then and they helped. But body aids weren't all that successful. I remember I had one professor while I was a resident at Children's Hospital. He wore a great big body aid and kept it hanging on his chest for everyone to see. I later found out that he never turned it on - just wearing it like that made everybody talk really loud!
AO/Beck: Dr. House, how did you get from chronic ears and middle ear surgery to skull-base surgery, operating on cerebellopontine angle tumors, acoustic neuromas, vestibular neurectomy, the type of things that I used to see you do day in and day out when I was at House?
House: The microscope made it possible for us to no longer treat chronic ears with just incision and drainage. Once we could see the structures, especially around the facial nerve, the goal became to create a dry ear and get rid of all the infection and debris, rather than just open it and leave it to drain. Still sometimes, the cavity got re-infected, and that's why I developed the facial recess approach.
AO/Beck: So the facial recess approach allows you to remove more of the infected tissue?
House: Right and we didn't take down the posterior canal wall so you didn't have a cavity post-op, but we could still see into the middle ear so we'd go through the canal and also through the facial recess and we could get all the infected tissue out. We were going for eradication of the infection rather than just opening and draining it. At that time, we also had to rebuild the ossicular chain. Lots of people developed prosthetics, and there were quite a lot to consider.
AO/Beck: Was it true that otologists would also use middle ear bones from deceased patients who had donated their ossicles?
House: Yes. We autoclaved those materials and they were stored in banks. Sometimes, when there was just cholesteatoma around the ossicular chain, we'd take the chain out, clean it off real well under a microscope, autoclave it, and put it back in!
AO/Beck: That's amazing. And what was the long-term result on that?
House: If the disease was gone and the ear was well aerated, it worked out really well.
AO/Beck: How long would those procedures take? Were they more like an hour or two or more?
House: Well that was another thing I worked on quite a bit. I really wanted to speed up the operating time and I developed surgical procedures on cadavers. I worked out the irrigation-suction system for one-handed operation to irrigate the surgical site and remove the debris and fluids, while drilling or working with the other hand, and I also worked out using diamond stone as well as regular burr to carefully remove bone, while reducing bleeding. When I first started, you would drill a little bit and then when you got bone dust you would stop, irrigate, suction, and then drill a little more. It was very time consuming. I can remember doing mastoidectomies that way and it would take two or three hours. But then with the irrigation-suction, which is now universally used, you can cut your time down to an hour or maybe an hour and a half. The diamond burr has the advantage that you can get very small, fine bone removals around facial nerves and other delicate structures. Additionally, it can rotate and cut in either direction. When it's rotating clockwise it tends to run to the right and if it's rotating counterclockwise it rolls to the left. So you set the rotation direction so that if the burr were to catch, it wouldn't roll into the facial nerve. You use your thumb to increase or decrease the suction, so when you rotate your thumb the cavity will fill with water and you put your thumb over the hole and suction it out.
AO/Beck: Was that a Bill House invention or was that House-Urban project?
House: I worked out the irrigation suction system.
AO/Beck: That's amazing. I mean I'm not an ear surgeon, but I've worked on thousands of ear and skull bases cases and I don't think there's anybody doing ear surgery in the world who's not using hand held irrigation-suction. In fact, it seems rather intuitive at this point! And the diamond burr how did you come up with that?
House: Well -- I was a dentist! We used diamond stones for drilling out teeth, cavities, and stuff. And water irrigation during dentistry was used because if you got the tooth too hot, it would kill it.
AO/Beck: OK, I'm with you. How did you make the leap from mastoidectomies and stapes surgery to skull base surgery?
House: Well it's a kind of interesting story. When I was a resident one of the doctors in town took an interest in me, his name was Gilbert Roy Owen. He made his own subspecialty of x-ray, and he would x-ray sinuses and mastoids. He took me under his wing and taught me particularly about mastoid x-rays. One of the things he emphasized was that whenever you have a unilateral loss, you need to x-ray the patient and look at the internal auditory canal. He showed me how to position the patient so you could see the internal auditory canal on an ordinary x-ray.
AO/Beck: Were those polytomes?
House: No, they were just plain x-rays. We used the transorbital approach and then he had one they called the Owen approach or the Owen position and so on. Very, very few doctors were ever taught to do this. So whenever I had a unilateral loss, I would get an x-ray.
AO/Beck: In retrospect, I imagine many of the unilateral losses must have been autoimmune disease, sudden sensorineural loss, Meniere's patients?
House: Right, some were, but if you saw a blown out canal then you zeroed in on that. At that time, the mortality rate in the California Tumor Registry for acoustic tumors was 40%. It was a very serious operation because we basically did not operate on patients with acoustics. They had either papilledema meaning increased intracranial pressure or pretty serious headaches and things like that. So the few doctors that were operating on acoustics were operating on very large tumors and the mortality was very high.
AO/Beck: In essence, I guess they thought the chance of successfully removing the tumor was not very good, so they were waiting intentionally because perhaps the tumor wasn't going to grow or maybe it wasn't going to get worse, but they knew they would cause damage if they operated.
House: That's exactly right. In fact, very early in my practice, a handsome and vigorous fireman presented with a unilateral loss and a blown out internal auditory canal. I referred him to the neurosurgeon and he said, Well look, all the patient has is a unilateral hearing loss and a little tinnitus. If I operate on him he's going to also lose his facial nerve and who knows what else. He may have cerebellar ataxia post-op and his chance of surviving was 60%. The neurosurgeon said, I advise you to wait. Don't do anything about it. Let's just see what happens. Well, it just so happened that he had a fairly rapidly growing tumor and a year later he had papilledema so they decided to go ahead with the surgery at that point.
I went in and watched the surgery. It was a bloody thing with the patient in a sitting up position. They did that so the blood would run out rather than pooling up. The patient never regained consciousness; he died about two days later.
I remember saying to the neurosurgeon, God, why didn't you operate on him sooner? He said, It was a big tumor, that's why these things happen. I said, Well yes, but I referred him to you when it wasn't a big tumor. Why didn't you do it then? So that was the whole thing. It was a classic Catch-22, very frustrating for all of us.
The mortality and morbidity and everything else from acoustics were so bad, the most prominent neurologist in New York recommended not operating on acoustic tumors at all. It just wasn't worth it.
AO/Beck: So somewhere along the line you must have said to yourself
I can do better than this.
House: Yes, I did. I thought I would have seen a lot better in there with a microscope, and I thought if we added that to the whole procedure then maybe we could do better. At that time I had already begun working on the middle fossa approach because there was a theory that patients got sensorineural loss or bone conduction loss with otosclerosis, because there was a lesion over the internal auditory canal. Actually, I think it said the first site was the foot plate area and the second one was right up over the internal auditory canal and it would press on the eighth nerve and cause sensorineural loss. So, I reasoned that if we could somehow take out that focus of otosclerosis that might've been pressing on the nerve, that we could maybe reverse the progressive sensorineural loss. I developed the idea of using the greater superficial petrosal nerve to lead me to the facial nerve and then the facial led me to the internal auditory canal because with the microscope, diamond stone, and irrigation we could do that.
AO/Beck: It's amazing to me how in retrospect, all of these developments and ideas led naturally from one to the next, sort of like dominoes falling one after the other. I guess it didn't seem like that at the time?
House: No, at the time, each situation was unique. I tried the middle fossa approach on three patients and none of them got any improvement in their hearing. I remember reporting on those three at an otosclerosis conference at Henry Ford Hospital. I presented my drawings because we operated from the head of the table, and I showed the picture of the patient upside down and the only comment I got was, God, I never realized you could operate on patients upside down before. And it was to them, very disdainful that I would do that. And another guy in the audience said, Humans vivisection. And there I was. Reporting failed cases.
AO/Beck: Well, not to sound trite, but with all of the successes and glory you had experienced at that time, this must've seemed horrible, like the very bottom of the barrel. I imagine it felt depressing and lonely!
House: Yes, it was difficult. But I remember stating that the middle fossa approach has made me sure that we could get into the internal auditory canal, and I suggested we could section the vestibular nerve that way. And that was all I could say, because I hadn't yet done it, not at that time.
AO/Beck: Those guys must have been looking at you with disdain and contempt at that moment.
House: Yes. My presentation of failed cases and suggestions for vestibular nerve sections were looked at with disgust and disdain by at least a few of the people in the audience!
AO/Beck: What was the reception like in the evening at the cocktail party? I mean did everybody walk away?
House: Yes. It was very sullen. Nobody talked to me. Then it occurred to me. If we could diagnose acoustic tumors earlier, and now that we had a way to identify exactly where the facial nerve was, and now that we knew the middle fossa approach was possible -- I thought if we could just diagnose these cases earlier, we could successfully operate on them.
THE CONCLUSION of this interview (PART TWO) will be published on Audiology Online on 2-23-2004.
House: Yes, it's been a while.
AO/Beck: If you don't mind, I'd like to explore your reflections and recollections, and perhaps go into a little more detail this time?
House: That's fine Doug. Please feel free to ask whatever you like.
AO/Beck: Let's start with college. What year did you start?
House: I started college the year Pearl Harbor happened, 1941. When Pearl Harbor was attacked, we all went out and signed up. I signed up for the Navy. The whole atmosphere was different at that time because of the attack. Everybody was geared up to go ahead and take care of it. I remember feeling like I'd sign up and the whole thing would be over in a couple of months. We were gonna teach them a lesson or two. That was the attitude at the time. I went to the recruiting office and the fellow at the desk said, You're in college aren't you? And I said, Yes, I am. He said, Well look, I'll sign you up for the reserves -- but for now, just go back to college. We don't have any boots, we don't have any tents, we don't have any guns and we don't have any ships. So there's nothing for you to do. Go back to college and we'll call you when we need you.
AO/Beck: And that was that? They never called during pre-dental?
House: Right - that's the way it was. They didn't call. I went back to Whittier College in California. I kept going to college and I started in pre-dental because my father was a prominent dentist. I had worked with him and I thought it would be great to become a dentist. So at that time, pre-dental was two years, we went to school summer and winter and I managed it in three semesters and a summer session, 60 credits. Nobody bothered me. I just went to school.
AO/Beck: Where did you go to dental school?
House: I was accepted into dental school at a couple of places, but I attended the University of California in San Francisco and graduated with a DDS in 1945. So I graduated from dental school 4 ½ years after high school.
AO/Beck: That really is amazing - particularly when compared to professional education today!
House: When I started dental school everybody in class was from an Army or a Navy program - except me. They said, Why aren't you in uniform? I said, Well -- nobody called me. They put me into a program called B12. Pretty soon I was on active duty as an apprentice seaman cadet and they sent me completely through dental school and paid all my expenses. The war ended just before I graduated from dental school and I married June between my junior and senior year. She was in nursing school at the time. I waited for her to get out of nursing school and then I took about nine months of surgery, and then the Navy called me for two years as a dentist.
AO/Beck: So they finally got you!
House: Yes they did. I was stationed up in Bremerton, Washington in a dental clinic for a year and a half and then on a Jeep aircraft carrier after that. Those carriers were built on the old Liberty Ship hulls. They put a top on them and they rolled like mad. It's just one big sail up there.
AO/Beck: It must have been amazing trying to do dentistry on one of those.
House: Yes, it was. But we weren't really at sea very much. I put in two years up there and later on I was assigned to a ship in San Diego.
AO/Beck: Okay. What year did you get out the Navy?
House: I got out in 1948.
AO/Beck: So for a couple of years you were actually a full-time dentist and officer?
House: That's right.
AO/Beck: And then when you got out of the Navy, did you practice dentistry?
House: No. My interest in oral surgery drove me to get a medical degree. It was apparent to me that if I wanted to do surgery, dental surgery was too limited in those days. I had been accepted to medical school before I put in my two years of active duty. I actually applied before I knew they were gonna make me go in for two years, and then after I got out of the Navy, they accepted me again to medical school. So I went for four more years to medical school and then another year of internship. I finished all that in 1953. I thought I was interested in being a maxillofacial surgeon but because of Howard's influence, as I watched him do otologic surgery during my residency, I became very interested in otology. The patients were very interesting and very grateful.
AO/Beck: Let me go back a moment just to be sure I understand. So your residency was in otolaryngology, but you were planning to become a maxillofacial surgeon?
House: Right. During the last part of my residency I had pretty much made up my mind to become an otologist, and I guess that must have been 1955 or 1956.
AO/Beck: At about that time fenestration was very popular and Dr. Howard House was doing an awful lot of them!
House: Yes, that's right, and John Shea came out with the stapedectomy in 1955.
AO/Beck: Was John Shea in Memphis at the time?
House: He was, but he came to Los Angeles and spent some time with Howard and I got to know him quite well. He was about my age. He had already finished his residency. Another thing that was personally influential during my residency was -- we didn't have microscopes. We did all of our work through what they called loops and a headlight. Howard found out about microsurgical techniques going on in Germany under Wolfstein and Zolner and he went over to observe. He ordered a microscope when he was in Germany and it was the first one imported into the USA.
AO/Beck: I've heard a few versions of this Dr. House -- was that the first microscope ever used in surgery in the USA?
House: Yes. As best we know, it was. To me, it was just an amazing thing to view what we could see with that microscope. I've compared it to the feeling when you walk along the rim of the Grand Canyon. It was awe-inspiring.
We saw all the structures so clearly with the microscope it was just fantastic, better than we had imagined.
AO/Beck: What was the first surgical application you used the microscope for?
House: Well at that time, Howard was doing stapes mobilizations through his otoscope. I first joined his practice in 1956 and I recall patients would we would mobilize the stapes with a needle, while viewing it through the otoscope. Of course, using the mircroscope made us better surgeons, and we got better results.
AO/Beck: I can't even imagine watching someone operate on the middle ear using only an otoscope! That is simply amazing. OK, so then in 1956 you joined Howard's otology practice in Los Angeles?
House: Right. He was very, very busy with fenestration cases. When stapes mobilization came out, he started doing those but the problem was that in a matter of a few weeks or months they would reaffix. When Shea came out with the stapedectomy, it was shocking to most people - intentionally taking out the stapes was a concept many people simply could not understand. There was tremendous controversy about that. John Shea came out and demonstrated the procedure and that was just about as I was beginning to practice otology.
AO/Beck: Were there a lot of complications back then? Specifically, did you see facial nerve problems or experience gushers or other problems while you were learning stapedectomy?
House: Well we didn't see gushers - they're so rare, but pretty soon there were a lot of reports about things like that. Jack Hough came out with a really great study on all the anomalies he saw during stapes surgery. The microscope opened all that up and knowledge increased dramatically.
AO/Beck: How many stapes would you have operated on, in a typical day on the OR, back in the late 1950s?
House: I was doing between four and six, two days per week. But Howard operated four or five days each week, and he operated Saturday morning as well.
AO/Beck: That's just incredible.
House: It was. He also had a lot of fenestration patients and I was taking care of a lot of those too.
AO/Beck: Was it common for fenestration patients to convert into stapedectomy patients?
House: Yes, many of them did. We began to convert them into stapedectomy, usually on the non-operated ear. I was taking care of a lot of fenestration patients, and they all had mastoid cavities and I had to clean them all the time. Many of those patients let me operate on their other ear because over time, I became acquainted with them.
AO/Beck: Did the patients ever say to you....I want to see the real Dr. House?
House: Oh yes. I was about 31 or 32 years old, and that happened pretty often. They knew and loved Howard and I was the new kid! Howard was doing so many stapes surgeries that we had patients lined up for him. There was a tremendous back log of stapes patients. It's important to understand that there were a lot of problems with fenestration. In fact, the dead ear rate was about 10%, so stapedectomy was welcomed by the patients and the surgeons!
AO/Beck: I had no idea the dead ear rate was that high with fenestration. What were the rest of the results like?
House: They were pretty good -- but we didn't operate unless the patients really met the guidelines. They had to be very good candidates or we wouldn't operate.
AO/Beck: Was it common to do bilateral fenestration -- or was that pretty unusual?
House: That was fairly unusual but there were cases like that now and then.
AO/Beck: I know that with stapes surgery, when you have somebody with bilateral otosclerosis and you operate on the first ear, the patient reports that the result is remarkable, day and night! But then, when you operate on the second ear it was more of a ho-hum thing, even if you hit a homerun and closed the air-bone gap, because they were accustomed to hearing well again. Was that true with fenestration?
House: Pretty much yes. For that reason it wasn't common to do the second ear because fenestration was a big deal. It was a week in the hospital, general anesthesia, an hour or hour and a half procedure, dizziness afterwards; it really was a big event.
AO/Beck: Did you do many fenestrations?
House: I did two fenestrations. It was the only operation I've ever done where I had 100% success - it worked fine. However, I just felt that it wasn't a good procedure because of all the other problems. Stapes surgery was just booming along, so I saw no reason to do any more fenestrations. The patients were under local anesthesia with the stapes procedure, and they would start to hear on the table and they'd say Oh my God! It was very exciting. We were very busy seeing otosclerotics, but very few of them had fenestration because of all the problems associated with it. So all of a sudden, once stapes surgery came around, there was an abundance of patients that were previously not suitable for fenestration, who were suddenly suitable stapedectomy candidates.
AO/Beck: I guess you and Dr. Howard must've trained hundreds of otologists. Did the possibility of having highly competent, House-trained competition ever present a problem for you? I recall stories of chairman from ENT-HNS departments who would train residents and fellows and they apparently had agreements that they couldn't practice within 25 or 50 miles.
House: That was very common. We didn't restrict people from practicing, and in fact, a few did set up their practices in Los Angeles. Some training sites wouldn't accept people from their own towns, but we felt that was not a good thing to do,
AO/Beck: I recall that the House group had a few names in the 1950s and 1960s. What was the first group name?
House: Some of the fenestration patients were very grateful for the care they received, and the patients set up the Los Angeles Foundation of Otology.
AO/Beck: The patients actually set that up?
House: Yes, they did it for Howard. Howard was so busy with stapes surgery; he turned over all the patients that came in for chronic ear surgery to me.
AO/Beck: So you were doing a lot of chronic ear surgery!
House: Yes, I got very interested in the whole thing because the radical cavities were so bad. One principle of infection management since time memorial was incision and drainage. That's what we did with radical mastoids. We opened everything up so it would drain and so it didn't back up into the brain. Before all that was worked out, in the late 1800's, brain abscess and fatality from ear infection was very real.
AO/Beck: In the early days of your practice, when patients had 80 or 90 dB sensorineural loss, or worse, what were the options? What did you tell them?
House: We fitted them with hearing aids as best we could. They were all body aids back then and they helped. But body aids weren't all that successful. I remember I had one professor while I was a resident at Children's Hospital. He wore a great big body aid and kept it hanging on his chest for everyone to see. I later found out that he never turned it on - just wearing it like that made everybody talk really loud!
AO/Beck: Dr. House, how did you get from chronic ears and middle ear surgery to skull-base surgery, operating on cerebellopontine angle tumors, acoustic neuromas, vestibular neurectomy, the type of things that I used to see you do day in and day out when I was at House?
House: The microscope made it possible for us to no longer treat chronic ears with just incision and drainage. Once we could see the structures, especially around the facial nerve, the goal became to create a dry ear and get rid of all the infection and debris, rather than just open it and leave it to drain. Still sometimes, the cavity got re-infected, and that's why I developed the facial recess approach.
AO/Beck: So the facial recess approach allows you to remove more of the infected tissue?
House: Right and we didn't take down the posterior canal wall so you didn't have a cavity post-op, but we could still see into the middle ear so we'd go through the canal and also through the facial recess and we could get all the infected tissue out. We were going for eradication of the infection rather than just opening and draining it. At that time, we also had to rebuild the ossicular chain. Lots of people developed prosthetics, and there were quite a lot to consider.
AO/Beck: Was it true that otologists would also use middle ear bones from deceased patients who had donated their ossicles?
House: Yes. We autoclaved those materials and they were stored in banks. Sometimes, when there was just cholesteatoma around the ossicular chain, we'd take the chain out, clean it off real well under a microscope, autoclave it, and put it back in!
AO/Beck: That's amazing. And what was the long-term result on that?
House: If the disease was gone and the ear was well aerated, it worked out really well.
AO/Beck: How long would those procedures take? Were they more like an hour or two or more?
House: Well that was another thing I worked on quite a bit. I really wanted to speed up the operating time and I developed surgical procedures on cadavers. I worked out the irrigation-suction system for one-handed operation to irrigate the surgical site and remove the debris and fluids, while drilling or working with the other hand, and I also worked out using diamond stone as well as regular burr to carefully remove bone, while reducing bleeding. When I first started, you would drill a little bit and then when you got bone dust you would stop, irrigate, suction, and then drill a little more. It was very time consuming. I can remember doing mastoidectomies that way and it would take two or three hours. But then with the irrigation-suction, which is now universally used, you can cut your time down to an hour or maybe an hour and a half. The diamond burr has the advantage that you can get very small, fine bone removals around facial nerves and other delicate structures. Additionally, it can rotate and cut in either direction. When it's rotating clockwise it tends to run to the right and if it's rotating counterclockwise it rolls to the left. So you set the rotation direction so that if the burr were to catch, it wouldn't roll into the facial nerve. You use your thumb to increase or decrease the suction, so when you rotate your thumb the cavity will fill with water and you put your thumb over the hole and suction it out.
AO/Beck: Was that a Bill House invention or was that House-Urban project?
House: I worked out the irrigation suction system.
AO/Beck: That's amazing. I mean I'm not an ear surgeon, but I've worked on thousands of ear and skull bases cases and I don't think there's anybody doing ear surgery in the world who's not using hand held irrigation-suction. In fact, it seems rather intuitive at this point! And the diamond burr how did you come up with that?
House: Well -- I was a dentist! We used diamond stones for drilling out teeth, cavities, and stuff. And water irrigation during dentistry was used because if you got the tooth too hot, it would kill it.
AO/Beck: OK, I'm with you. How did you make the leap from mastoidectomies and stapes surgery to skull base surgery?
House: Well it's a kind of interesting story. When I was a resident one of the doctors in town took an interest in me, his name was Gilbert Roy Owen. He made his own subspecialty of x-ray, and he would x-ray sinuses and mastoids. He took me under his wing and taught me particularly about mastoid x-rays. One of the things he emphasized was that whenever you have a unilateral loss, you need to x-ray the patient and look at the internal auditory canal. He showed me how to position the patient so you could see the internal auditory canal on an ordinary x-ray.
AO/Beck: Were those polytomes?
House: No, they were just plain x-rays. We used the transorbital approach and then he had one they called the Owen approach or the Owen position and so on. Very, very few doctors were ever taught to do this. So whenever I had a unilateral loss, I would get an x-ray.
AO/Beck: In retrospect, I imagine many of the unilateral losses must have been autoimmune disease, sudden sensorineural loss, Meniere's patients?
House: Right, some were, but if you saw a blown out canal then you zeroed in on that. At that time, the mortality rate in the California Tumor Registry for acoustic tumors was 40%. It was a very serious operation because we basically did not operate on patients with acoustics. They had either papilledema meaning increased intracranial pressure or pretty serious headaches and things like that. So the few doctors that were operating on acoustics were operating on very large tumors and the mortality was very high.
AO/Beck: In essence, I guess they thought the chance of successfully removing the tumor was not very good, so they were waiting intentionally because perhaps the tumor wasn't going to grow or maybe it wasn't going to get worse, but they knew they would cause damage if they operated.
House: That's exactly right. In fact, very early in my practice, a handsome and vigorous fireman presented with a unilateral loss and a blown out internal auditory canal. I referred him to the neurosurgeon and he said, Well look, all the patient has is a unilateral hearing loss and a little tinnitus. If I operate on him he's going to also lose his facial nerve and who knows what else. He may have cerebellar ataxia post-op and his chance of surviving was 60%. The neurosurgeon said, I advise you to wait. Don't do anything about it. Let's just see what happens. Well, it just so happened that he had a fairly rapidly growing tumor and a year later he had papilledema so they decided to go ahead with the surgery at that point.
I went in and watched the surgery. It was a bloody thing with the patient in a sitting up position. They did that so the blood would run out rather than pooling up. The patient never regained consciousness; he died about two days later.
I remember saying to the neurosurgeon, God, why didn't you operate on him sooner? He said, It was a big tumor, that's why these things happen. I said, Well yes, but I referred him to you when it wasn't a big tumor. Why didn't you do it then? So that was the whole thing. It was a classic Catch-22, very frustrating for all of us.
The mortality and morbidity and everything else from acoustics were so bad, the most prominent neurologist in New York recommended not operating on acoustic tumors at all. It just wasn't worth it.
AO/Beck: So somewhere along the line you must have said to yourself
I can do better than this.
House: Yes, I did. I thought I would have seen a lot better in there with a microscope, and I thought if we added that to the whole procedure then maybe we could do better. At that time I had already begun working on the middle fossa approach because there was a theory that patients got sensorineural loss or bone conduction loss with otosclerosis, because there was a lesion over the internal auditory canal. Actually, I think it said the first site was the foot plate area and the second one was right up over the internal auditory canal and it would press on the eighth nerve and cause sensorineural loss. So, I reasoned that if we could somehow take out that focus of otosclerosis that might've been pressing on the nerve, that we could maybe reverse the progressive sensorineural loss. I developed the idea of using the greater superficial petrosal nerve to lead me to the facial nerve and then the facial led me to the internal auditory canal because with the microscope, diamond stone, and irrigation we could do that.
AO/Beck: It's amazing to me how in retrospect, all of these developments and ideas led naturally from one to the next, sort of like dominoes falling one after the other. I guess it didn't seem like that at the time?
House: No, at the time, each situation was unique. I tried the middle fossa approach on three patients and none of them got any improvement in their hearing. I remember reporting on those three at an otosclerosis conference at Henry Ford Hospital. I presented my drawings because we operated from the head of the table, and I showed the picture of the patient upside down and the only comment I got was, God, I never realized you could operate on patients upside down before. And it was to them, very disdainful that I would do that. And another guy in the audience said, Humans vivisection. And there I was. Reporting failed cases.
AO/Beck: Well, not to sound trite, but with all of the successes and glory you had experienced at that time, this must've seemed horrible, like the very bottom of the barrel. I imagine it felt depressing and lonely!
House: Yes, it was difficult. But I remember stating that the middle fossa approach has made me sure that we could get into the internal auditory canal, and I suggested we could section the vestibular nerve that way. And that was all I could say, because I hadn't yet done it, not at that time.
AO/Beck: Those guys must have been looking at you with disdain and contempt at that moment.
House: Yes. My presentation of failed cases and suggestions for vestibular nerve sections were looked at with disgust and disdain by at least a few of the people in the audience!
AO/Beck: What was the reception like in the evening at the cocktail party? I mean did everybody walk away?
House: Yes. It was very sullen. Nobody talked to me. Then it occurred to me. If we could diagnose acoustic tumors earlier, and now that we had a way to identify exactly where the facial nerve was, and now that we knew the middle fossa approach was possible -- I thought if we could just diagnose these cases earlier, we could successfully operate on them.
THE CONCLUSION of this interview (PART TWO) will be published on Audiology Online on 2-23-2004.
