Ear Reconstruction Flashcards
Ear molding should be in the first month only
F Timely ear molding less than 3 months of age, ideally less
than I month of age is a powerful option for miscellaneous
ear anomalies to obviate the need for surgery
Blood supply to the ear ?
vascular supply comes from the
superficial temporal anteriorly and posterior auricular vessels posteriorly.
The sensory supply to the auricle
The sensory supply to the auricle is mainly derived from the
inferiorly coursing greater auricular nerve ( C2-CJ
the neve supply to the upper portion of the ear?
Upper portions of
the auricle are supplied by lesser occipital (C2-C3) and auriculotemporal nerves (V3) (tragus and crus helicis)
Nerve supply to the the concha
is supplied by a branch of vagal nerve
what is Arnold nerve?
Arnold nerve (CN 7,9,10) 1s
an auricular branch of the vagus nerve that receives contributions from
the facial nerve and glossopharyngeal nerve. Arnold’s nerve supplies the posterior inferior external auditory canal and meatus, and inferior conchal bowl.
Lymphatic drainage of the ear?
correlates with six embryonic hillocks. The tragus, root of the helix, and superior helix arise from first branchial
arch (anterior hillocks 1-3) and drain into parotid nodes.
The antihelix, antitragus, and lobule arise from second branchial arch (posterior hillocks 4-6) and drain into cervical nodes.
When auricle starts to protrude
The auricle begins to protrude from the developing face at approximately 3 to 4 months of gestation
The auricle arises
from which branchial arch?
The auricle arises
from two branchial arches: mandibular branchial arch (first) and
hyoid branchial arch (second)
how much the normal ear size ?
The vertical height of an adult auricle is approximately 55 to
65 mm. Width is approximately 50% to 55% of its length
auricle is normally located approximately 10 mm behind the sideburn
auricle is normally located approximately 20 mm behind the sideburn
What is cryptosia ?
in which upper pole of ear
cartilage is buried underneath the scalp The superior auriculocephalic sulcus is absent but can be demonstrated when you pull up the helical pole
The common cartilage deformity in cryptotia?
A common cartilage deformity associated with cryptotia is helix-scapha adhesion, which may be addressed by cartilage
remodeling techniques.
Type of stahl ears
Type I: Obtuse-angled bifurcation of antihelix; looks as though
superior crus is missing
Type 2: Trifurcation of antihelix
Type 3: Broad superior crus and broad third crus (protruded
scaphoid fossa)
Ear molding is not benefit in Stahl ear ?
Ear molding may work well if ear molding is started in early
infancy.
what is Constricted Ear?
helix and
scapha fossa are hooded, and crura of antihelix is flattened
the surgical tech of (group 1,2A Tanzer classification
The musgrave technique is a useful method to expand the helix.
When superior crus is deficient, partial helix plus superior crus frame from rib cartilage5 can normalize the deformity
The features of Tanzer group 2B group
Has both skin and cartilage defects in the
upper one-third of the auricle. The loss of folding may
involve anti helical crura, and hooding is more pronounced.
The height of the ear is sharply reduced
Park tech in the reconstruction of ear deformity of class 2B Tanzer involve 6 rib as a cartilage graft
F Grotting flap (postauricular
flap) for skin defect and 8 th rib for cartilage defect
What are the option of management of Tanzer group 3
Brent recommends treating severe constricted ear as if it is a
form of microtia, when the construction is severe enough to
produce a height difference of 1.5 cm.
Nagata recommends treating severe constricted ear as a concha-type microtia, to replace the defective framework with a full rib cartilage
framework
surgical molding is possible in hypo plastic and non hypoplastic ear
F If ear deformities are not hypoplastic, nonsurgical correction is easy and reliable
Stahl ear protruding ears and cryptotia respond responds
well to the nonsurgical correction
Stahl ear responds
well to the nonsurgical correction only during the neonatal period,
whereas protruding ears and cryptotia respond until approximately
6 months of age (Matsuo)
Most agree that if ear molding is started after 1 months of age, the response tends to be poor
F Most agree that if ear
molding is started after 3 months of age, the response tends to be
poor
What is the most congenital ear anomaly that responds poorly to molding?
Helix-antihelix adhesion responds poorly to the ear molding
treatment and may not be an indication of the ear molding
the most common complication of molding ?
Skin
irritation is probably the most frequent complication, possibly due
to tape or adhesive.
Percentage of unilateral microtia
80% to 90% of microtia is unilateral, and 10% to
20% is bilateral
common syndrome associated with microtia
is hemifacial microsomia and Treacher-Collins syndrome
Treacher-Collins syndrome, inherited in an autosomal
dominant fashion, often presents with bilateral microtia
Isolated microtia rarely run
in families
T
Nagata’s classification
Anotia: Absence of auricular tissue
Lobule type: Vestige ear with lobule, without concha, acoustic
meatus, and tragus
Concha type: Vestige ear with lobule, concha, acoustic meatus,
and tragus
Small concha type: Vestige lobule with small indentation of concha (need lobule-type construction)
Atypical microtia: Cases do not fall into previous categories
Hoe many patients with microtia have associated anomalies
About 20% to 60% of children with microtia have associated anomalies or an identifiable syndrome; therefore, individuals with microtia should be examined for other dysmorphic features
Always need genetic counseling with microtia
F If there is
family history of the syndrome, genetic counseling may be necessary
Moderate defect Cartilage Construct for Constricted Ear, how ?
Floating rib (Park)
Hemifacial microsomia is often associated with difficult airway for intubation t f
T
partial facial paralysis is frequent
finding in microtia
T
Percentage of cholesteatoma in microtia?
cholesteatoma (squaipous epithelium
trapped in the middle ear), present in 4% to 7% of atresia
In bilateral microtia, som times we need to use of bone-conductive hearing aid .
F In bilateral microtia, early and conscientious use of bone-conductive hearing aid is imperative for hearing and speech development
Most of hearing deficits in children with bilateral microtia are
managed with hearing aids
T
Treatments of microtia ideally involve
reconstruction of the external ear only
F Treatments of microtia ideally involve
reconstruction of the external ear and the restoration of normal
hearing.
The cause of hearing loss in microtia?
Hearing impairment in microtia is related to abnormal
auditory canal, tympanic membrane, and middle ear
middle ear
surgery for hearing restoration is recomended in bilateral microtia
T potential gains from middle ear surgery in unilateral microtia are
outweighed by the potential risks and complications for the surgery
The bone-anchored hearing aid need functioning middle ear or patent canal.
F. The bone-anchored hearing aid does not
need functioning middle ear or patent canal
In bilateral microtia we cwn use single BAHA ?
T Unilateral BAHA is usually placed
because a single aid will stimulate both cochleae simultaneously
What are the drawbacks of BAHA?
The drawback of BAHA is the interface between titanium and skin: It
may cause skin irritation or infection. BAHA has a retention rate
of over 95% on long-term follow-up, with a soft-tissue reaction rate
of 30%
Microtia associated with craniofacial microsomia needs attention for
specific characteristics which are»_space;»>
Dystopic vestige
Low hairline
Soft-tissue defect
Vascular anomalies
Microtia with Treacher-Collins Syndrome
Small face
Low hairline: To eliminate hair on the new auricle, either temporoparietal fascia (TPF) flap or random-pattern fascia flap
Coronal scar: When the patient already has a coronal scar, surgeons should be aware that STA is severed. That means TPF is
not available Occipital fascia flap may be indicated
Tanzer, whose
excellent results established autogenous construction with rib cartilage, 18 is considered to be the father of modern auricular construction
T
Different between Nagata and brent tech
Nagat two stage - brent four stage
Nagata at age 10 years - brent at age 6
Brent harvested rib cartilage with perichondrium attached to it
Nagata harvests rib cartilage without perichondrium
Nagata take cartilage from ribs six to nine
T
silicone ear framework
is discontinued today
T Becoz it extrudes, causes infection, and loses definition in the long term
The advantage of porous
polyethylene implant over autogenous construction
it can be
applied to younger children whose costal cartilage are less mature
and not ready for autogenous reconstruction
The disadvantage of
porous polyethylene framework
use ofTPF flap,
long-term risk of alloplastic implant exposure or loss,
and compromise any future autogenous options.
The disadvantages of prosthesis
include intermittent soft-tissue problems, long-term maintenance, prosthetic remakes every 2 to 5 years,
ongoing cost, compromise of future autogenous options, and need for
a compliant patient
The cause of unsatisfactory ear reconstruction?
can be divided into
three main categories: inappropriate skin envelope, inappropriate ear
framework, and inappropriate ear location
TPF
flap is the workhorse for secondary ear reconstruction
T
If TPF is not available, what are the options?
If TPF is not available, pedicle-occipital facial flap or free vascularized fascia flap transfer are the option for the new skin envelope.
Most common complication from surgery is
that the construct does not look like a normal auricle T F
T
Nagata stated that proper
skin thickness for ear reconstruction is 5 mm.
F o. Nagata stated that proper
skin thickness for ear reconstruction is 2 mm.
How we can prevent the infection in microtia ?
For concha-type microtia, it is important
to understand and recognize the middle ear pathology (otitis
media/cholesteatoma) preoperatively
Immediate postoperative infection after total ear
reconstruction is rare (<0.5%)
T
How we can prevent cartilage resorption?
Nagata believes that placing a TPF flap, covering the entire
the posterior surface of the auricle will augment the vascular supply
to the cartilage framework and prevent the cartilage resorption
How we can prevent the hypertrophic scar?
Oblique donor site skin incision is more
likely to cause hypertrophic scar. Transverse skin incision parallel to skin wrinkle is better to prevent hypertrophic scar.
Brent and Firmin use fine wires
(38G) for fixation
F Brent uses nylon sutures for framework fixation
to avoid wire extrusion. Nagata and Firmin use fine wires
(38G) for fixation
TPF layer sharp flap dissection
with scalpel usually cause alopecia.
F TPF layer sharp flap dissection
with scalpel usually does not cause alopecia.
Temporal fascia flap used for?
The Nagata
technique routinely uses TPF flap for ear elevation to cover
the entire posterior aspect of the new auricle.28 TPF may also
be used in low hairline cases or Medpor framework to cover
anterior surface of the framework
Pearl” applied twostage total ear reconstruction principle to the partial amputation of
the auricle.
T
Option for Upper-third defects
Local skin flaps
□ Helical advancement
□ Contralateral conchal cartilage graft covered with a retroauricular flap
□ Chondrocutaneous composite flap
□ Rib cartilage graft covered with retroauricular skin or temporoparietal flap/skin graft
Middle-third defects
□ Primary closure with excision of accessory triangles
□ Helical advancement
□ Concha! cartilage graft and retro auricular flap
□ Rib cartilage graft and retro auricular flap and/or temporoparietal flap
External auditory canal reconstruction Restenosis after skin grafting is common
T acrylic stent is recommended for several months to prevent restenosis.
Reattaching
large pieces of auricular tissue as composite grafts is a secssuful process
F Reattaching
large pieces of auricular tissue as composite grafts is doomed to failure
What is the Mladick’spocket principle
Dermabrased amputated cartilage
is reattached to the remaining auricle, then buried underneath
the retro auricular skin pocket. The graft is left in place for
3 weeks, then at the second-stage surgery, cartilage is exposed
with soft tissue attached to the cartilage, and the skin is
grafted to complete the reconstruction
What is the Baudet’s fenestration techniques?
Baudet’s fenestration techniques35: Posterior skin of the amputated part is removed. Fenestration is made in avulsed auricular cartilage to increase the vascular recipient area
The most common late complication in auricular reconstruction
The most common late complication in auricular reconstruction is chest wall deformity, which occurs in
approximately two-thirds of cases
The most significant early complications
are skin loss, infection, and hematoma,
T
Newly constructed auricle can grow with the child
New constructed auricle commonly remains
the same size over time (48%) but may increase in size as the
child grows, (42%) in Brent’s series.
the last part of the oracles to develop?
The lobule is the last part of the auricle to develop
Instahl ear Surgical treatment is broadly categorized into two types: cartilage/skin excision and cartilage alteration
T
Type 1 Stahl ear needs
special attention, to reconstruct missing superior crus, by using
excised third crus or rib cartilage graft or creating superior crus by
sutures or cartilage cutting
T
TANZER CLASSIFICATION OF CONSTRICTED EAR
1 Involvement of helix only
2 Involvement of helix and scapha
A No supplemental skin needed at margin of auricle
B Supplemental skin needed at margin of auricle
3 Extreme cupping deformity; often associated with
incomplete migration, forward title, stenosis of external
auditory canal, and deafness
Constricted ear is often referred as cup or lop ear
T
Mild deformities of helix, often called lop ear
T
Diagnostic Studies in microtia
Temporal bone imaging
o High-resolution CT scan for evaluating middle ear ossicles to
assess the possibilities of future otologic surgery
o MRI to determine the course of facial nerve, often displaced,
especially in the absence of pneumatized mastoid
microtia patients have a hearing threshold
of 40 to 60 dB on the affected side. By comparison, normal function
allows us to hear sounds between O and 20 dB
t
Brent technique
Brent technique: Four-stage reconstruction beginning at 6 years
of age’9:
o Creation and placement of a rib cartilage auricular framework
o Rotation of the malpositioned ear lobule into the correct position
o Elevation of the reconstructed auricle and creation of a retro auricular sulcus
o Deepening of the concha and creation of the tragus
The surgeon
must assess the presence of STA from the base (near the caudal end
of the auricle location) up to the parietal area (10 cm above the upper
helix portion)
t
If wires are used for framework, the wires should be removed, otherwise infection may
persist.
t
Exposure of framework is more common
in synthetic framework than autogenous rib cartilage framework
t
Most of the available method
use two-stage retroauricular flap to create the lobule
t
A reconstructed earlobe, however, will
maintain its contour only if cartilage is included
T
Part of the first arch cartilage
(Meckel cartilage) ossifies and forms the malleus and incus of
the middle ear.
T
Part of the second
arch cartilage (Reichert cartilage) ossifies to form the stapes of
the middle ear and styloid process
T
The fourth to sixth arch cartilages fuse
to become the laryngeal cartilages
T
The area of
skin lossshould be debrided and only reconstructed ifthe area is
greater than l cm
T
