Ear Reconstruction 01-22 Flashcards
During second-stage ear reconstruction with elevation of the costal cartilage framework, a temporoparietal flap is elevated to cover a cartilage block. The blood supply of this flap most commonly comes from which of the following arteries?
A) Angular
B) Maxillary
C) Occipital
D) Posterior auricular
E) Superficial temporal
The correct response is Option E.
Elevation of the ear reconstruction framework can be covered by using a temporoparietal flap (TPF) if needed. The most common blood supply of the TPF is typically the superficial temporal artery but less frequently can be the posterior auricular artery or the occipital artery branches. The TPF flap can be safely raised on these less common pedicles as needed.
A 38-year-old man has the ear deformity shown in the photograph. He would like to know if there is a name for the appearance of his ear. On the basis of the image, which of the following is the most likely diagnosis?
A) Constricted ear
B) Cryptotia
C) Microtia
D) Prominent ear
E) Stahl ear
The correct response is Option A.
Constricted ear deformities have a varying degree of hypoplasia of the superior third of the auricle. This patient has a mild form of a constricted ear deformity with presentation of a lop ear. Emblematic for a lop ear is the “folding” of the helical rim. In more severe cases, the antihelical fold can efface and the patient can present with a cup ear deformity. In an infant, ear molding is the treatment of choice. If the patient presents later in life, and in instances where the vertical height is near normal, excision of the folded aspect of the helix may suffice. If there is considerable lack of vertical height, the folded cartilage can be used as a flap to increase the auricular height. A variety of cartilaginous and loco-regional flap combinations have been described for this indication. The most well-known is the Banner flap.
A Stahl ear is characterized by an additional prominent fold in the scaphoid fossa, which results in an everted helical fold and pointed appearance of the ear. Like a constricted ear, this can be addressed with ear molding or with surgical correction later in life.
Prominent ears are defined as having an increased auriculocephalic angle (>25 degrees) and distance (>2 cm). This is measured between the mastoid and the posterior concha. Contributing factors can be an increased conchoscaphal angle (usually <90 degrees) due to inadequate development of the antihelical fold or an increased conchal depth (>1.5 cm). Surgery addresses one or both of those issues by excision of conchal cartilage and/or conchoscaphal sutures (Mustardé sutures).
Cryptotia is defined by the superior helical cartilage being buried underneath the temporal skin. On clinical examination, the ability to recreate a normal ear appearance with digital manipulation is the defining feature. In patients who did not have access to ear molding, a variety of techniques using locoregional flaps have been described to externalize the buried segment.
Microtia exists on a spectrum and involves absence of some or all structures of the ear (anotia). Molding is therefore not an option, and reconstructive procedures including use of autologous and synthetic material are indicated. This patient is suffering from a deformity and not an absence of auricular tissue.
A 5-year-old girl presents to the office for surgical correction of right microtia. After discussing various treatment options, her parents decide to proceed with porous polyethylene reconstruction with temporoparietal fascial flap. Which of the following complications is most likely to occur?
A) Exposure
B) Hematoma
C) Implant fracture
D) Infection
E) Pneumothorax
The correct response is Option A.
The most common complication after porous polyethylene-based microtia reconstruction is exposure of the implant. In a series of over 1000 reconstructions with porous polyethylene, implant fracture was reported at 25% in the early-case series and 1.5% in the late-case series. Implant exposure was 44% and 4% in the same paired case series, respectively. Hematoma and infection are rare complications associated with implant-based reconstruction. Pneumothorax is associated with autologous reconstruction, not implant-based reconstruction.
A 2-month-old female infant is evaluated for the ear anomaly shown in the photograph. Which of the following most accurately describes the anomaly?
A) Anotia
B) Crumple ear
C) Cryptotia
D) Lop ear
E) Stahl ear
The correct response is Option C.
This is cryptotia, a deformity of the ear in which the superior helical rim is buried beneath the skin of the scalp. Some studies report successful treatment with early ear molding, but this often requires elevation of the helical rim and application of a skin graft or regional flap to line the posterior aspect.
Anotia refers to complete absence of the ear structures, while lop ear is an ear that is typically constricted and has an overhang or hooding of the superior helical rim. Crumple ear is a form of constricted ear with variable cartilage abnormalities that give it an irregular appearance. Lastly, Stahl ear refers to an otherwise normal-sized ear with a third crus, usually accompanied by an evagination of the helical rim.
A 7-year-old boy is scheduled to undergo repair of a congenital right ear deformity. On examination, the superior helix is not visible but is palpable under the scalp. There is no sulcus of the superior ear. Which of the following is the most appropriate treatment for this patient?
A) Application of scaphoconchal sutures
B) Apply ear molding for the following 3 months
C) Excision of helical skin
D) Excision of skin and cartilage from scapha
E) Incisional release with skin grafting
The correct response is Option E.
This patient has cryptotia, which occurs when the superior aspect of the ear is buried under the skin. The auricular cartilage can be normal under the skin. Surgical treatment involves a superior incision to release the cartilage and then resurfacing the posterior defect with local tissue or full-thickness skin grafting.
Scaphoconchal sutures, or Mustarde sutures, are used in the treatment of the prominent ear. Prominent ears typically have flattened antihelix and may have conchal bowl hypertrophy. Scaphoconchal sutures are used to recreate the antihelical fold.
Excision of helical skin is used to treat mild forms of constricted ears. Constricted ear occurs when the helical rim is deficient in circumference for the scapha, which creates a cupped shape. In mild forms, the overhanging skin of the helix can be excised. More severe forms require lengthening of the helix and scaphoconchal sutures to pull the ear back.
Ear molding is not indicated for cryptotia.
Excision of skin and cartilage from the scapha is used to treat macrotia, or large ears. The helical rim tends to be too long after the skin and cartilage is excised, therefore, a wedge of the helical rim is typically excised.
A 5-year-old boy presents to the office for evaluation of ear deformity. Examination shows an abnormal bar of cartilage, extending from the antihelix to the helix at approximately the junction between the upper and middle thirds of the ear. Which of the following is the most likely diagnosis?
A) Constricted ear
B) Cryptotia
C) Microtia
D) Question mark ear
E) Stahl ear
The correct response is Option E.
In Stahl ear, there is an abnormal bar of cartilage (sometimes called the third crus), extending from the antihelix to the helix at approximately the junction between the upper and middle thirds of the ear. If that abnormal cartilage is obvious, it must be excised.
In a constricted ear, the fundamental abnormality is that the helical rim is deficient in circumference for the scapha to which it is attached. The inadequate length of the helix “constricts” the ear and forces it into a cupped shape that protrudes from the head.
In cryptotia, the superior aspect of the ear is hidden beneath the temporal scalp. In some cases, the auricular cartilage is normal and requires only to be extracted from its hiding place. Lateral traction on the ear will reveal a normal auricle.
In the question mark ear, there is excess scapha in the upper portion of the ear and a deficiency at the junction of the middle and lower thirds, resulting in a “question mark” shape.
Microtia is a congenital condition in which the cartilage of the outer ear is underdeveloped or absent.
Which of the following otoplasty techniques is most appropriate to create the antihelical fold in patients with prominent ears?
A) Barbed resorbable suture
B) Bolster dressing with external suture
C) Furnas suture
D) Mustarde suture
E) Vertical mattress suture with resorbable suture
The correct response is Option D.
Otoplasty is commonly performed to correct prominent ears. Some consider prominent ears to be caused by the inadequate formation of the postauricular muscles in utero, which leads to a failure to form the antihelical fold and adequate setback of the auricle. This can result in psychosocial issues in children and adults. Since most of the ear formation occurs by age 5 years, most otoplasties are performed after that age.
Two basic concepts are associated with otoplasty: cartilage cutting and cartilage scoring. Each has its proponents and some use both techniques in reshaping the ear.
Correction of the antihelical fold is most commonly performed using the Mustarde suture. It is a non-absorbable suture placed over a weakened cartilage structure to create the antihelical crease. Stentrom described scratching the posterior cartilage to weaken the memory of the cartilage prior to application of the Mustarde suture to allow it to fold and stay folded more easily.
Furnas described the conchal setback suture to rotate the ear and decrease the angle between the concha and mastoid to approximately 25 to 35 degrees.
Vertical mattress sutures are not used for creation of the antihelical fold.
The bolster dressing with an external suture is more appropriately used after drainage of an auricular hematoma.
An 82-year-old man is referred by his Mohs micrographic surgeon for reconstruction of a nasal defect after margins are cleared. The 8 mm × 8 mm defect is full-thickness at the alar rim and soft triangle, and involves skin, cartilage, and lining. The plastic surgeon plans to use a composite graft from the ear in a single-stage reconstruction under local anesthetic. Which of the following is the most appropriate ear donor site for reconstruction of the defect?
A) Bilobed flap for skin and anterior conchal bowl graft for cartilage and lining
B) Full-thickness harvest of tragus
C) Full-thickness helical root composite graft with cartilage limb extensions
D) Full-thickness helix wedge with primary closure
E) Posterior ear skin and concha cartilage composite graft
The correct response is Option C.
In this case, all three layers require reconstruction. Cartilage support and careful selection of grafts can decrease alar notching. The helical root provides three-layer reconstruction in a simple full-thickness composite graft. Three-layer composite grafts are most successful when less than 1 cm. Helical cartilage can be harvested extending beyond the skin boundaries to decrease notching and provide enhanced rim support. The attached skin on the deep surface is similar to lining and the outer skin layer is more fibro-fatty like the alae/tip skin. This donor site is rarely heavily sun damaged and can be closed primarily without significant cosmetic issues.
An otherwise healthy 3-day-old term female infant is brought to the clinic for evaluation of a prominent ear deformity. The parents are interested in nonsurgical options, and they would like to pursue ear molding but are concerned about the complications associated with molding devices. The parents should be advised that the most common complication of such devices is which of the following?
A) Chondritis
B) Otitis media
C) Overcorrection
D) Sensorineural hearing loss
E) Skin ulceration
The correct response is Option E.
Although all of the answers are potential complications of treatment with ear molding, the most common complication is skin ulceration. In a recent study, skin ulceration occurred at a rate of 7.6%. Other studies have reported the rate of skin ulceration around 3%. Although chondritis and allergy to adhesives are complications, their rates were lower than 3 to 7.6%. Since this is an external system, it should not impact eustachian tube dysfunction. Ear molding does not contribute to hearing loss. Overcorrection is not likely with molding alone.
A 2-week-old female infant is evaluated because of a prominent ear deformity. Which of the following is the most appropriate early management to address this deformity?
A) Cartilage grafting
B) External molding
C) Injection of hyaluronidase
D) Otoplasty
E) No intervention at this time
The correct response is Option B.
External molding is the early treatment of choice for a prominent ear deformity. Ideally, this is started by 2 weeks of age, but improvement has been seen in patients up to 3 months of age and is worth trying. Splinting is a shorter therapy used for Lop ear and Stahl ear deformation. Injectable chondroplasty using hyaluronidase is still in the trial phase, but if effective, would allow molding to be used in children older than 3 months of age. Otoplasty at 6 years of age is the alternative if molding therapy is unsuccessful.
A 50-year-old man desires correction of his drooping right eyelid. Medical history includes traumatic injury to the eye two years ago. Physical examination shows ptosis of the right eyelid. Levator muscle function is less than 5 mm. No other abnormalities are noted. The most appropriate procedure for correction of the ptosis functions through which of the following mechanisms?
A) Activation of the frontalis muscle
B) En block removal of a portion of the posterior lamella
C) Plication of the levator aponeurosis
D) Release of muscle fibrosis
E) Repositioning of the levator aponeurosis
The correct response is Option A.
Only using muscle outside of the eyelid to power elevation will yield the desired action. This would involve suturing the eyelid, namely the tarsal plate, to the frontalis muscle via either alloplastic material, autogenous fascia, or a biologic product. Activation of the frontalis muscle will then elevate the eyelid independent of the levator apparatus.
In the setting of chronic non-function (two-year history of traumatic eyelid ptosis and less than 5 mm of eyelid elevation), use of local structures would not be warranted. Release, plication, or repositioning of the dysfunctional levator muscle would not be successful in restoring eyelid elevation.
A 10-year-old boy presents with an ear injury sustained after a picture frame fell onto his head. The injury is shown in the photograph. He never lost consciousness and has no other injury. Microsurgical reattachment is not an option. Which of the following is the most appropriate initial treatment?
A) Debridement and closure
B) Dressing with petroleum gauze
C) Immediate flap reconstruction
D) Reattach as a composite graft
E) Split-thickness skin graft
The correct response is Option D.
While composite grafting of large ear avulsions has a globally poor outcome, the avulsed fragment in this patient is a thin piece of the helical rim that includes only a small piece of the helical rim cartilage. The shape of the defect, minimal cartilage involvement, and the fact that this was a clean injury in a young patient, makes an initial attempt to replace the tissue as a composite graft the best initial option. At worst, the tissue acts to cover the wound until a definitive reconstruction can be planned. At best, the tissue survives to some degree and salvages some of the delicate and very hard to replace helical rim contour. This patient described in the clinical scenario had 80% survival of the tissue with this technique and required no further reconstruction.
The exposed cartilage is at risk for infection and may dessicate, so a simple dressing change with petroleum is ill advised. Debridement and closure might be possible if more cartilage was removed, but this further compounds the tissue loss. A split-thickness skin graft contracts and may not take well on exposed cartilage. Immediate flap reconstruction is possible, but a flap can always be done at a later time if the composite graft does not survive.
An 18-year-old man desires correction of a unilateral congenital Stahl ear deformity. Which of the following auricular characteristics is most likely to be observed on physical examination?
A) Accessory third crus of the antihelix
B) Conchal projection secondary to prominent mastoid
C) Enlarged conchal cartilage
D) Hyperplasia of the superior crus of the antihelix
E) Pointed thickening at the junction of the upper and middle third of the helix
The correct response is Option A.
Stahl congenital ear deformity can present with varying degrees of severity and is characterized by the presence of an abnormal third crus of the antihelix. There is also often an associated flattening of the helix, unfurling of the helical rim, a posterosuperior projection of the helical rim, and absence or hypoplasia of the superior crus of the antihelix.
A pointed thickening at the junction of the upper and middle third of the helix is seen in Darwin’s tubercle. Conchal projection secondary to prominent mastoid can be seen in mastoid prominence. Enlarged conchal cartilage is seen in prominent ear.
A 25-year-old man sustained a laceration to the face from a knife in an altercation 1 year ago. He did not receive treatment at the time of injury and now has complete left unilateral facial nerve transection and paralysis. Placement of an upper eyelid gold weight is necessary for eye protection. Which of the following is the appropriate location for placement of the weight?
A) Between the tarsal plate and conjunctiva
B) Centered over the junction of the central and lateral one-third of the eyelid
C) Deep to the levator aponeurosis and superficial to the tarsal plate
D) Immediately superior to the tarsal plate
E) Superficial to the levator aponeurosis and tarsal plate
The correct response is Option E.
The appropriate location for placement of an upper eyelid gold weight is superficial to the levator aponeurosis and tarsal plate, with the inferior edge of the gold weight within a few millimeters of the lash line. It is placed centered over the junction of the medial and central one-thirds of the eyelid and medial limbus.
Lagopthalmos, or the inability to completely close the eyelids, is a common problem after facial nerve transection. The most common surgical treatment modality of lagopthalmos is placement of an upper eyelid gold or platinum plate to weigh down the upper eyelid, allowing for complete eyelid closure, precluding dessication and corneal damage.
A 64-year-old woman is evaluated because of right-sided epiphora. Examination shows the condition of the patient’s eyelids is appropriate for her age. Which of the following is the best diagnostic evaluation to determine if this patient has nasolacrimal duct obstruction?
A) Goldmann tonometry
B) Jones test
C) Optical coherence tomography
D) Seidel test
E) Snap-back test
The correct response is Option B.
The best diagnostic test for nasolacrimal duct obstruction is the Jones test. The Jones I test evaluates lacrimal outflow under normal physiologic conditions. Fluorescein dye is instilled into the conjunctival cornice. The dye is then recovered from the nose after 5 minutes by asking the patient to blow their nose. Absence of dye from the Jones I test could mean a false-negative result, physiologic dysfunction, or anatomic obstruction. A Jones II test is performed following an unsuccessful Jones I test. For the Jones II test, the residual fluorescein is flushed from the conjunctival sac with clear saline. The investigator then asks the patient to expel the drainage from the pharynx and determines the presence or absence of fluorescein in the retrieved saline fluid. Absence of fluorescein indicates a complete nasolacrimal duct obstruction or canalicular obstruction.
The snap-back test is incorrect because it tests horizontal lower eyelid laxity. It is performed by displacing the lower eyelid inferiorly. With normal laxity, it almost immediately snaps back into place against the globe. With increased laxity, the lid will require one or more blinks to resume the normal apposition.
Optical coherence tomography is a noninvasive imaging test that uses light waves to take cross-section pictures of the retina. The Seidel test can detect leaking aqueous or exposed vitreous. Fluorescein ophthalmic strips are wet with normal saline. The fluorescein is dark orange but becomes bright green under blue light when it comes in contact with aqueous.
Goldmann tonometry measures intraocular pressure. A prism mounted on the tonometer head is placed against the cornea. When an area of 3.06 mm has been flattened, the opposing forces of corneal rigidity and the tear film are approximately equal and cancel each other out. The intraocular pressure can then be calculated.
An 8-year-old boy is brought to the office with a congenital abnormality of the ear. A photograph is shown. When the ear is pulled on traction, the upper pole cartilage becomes visible under the skin. This abnormality is most likely caused by which of the following?
A) Anomaly of the intrinsic postauricular muscles
B) Effacement of the scaphofossa
C) Formation of a third antihelical crus
D) Hemifacial microsomia
E) Intrauterine pressure
The correct response is Option A.
This patient has cryptotia of the ear. It is also known as pocket ear. The upper part of the ear is adherent and the cartilage is buried under the skin in a pocket. Other deformities may be present, such as a missing upper sulcus, underdeveloped scapha, and antihelical crura.
It is caused by an anomaly of the intrinsic oblique and transverse auricular muscles.
Surgical treatment requires release from the pocket and resurfacing of the post- and retroauricular defects. In some cases otoplasty may be required for normalization. A number of techniques are described.
Intrauterine pressure may cause ear deformities, which may spontaneously resolve or are amenable to neonatal molding techniques. It does not cause cryptotia.
Stahl ear is associated with formation of a third antihelical crus.
Hemifacial microsomia is associated with microtia. Microtia is sometimes the only manifestation of hemifacial microsomia, but subtle clinical findings are often present, such as mild facial nerve weakness or soft tissue hypoplasia on the involved side.
A 6-year-old boy with microtia is evaluated for single-staged alloplastic reconstruction. In addition to the prosthesis itself, discussing with the parents soft-tissue reconstruction should focus on tissues dependent on which of the following vasculature?
A) Facial
B) Occipital
C) Submental
D) Superficial temporal
E) Supraorbital
The correct response is Option D.
Although alloplastic reconstruction can be successfully performed in a single stage, 3D printed, and still allow for atresia repair, there is still a soft-tissue component that needs to be addressed. In general, the superficial temporal/temporoparietal fascia flap is the work-horse flap and is based on the superficial temporal vasculature. This requires incisions into the hair-bearing scalp; alopecia and irregular parting of the hair are possible negative outcomes. Additional skin grafting must also be discussed. The other vasculature listed is not directly important for this type of surgery.
Which of the following best describes the main difference between the Nagata and Brent techniques of ear reconstruction for microtia?
A) Nagata is performed at 5 years of age, while Brent is only performed around 12 years of age
B) Nagata is performed in two stages, while Brent is performed in three or more
C) Nagata uses a microvascular omental flap, while Brent only uses local tissue
D) Nagata uses a porous polyethylene framework, while Brent uses autologous cartilage
E) Nagata uses local tissue for framework reconstruction, while Brent uses autologous cartilage and iliac crest bone
The correct response is Option B.
The primary advantage of the Nagata technique is that it typically uses fewer stages than the Brent technique. The principle difference between the two approaches lies in how the lobule and the tragus are reconstructed. In the traditional Brent sequence, lobule creation/elevation and tragal reconstruction are separate stages, while in the Nagata approach, these are created/elevated during the same stage as framework implantation.
Although microvascular techniques may be added as adjunct procedures to a particular approach, they are typically used as a salvage method for a secondary reconstruction if there is framework exposure or loss in either technique.
The Nagata and Brent techniques use autologous rib cartilage for framework reconstruction. Neither technique routinely uses iliac crest bone. The Reinisch technique is a more recently described approach to microtia ear reconstruction and uses a porous polyethylene implant, but the Brent and Nagata techniques have typically used autologous costal cartilage for the framework.
A 66-year-old man sustains an isolated complete amputation of the right ear from an injury at work. First responders were able to recover the part, which they wrapped in a wet towel and placed on ice. An attempt is made for microvascular reanastomosis, but no vein can be identified to establish adequate outflow. Which of the following approaches will most likely yield the best long-term aesthetic outcome?
A) Dermabrasion of the epidermis of the amputated part, burial in a subcutaneous pocket, and staged elevation of the ear
B) Disposal of the amputated part with delayed costal cartilage reconstruction
C) Microvascular replantation without venous anastomosis followed by postoperative leech therapy
D) Removal of the skin of the amputated part followed by temporoparietal flap coverage
E) Replantation of the ear without microvascular anastomoses followed by postoperative hyperbaric oxygen therapy for 3 weeks
The correct response is Option C.
Microvascular replantation has demonstrated superiority over the other treatment options mentioned, even when venous outflow cannot be established. Indeed, a recent systematic review demonstrated no significant difference in salvage rate, transfusion rate, or postoperative appearance between cases where venous outflow was established and where it was not. Dermabrasion and subcutaneous burial (Mladick technique) was the most common method prior to the microvascular era, but has been shown to lead to inferior results compared with microsurgical approaches. The other techniques are useful as salvage procedures or in special cases where microvascular surgery is contraindicated.
A 19-year-old woman undergoes excision of squamous cell carcinoma of the right auricle that results in a 2.5-cm defect of the mid-helix. A photograph is shown. Which of the following is the most appropriate method of reconstruction?
A) Auricular prosthesis retained by osseointegrated implants
B) Porous polyethylene implant covered by temporoparietal fascia flap and skin graft
C) Postauricular flap and conchal cartilage graft
D) Retroauricular revolving door flap
E) Wedge closure
The correct response is Option C.
A number of local flaps have been used to reconstruct the helix. One of the most reliable ways to reconstruct the middle third of the helix is to use a postauricular flap as described by Dieffenbach. This flap is supplied by the posterior auricular artery and vein. Wrapping the flap around a conchal cartilage graft prevents late cicatricial deformity. This flap pins the ear back and requires dividing the base of the flap in a second stage several weeks later to return the ear to a normal position. A full-thickness skin graft is used to cover the donor site defect. The Antia-Buch chondrocutaneous advancement flap may also be used for helical rim defects, but tends to result in a cupped and noticeably smaller ear for longer defects such as this.
The retroauricular “revolving door” or “flip-flop” flap is also based on postauricular skin, but it is an island flap used to reconstruct conchal bowl and occasionally antihelical defects. Wedge closure can be used for defects up to about one third of the helical rim but would result in an ear asymmetry, making the auricle noticeably smaller in this defect. A porous polyethylene implant covered by temporoparietal fascia flap and skin graft, as well as an implant retained auricular prosthesis, are options for near total and total auricular defects. They would be difficult to fixate to the remaining ear for small helical defects.
A 7-day-old infant is brought to the office for evaluation of widened conchal-mastoid angle and an absent antihelical fold of the left ear. There is a history of maternal hepatitis and oligohydramnios. Which of the following is the most appropriate initial step in management?
A) Immediate initiation of rigid ear molding system
B) Otolaryngology consultation for inner ear evaluation
C) Reassurance that the deformity will correct itself
D) Reevaluation in 6 weeks
E) Surgical repair at 5 years of age
The correct response is Option A.
This infant has a “prominent/cup ear,” the most common type of ear deformity, which is characterized by a widened conchal-mastoid angle and an absent antihelical fold.
The traditional approach on ear deformities has been observation, but studies have concluded that only approximately 30% will self-correct. Ear molding techniques provide tremendous benefit to the lives of many children whose misshapen ears do not self-correct. This is possible because the higher postpartum circulating maternal estrogen will increase the amount of hyaluronic acid, a key component of the ear cartilage, and will cause a temporary malleability to the infant’s ear cartilage. Timing is important. Waiting more than 6 weeks will cause the loss of the window of opportunity to reshape the ear as the maternal estrogen is decreased. A rigid ear molding system applies a combination of anterior and posterior forces to selectively shape and expand the targeted areas (i.e., helical rim, scapha, antihelix, superior crus, concha, and lobule).
Molding in the neonatal period corrects the auricular deformities long before the onset of peer teasing and bullying. It also decreases the need for surgical correction and the associated pain and costs of surgical corrections. The results may exceed what can be achieved with the surgical alternative. Surgery is required for deformities that cannot be corrected with ear molding and is usually performed after the age of 6 years.
Since there is no inner ear pathology associated with “prominent/cup deformity,” otolaryngology consultation is not needed.
Which of the following newborns would be the best candidate for ear molding?
A) One-day-old newborn with helical rim deformation
B) One-day-old newborn with helical rim malformation
C) One-week-old newborn with conchal deformation
D) One-week-old newborn with conchal malformation
Please note: Upon further review, this item was not scored as part of the examination.
The correct response is Option C.
The correct response is a patient with ear deformation at 1 week of age. When deciding on molding, the first question to ask is what is the difference between malformation and deformation. An ear malformation is when there is a partial absence of either the skin or cartilage of the external ear. These patients tend to be less optimal candidates for molding. Patients with ear deformations have fully developed but misshapen ears and therefore are better candidates for molding. The plasticity of the cartilage is due to maternal circulating estrogen which peaks at day 3 and returns to baseline at week 6, and up to 30% of infants will self correct in the first week of life. One-day-old is too soon to begin molding because in 24 hours, some of these deformities will spontaneously resolve.
An 8-year-old boy is brought to the clinic with a right congenital ear anomaly that affects his interaction with his peers. A photograph is shown. Which of the following is the most appropriate treatment?
A) Ear molding
B) Multiple stages of surgery for rib cartilage construct, elevation of construct, and soft-tissue reconstruction
C) Surgery with cadaveric cartilage
D) Surgery with distant rib cartilage
E) Surgery with local cartilage
The correct response is Option E.
The photographs show Stahl ear, a congenital ear anomaly that is characterized by an abnormal third crus of the antihelix. This is a fairly uncommon deformity, and multiple surgical methods have been described. Compared with other ear anomalies, there is usually enough local cartilage in Stahl ear, so most authors recommend local cartilage flaps or grafts, and otoplasty techniques, to remove the third crus and reconstruct a more normal antihelical fold.
Ear anomalies that lack significant cartilage may require larger cartilage grafts, such as rib. Multi-stage surgery is for reconstruction of microtia, which has a severe paucity of normal cartilage and soft-tissue structures.
A 19-year-old man sustains a partial amputation fight-bite injury to the ear. The wound has been revised and a photograph of the residual defect is shown. The patient wants the ear to have a normal appearance. Which of the following is the best option to restore normal aesthetics to the ear?
A) Addition of a silicone framework
B) Composite cartilage grafting
C) Reconstruction with a temporoparietal fascia flap with skin grafting
D) Serial fat injections
E) Staged autologous reconstruction with costal cartilage
The correct response is Option E.
This patient has sustained a three-dimensional and sizable defect of the ear. He is missing a portion of the helical rim, the scaphoid fossa to the antihelix. This is a difficult reconstructive challenge. The anatomic components that are missing are skin and underlying cartilage. The best option for obtaining a normal-appearing ear would be reconstruction with a cartilage framework carved to replace the cartilage and to support the overlying skin to retain the form of the ear. This could be done as a stage procedure.
Fat injection would not be adequate to replace the missing components or to give adequate shape to the ear.
A silicone framework within a scarred bed would be prone to complication, most notably infection and/or extrusion. The defect is too large to be replaced by a composite cartilage graft.
Although a temporoparietal fascia flap could potentially be used to cover a cartilage framework, used alone it would not give adequate form to reconstruct this defect.
Parents of a healthy 3-day-old male newborn request consultation for management of their child’s bilateral lop ear deformities. Which of the following is the most appropriate next step in management?
A) Await spontaneous correction
B) Fit the infant’s head and ears for a helmet
C) Initiate ear molding devices immediately
D) Prescribe oral estrogen blocker therapy
E) Schedule bilateral otoplasty surgery at age 3 months
The correct response is Option C.
Newborn infant ear deformities, in order of frequency, are prominent/cup ear, lop ear, mixed deformities, Stahl ear, helical rim anomalies, conchal crus deformity, and cryptotia. Bilateral congenital ear deformities occurred in 70% of 340 patients in one study, with unilateral involvement in 30%. While surgical correction of deformed ears constituted the mainstay of therapy for decades, more recent developments in ear molding techniques have demonstrated 90% success in some studies. The presence of circulating maternal estrogen is blamed for lack of helical cartilage rigidity. This fact allows clinicians to shape the ear and, if pursued for a sufficient period of time, therapy will eliminate the deformity without need for surgical intervention. For the technique to be maximally effective, molding should be initiated by the end of the first week after birth. When begun even a few weeks later, the success rate falls to 50%. Surgical intervention is more likely to be performed just before the child reaches preschool age, allowing the ear to reach most of its adult size first. Helmets may have applicability in cranial reshaping but are not suited for management of deformed ears. Oral medication of any kind is unlikely to affect ear shape. Awaiting spontaneous correction as the child ages is the least likely means of achieving corrected ear shaping.
A 5-year-old girl is brought to the physician because her parents are interested in correction of the unilateral ear anomaly shown in the photographs. Which of the following materials is most likely to be used in the procedure to correct this anomaly?
A) Acellular dermal matrix
B) Autogenous rib cartilage
C) Porous polyethylene
D) Silicone
E) Skin
The correct response is Option E.
This patient has cryptotia. The superior helical rim and scapha are not absent but lie buried under the supra-auricular skin. Although some authors have advocated expanding the superior helical framework, this is rarely indicated. In this patient with very mild auricular shortening, supplementing or reconstructing the cartilage framework with rib cartilage, polyethylene, or silicone is unnecessary. Instead, the ear framework simply released its posterior aspect and the resultant defect lined with full-thickness skin graft or any number of skin flaps raised from the postauricular region. The use of acellular dermal matrix is not an accepted method of correcting cryptotia.
An 89-year-old man presents with a 5 x 5-cm ulcerated, biopsy-proven squamous cell carcinoma of the skin involving the pinna of the right ear. On examination, no palpable adenopathy is noted. Radiation Therapy (RT) is planned. Which of the following is the primary predictor of local control rates of RT in this patient?
A) Age of patient
B) Histology of tumor
C) Location of tumor
D) Presence of ulceration
E) Size of tumor
The correct response is Option E.
The National Comprehensive Cancer Network (NCCN) has published guidelines for radiation therapy for primary squamous cell carcinoma (SCC). Local control rates for SCCs less than 1 cm were 91%; those 1 to 5 cm were 76%, those larger than 5 cm were 56%.
Mohs micrographic surgery has the highest reported cure rates for SCC compared with all other modalities. However, these rates begin to drop with increased tumor size, differentiation, discontinuity, perineural invasion, and history of recurrence.
Of the head and neck sites, involvement of the ears and lips confers the highest risk for metastatic disease at 8.8% and 13.7%, respectively. In tumors greater than 2 cm in size, the risk may increase.
In the past, it was felt that lesions overlying cartilage should not be treated with radiation therapy due to the risk of chondronecrosis. It is now known that such sites can be safely treated with fractionated radiation therapy.
Radiation therapy for regional node involvement should be considered. NCCN guidelines suggest 25 (2Gy) fractions to clinically negative but “at risk” nodal basins over a 5-week period.
Age, tumor location, ulceration, and histology are secondary predictors to tumor size.
A 28-year-old man is evaluated after sustaining a laceration across the ear from the tragus to the antitragus. A ring block of the ear using 1% lidocaine is performed prior to repair. The patient reports pain when the conchal skin near the external auditory canal is sutured. Which of the following nerves is most likely NOT anesthetized in this patient?
A) Auricular branch of the vagus (X) nerve
B) Branch of the glossopharyngeal (IX) nerve
C) Great auricular (C2, C3) nerve
D) Lesser occipital (C2, C3) nerve
E) Trigeminal (V2) nerve
The correct response is Option A.
The auricular branch of the vagus (X) nerve (Arnold’s nerve) innervates the external auditory canal and conchal area of the ear. This would not be blocked with a ring block. Direct infiltration of this area is needed.
The lesser occipital nerve innervates the superior pinna. A branch of the glossopharyngeal nerve innervates the middle ear. The trigeminal nerve does not innervate the ear. The great auricular nerve innervates the lobule and the majority of the pinna.
A 7-year-old girl is evaluated because of the ear anomaly shown. CT scan of the temporal bone of the affected ear shows an absent stapes and incus. Construction using autogenous rib cartilage is planned. The girl’s family inquires about options for improving hearing to the affected ear. Which of the following is the most appropriate response?
A) Atresia repair should be performed after auricular reconstruction
B) Atresia repair should be performed before auricular reconstruction
C) A bone-anchored hearing aid should be placed after auricular reconstruction
D) A bone-anchored hearing aid should be placed before auricular reconstruction
E) Hearing cannot be improved in this patient
The correct response is Option C.
Staged autogenous cartilage reconstruction remains the gold standard to correct microtia. The urgency and method of treatment for associated hearing loss depends on whether the problem is unilateral or bilateral, whether external ear construction is planned, and the condition of the middle ear structures. Bilateral hearing loss can result in problems with language development and learning and requires early intervention to improve or restore hearing. This is usually done with external hearing aids in early childhood followed by atresia repair or a bone-anchored hearing aid (BAHA) later in life. Historically, most authorities have concluded that patients with congenital unilateral hearing loss naturally adjust and experience few functional implications. Consequently, most do not routinely recommend operative correction for unilateral hearing loss. There are some recent reports of improved language This examination contains test materials that are owned and copyrighted by the American Society of Plastic Surgeons. Any reproduction of these materials or any part of them, through any means, including but not limited to, copying or printing electronic files, reconstruction through memorization or dictation, and/or dissemination of these materials or any part of them is strictly prohibited. Keep printed materials in a secure location when you are not reviewing them and discard them in a secure manner, such as shredding, when you have completed the examination. Page 249 of 426 development after early biaural hearing restoration, and some clinicians now support early treatment. If correction is considered, the two primary options are atresia repair, wherein the canal is opened and the middle ear is reconstructed, or use of a hearing aid. Atresia repair is usually deferred until the external ear framework is placed or the reconstruction is complete. The success depends on the presence and normalcy of the middle ear structures. Jahrsdoerfer’s 10-point scoring system (10 being most suitable for reconstruction) grades the anatomic appearance and relationship of the middle ear structures by temporal CT scan. Middle ear reconstruction is contraindicated for a score of 5 or less. Based on the information provided, this patient with anotia (-1 point), absence of the stapes (-2 points) and absence of the incus (-2 points), has a maximum score of 5 and would not be a good candidate for middle ear reconstruction. Certainly, this procedure would not improve hearing as well as a hearing aid such as the BAHA. BAHA uses osseointegrated implants to affix a hearing aid. This provides excellent correction of conductive hearing loss and is widely used. BAHA is the best surgical option to restore hearing in this patient if so desired. However, placement should be deferred until after the autologous ear reconstruction is completed.
A 7-year-old Asian American boy is brought to the office because of congenital cryptotia. Which of the following is the most likely pathophysiologic explanation for his condition?
A) Abnormal distribution of the intrinsic transverse and oblique auricular muscles
B) Failure of the antihelix to furl during weeks 12 to 16 of gestation
C) Failure of hillocks 3 and 4 to arise from the first and second branchial arches
D) Incomplete fusion of the six hillocks
E) Malformation of the conchal bowl
The correct response is Option A.
Cryptotia is a congenital ear deformity in which the upper pole appears buried beneath the mastoid skin. It is a common auricular malformation in Asians. Children with this condition often present when they are in elementary school, and are unable to wear eyeglasses. The cause of this condition is the abnormal distribution of the intrinsic auricular muscle. Malformation of the conchal bowl results in prominence of the pinna from the head. Incomplete fusion of the six hillocks does not result in cryptotia, nor does it result from failure of the two superior hillocks (3 and 4) to arise from the branchial arches. Failure of the antihelix to furl during weeks 12 to 16 results in a protruding scapha.
A male newborn is evaluated in the hospital because of prominent ears. Nonsurgical correction with auricular molding is recommended. In order to achieve optimal correction, therapy should be initiated at which of the following ages?
A) 3 days
B) 14 days
C) 1 month
D) 6 months
E) 1 year
The correct response is Option A.
If treatment is initiated within the first few days of life, auricular molding can adequately and permanently treat some congenital ear deformities. Treatment must be initiated before 3 days of age and continue to 6 months of age. The efficacy of this mode of treatment is attributed to cartilage pliability due to high concentrations of circulating maternal estrogen in the first few days of life. Maternal estrogen concentrations are highest in the first 3 days of life and begin to decrease thereafter. In order to achieve good results with auricular molding, treatment must be initiated while maternal estrogen concentrations are increased and therefore cartilage pliability is high.
Which of the following best describes the ear anomaly seen in the photograph?
A) Cryptotia
B) Microtia
C) Pixie ear
D) Prominent ear
E) Stahl ear
The correct response is Option A.
Cryptotia is a congenital anomaly in which the upper part of the retroauricular sulcus is absent or buried under the temporal skin. Various surgical techniques have been reported for correction of cryptotia, starting with a V-Y plasty in 1933. Conventional methods using local flap, skin grafting, tissue expander, Z-plasty, and any combined approaches correct the skin deficiency of the upper auricle. However, cosmesis can still be unsatisfying because of a visible periauricular scar, color mismatch, or a contracture deformity. Cryptotia may be treated early nonsurgically with splinting of the ear or with surgical release at a later age.
Microtia is a hypoplastic condition of the ear which includes a spectrum from complete absence of the ear (anotia) to a smaller than normal ear with normal morphology. Microtia is seen in patients with the hemifacial microsomia. In fact, patients with isolated microtia are considered to have a mild form of hemifacial microsomia.
Pixie ear deformity is a complication of rhytidectomy.
Prominent ear has a widening of the conchal-scaphal angle, an increased auriculocephalic distance, and loss of the antihelical fold.
Stahl ear, also known as Spock ear, has a third crus, a flat helix, and a malformed scaphoid fossa.
An 8-year-old boy is scheduled to undergo otoplasty to correct prominence of the ears. Recreation of the antihelical fold, conchal setback, and lobule setback are planned. Mustardé sutures will be used to recreate the antihelical fold. The most appropriate location for placement of the Mustardé sutures in this patient is between which of the following structures?
A) Conchal cartilage and conchal cartilage
B) Conchal cartilage and mastoid fascia
C) Scapha cartilage and conchal cartilage
D) Scapha cartilage and mastoid fascia
E) Scapha cartilage and scapha cartilage
The correct response is Option C.
Placement of Mustardé sutures is the most common maneuver performed for a routine otoplasty and consists of horizontal mattress sutures placed between the scapha cartilage and the conchal cartilage in order to recreate the antihelical fold. Conchal setback sutures are also commonly used during an otoplasty and fixate the conchal cartilage to the mastoid fascia. Scapha cartilage would not be fixated to the mastoid fascia or else a significant pinning deformity would result. Occasionally, a wedge of excess conchal cartilage is excised to lessen the degree of conchal prominence in cases of excess. In this situation, conchal cartilage is sutured to conchal cartilage to close the resultant defect so that no contour irregularity is produced from the resection. This would not, however, have any effect on producing an antihelical fold. There is no indication for scapha cartilage to be fixated to scapha cartilage for routine otoplasty.
A male newborn is brought to the office because of bilateral prominent ears. His ears are symmetric in size and shape. The superior crura are undefined and the conchal-scaphal angle is greater than 150 degrees. Conchal depth and projection show no abnormalities. The newborn?s parents desire correction of the ear prominence. Which of the following is the most appropriate management?
A ) Cartilage abrasion
B ) Conchal-mastoid sutures
C ) Conchal-scaphal sutures
D ) Ear molding
E ) Observation
The correct response is Option D.
Auricular deformation, including prominent ears, is a relatively common problem in infants. The position of the ear can change with growth and development but this process is inconsistent and unreliable. Some anomalies, such as Stahl ear, lop ear, and constricted ear, do not typically improve as the child grows. Ear molding in young infants is a very effective method to permanently improve auricular position and shape. The process is most effective in infants who are younger than 3 months of age, and is generally ineffective in older children. A custom-made mold is typically fashioned out of soft putty and affixed into the ear with surgical tape or adhesive strips. A commercial version is also available. Depending on the severity of the deformity and the age of the infant, molding is continued for several weeks to a few months. The reported results of properly done ear molding are impressive.
Cartilage abrasion along the anterior scapha and posterior cartilage suturing are surgical techniques that have been successfully employed to treat prominent ears. However, operative treatment of prominent ears is typically reserved for older children with unresolved deformities. A period of observation is unlikely to result in a significant change in ear position and will leave surgery as the family’s only remaining treatment option.
A male newborn is evaluated because of left-sided microtia. Examination shows a small amount of vestigial cartilage and an anteriorly rotated earlobe. Which of the following is the most appropriate management?
A ) Canaloplasty prior to 1 year of age
B ) Costochondral ear reconstruction at 7 years of age
C ) Earlobe rotation after 3 months of age
D ) Excision of the vestigial ear structures prior to 1 year of age
E ) Placement of silicone framework at 7 years of age
The correct response is Option B.
Treatment of microtia is frequently performed with autologous tissue when the patient is approximately 6 to 7 years old. At this time, there is sufficient material at the areas of costal cartilage fusion to permit adequate reconstruction. Furthermore, normal ear development is largely complete, although the width of the ear and its distance from the scalp continue to increase until the patient is approximately 10 years old. Reconstruction is not an option for younger children, especially infants. However, surgery to place bone-conduction hearing aids will improve hearing on the affected side and may be performed when the patient is 6 to 12 months old. In patients with unilateral microtia, creation of an ear canal should be delayed until the patient is 13 to 19 years old to minimize scarring and not interfere with external reconstruction. Placement of an alloplastic framework, such as porous polyethylene, has been described in younger patients. However, silicone, which has a greater incidence of extrusion and infection, is not an option.
A 22-year-old man comes to the office because he is dissatisfied with the appearance of his ears. Physical examination shows bilateral effacement of the antihelical folds, conchal hypertrophy, and severe prominence of the lobules. Otoplasty is performed with a posterior incision and placement of permanent sutures from the scaphal cartilage and helical sulcus cartilage to the mastoid fascia. Following surgery, the patient is satisfied with the appearance of the upper and middle parts of the ears but notes persistent prominence of the lobules. Which of the following is the most likely cause?
A ) Inadequate reduction of the antitragus
B ) Inadequate reduction of the cavum conchae
C ) Overtightening of the scapha-mastoid sutures
D ) Suturing the triangular fossa to the temporal fascia
The correct response is Option B.
As the cartilage angle between the cavum conchae and the antitragus becomes more acute, hypertrophy of the cavum conchae projects the lower third of the ear, forcing the lobule outward. Failure to adequately reduce the cavum conchae before suture placement will lead to persistent prominence of the lobule.
The antitragus and lobule are not directly excised during standard otoplasty. Overtightening of the scapha-mastoid sutures leads to a ‘pinned-back’ appearance. Suturing the triangular fossa to the temporal fascia corrects prominence of the upper ear.
A 7-year-old girl is brought to the office by her parents because of prominent ears. Physical examination shows a classic cup ear deformity. Surgical correction is planned. Which of the following is the most likely complication?
A ) Epidermolysis
B ) Hematoma
C ) Hypertrophic scarring
D ) Infection
E ) Recurrence
The correct response is Option E.
In 1845, Dieffenbach described the first treatment of protruding ear (post-traumatic) through the resection of the posterior skin and suturing of the auricular cartilage to the mastoid region. Ely described his technique for correcting prominent ears by elective surgery in 1881. As it was then, it still is today; the most common complication is recurrence. The rate has been quoted as low as 3% to as high as 24%. Other complications include hematoma (2%), epidermolysis (3%), suture granulomas/extrusions (3%), dehiscence (1%), hypertrophic scarring (3%), keloid formation (2%), overcorrection (1.5%), infection (1%), palpability (2%), hypersensitivity (2%), asymmetry (3%), and unnatural appearance (2%).
A 53-year-old woman comes to the office because of a 2-year history of a lump on her right ear. Physical examination shows a 2.5 × 2 × 1.5-cm neurofibroma on the concha. Resection of the skin of the entire conchal bowl and the underlying conchal cartilage is planned. Which of the following flaps is most appropriate for reconstruction of the defect?
A) Postauricular island
B) Rhomboid
C) Rim advancement
D) Rotation advancement
E) Temporalis fascia
The correct response is Option A.
Lesions arising on the thin anterior skin of the concha involve the perichondrium; thus, adequate excision usually requires the removal of underlying conchal cartilage. The defect may be closed with a skin graft, but closure with a local flap takes less time and provides better results in skin color, lack of contraction, and reestablishment of contour. The postauricular ?revolving door? island flap is most appropriate for repair of the defect described; it is ideally suited for particularly large defects of the concha. The larger the pedicle, the more secure the flap. Total concha replacement can occur with this skin flap. The design of the flap is partially on the posterior ear and partially on the mastoid area. A skin incision is made around the island, and the flap is raised posteriorly and anteriorly. The skin is incised through the anterior surface of the ear, and the posterior skin elevation stops at the ear mastoid groove. This vertical attachment becomes the pedicle of the flap, or the ?hinge? of the ?revolving door.? The posterior skin island can be rotated like a revolving door into the interior conchal defect, and the conchal defect is reconstructed while the posterior defect is closed primarily. This flap is also useful for smaller conchal defects. However, the pedicle will be narrower.
A rhomboid flap would be inappropriate in this area because there is not an adequate donor site for this flap. Rhomboid flaps are more appropriate in the cheek and in areas of lax skin. Rim advancement flaps and rotation advancement flaps are ideally suited for defects of the helix of the ear. Smaller defects can be adequately treated by advancing the rim, while larger defects require undermining of the postauricular skin and thus creating a rotation advancement flap. Temporalis fascia flaps are ideal for total ear resurfacing but also require skin coverage over the fascia.
A 16-year-old boy is brought to the emergency department after sustaining an avulsion injury involving the skin of the anterior part of the left ear. Physical examination shows a 2 × 2-cm flap elevated off the conchal bowl. Which of the following arteries is most likely to be involved?
A) Infraorbital
B) Occipital
C) Posterior auricular
D) Superficial temporal
E) Transverse facial
The correct response is Option C.
The primary blood supply to the anterior surface of the ear is the posterior auricular artery. Arterial supply of the auricle comes from the posterior auricular artery and from the superficial temporal artery. The anterior surface of the ear is supplied by perforators of the posterior auricular artery. Only a small branch of the superficial temporal artery crosses the superior helix to supply the triangular fossa. The occipital artery provides a minor contribution to the posterior aspect of the ear.
Neither the transverse facial artery nor the infraorbital artery provides supply to the auricle. The transverse facial artery runs anteriorly to supply the parotid gland, parotid duct, and masseter muscle. The infraorbital artery provides supply to the medial angle of the orbit, the dorsal nasal area, and the upper lip.
An otherwise healthy 2-week-old male newborn is brought to the office because his parents are concerned about the appearance of his right ear. Physical examination shows a folded upper helix. All components of the auricular structure are present. Gentle digital manipulation restores the ear to normal shape. Which of the following is the most appropriate initial management?
A) Application of a conforming splint
B) Burying of the helical cartilage in a retroauricular pocket
C) Rasping of the antihelical fold with an otoabrader
D) Resection of the superior auricular muscle
E) Surgical repair with cartilage grafts
The correct response is Option A.
Lop ear is among the deformations that are acquired in utero, as opposed to true congenital malformations, in which elements of the auricle may be underdeveloped or missing altogether. Circulating maternal estrogens are thought to be the cause of the softened cartilage, which lacks sufficient stiffness to support the upper helix. The cartilage should respond to shaping with a splint that is formed to match the contour of the normal helix. The splint is applied for several weeks or more. The other options involving surgical management are not indicated as primary therapy in the patient described. Resection of the superior auricular muscle may increase the superior auriculocephalic distance and aggravate the malposition of the upper helix. Cartilage rasping is indicated for the treatment of prominent ears in an older child to create a normal antihelical fold. Burying the helical cartilage beneath the mastoid skin is indicated for management of soft-tissue avulsion injury as a prelude to reconstruction. Surgical repair with cartilage grafts is unnecessary.
An 8-year-old girl (shown) is brought to the office because of bilateral microtia. She has severe conductive hearing loss bilaterally. Her middle ear ossicles are fused, and she is not a good candidate for middle ear reconstruction. Reconstruction of the ears using autologous rib cartilage and placement of bone-anchored hearing aids (BAHAs) are planned. Which of the following is the most appropriate time for placement of the BAHAs?
A ) During elevation of the carved-rib framework
B ) During placement of the carved-rib framework
C ) During rotation of the earlobe
D ) Following completion of the ear reconstruction
E ) Prior to the ear reconstruction
The correct response is Option D.
Patients with severe microtia almost invariably have conductive hearing loss resulting from abnormalities of the middle ear. In some patients, the auditory ossicles are sufficiently formed to allow attempted reconstruction of the auditory canal and the middle ear ossicles. Eligibility for this procedure depends upon the development and shape of the auditory ossicles (Jahrsdoerfer grade), as determined by a specialized CT scan of the temporal region. In patients with unilateral microtia and normal contralateral hearing, assistive devices or middle ear reconstruction are
rarely indicated and would serve only to improve sound localization. In these patients, protection of hearing in the normal ear is paramount. When bilateral conductive hearing loss is present, methods to improve hearing competence include external hearing aids, bone-anchored hearing aids (BAHAs), and middle ear reconstruction in selected patients. The BAHA is affixed in the mastoid region using an osseointegrated implant. Since this can compromise the integrity and mobility of the skin envelope that will cover the autologous rib cartilage framework, it is often recommended that placement of the BAHA device be deferred until after the ear construction is complete.
A 4-year-old girl is brought to the office because her parents are concerned about an abnormality of her ear (shown). Which of the following is the most likely diagnosis?
A ) Cup ear
B ) Macrotia
C ) Microtia
D ) Prominent ear
E ) Stahl ear
The correct response is Option E.
Stahl syndrome is a hereditary auricular deformity caused by an abnormal cartilaginous pleat, which extends from the crus antihelix to the edge of the helix, deforming the regular curvature of the ear. The prominent ear is typically comprised of (1) an increased conchoscaphal angle, (2) deepened conchal bowl, and (3) prominent lobule. Microtia refers to a spectrum of congenital external ear deformities ranging from a slightly smaller ear to almost complete absence.
A 17 year old boy is brought to the office three days after he sustained trauma to the ear during practice with his wrestling team. A photograph is shown. Which of the following is the most appropriate management?
(A) Incision and evacuation followed by application of a bolster dressing
(B) Intravenous administration of an antibiotic for 48 hours followed by oral administration of an antibiotic for five days
(C) Needle aspiration
(D) Observation for two weeks followed by drainage if fluid is present in the wound
(E) Resection of the posterior cartilage and sculpting of the anterior cartilage
The correct response is Option A.
The history and photograph of the patient described indicate an othematoma caused by shearing of the skin from the cartilage. Early diagnosis of this hematoma will prevent cauliflower ear deformity. Complete evacuation via a small incision with application of a bolster dressing to prevent reaccumulation of the fluid or blood is the most appropriate management.
The use of intravenous antibiotics to treat the hematoma is inappropriate, and there is no sign of infection. Needle aspiration may help, but the hematoma is unlikely to be completely evacuated. Allowing the hematoma to remain can result in calcification. Observation may lead to cauliflower ear deformity. Resection of the posterior cartilage and sculpting of the anterior cartilage is the treatment option for chronic calcification or cauliflower ear deformity, but not for acute othematoma.
A 16 €‘year €‘old boy who underwent costochondral reconstruction of the right ear 20 days ago because of microtia has had pain, erythema, fluctuance, and swelling of the ear as well as fever for the past 48 hours. A photograph is shown. In addition to intravenous administration of an antibiotic, which of the following is the most appropriate management?
(A) Application of mafenide acetate (Sulfamylon)
(B) Incision and drainage, washout, and placement of irrigating drains
(C) Incision and removal of the cartilage construct and placement of irrigating drains
(D) Needle aspiration and application of a compressive bolster dressing
(E) Observation
The correct response is Option B.
The clinical scenario described is dire because of the likely loss of the costochondral ear reconstruction. The cartilage may have gained enough vascularity to help avoid loss of the construct. In addition to intravenous administration of an antibiotic, incision and removal of the construct must be considered, but a trial of incision and drainage, washout, and placement of irrigating drains is warranted in an attempt to avoid loss of this graft. If the fever and cellulitis do not improve quickly, then removal of the construct is warranted as a secondary procedure.
Application of Sulfamylon, needle aspiration, and observation are not aggressive enough for this severe infection.
A 28-year-old man comes to the office six months after he sustained partial amputation of the left ear due to a human bite (shown - defect in red). For successful reconstruction, which of the following anatomic areas of the ear must be addressed?
(A) Antihelix and triangular fossa
(B) Antitragus and intertragic notch
(C) Concha and scaphoid fossa
(D) Crus of helix and tubercle
(E) Helix and lobule
The correct response is Option E.
Even though the upper helix is still present, the middle helix below the auricular tubercle and the lower helix in continuity with the lobule are absent. Precise understanding of the anatomy of the ear is important in the planning of reconstruction regarding framework and soft-tissue requirements.
The antihelix is intact and represents the border of the defect. Inferiorly, the antihelix ends in the antitragus; superiorly, it divides into two crura. The triangular fossa separates the superior crus from the inferior crus. The intertragic notch is located between the tragus and antitragus. The concha constitutes the bowl €‘shaped area in the center of the ear from which the root or crus of the helix arises. The scaphoid fossa is the groove between the upper helix and the superior crus of the antihelix. The auricular tubercle is a thickening in the helix located between the upper and middle thirds of the helix.
A 14-year-old boy has the bilateral congenital ear deformity shown above. In correction of this deformity, alteration of which of the following anatomic areas is most appropriate?
(A) Antihelix and helical rim
(B) Concha and antihelix
(C) Concha and lobule
(D) Helical rim and lobule
(E) Lobule and scapha
The correct response is Option B.
The external ear consists of a three-tiered cartilaginous framework with skin on its anterior surface. The complete ear includes the scapha, concha, helix, antihelix, tragus, and lobule as shown below.
In most cases, prominent ears result from inadequate formation of the antihelical fold. In many cases, conchal hypertrophy contributes to or is the primary cause of the prominence. To address this patient’s prominent (protruding) ears, conchal reduction must be performed via an anterior or posterior approach and an antihelical fold must be created. The anterior approach allows reduction of the skin and cartilage of the concha; the posterior approach allows only cartilage reduction.
For each deformity of the ear, select the corresponding anatomic site in the photograph shown on page 44 (A-E).
(A) Concha cavum
(B) Helical rim
(C) Scapha
(D) Superior crus of the antihelix
(E) Triangular fossa
1 Effacement of this structure most commonly results in prominence of the ear.
2 Hypertrophy of this structure most commonly results in prominence of the middle third of the ear.
The correct response for Item 1 is Option D and for Item 2 is Option A.
In children with congenital ear prominence, the superior and middle thirds of the ear are most likely to be affected. The most likely cause of a prominent superior third of the ear is absence or effacement of the superior crus of the antihelix. As a result, the conchoscaphal angle is greater than 90 degrees and the helix is positioned more than 12 to 15 mm from the temporal region. The cephaloauricular angle is also increased, typically measuring more than 25 degrees. Appropriate management involves scoring and suturing of the cartilage to recreate the natural roll of the antihelix.
In contrast, prominence of the middle third of the ear is most likely caused by hypertrophy of the concha cavum. In affected patients, the concha cavum has a depth of more than 1.5 cm. The middle third of the ear is located more than 16 to 18 mm from the mastoid region. Options for correction include excision and/or reduction of the concha or setback with concha-mastoid sutures.
The scapha is the concave region between the helical rim and antihelix, and the triangular fossa is the concave area between the superior and inferior crura of the antihelix. Although the helical rim, scapha, and triangular fossa lie in the superior third of the ear, they do not typically cause prominent ears.
A 77-year-old man has a 12-mm squamous cell carcinoma on the lateral margin of the right helix. He is scheduled to undergo excision of the lesion with confirmation of margins by frozen section, followed by immediate reconstruction. Which of the following flaps is most appropriate for ear reconstruction?
(A) Antia-Buch flap
(B) Postauricular flap
(C) Temporoparietal fascial flap
(D) Temporalis muscle flap
The correct response is Option A.
The Antia-Buch flap is most appropriate for reconstruction of this patient’s ear defect. The lesion can be excised easily because of its location on the lateral rim and of the size of the auricle. Following excision, the resultant defect is effectively reconstructed using the Antia-Buch flap, which is a local flap that uses tissue from the helical rim based on the postauricular skin to reconstruct the helical margin. It is a reliable, single-stage procedure that is acceptable aesthetically. The surgeon may need to excise a “dog ear”-shaped area of tissue from the conchal bowl and incise and advance the helical margins separately. However, because the two ears are not viewed simultaneously, moderate differences in ear size are frequently unnoticed.
A postauricular flap does not provide thin, contoured, helical-type tissue and requires several procedures for adequate coverage. The temporoparietal fascial flap provides thin, pliable soft-tissue coverage for a cartilage or alloplastic framework, as in patients undergoing microtia reconstruction. A temporalis muscle flap is excessively bulky and is not appropriate for ear reconstruction because it would obliterate the intricate detailing of the ear.
A 15-year-old boy undergoes reconstruction of a 15-mm2 traumatic defect of the right ear with a graft harvested from the contralateral ear. On examination two days after the procedure, the graft appears dusky. A photograph is shown above. Which of the following is the most appropriate next step in management?
(A) Hyperbaric oxygen therapy
(B) Application of leeches
(C) Release of the sutures
(D) Debridement of the graft
The correct response is Option A.
In this 15-year-old boy who exhibits duskiness at the graft site two days after undergoing composite grafting of the ear, the most appropriate next step is initiation of hyperbaric oxygen therapy. This will provide oxygenation during the critical ischemia period for the graft and thus is likely to improve the outcome. Hyperbaric oxygen therapy enhances antimicrobial activity by facilitating the oxidative burst of polymorphonuclear neutrophils. It increases the hyperoxygenation of tissue to a level that is 10 to 15 times greater than normal. In addition, it stimulates angiogenesis and blunts the ischemia-reperfusion injury response.
Application of leeches is appropriate if arterial input is adequate but venous outflow is insufficient, as in patients undergoing microsurgical replantation who demonstrate thrombosis of the vein, or if a suitable vein does not exist for anastomosis. However, duskiness of the ear is an indication of arterial insufficiency, and leeches would fail to attach if they were applied.
Because a composite graft receives its vascularity through diffusion from the surrounding wound bed, releasing the sutures would inhibit the “take” of the graft to the bed. Similarly, performing debridement two days after grafting is excessive. Instead, the composite graft should be left in place for a minimum of two weeks in order to demonstrate healing and incorporation, as long as infection does not develop.
The most likely cause of isolated unilateral microtia in a neonate is maldevelopment of mesenchymal proliferations around which pharyngeal cleft(s) during which trimester?
The correct response is Option A.
The external ear develops during the end of the first trimester from six mesenchymal proliferations around the first pharyngeal cleft. These proliferations arise from the tissues of the first and second pharyngeal arches and are known as auricular hillocks. They slowly enlarge and eventually fuse to form the external ear. This process occurs between four and one half weeks and 10 weeks of intrauterine development as other facial structures are being formed.
Although the external ear, along with other facial structures, grows during the second trimester of fetal development, it has already been formed during the first trimester. Tissues around the second pharyngeal cleft contribute to the formation of the muscles of facial expression, the tonsils, the hyoid bone, and other structures but are not involved in the formation of the external ear.
