Interview with Lance Jackson M.D.
AO/Beck: Hi Dr. Jackson, thanks for joining me this morning.
Jackson: Good Morning Dr. Beck. I appreciate the opportunity to speak with you and share some insights with you and your readers.
AO/Beck: I know you've recently joined your otology practice with Dr. Kreuger's here in San Antonio, and I'm very glad to have you in town! Before we start talking about minimally invasive otologic sugeries, would you please give us a little biographical sketch?
Jackson: Certainly. I was raised in San Antonio. After completing high school, I was first interested in engineering and decided to attend the Massachusetts Institute of Technology. While at MIT, I became interested in medicine as well and decided to apply my engineering background to research in the medical field. Thus, I completed an electrical engineering degree. I was fortunate to have the opportunity to conduct research in biomedical signal processing, and one of our papers was published in the New England Journal of Medicine. I also worked as an engineer for companies including Texas Instruments and Sun Microsystems before entering medical school. For medical school, I attended Washington University in St. Louis. For otolaryngology residency training, I went to Stanford University and enjoyed the spectacular San Francisco Bay Area during those five years. I completed a Neurotology fellowship at the Ear Research Foundation with Drs. Herb Silverstein and Seth Rosenberg. I stayed at the Ear Research Foundation for additional years as director of medical education before deciding to move my practice and family back to my hometown of San Antonio, Texas.
AO/Beck: Very good. I know you've also published extensively in the otologic literature and your presentations are equally impressive. Let's start with a definition please. What is the difference, theoretically and/or pragmatically, between traditional surgery and minimally invasive surgery? And, can you perhaps address advantages and disadvantages of each?
Jackson: For decades, traditional ear surgery has been performed in a hospital-based operating room with the use of general anesthesia or intravenous sedation. In recent years, otologic surgeons have started to discover that similar surgical results can be achieved with less invasive techniques. While the field of otology is particularly suited for minimally invasive techniques, most surgical specialties are also moving in the direction of less invasiveness, helping to reduce pain and speed recovery. With the use of new surgical tools, such as endoscopes and lasers, we have been able to transfer many ear operations from the formal operating room to the office procedure room, and we have also been able to minimize patient exposure to general anesthesia and IV sedation. Minimally invasive techniques are performed through smaller incisions and generally expose the patients to less overall risks. Frequently, the need for a hospital surgery is avoided, thus reducing the associated large medical costs, eliminating the need for an anesthesiologist, and reducing time inefficiencies to both the patient and surgeon. Other advantages of minimally invasive surgery include better patient acceptance. However, only certain otologic conditions can be treated with minimally invasive techniques, and there will always remain a need for hospital-based surgery.
AO/Beck: In your recent 2003 book, titled Minimally Invasive Otological Surgery (publisher, Thomson-Delmar ISBN # 0-7693-0138-X, by Silverstein, Rosenberg, Poe and Jackson) you spoke about LASER assisted Tympanostomy with and without PE tubes. Would you please address that for us?
Jackson: Before Laser Assisted Tympanostomy (or LAT for short), the two ways to surgically treat serous otitis media and eustachian tube dysfunction were with PE tube placement and with myringotomy. When PE tubes are placed, they typically remain in the drum for 6 to 24 months, and require the patient to follow precautions to keep the ears dry until the drum heals, if at all. Conversely, with myringotomy, the hole in the drum remains for up to only 2 to 3 days, and such a short period of middle ear aeration is minimally effective in providing long-term relief. A major advantage of LAT using a CO2 laser is that the laser opening remains in the drum for roughly 3 to 4 weeks. We find in many patients that this period of aeration is adequate to resolve the symptoms and eustachian tube problems, while at the same time not committing the patients to prolonged periods of lifestyle restrictions due to indwelling PE tubes. LAT can be performed in both adults and children. We published a study in the American Journal of Otology showing that roughly half of children avoided the need for PET placement with use of LAT, and thus avoided a trip to the operating room and exposure to general anesthesia. Approximately 80% of adults with serous otitis media responded to LAT. As discussed in our book, we also describe how the laser is a very useful tool for other office-based procedures, including middle ear exploration and inner ear perfusion.
AO/Beck: One other point if I may....is there an ideal aeration time for ventilating the middle ear via tympanostomy? I know many parents are concerned if the child's PE tube is in too long, or falls out too quickly.
Jackson: Very insightful Doug. Dr. Armstrong who developed the early PE tubes supported the notion that a 2 to 4 week period is adequate to treat serous otitis media with effusion. Based upon the results of our study using LAT in children, I think we support the idea that about 4 weeks may be a proper period of time. Additionally, the shorter the period of aeration, the less the chance of persistent tympanic membrane perforation, which is another reason to keep aeration as short as necessary to provide relief of symptoms.
AO/Beck: On the same subject, I think the term Laser Assisted Otoendoscopy is a relatively new term. Can you please tell me what this means, and what are the applications and indications for this procedure?
Jackson: The term Otoendoscopy refers to the use of a small endoscope to inspect the middle ear and mastoid cavity. Laser Assisted means that a laser can be used to make a tympanotomy opening in the tympanic membrane to allow an entry point for passage of the endoscope. Although a standard myringotomy knife can be used to make an opening in the drum, the advantage of the laser is that the opening is bloodless, thus preventing clouding of the optics with blood products. Historically, middle ear exploration was performed in the past in a formal operating room by lifting the eardrum as part of a tympanomeatal flap to directly inspect the middle ear with a microscope. Now, we can do this endoscopically in the office by making a 2 mm opening in the drum, and passing a rigid 1.7 mm diameter scope through the opening. Straight and angled-tip scopes exist, which allow the surgeon to look around corners that can't be seen with a standard otologic microscope. Otoendoscopy has many applications which we discuss in our book. It can be used to inspect the middle ear for causes of an unexplained conductive hearing loss, to look for middle ear tumors, to assess for a perilymphatic fistula, and to assess for recurrence of middle ear or mastoid cholesteatoma. We also use the endoscope to evaluate the round window and remove any obstructing adhesions prior to perfusion of the inner ear. When performing fat myringoplasty in the office, the undersurface of the drum perforation is evaluated with an angled endoscope to ensure that skin is not growing into the middle ear, which could cause failure of the procedure. Some interesting pathologies that we have discovered with office laser assisted otoendoscopy include glomus tympanicum tumors, stapes crural fractures, traumatic incus displacement, and cholesteatoma.
AO/Beck: In your book I noticed endoscopic exploration can also be used for the eustachian tube? But pragmatically, does it make a significant difference? In other words, if the patient has eustachian tube dysfunction diagnosed based on their clinical signs and symptoms and standard E. Tube tests done in the office, does the endoscopic exploration typically change the treatment or diagnosis?
Jackson: Endoscopic visualization of the eustachian tube in the office is helpful for several reasons. First of all, visualization and photodocumentation of the status of the eustachian tube helps in confirming pathology and assessing response to treatment on repeat visualization. Also, with a new treatment we have described where we perfuse the eustachian tube with steroids, endoscopy helps guide placement of the medication delivery device. Since office tests of eustachian tube function are reasonably accurate, endoscopic exploration is supplementary and helpful, but overall does not dramatically change the overall course of therapy.
AO/Beck: Certain inner ear disorders have been treated by perfusing the inner ear with various chemicals. One of the conduits used for perfusion is the MicroWick. Would you please describe the MicroWick and it's applications?
Jackson: The MicroWick is a cylindrical sponge-like device measuring 1 by 9 mm long that was developed by a co-author of my book, Dr. Herb Silverstein. The device was FDA approved in 1999, and we have established several key applications on which we have presented and published. To treat the inner ear, the MicroWick is guided through a PE tube so that one end lies against the round window membrane, and the other end lies in the ear canal. Then, the patient can self-treat the inner ear (under physician guidance of course) by applying medicated drops to the ear canal. These drops are absorbed by the MicroWick and then delivered to the round window for perfusion into the inner ear, allowing high concentrations of the medication to be achieved while avoiding systemic side effects. We have effectively used the device to perfuse the inner ear with gentamicin in patients with disabling vertigo related to Meniere's disease, and 85% control of vertigo has been achieved through this minimally invasive fashion. The device has also been used to treat the inner ear with steroid drops in patients with idiopathic sudden sensorineural hearing loss and autoimmune inner ear disease. Excellent improvement in hearing losses has been achieved that were not fully responsive to oral steroids. We have also begun investigating perfusion of the inner ear with Lidocaine for the treatment of tinnitus.
AO/Beck: And of course, please tell me the advantages and disadvantages of the MicroWick?
Jackson: We believe the MicroWick is advantageous for treating ear conditions for a number of reasons. It can be placed in a minimally invasive fashion and allows directed treatment of the inner ear. Similar to the way patients can self-apply eye drops to treat eye disease, with the MicroWick the patient self-applies the medication, thus allowing near continuous perfusion of the inner ear over a long period of time. This is in contrast to the frequently used method of transtympanic injections in which the patient has to return to the physician's office for repeated injections and experience the discomfort of repeated procedures while not achieving prolonged high concentrations of medication in the inner ear. The other method of inner ear perfusion utilizes a surgically placed catheter and infusion pump, which requires placement in a formal operating room and increased costs. Another advantage of MicroWick perfusion is that systemic side effects of the treating medication are minimized. For example, some patients cannot safely tolerate oral steroids due to other medical conditions, such as diabetes or peptic ulcer disease, and the MicroWick allows treatment of the inner ear directly without exposing patients to the risk of oral medications. When the treatment is concluded, the MicroWick can be easily removed in the office.
AO/Beck: Can you please tell me about the Laser Stapedotomy Minus Prosthesis (STAMP). What is that all about and how is it different from a stapedotomy, and how is it different from the stapes mobilization from decades ago?
Jackson: The Laser STAMP procedure involves using the laser to make specific cuts to the anterior stapes crus and across the footplate. This allows mobilization of the posterior two-thirds of the footplate while maintaining natural ossicular continuity from the incus through the posterior stapes crus. To be a candidate for Laser STAMP, patients have to have otosclerosis isolated to a focus at the anterior stapes footplate, which can only be determined by direct inspection during the procedure. Consequently, patients are counseled and prepared for Laser STAMP versus conventional stapedotomy with a prosthesis. The advantages of the Laser STAMP procedure are that no artificial prosthesis is placed, thus avoiding prosthesis-related complications, such as prosthesis displacement and incus necrosis, which are frequently the causes of the need for revision surgery. Also, the stapedial tendon is preserved, which helps protect against hyperacusis. The stapes mobilization procedure was first described by Dr. Rosen in the early 1950's, but stapes refixation frequently occurred within several months, causing the procedure to be abandoned. With the Laser STAMP, only the portion of the stapes footplate not involved with otosclerosis is mobilized, so the risk of refixation is minimal. In a study we published on 46 patients who underwent Laser STAMP, the incidence of stapes refixation was found to occur rarely.
AO/Beck: I have heard many positive reports about the Baha System. Would you please tell me your thoughts on the device, and what are the patients telling you post-fitting?
Jackson: The Baha is a great option for patients with conductive hearing loss, such as those with chronically draining ears and external auditory canal stenosis or atresia. Also, it has become an option for those with a unilateral sensorineural hearing loss, becoming an alternative to CROS aids. The Baha System can be implanted under local anesthesia in a minimally invasive fashion. Following implantation in patients with bilateral conductive hearing losses, the recipients have been very impressed with the quality of sound. The performance of the device can be simulated preoperatively by having the patient use an external bone conducting hearing device-most are impressed after this simulation and can determine if the Baha may be right for them.
AO/Beck: Thanks so much for your time Dr. Jackson. I appreciate your time and talents!
Jackson: It was my pleasure Doug. I compliment you and Audiology Online on this forum for education and dissemination of information.
For more information about the Baha System, Click here.
