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Facial Plastics & Trauma > Auricular Repair & Otoplasty > Flashcards

Auricular Repair & Otoplasty Flashcards

1
Q

√Describe the normal dimensions and angles of the adult ear

A
  1. Superior limit: Brow level
  2. Vertical axis: 20 degrees inclination posteriorly
  3. Vertical height: around 6cm
  4. Width: 55% of height (Goode = 0.55-0.6)
  5. Protrusion: 1-2cm = 15-30 degrees

Kevan FP Page 69

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2
Q

√What is the normal growth pattern of the ear after birth? At what age does it reach adult size?

A
  1. Rapid growth in first 3 years of life
  2. 85% growth by 3 years of age
  3. 95% growth by 5 years of age
  4. Then growth proceeds slowly until age 12

Otoplasty recommended ~age 5-6 years old (when child starts school)

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3
Q

√Define Prominauris. What causes it, list two most common reasons

A

Prominauris = prominent ears

Top two common deformities:
1. Deep conchal bowl
2. Absent antihelical fold
3. Lobule malpositioning (also addressed during otoplasty)

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4
Q

√What are the ideal helix-mastoid distances when conducting otoplasty?

A
  1. Mastoid to Superior helix = 10-12mm
  2. Mastoid to Mid-helix = 16-18mm
  3. Mastoid to Lobule = 20-22mm
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5
Q

√Describe non-surgical management of protruding ears 3

A
  1. Observation
  2. Auricular molding or surgical taping (usually has poor results unless started within days of birth. Auricular molding from 3 days of birth until 6 months. Surgical tape also ideally done within days of birth)
  3. Adhesive based prosthetic
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6
Q

√What is the usual timing of otoplasty?

A

Age 5-6

Ear has achieved almost its adult size, but before school starts to prevent teasing

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7
Q

√Describe 4 techniques for creating/modifying the anti-helical fold

A
  1. Stenstrom Technique
    - Involves scoring the anterior cartilage with a rasp, anterior to the proposed antihelix, tunnel beneath the perichondrium
    - Cartilage then bends AWAY from the scored side
    - To remember how this bends, think of how a scored sausage bends when you cook it (away from the side thats scored)
    - Results in mild improvement
  2. Mustarde Technique
    - Cartilage sparing technique
    - Involves making a posterior auricular incision and reconstituting the antihelical fold with horizontal mattress sutures
    - Advantages: Cartilage sparing, can create normal appearing antihelical fold
    - Disadvantages: Can cause suture extrusion, does not address conchal bowl
  3. Converse Technique
    - Involves creating/cutting an island of cartilage which then sits anteriorly to the rest of the conchal cartilage; suture the island of cartilage onto itself so it is folded over
    - Advantages: More permanent antihelical fold, can also create a normal appearing fold, useful in patients with thick cartilage
    - Disadvantages: Experienced surgeon must perform. Not cartilage sparing
  4. Pitanguy Technique
    - Similar to converse technique, except the island of cartilage is excised and removed, and the remaining parts are opposed and sutured together/overlapped (incision from post auricular)
    - Similar advantages and disadvantages to converse

Kevan FP Page 70

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8
Q

√Describe 2 techniques to modify the conchal bowl

A
  1. Cartilage excision or overlapping
    - Excise or overlap the cartilage in the conchal bowl to reduce the depth.
  2. Furnas Conchomastoid sutures
    - Sutures the conchal cartilage to the mastoid fascia to achieve a set-back

Kevan FP Page 71

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9
Q

√Describe an approach to address both the conchal bowl and antihelical fold in prominent ears

A

Farrior Technique
- Involves removing wedges from posterior concha to change curvature of conchal bowl (reduce depth and flatten it) and then excise a portion and projecting it to create an antihelical fold
- Essentially a combination of a cartilage scoring technique + Pitanguy’s technique

Kevan FP Page 71

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10
Q

√Describe the technique for lobule repositioning

A

Modified fishtail excision

Kevan FP Page 71

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11
Q

What are the top 3 most common auricular defects?

A
  1. Prominauris
  2. Lop ear
  3. Stahl’s ear
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12
Q

√What is the Roger’s classification of auricular defects?

A

Rogers classification:
1. Type 1 = Microtia
2. Type 2 = Lop ear (second most common)
3. Type 3 = Cup ear
4. Type 4 = Prominauris (most common)

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13
Q

What is cryptotia?

A

Where the root of the helix is buried in temporal lobe skin

Kevan FP Page 72

https://services.nhslothian.scot/earrecon/wp-content/uploads/sites/46/2022/06/cryptotia.jpg

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14
Q

What is Stahl’s ear? (aka Satan’s ear)

A

Third most common auricular deformity

Where there is an addition (third) perpendicular superior crus of the antihelix that traverses the scaphoid fossa, resulting in a pointy, triangular elongation of the auricle

Kevan FP Page 72
Vancouver 392

https://www.chop.edu/sites/default/files/styles/gallery–main/public/stahls-ear-deformity-screenshot-layout-780x439-4.jpg?itok=nBPX4XKJ
https://www.chop.edu/sites/default/files/styles/gallery–main/public/stahls-ear-deformity-screenshot-layout-780x439-6.jpg?itok=uofKBhXU

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15
Q

What is a constricted/lop ear?

A

= Lop ear

Lidding or folding over of helical skin over the triangular ± scaphoid fossa
Due to poorly developed superior helix or scapha, triangular fossa, and posterior crus and antihelix

Lidding = mild version of lop ear (mild folding over)
Lop ear = severe folding over of helical skin
Constricted ear = partial absence of cartilage at the upper third of helical rim and sometimes concha, results in purse string at helix

Kevan FP Page 72
Vancouver 392

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16
Q

What is a helical rim?

A

Flattened superior helix

  • Not to be confused with Stahl’s ear, this is a very flat “pushed in” look to the helix

See Kevan FP Page 72

https://d1l9wtg77iuzz5.cloudfront.net/assets/6153/282425/original_Helical_Rim_Ear_Deformity.jpg?1573947928

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17
Q

What is a cup ear?

A

Excessive helical rim and cupped
- Overdeveloped concha, underdeveloped antihelix and helix (hence, looks like a cup)

(see Kevan FP Page 72)
Vancouver 392

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18
Q

What is a conchal crus?

A

Abnormal fold of cartilage crossing the mid portion of the concha symba that appears to divide the ear in half. Often a result of prominent ear

https://s40764.pcdn.co/wp-content/uploads/sites/242/2022/12/Conchal-Crus.jpg.optimal.jpg

Kevan FP Page 72

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19
Q

List 10 possible complications of otoplasty

A

MOST COMMON:
1. Inadequate correction - Most common
2. Hematoma - easiest to detect but most emergent
3. Chondritis - most feared
4. Telephone ear deformity (result of over-correction of middle third portion of ear and over-resection of conchal bowl - middle 1/3 over-corrected, upper and lower third under-corrected)

“CHIT” like SHIT = Chondritis, Hematoma, Inadequate correction, Telephone ear

OTHER:
1. Scar
2. Adverse cosmesis
3. Cauliflower ear
4. Stuck-down ears (overall overcorrection)
5. Cartilage or skin necrosis
6. EAC stenosis

Vancouver 394

20
Q

√Describe the epidemiology of microtia. What is the incidence in live births? Sex predominance? Ear predominance?

A

1/7-8000 live births
M>F
R>L

21
Q

√Describe the genetics of microtia. What percentage are associated with other developmental abnormalities? What are 3 associated conditions?

A

50% of patients with microtia have other developmental abnormalities or syndromes

Associated conditions:
1. Treacher Collins
2. Branchio-oto-renal syndrome
3. Oculo-auriculo-vertebral syndrome (Goldenhaar)

22
Q

Describe the characteristic features of Treacher Collins. Specifically, what is the mutation, what chromosome, what protein is affected, what is the inheritence?

List 15 features and their classifications

A

Mutation: TCOF1
Chromosome: 5 (same # as TCOF1)
Protein: Treacle protein
Inheritance: Autosomal dominant

Features:
A. Facial Abnormalities
1. Convex Profile
2. Prominent nasal dorsum
3. Maxillary hypoplasia
4. Micrognathia
5. Glossoptosis

B. Ear abnormalities
1. Microtia
2. Middle ear abnormalities
3. EAC stenosis
4. CHL, SNHL

C. Eye Abnormalities
1. Downsloping palpebral fissures
2. Lower lid colobomas (part of tissue of iris missing)
3. Hypoplasia of the lower lids

D. Airway abnormalities
1. Narrow upper airway
2. Cleft palate (PRS)
3. Choanal atresia

Kevan FP Page 73

23
Q

Describe the genetics, and 10 clinical features of Goldenhar syndrome

A

Unilateral findings - hemifacial microsomia

Genetics - unclear; mostly sporadic

Clinical Features:
A. Facial features
- Asymmetric facial development
- Unilateral underdeveloped mandible, orbit, facial muscles
- ± CNVII abnormalities

B. Eyes:
- Upper lid coloboma
- Limbal dermoid

C. Ears:
- Anything from mildly deformed ears to anotia, EAC atresia, ossicular abnormalities

D. Spine
- Cervical Hemivertebrae

24
Q

Describe the clinical diagnostic criteria for Brachio-Oto-Renal Syndrome. What is the mutation and what chromosome? What is the other name for the syndrome?

A

aka. Melnick-Fraser Syndrome
Mutation: EYA1 Gene
Chromosome 8q13 (‘8 looks like B in BOR)

Diagnostic Criteria
- Major Criteria:
1. B = Branchial anomalies
2. O = Otologic abnormalities (pre-auricular pits)
3. R = Renal anomalies
4. Deafness

  • Minor Criteria:
    1. External ear abnormalities
    2. Middle ear abnormalities
    3. Inner ear abnormalities
    4. Pre-auricular tags
    5. Other: facial asymmetry, palate abnormalities

Diagnosis requires:
1. 3 Major criteria; or
2. 2 Major + 2 Minor criteria; or
3. 1 Major + 1st degree relative

25
Q

Describe the Aguilar & Jahrsdoerfer Classification for Microtia. How does it differentiate from the Marx Classification?

A

Aguilar & Jahrsdoerfer Classification (amendment of the 1926 Marx classification)
Grade 1: Normal ear, or slightly smaller
Grade 2: Obvious deformities, but framework present
Grade 3: Nub of lobule only (“peanut ear”) or anotia

Marx Classification:
Grade 1: Abnormally small auricle. All landmarks identifiable
Grade 2: Abnormal auricle, missing some landmarks but major structures (cartilage, skin, etc) are present
Grade 3: Small auricular remnant only (e.g. peanut ear) with no recognizable auricle.
Grade 4: Anotia

26
Q

Describe the Jahrsdoerfer criteria for consideration of EAC reconstruction

A

Total of 10 points based on high-res CT findings of the temporal bone
- ≥7 required to be a reasonable candidate for aural atresia repair
- ≥8 = 80% success
- ≤ 5 = not surgical candidates

  1. Present stapes superstructure (2 points)
  2. Incudostapedial joint
  3. Incudomalleal joint
  4. Intact round window
  5. Intact oval window
  6. Pneumatized middle ear space
  7. Pneumatized mastoid
  8. Normal course of facial nerve
  9. Normal appearance of external
27
Q

Describe the Rogers classification for auricular abnormalities

A

Rogers (1974)
Type 1: Microtia
Type 2: Lop ear
Type 3: Cup ear
Type 4: Prominent ear

Vancouver Notes

28
Q

Describe the Tanzer classification for auricular abnormalities

A

Tanzer (1977)
Type 1: Anotia
Type 2: Microtia (2a = with EAC atresia; 2b = without EAC atresia)
Type 3: Middle third hypoplasia
Type 4: Superior third hypoplasia (4a = constricted cup and lop ear; 4b = Cryptotia; 4c = Hypoplasia of the entire superior third)
Type 5: Prominauris

29
Q

Describe the Weerda classification for auricular abnormalities

A
  1. First degree Dysplasia
    - Most structures of auricle are recognizable
    - Surgical reconstruction does not require additional skin or cartilage
  2. Second Degree Dysplasia
    - Some structures of a normal auricle are recognizable
    - Surgical reconstruction requires some use of skin and cartilage
  3. Third Degree Dysplasia
    - None of the structures of a normal auricle are recognizable (anotia)
    - Surgical reconstruction requires skin + large amounts of cartilage
30
Q

What are 3 non-surgical options for microtia

A
  1. Observation
  2. Molding or surgical taping (only an option if started within the first few days of life)
  3. Adhesive based prosthetic
31
Q

List 3 different ways for reconstructive options for microtia

A
  1. Implant based prosthetic
  2. Autologous rib reconstruction
  3. Synthetic MEDPOR reconstruction
32
Q

What are the indications for prosthetic reconstruction of auricular defects? 4

A
  1. Failued autogenous reconstruction
  2. Significant hypoplasia of soft tissue/skeleton
  3. Low hairline
  4. Acquired total or subtotal defect (in adults)

“FAiLS”
- Failure to reconstruct with autogenous
- Acquired total or subtotal defect as an adult
- Low hairline
- Soft tissue and skeleton severe hypoplasia

33
Q

Describe the implant based prosthetic for microtia and how this is done

A
  • Abutment placed into temporal bone and allows to ossteointegrate (3-4 months)
  • Implant then attached to abutment
34
Q

Describe three methods autologous rib reconstruction for microtia

A

Negata (2-stage)
1. Start at >10 years of age (requires adequate costal cartilage)
2. STAGE 1: Lobule is split and transposed, cartilage framework is reconstructed and inserted in a subcutaneous pocket. 4 cartilages harvested here.
3. STAGE 2: Framework is elevated with a second costal cartilage block, retroauricular sulcus covered with fascia and skin graft. 2 cartilages harvested here.

Park (3-stage)
1. STAGE 1: Tissue expander under fascial layer in mastoid
2. STAGE 2: Costal cartilage 3D framework placed into expanded cavity
3. STAGE 3: Skin incisions to shape the tragus, helix, conchal floor, etc.

Brent (4-stage)
5 stages if you include atresia repair
1. STAGE 1: Cartilage harvest and auricular framework construction
2. STAGE 2: Lobule transposition
3. STAGE 3: Atresia repair (if applicable)
4. STAGE 4: Tragal reconstruction
5. STAGE 5: Auricular elevation
Cartilages harvested: 3

Kevan FP Page 75

35
Q

Describe the MEDPOR reconstruction for microtia

A
  • Popularized by Reinisch in Beverly Hills
  • Reconstruction with biocompatible polyethylene
  • Can be a single stage
  • Can be offered in younger patients (no need to wait for rib to be large enough)
36
Q

What is the typical order of operations for total auricular reconstruction? 5

A

Aguilar’s Integrated Auricular Reconstruction Protocol

“Fuck I’m LATE”
F = Framework reconstruction (autologous rib)
L = Lobule transposition
A = Atresia repair (if applicable)
T = Tragal repair
E = Auricular elevation

37
Q

List 9 possible complications of microtia repair

A
  1. Pneumothorax (cartilage harvest)
  2. Hematoma
  3. Hypertrophic scar or keloid
  4. Cartilage extrusion
  5. Implant extrusion or infection
  6. Perichondritis
  7. Cartilage necrosis
  8. EAC stenosis
  9. Adverse cosmesis (poor contour, shape)
38
Q

In unilateral and bilateral microtia, what ear is used as a template?

A

Unilateral microtia - contralateral ear

Bilateral microtia - mother’s ear

39
Q

What are the goals of aural atresia repair? 2

A

Create a patent, skin lined EAC
Achieve an air-bone gap within 20-30dB

40
Q

Discuss 5 risks of aural atresia repair

A
  1. EAC stenosis
  2. Persistent CHL (50% have a persistent >30dB ABG)
  3. High frequency SNHL
  4. TM graft lateralization
  5. Facial nerve injury

“NSLSC” (National student loans Service centre)
N = Facial nerve injury
S = Stenosis of the EAC
L = Lateralization of TM graft
S = SNHL high frequency
C = Conductive hearing loss persistent (50% > 30dB ABG)

41
Q

Discuss the pathophysiology of cauliflower ear. How is an auricular hematoma treated?

A
  1. Subperichondrial hematoma –> cartilage necrosis –> new cartilage formation with loss of normal architecture
  2. If there are helical burns – risk of suppurative chondritis –> need to debride and drain any collections

Treatment of auricular hematoma:
1. Prompt incision and drainage
2. Placement of a bolster x 7-10 days
3. Prophylaxis for perichondritis (antipseudomonal; ciprofloxacin)

42
Q

Post I+D of auricular hematoma and an auricular keloid is developed, what is the management here?

A

DO NOT EXCISE
1. Serial kenalog injections monthly x 3 months

43
Q

Discuss total auricular avulsion. What 4 factors will determine your ability to repair?

A

Factors determining ability to repair:
1. Status of the avulsed portion: Size? intact? viable?
2. Status of the remaining tissue: how much is available? is healing required prior to recon? Is EAC stenting required?
3. Timing of injury (ischemic window)
4. Clean vs. contaminated vs. dirty (immediate repair if clean, delay up to 7 days with antibiotics if dirty - >24hr for laceration, > 5hr if animal/human bites)

“WHO, WHAT, WHEN, WHERE”
- WHO = the person’s remaining tissue - status of remaining tissue
- WHAT = what injured them? something clean or contaminated?
- WHEN = timing of injury (ischemia window)
- WHERE = where are the injured tissues, status of avulsed portion

44
Q

What are the general options for auricular reconstruction?

A
  1. Secondary intention - lobule and helix are the worst at this
  2. Primary closure - helical defects < 2cm, if > 2cm then need a postauricular flap
  3. FTSG (post auricular)
  4. Composite graft from opposite ear (half of width of defect)
45
Q

What are 5 repair options for total auricular avulsion?

A

Repair options:
1. Microvascular reimplantation with superfiical temporal artery
2. Baudet technique: Where the avulsed segment is de-epithelialized and fenestrated, then reattached
3. “Pocket principle” (similar principle to Baudet technique, but two staged): Avulsed segment is de-epithelialized and fenestrated. This is then placed on a posterior-auricular scalp flap (“pocket”) to be reperfused over weeks prior to reimplantation. Second stage - incise and release the lateral surface with re-approximation of skin.
3. Temporoparietal flap
4. Free flap
5. Negata/Park reconstruction
6. Prosthesis (osseointegrated)
7. ± HBOT if ischemia

46
Q

For total auricular avulsion, how do you know where to put the helix? What landmarks can you use?

A
  • Align superior helix to lateral brow
  • Inferior lobule to nasal ala

Facial Plastics & Trauma (9 decks)

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