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Flashcards in 53 Microtia & Otoplasty Deck (24):
1

What is otoplasty?

What is otoplasty?

Otoplasty is the manipulation of abnormally shaped cartilages to achieve a more natural appearing shape of the external ear. This can be achieved by surgical and nonsurgical methods.

2

What are the indications for otoplasty?

What are the indications for otoplasty?

Otoplasty is not based on the ear shape, but rather the patient’s perception of the ear shape. Look at the patient’s ears and listen to the patient’s concerns. If the ears are asymmetric or if their shape draws attention to the ears instead of the person’s face, otoplasty may be indicated. If the patient sees only his or her ears in the mirror or is teased because of their size or shape, otoplasty can improve self-esteem.

3

What anatomic landmarks of the external ear are important in otoplasty? (Figure 53-1)

What anatomic landmarks of the external ear are important in otoplasty? (Figure 53-1)

The circumference of the external ear is described by the helix, lobule, and tragus. The inner folds of the ear consist of the antihelix and antitragus. The antihelix divides the external ear superiorly into the superior and inferior crus. Between the crura is the fossa triangularis. Between the helical rim and the antihelical fold is the scaphoid fossa. Between the antihelix and the tragus is the conchal bowl, which is divided by the root of the helix into the concha cymba above and the concha cavum below. The tragus overlies the ear canal opening.

Figure:  Landmarks of the external ear: (1) superaurale, (2) subaurale, (3) preaurale, (4) postaurale, (5) otobasion superius (6) otobasion inferius, (7) deepest point on the notch on upper margin of tragus, (8) lowest point on the lower border of tragus, (9) protragion, (10) concha superior (the intersection of the lower edge of the anterior end of the crus antihelicis inferius and the posterior border of crus helicus, (11) incisura intertragica inferior (the deepest point in the incisura intertragica), (12) incisura anterior auris posterior (the most posterior point on the edge of incisura anterior auris), (13) strongest antihelical curvature, (14) deepest lateral border of external auditory meatus, (15) lobule anterior (ear attachment line is drawn joining the otobasion superior and inferior. The point on this line just below the incisura intertragica where the cartilage ends is the landmark.) and (16) lobule posterior (the most posterior point on the margin of lobule perpendicular to lobule anterior).

4

How are external ear malformations classified?

How are external ear malformations classified?

Various grading systems have been proposed for congenital malformations of the auricle. Most reliable for documentation or discussion between health care providers is an anatomic description of the abnormality since no staging system is widely recognized. Description of the abnormality can help direct thought about reconstruction or correction. Commonly used terms are protruding or prominent ears, lop ears, Stahl’s ears, constricted ears, cryptotia, microtia, and anotia.

5

Describe the dimensions of a normal ear.

Describe the dimensions of a normal ear.

A normal ear is in proportion to the person’s face. It blends and looks “natural.” Ears are fully grown by 9 years of age. They do not change shape spontaneously beyond 12 months of age. Whereas no one size or shape is normal for all people, some approximate measurements can be helpful in assessing the degree of abnormality of an ear. Ear height is typically 55 to 65 mm, and width is from 30 to 45 mm. Width is usually 50% to 60% of the height. The ear is rotated so that the top is 15° to 30° more posterior than the earlobe. At its midpoint, the ear protrudes from the scalp about 18 to 20 mm. The angle of protrusion of the ear from the head is usually <21° in a female and <25° in a male. The root of the helix is usually 60 to 70 mm posterior to the lateral canthus of the eye.

6

What is a prominent or protruding ear deformity?

What is a prominent or protruding ear deformity?

This common external malformation is diagnosed when the angle of the ear to the head is >35°. It is most commonly a result of the lack of antihelical fold development. The ear then protrudes more than the 20 mm expected from the scalp. The prominent ear takes over the frontal profile. Instead of seeing a person’s face, the eyes of the observer are drawn to the ears. A normal ear shape and angle of protrusion can be attained by gentle repositioning of the ear with finger pressure.

7

What is a constricted or cup ear deformity?

What is a constricted or cup ear deformity?

This ear deformity is characterized by the inability of gentle finger pressure to attain a normal shape or position of the ear. A deficiency of skin, cartilage, or both restricts the “unfolding” of the ear.

8

How is microtia or anotia characterized?

How is microtia or anotia characterized?

In the microtic ear, the cartilage shape is not normal The classic description is a cartilage remnant that looks like a rolled “peanut” positioned at the root of the helix. The lower portion of the microtic remnant is soft fatty tissue—the earlobe remnant. Superiorly, the remnant is composed of crumpled cartilage under the skin. An atypical microtia may have the beginnings of normal ear architecture but with obvious disruption in development. Anotia is absence of the external ear. A small earlobe remnant may be present and is often not in the expected location.

9

Summarize the goals of otoplasty.

Summarize the goals of otoplasty.

The primary goal of otoplasty is to make the patient (and often the parents) happy. The postoperative ear or ears should be symmetric. From the frontal view, you should have a small glimpse of both ears at the same time. On lateral view, the ear should have smooth contours with recognizable major anatomic features: helical rim, antihelical fold with crus, scapha, conchal bowl, and lobule. The posterior view should exhibit appropriate scalp-to-ear distances (<20 mm).

10

When should otoplasty be offered to a patient?

When should otoplasty be offered to a patient?

The age at which otoplasty can be performed depends on the type of corrective surgery needed. The goal of timing is to avoid psychological insult to the child by completing the repair as soon as possible while balancing the maturity needed for participation and cooperation in surgical and postoperative care.

11

What is the youngest patient age at which otoplasty can be performed?

What is the youngest patient age at which otoplasty can be performed?

The first opportunity for the correction of abnormal ear shapes is within the first several days after birth. Reshaping with wax and tape within the first 96 hours of life can obviate the need for surgery in the future. The splint or molding technique requires 2 weeks of reshaping if applied during the neonatal period. Older infants may require longer periods of shape control. Recently, the use of a splint and double-sided tape for many months was reported in children up to 5 years of age as a means of avoiding surgical correction.

12

What is the youngest patient age at which more complicated techniques can be done?

What is the youngest patient age at which more complicated techniques can be done?

If the abnormality can be corrected by gentle finger pressure into a desired shape, then a permanent change in shape can be accomplished with the incisionless technique as early as age 2 years when general anesthesia is considered safe for elective procedures. If the abnormality cannot be corrected by gentle finger pressure then the child will need an open procedure and will need to be able to participate in the postoperative care and suture removal. An open otoplasty is typically performed as early as 5–6 years of age for very motivated children and parents but may be delayed until the child is ready. Boys are often slower than girls at being ready for the cooperation needed in the postop care of either an otoplasty or microtia construction. When microtia construction with autologous rib grafting is to be considered, the ribs must be large enough to carve. Some techniques can start as early as age 6–7 years of age but the newer 3D techniques require more rib and most children do not have enough rib stock until age 10–12 years of age.

13

What is the oldest patient age at which otoplasty can be done?

What is the oldest patient age at which otoplasty can be done?

No age is too old for otoplasty. Many adults who did not have the opportunity for ear corrective surgery in childhood still desire a normally shaped ear. Both open and closed procedures may be appropriate.

14

What are the options for protruding ear otoplasty?

What are the options for protruding ear otoplasty?

Open versus closed: Open techniques begin with skin excision and progress to weakening or thinning the cartilage, reshaping with mattress sutures, or dividing the cartilage with removal of cartilage to reduce the conchal bowl. Closed options include tape and wax or splint application as well as the incisionless otoplasty described by Fritsch. Incisionless otoplasty employs permanent horizontal mattress sutures placed percutaneously.

Cartilage sparing versus cartilage removal: Surgeons are highly opinionated as to whether cartilage can be reshaped with mattress sutures, scoring, or thinning by drilling, or whether cartilage must be removed to attain a desirable ear shape. Either option can be used successfully, but usually only one option is adopted as “the way” by an individual surgeon.

15

How long do dressings need to be used after otoplasty?

How long do dressings need to be used after otoplasty?

One of the advantages of the incisionless technique is that no dressing is needed. A soft headband can be used at night, if desired, for comfort. When an open technique is used, the dressing is usually kept in place for 2 weeks. This period allows the skin flap to reattach and the cartilage to begin healing if it has been divided or removed. An elastic headband is worn at night for an additional 4 to 6 weeks to prevent accidental forward displacement of the ear until full healing is complete. This concern is greatest if cartilage is removed or divided.

16

Describe the early complications of otoplasty for protruding ears.

Describe the early complications of otoplasty for protruding ears.

Hematoma is the major concern after open otoplasty. If a hematoma goes undiagnosed and untreated, perichondritis and loss of cartilage result. Persistent postoperative pain can be a sign of hematoma. Proper treatment consists of immediate evacuation of the clot and debridement of any necrotic tissue resulting from pressure of the hematoma, followed by reapplication of the compressive dressing. Other early complications include skin necrosis secondary to dressing pressure, skin hypersensitivity to pressure or temperature, and suture spitting. All of these, except suture extrusion, are avoided with the incisionless technique because no dressing is used postoperatively and no dead space for hematoma formation is raised during the procedure.

17

What are the significant late complications of otoplasty for protruding ears?

What are the significant late complications of otoplasty for protruding ears?

The most common late complication is unhappiness with the postoperative correction, usually because of undercorrection, asymmetry, or cartilage deformation over time. In an open procedure, scar hypertrophy or keloids may result. In an open or closed otoplasty, suture knot protrusion can result over time. Keloids should be considered a possibility at the puncture sites but are rarely encountered.

18

What is a “telephone ear” deformity?

What is a “telephone ear” deformity?

A telephone ear deformity describes the shape of an overcorrected midportion of the ear. The resultant shape is reminiscent of the original hand piece of a telephone with a separate receiver and a mouthpiece with a connecting narrower handle. The deformity is best appreciated on frontal view. Such overcorrection can be due to excessive removal of postauricular skin or mastoid soft tissue or by overtightening set-back sutures of the concha to the mastoid.

19

What historical names should I know if I want to discuss otoplasty for protruding ears?

What historical names should I know if I want to discuss otoplasty for protruding ears?

Many surgeons have made inroads in the correction of ear shapes. Mustardé is known for the development of the horizontal mattress suture to reshape the antihelical fold (Figure 53-2). This same horizontal mattress suture has been adapted to a percutaneous technique of incisionless otoplasty. Converse and Furness otoplasty techniques use cartilage repositioning and weakening in their otoplasties. Converse uses the cartilage weakening and repositioning to create the appearance of an antihelical fold. The Furness technique does not address the antihelical fold but focuses on the conchal bowl protrusion by suturing the bowl to the mastoid periosteum, rotating the ear posteriorly and thus decreasing protrusion. This technique is often used in conjunction with a technique for reshaping the antihelical fold.

20

How is correcting a “cup” or constricted ear different from correcting a protruding ear?

How is correcting a “cup” or constricted ear different from correcting a protruding ear?

A cup or constricted ear is missing enough skin, cartilage, or both so that a normal shape cannot be attained through the techniques used for protruding surgery. New skin or cartilage or advancement of tissue must be used to release the constricted part of the ear (Figure 53-3).

Each ear is slightly different, and a full armamentarium of reconstructive options must be learned and used to get consistent results. The deficiencies usually lie in the helical rim, scapha, and root of the helix. Techniques to unfurl and fan open have been described, but may fail over time because the skin/soft tissue envelope collapses the new expanded cartilage shape. Rotational or advancement flaps have more stability. A preferred technique is to release the root of the helix as a V-Y advancement flap, incorporating the ridge of cartilage between the concha cavum and concha cymba. Several millimeters of length can be borrowed and advanced into the height of the ear. The donor site is closed primarily. Skin grafts are used if needed in the new fossa triangularis area, and the cartilage is reshaped with horizontal mattress sutures to add strength and stability over time.

21

When does a lobule need to be corrected?

When does a lobule need to be corrected?

The earlobe may angle forward, particularly in a cupped or protruding ear. The upper cartilage can be corrected, but the ear can still look abnormal if the earlobe is not repositioned. The earlobe angles forward if there is an abnormally long or flared caudal helical cartilage. Resecting or repositioning this tail of cartilage will result in less anterior angulation of the lobule. Sometimes skin behind can be removed to assist in earlobe correction. If the earlobe is to be reduced in size, a geometric resection with overlapping and, if possible, different anterior and posterior closures, will result in less scar contracture and earlobe notching.

22

Can a huge ear be reduced in size overall?

Can a huge ear be reduced in size overall?

Of course! Auricular reduction may be necessary to attain symmetry with a smaller opposite ear. Sometimes it is easier to reduce the larger ear than to expand the deficient one. All methods of reduction surgery involve geometric excision and closure. This approach decreases the chance of a notched scar along the sweeping helical rim.

23

What can be done with a microtic ear?

What can be done with a microtic ear?

A person with microtia can be treated with a silicone prosthesis that is made to look like the opposite ear and attached with skin glues or, more recently, with bone-anchored screws or magnets.

Surgical correction can be attained with a buried silicone or Silastic ear mold, but the mold is prone to extrusion and malformation with the trauma of childhood play or sports. The long-term effects of a foreign body in children are also significant; thus, this form of reconstruction should no longer be considered, particularly in children.

Synthetic biocompatible porous polyethylene frameworks can be used with a temporalis fascia flap as a one- or two-stage operation. This procedure was popularized by Reinisch in the early 1990s. Concerns for long-term rejection or trauma have lessened with recent publications on long-term outcomes. This procedure can be done as early as 3 years but an adult sized ear is placed because the ear will not grow over time.

Brent describes a four-stage autologous rib reconstruction. This form of reconstruction has been used for the past 40 years with good results. The first stage is the harvesting, carving, and placement of the autologous rib graft. Portions of 3 or 4 ribs (depending on the need for tragal reconstruction) are used to form the helical rim, antihelical fold, scapha, and fossa triangularis. The second stage rotates the microtic remnant earlobe onto the cartilage framework and attaches it there. The third stage is ear elevation away from the head with a skin graft. The fourth stage, if necessary, involves creation of a tragus and deepening of the conchal bowl. This type of reconstruction is typically begun after age 6, but boys are usually recommended to wait until age 10 for full cooperation. Usually 9 to 12 months are required to complete all 4 stages.

Beginning in the mid-1980s another autologous rib reconstruction method was developed by Nagata. This two-stage operation is performed beginning at age 10 and requires an evaluation for adequate costal cartilage volume. The first stage includes harvesting, fabrication of the three-dimensional costal cartilage framework, and grafting it into place. The second stage elevates the auricle to match projection. Results are more reliable with the topographic method of ear cartilage fabrication as carving is not as dependent on in situ rib width and depth. During the same period, Firman developed a similar three dimensional model of microtia construction from autologous rib. Today many mictrotia surgeons borrow from both Firman and Nagata to create a rib based framework.

24

What does the future hold for microtia construction?

What does the future hold for microtia construction?

Currently the development of a bone anchored hearing aid embedded in a silicone prosthetic ear is being trialed outside the United States. Ongoing research in tissue engineering with the goal of harvesting autologous chondrocytes continues to teach us more and more about cell growth and immunology, but there are no clinical applications available at this time. Currently 3D printing of the opposite ear as model to carve on the operative field is feasible and the hope is that the 3D model will be able to be seeded with live cartilage that will reproduce and hold its shape over time so that the patient is not dependent on cartilage availability, can therefore undergo construction sooner, not have a donor defect and will have an “implant” that will grow with the child proportionally.

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