Interview with William Hitselberger M.D., Neurosurgeon, Los Angeles, California
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Topic: Neurosurgery, Acoustic Neuromas, Gamma Knife and related topics...
Beck: Good morning Dr. Hitselberger. It is always a pleasure to meet with you, and I am very appreciative of your time this morning.
Hitselberger: Good Morning Dr. Beck. Nice to be with you again, too!
Beck: I should disclose that you and I have known each other for some 20 years...In fact, when I started my fellowship at House, you were the primary neurosurgeon that operated with Drs. William House, Derald Brackmann and the other neurotologists from the House group. I am still amazed when I recall the many days you would operate on two or three acoustic neuromas in a single day. My recollection is that you've operated on 6000 skull base tumors - is that right?
Hitselberger: Yes, I think so. We've done quite a few in the last 40 years or so. I think we're just over 6000.
Beck: Dr. Hitselberger, before we get too far along... I wonder if you would tell me a little about your education. Where did you go to school and when did you graduate?
Hitselberger: I went to the University of Wisconsin at Madison. That was
the best education I could ever have! Every course I took was fabulous. I learned something new and useful in every class -- it was worth the time and the effort. I never had a bad professor! After that, I went to Harvard Medical School. It was not at all what I had hoped for! I graduated from Harvard in 1956, almost 50 years ago, but their emphasis at that time was on research and that just wasn't interesting to me. I was far more interested in clinical issues. It's hard for me to remember taking really pragmatic, useful classes there. After that, I did my internship, military service and residency through the University of Minnesota, the Mayo Clinic, and Henry Ford Hospital in Detroit. So I had a pretty good residency, not outstanding, but pretty good.
Beck: When you look at how neurotologists and neurosurgeons work together on skull base cases, it seems routine and normal now, but I know from my discussions with Dr. Bill House and from his writings, that in the early days, the local medical community didn't think kindly of the way you two approached skull base tumors! In fact, my recollection is that the local surgeons pretty much thought you guys were nuts!
Hitselberger: Yes, well there was a lot of that! There was a lot of antagonism mainly between the neurosurgeons and us. The local guys really tried hard to get Dr. Bill House and me kicked off the hospital staff. They thought we were doing something only neurosurgeons should be doing. So it was pretty ugly for a long time. But it's important to understand that neurosurgeons didn't know squat about ENT or audiology. They couldn't read audiograms and they didn't understand issues related to hearing! Dr. House and I thought "cross training" made a lot of sense back then and it seems to make sense to me now, too. The best approaches to the benign tumors of the skull base, such as meningiomas and acoustics are through ENT approaches -- and that's just the plain, simple truth. The neurosurgeons spend 6 years in their residency, and there's plenty of time to learn about ENT and ophtho approaches to the skull base and brain, but it really isn't done very much, unless the particular resident takes it upon themselves to learn that stuff and gain that experience. If they don't see how the neurotologists get to the skull base, they'll go sub-occipitally, and that's not the best approach to acoustics 99 percent of the time.
Beck: I guess the issue really does boil down to the individual skills of the surgeon and the surgical approach. Traditionally, acoustics had been approached sub-occipitally, but then you and Dr House explored the translabyrinthine approach, which involved Dr. House essentially drilling through the ear and then once he got to the skull base you removed the tumor. Is that right?
Hitselberger: That's right. But it was really Dr. House that initiated and explored the translab approach. It was an approach that allowed each of us to maximally use our skills to safely approach and remove these tumors. And the thing was, the only reason Dr. House developed the translab technique was because the previous techniques which the neurosurgeons used, had unbelievably high morbidity and mortality rates associated with them...they were really unacceptable. In California, just before we started working together, the mortality rate for patients with acoustics was about 40 percent -- and that was just terrible. Bill House pretty much figured out the translabyrinthine approach, and he was the first surgeon to use the operating microscope in the operating room. Dr. House taught the neurosurgeons about using the microscope. In 1963, Dr. House and I started working together. I was right out of my neurosurgical residency. Dr. House taught me the anatomy of the temporal bone and I started working in the t-bone lab to drill out the temporal bone and learn how to do that part of the surgery.
Beck: I suppose that must've been somewhat uncomfortable professionally? Back in the early and mid-1960s, it was not common for otologists to work with neurosurgeons and it must've really threatened your relationship with the local and national neurosurgical community?
Hitselberger: Yes, well, it was a little awkward. Back then it was the ultimate "turf-battle." Here I was, a newly graduated neurosurgeon, working on the skull base with an ear doctor...it was really unpleasant for us for quite a while, but I didn't let it bother me. I thought of it as taking a residency from Dr. Bill House, who just happened to be the best otologist in the world. I spent a lot of time trying to learn what he was showing me and I remember Dr. House used to say "You know Hitselberger -- if I can teach you -- I can teach anybody!" But it really was difficult for me. There's lots of tiny little anatomic quirks and anomalies in the temporal bone and it's difficult anatomy to learn and operate on, and then there's the issue of working through the microscope...so I had a lot to learn, and it took time, but I think I finally got it right.
Beck: Yes, I think you did! I had the pleasure of watching the two of you work together while I was monitoring various cranial nerves, probably a hundred times or more, and I thought the relationship and the knowledge you two shared was rather magical.
Hitselberger: Yes, it was unique. I knew I could do a lot, and maybe even all of the temporal bone drilling, and frankly, Dr. Bill House could remove tumors as well as most neurosurgeons, too. So we knew each other's moves and we had a common knowledge and foundation from which we worked. We knew how to maximize our team approach for the best possible surgical result. It really was very nice. We worked together, we understood the other's expertise, and it was a great team approach.
Beck: I can recall cases when you would come into the room just as Dr. House was incising the dura and you would look through the microscope sidearm and say something like...."Bill, lemme know if you need help, I'll be in the next OR." Sometimes he would just go ahead and remove the tumor, and sometimes you would. It just depended on the size and location of the tumor.
Hitselberger: Yes, for some tumors we were pretty much interchangeable!
Beck: Are co-operative relationships more common now, or are we going to finer and finer sub-specializations?
Hitselberger: I don't really know, but I suspect those relationships are going away! Many times surgeons become more concerned with protecting their turf, rather than doing the best possible job for the patient -- and that's terrifically unfortunate. I suspect surgical roles are becoming more and more fixed, and the roles are more and more narrow and finite.
Beck: Earlier in the discussion you mentioned that when you and Dr. House started operating on acoustic neuromas, the mortality was 40 percent...what are the most recent numbers?
Hitselberger: Well, I can't tell you the exact number down to the tenth of a decimal, but it's way below one percent.
Beck: That's really amazing progress in 40 years.
Hitselberger: Yes it truly is. We have better diagnostic tools so we can, and do, find tumors when they are much smaller and easier to remove, and of course we have better techniques now and better surgical tools, to say nothing of far greater knowledge, so it has come full circle in many respects.
Beck: And with regard to facial nerve injury during acoustic neuroma removal surgeries? Any recent numbers on that?
Hitselberger: Well, again, I really haven't looked at the numbers for a long time, but I think it's fair to say that having a permanent facial nerve injury secondary to our acoustic neuroma removal is probably less than two or three percent. Some patients have a temporary weakness that resolves in less than a year. So if you look at the whole group, one year post-op, I think no more than 2 or 3 percent have facial weakness.
Beck: Dr. Hitselberger, can you please share your thoughts on Gamma Knife, Proton Beam and related radiographic treatments for skull base tumors?
Hitselberger: Sure, Great topic! There are a number of things to consider with Gamma Knife and other radiologic therapies like Proton Beam.... First, radiologic therapies don't remove tumors. If the tumor grows, or the treatment is not successful, when we go in to remove the tumor surgically, it's a bigger problem. By the time we operate, additional time has gone by and the tumor might be larger. Also, the scarring which results from radiologic treatment makes it more difficult to remove the tumor surgically because the capsule is harder to define and the tumor can be more adherent to healthy brain or other cranial nerve tissue. Another serious, yet extremely rare issue, is the tumor can actually change it's biologic characteristics from benign to malignant following radiologic therapy. We have seen radiated tumors, on rare occasion, which have changed to malignant. Radiologic treatment has another important issue and that has to do with recurrence. We've probably seen some 50 cases in which tumors have re-grown, it's not just an odd one or two cases, there are quite a few around and I think our series is probably the largest in the world. We hope to publish that paper late in 2004, or in 2005, detailing our findings. On that same issue, when people have radiologic therapy, they need to be followed by radiographic studies every year, and that's not a great thing either. Another issue, which few people think about, is getting health or life insurance. The issue is -- almost no one will insure you after radiologic treatment, because you still have a brain tumor -- at least that's what I've heard from underwriters. Lastly, radiation therapy doesn't cure benign tumors anywhere else in the body, so I'm not really sure why people try to apply it to acoustic neuromas, it's just not a great idea most of the time. So all-in-all, I think Gamma Knife and Proton Beam therapies are interesting, and they have their place in certain, selected, unusual situations, but I think surgical removal is usually the preferred treatment. In fact, I can only recall referring one patient for radiotherapy, and that was a very unusual case.
Beck: One last thing I wanna mention for the benefit of students reading this...I was incredibly fortunate to work with you and the House group in the 1980s, and I'm very grateful for that opportunity...but one thing I've thought of time and time again was the fact that if one of us had an idea for an electrode design, or we wanted to see if we could record action potentials directly from the eighth nerve, or the cochlear nuclei, you and Dr. House encouraged us to think it through as best we could, make the electrode in the lab, and then we sterilized it and brought it to you in the OR, and we tried it. I cannot imagine how many levels of IRB and administrative approvals it would take to get that approved today...and although I'm appreciative of the current safeguards and why they're there...I wonder if we've gone overboard with protectionism?
Hitselberger: Well, usually the best ideas come from younger people who don't know the limits and haven't been beaten up by the administration! Bill House said this to me time and time again...When you first get a new idea, like he did in the 1950s for cochlear implants, or creating new surgical techniques or surgical instruments...many of which he created...When you come up with new ideas, real scientific breakthroughs, the first thing that happens is your peers and colleagues tell you it's a stupid idea and it'll never work. The second thing that happens is they tell you someone else already did it. The third thing they tell you is they can do it better. And then finally, the fourth thing is, they steal the idea! One of your colleagues takes credit for the idea and says they told you about it and what a great idea it was when they first thought it up!
Beck: And I know those things have happened time and time again with you and Dr. House!
Hitselberger: One incident from some 20 years ago, was when we did the first auditory brainstem implant (ABI). I recall walking over to the operating room with Bill and I said to him, "You know, I think we forgot to clear this procedure with the surgical committee." He looked at me and he smiled and said, "I won't tell them if you won't tell them." And we didn't tell them! But it really wasn't cavalier at all. We had worked through all the negatives with the patient, and she knew the risks and complications. We knew that if it wasn't right, we could remove it without too much trouble, which actually happened. She did actually hear with the device, although it was pretty crude. Post-op she had some side effects involving the ascending pain fibers so we removed the ABI. But then, once it was removed, she really wanted us to try again and we did, and it was a terrific success the second time and she wears it to this day. The second time I placed it on the ventral cochlear nucleus and it's been great. So, because the patient really pushed to have it done, we've now done over 170 ABIs. So it was another "administrative oversight" but it was scientifically sound, it was a great idea, the patient knew the risks and wanted us to try, and it really worked out very well, and she's had it for over 20 years!
Beck: Dr. Hitselberger, thanks so much for meeting with me, and for being do generous with your thoughts and time. It is a rare delight to spend time with you.
Hitselberger: Thanks Doug. It was fun for me too.
Hitselberger: Good Morning Dr. Beck. Nice to be with you again, too!
Beck: I should disclose that you and I have known each other for some 20 years...In fact, when I started my fellowship at House, you were the primary neurosurgeon that operated with Drs. William House, Derald Brackmann and the other neurotologists from the House group. I am still amazed when I recall the many days you would operate on two or three acoustic neuromas in a single day. My recollection is that you've operated on 6000 skull base tumors - is that right?
Hitselberger: Yes, I think so. We've done quite a few in the last 40 years or so. I think we're just over 6000.
Beck: Dr. Hitselberger, before we get too far along... I wonder if you would tell me a little about your education. Where did you go to school and when did you graduate?
Hitselberger: I went to the University of Wisconsin at Madison. That was
the best education I could ever have! Every course I took was fabulous. I learned something new and useful in every class -- it was worth the time and the effort. I never had a bad professor! After that, I went to Harvard Medical School. It was not at all what I had hoped for! I graduated from Harvard in 1956, almost 50 years ago, but their emphasis at that time was on research and that just wasn't interesting to me. I was far more interested in clinical issues. It's hard for me to remember taking really pragmatic, useful classes there. After that, I did my internship, military service and residency through the University of Minnesota, the Mayo Clinic, and Henry Ford Hospital in Detroit. So I had a pretty good residency, not outstanding, but pretty good.
Beck: When you look at how neurotologists and neurosurgeons work together on skull base cases, it seems routine and normal now, but I know from my discussions with Dr. Bill House and from his writings, that in the early days, the local medical community didn't think kindly of the way you two approached skull base tumors! In fact, my recollection is that the local surgeons pretty much thought you guys were nuts!
Hitselberger: Yes, well there was a lot of that! There was a lot of antagonism mainly between the neurosurgeons and us. The local guys really tried hard to get Dr. Bill House and me kicked off the hospital staff. They thought we were doing something only neurosurgeons should be doing. So it was pretty ugly for a long time. But it's important to understand that neurosurgeons didn't know squat about ENT or audiology. They couldn't read audiograms and they didn't understand issues related to hearing! Dr. House and I thought "cross training" made a lot of sense back then and it seems to make sense to me now, too. The best approaches to the benign tumors of the skull base, such as meningiomas and acoustics are through ENT approaches -- and that's just the plain, simple truth. The neurosurgeons spend 6 years in their residency, and there's plenty of time to learn about ENT and ophtho approaches to the skull base and brain, but it really isn't done very much, unless the particular resident takes it upon themselves to learn that stuff and gain that experience. If they don't see how the neurotologists get to the skull base, they'll go sub-occipitally, and that's not the best approach to acoustics 99 percent of the time.
Beck: I guess the issue really does boil down to the individual skills of the surgeon and the surgical approach. Traditionally, acoustics had been approached sub-occipitally, but then you and Dr House explored the translabyrinthine approach, which involved Dr. House essentially drilling through the ear and then once he got to the skull base you removed the tumor. Is that right?
Hitselberger: That's right. But it was really Dr. House that initiated and explored the translab approach. It was an approach that allowed each of us to maximally use our skills to safely approach and remove these tumors. And the thing was, the only reason Dr. House developed the translab technique was because the previous techniques which the neurosurgeons used, had unbelievably high morbidity and mortality rates associated with them...they were really unacceptable. In California, just before we started working together, the mortality rate for patients with acoustics was about 40 percent -- and that was just terrible. Bill House pretty much figured out the translabyrinthine approach, and he was the first surgeon to use the operating microscope in the operating room. Dr. House taught the neurosurgeons about using the microscope. In 1963, Dr. House and I started working together. I was right out of my neurosurgical residency. Dr. House taught me the anatomy of the temporal bone and I started working in the t-bone lab to drill out the temporal bone and learn how to do that part of the surgery.
Beck: I suppose that must've been somewhat uncomfortable professionally? Back in the early and mid-1960s, it was not common for otologists to work with neurosurgeons and it must've really threatened your relationship with the local and national neurosurgical community?
Hitselberger: Yes, well, it was a little awkward. Back then it was the ultimate "turf-battle." Here I was, a newly graduated neurosurgeon, working on the skull base with an ear doctor...it was really unpleasant for us for quite a while, but I didn't let it bother me. I thought of it as taking a residency from Dr. Bill House, who just happened to be the best otologist in the world. I spent a lot of time trying to learn what he was showing me and I remember Dr. House used to say "You know Hitselberger -- if I can teach you -- I can teach anybody!" But it really was difficult for me. There's lots of tiny little anatomic quirks and anomalies in the temporal bone and it's difficult anatomy to learn and operate on, and then there's the issue of working through the microscope...so I had a lot to learn, and it took time, but I think I finally got it right.
Beck: Yes, I think you did! I had the pleasure of watching the two of you work together while I was monitoring various cranial nerves, probably a hundred times or more, and I thought the relationship and the knowledge you two shared was rather magical.
Hitselberger: Yes, it was unique. I knew I could do a lot, and maybe even all of the temporal bone drilling, and frankly, Dr. Bill House could remove tumors as well as most neurosurgeons, too. So we knew each other's moves and we had a common knowledge and foundation from which we worked. We knew how to maximize our team approach for the best possible surgical result. It really was very nice. We worked together, we understood the other's expertise, and it was a great team approach.
Beck: I can recall cases when you would come into the room just as Dr. House was incising the dura and you would look through the microscope sidearm and say something like...."Bill, lemme know if you need help, I'll be in the next OR." Sometimes he would just go ahead and remove the tumor, and sometimes you would. It just depended on the size and location of the tumor.
Hitselberger: Yes, for some tumors we were pretty much interchangeable!
Beck: Are co-operative relationships more common now, or are we going to finer and finer sub-specializations?
Hitselberger: I don't really know, but I suspect those relationships are going away! Many times surgeons become more concerned with protecting their turf, rather than doing the best possible job for the patient -- and that's terrifically unfortunate. I suspect surgical roles are becoming more and more fixed, and the roles are more and more narrow and finite.
Beck: Earlier in the discussion you mentioned that when you and Dr. House started operating on acoustic neuromas, the mortality was 40 percent...what are the most recent numbers?
Hitselberger: Well, I can't tell you the exact number down to the tenth of a decimal, but it's way below one percent.
Beck: That's really amazing progress in 40 years.
Hitselberger: Yes it truly is. We have better diagnostic tools so we can, and do, find tumors when they are much smaller and easier to remove, and of course we have better techniques now and better surgical tools, to say nothing of far greater knowledge, so it has come full circle in many respects.
Beck: And with regard to facial nerve injury during acoustic neuroma removal surgeries? Any recent numbers on that?
Hitselberger: Well, again, I really haven't looked at the numbers for a long time, but I think it's fair to say that having a permanent facial nerve injury secondary to our acoustic neuroma removal is probably less than two or three percent. Some patients have a temporary weakness that resolves in less than a year. So if you look at the whole group, one year post-op, I think no more than 2 or 3 percent have facial weakness.
Beck: Dr. Hitselberger, can you please share your thoughts on Gamma Knife, Proton Beam and related radiographic treatments for skull base tumors?
Hitselberger: Sure, Great topic! There are a number of things to consider with Gamma Knife and other radiologic therapies like Proton Beam.... First, radiologic therapies don't remove tumors. If the tumor grows, or the treatment is not successful, when we go in to remove the tumor surgically, it's a bigger problem. By the time we operate, additional time has gone by and the tumor might be larger. Also, the scarring which results from radiologic treatment makes it more difficult to remove the tumor surgically because the capsule is harder to define and the tumor can be more adherent to healthy brain or other cranial nerve tissue. Another serious, yet extremely rare issue, is the tumor can actually change it's biologic characteristics from benign to malignant following radiologic therapy. We have seen radiated tumors, on rare occasion, which have changed to malignant. Radiologic treatment has another important issue and that has to do with recurrence. We've probably seen some 50 cases in which tumors have re-grown, it's not just an odd one or two cases, there are quite a few around and I think our series is probably the largest in the world. We hope to publish that paper late in 2004, or in 2005, detailing our findings. On that same issue, when people have radiologic therapy, they need to be followed by radiographic studies every year, and that's not a great thing either. Another issue, which few people think about, is getting health or life insurance. The issue is -- almost no one will insure you after radiologic treatment, because you still have a brain tumor -- at least that's what I've heard from underwriters. Lastly, radiation therapy doesn't cure benign tumors anywhere else in the body, so I'm not really sure why people try to apply it to acoustic neuromas, it's just not a great idea most of the time. So all-in-all, I think Gamma Knife and Proton Beam therapies are interesting, and they have their place in certain, selected, unusual situations, but I think surgical removal is usually the preferred treatment. In fact, I can only recall referring one patient for radiotherapy, and that was a very unusual case.
Beck: One last thing I wanna mention for the benefit of students reading this...I was incredibly fortunate to work with you and the House group in the 1980s, and I'm very grateful for that opportunity...but one thing I've thought of time and time again was the fact that if one of us had an idea for an electrode design, or we wanted to see if we could record action potentials directly from the eighth nerve, or the cochlear nuclei, you and Dr. House encouraged us to think it through as best we could, make the electrode in the lab, and then we sterilized it and brought it to you in the OR, and we tried it. I cannot imagine how many levels of IRB and administrative approvals it would take to get that approved today...and although I'm appreciative of the current safeguards and why they're there...I wonder if we've gone overboard with protectionism?
Hitselberger: Well, usually the best ideas come from younger people who don't know the limits and haven't been beaten up by the administration! Bill House said this to me time and time again...When you first get a new idea, like he did in the 1950s for cochlear implants, or creating new surgical techniques or surgical instruments...many of which he created...When you come up with new ideas, real scientific breakthroughs, the first thing that happens is your peers and colleagues tell you it's a stupid idea and it'll never work. The second thing that happens is they tell you someone else already did it. The third thing they tell you is they can do it better. And then finally, the fourth thing is, they steal the idea! One of your colleagues takes credit for the idea and says they told you about it and what a great idea it was when they first thought it up!
Beck: And I know those things have happened time and time again with you and Dr. House!
Hitselberger: One incident from some 20 years ago, was when we did the first auditory brainstem implant (ABI). I recall walking over to the operating room with Bill and I said to him, "You know, I think we forgot to clear this procedure with the surgical committee." He looked at me and he smiled and said, "I won't tell them if you won't tell them." And we didn't tell them! But it really wasn't cavalier at all. We had worked through all the negatives with the patient, and she knew the risks and complications. We knew that if it wasn't right, we could remove it without too much trouble, which actually happened. She did actually hear with the device, although it was pretty crude. Post-op she had some side effects involving the ascending pain fibers so we removed the ABI. But then, once it was removed, she really wanted us to try again and we did, and it was a terrific success the second time and she wears it to this day. The second time I placed it on the ventral cochlear nucleus and it's been great. So, because the patient really pushed to have it done, we've now done over 170 ABIs. So it was another "administrative oversight" but it was scientifically sound, it was a great idea, the patient knew the risks and wanted us to try, and it really worked out very well, and she's had it for over 20 years!
Beck: Dr. Hitselberger, thanks so much for meeting with me, and for being do generous with your thoughts and time. It is a rare delight to spend time with you.
Hitselberger: Thanks Doug. It was fun for me too.
