Ear Reconstruction Flashcards
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.
2018
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.
2018
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
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.
2018
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.
2017
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.
2017
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.
2017
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.
2017
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 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.
2016
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.
2014
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.
2019
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.
2019
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.
2019
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.
2019
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.
2019
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.
2020
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.
2020
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.
2020
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.
2020
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.
2020
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.
2020
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.
2020
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.
2021
