Letter to the Editor Concerning MacDonald, Gifford, et al. (2025)

The 2025 report by MacDonald et al.1 documents that electrically-elicited stapedius reflexes are visualized intraoperatively (“the surgeon used an operating microscope to visually observe contraction of the stapedius muscle to report the presence or absence of reflex”) in the majority (11 of 14 adult ears studied by them) being stimulated through a cochlear implant. Also documented is that the needed intensity of electrical stimulation to elicit the visualized intraoperative ipsilateral reflex is greater than the intensity needed one month postoperatively to elicit an admittance-recorded reflex in the contralateral ear. Their findings are consistent with our experiences with children.2 We question, however, their report of observing the stapedius muscle intraoperatively. The muscle is inside the pyramidal eminence bone in mammals,3 in contrast to birds.4 Most reports, eg,1,5 of the last 65 years about viewing the human stapedius reflex, surprisingly state viewing the muscle, ie, seeing through bone. More recent (and we suggest, more exact) reports note a change in the stapedius tendon.6,7 We submit that MacDonald et al.1 observed the reflex as a change in contour of the stapedius tendon, or a slight change in the position of the stapes (as evidenced by a shift in the location and size of a tiny light reflection on the stapes capitulum or posterior crus). This is not new information, having been described by at least Lüscher,8 Lindsay et al.,9 Kobrak,10 and Jepsen.11 To those who regard our concern as persnickety, we respond that precision in terminology is just as important as precision in microsurgery.