Ear Reconstruction

Question 1

ear parts?

Answer 1

1. Helix
2. Scapha
3. Antihelix
4. Antitragus
5. Posterior crus antihelix 6. Triangular fossa
6. Anterior crus antihelix
7. Cymba of concha
8. External auditory meatus 10. Tragus
9. Cavum of concha
10. Lobule

Question 2

Which branchial arches give rise to the ear?

Answer 2

The first two branchial arches give rise to six hillocks that form the ear.
The first arch forms the malleus, incus, and anterior hillocks (1–3). The second arch forms the stapes and posterior hillocks (4–6).

Question 3

What structures arise from the anterior (1–3) hillocks?

Answer 3

The tragus, root helix, and superior helix.

Question 4

What structures arise from the posterior (4–6) hillocks?

Answer 4

The antihelix, antitragus, and lobule.

Question 5

What ear structures are formed from the first branchial groove?

Answer 5

The external auditory canal and concha.

Question 6

What is the average length of the ear?

Answer 6

The average length is 6 cm. Approximately 90% of the growth occurs by 5 years of age.

Question 7

What is the angle of protrusion of the ear?

Answer 7

30◦ .

Question 8

What is the vascular supply of the ear?

Answer 8

The ear is supplied by the following branches of the external carotid artery:
1. The lateral ear is supplied by the superficial temporal and posterior auricular arteries.
2. The medial ear is supplied by the posterior auricular and posterior occipital arteries.
3. The triangular fossa and scapha are supplied by the helical branch of the superficial temporal artery. 4. The concha is supplied by septal perforators of the posterior auricular artery.

Question 9

What is the vascular supply to the ear cartilage?

Answer 9

The cartilage is an avascular structure, which is supplied by the surrounding perichondrium and soft tissue.

Question 10

What is the lymphatic drainage of the ear?

Answer 10

While lymphatic drainage may vary, it generally follows embryologic development:
1. The superolateral ear and anterior external auditory meatus drain to the parotid nodes.
2. The superomedial ear and posterior external auditory meatus drain to the mastoid nodes. 3. The inferior ear and lower external auditory meatus drain to the superficial cervical nodes. 4. The concha and meatus drain to the preauricular nodes.

Question 11

Describe the innervation of the ear.

Answer 11

1. The auriculotemporal branch (V2) supplies the superolateral ear.
2. The great auricular branch (C2–3) supplies the inferolateral and inferomedial ear.
3. The lesser occipital branch (C2–3) supplies the superomedial ear.
4. The auditory (“Arnold’s”) branch (X) supplies the concha and external auditory canal.

Question 12

How do you anesthetize the ear?

Answer 12

Anesthesia of the ear, except the concha and external auditory canal, can be performed with a ring block around the
base of the ear. Anesthesia to the concha and external auditory canal must be performed with local infiltration.

Question 13

What is the treatment for ear burns?

Answer 13

The primary goal is to prevent chondritis. Topical mafenide is used for dressing changes. The eschar is left in place as
a biologic dressing. Defects with intact perichondrium will heal in, while others will require late excision and repair.

Question 14

What is the treatment for frostbite of the ear?

Answer 14

Topical mafenide is used for burns and frostbite. It is highly soluble, which allows penetration of eschar and
cartilage. Sulfonomides are carbonic anhydrase inhibitors, which can lead to metabolic acidosis.

Question 15

What is the management of an ear hematoma?

Answer 15

Ear hematomas are treated by aspiration or incision and drainage. Bolster dressing is applied to prevent reaccumulation. Hematoma forms between the cartilage and perichondrium of the ear. This disrupts the vascular supply to the cartilage, which may become necrotic or infected. Clotted blood forms a fibrotic mass that deforms the overlying tissue. This is known as a “cauliflower,” “boxer’s,” or “wrestler’s” ear.

Question 16

What are the most common malignancies of the ear?

Answer 16

1. Squamous cell cancer: 50% to 60%
2. Basal cell cancer: 30% to 40%
3. Melanoma: 1% to 2%

Question 17

How are defects of skin and perichondrium repaired?

Answer 17

Primary closure is used for small defects. The cartilage may be removed and a skin graft applied onto the medial skin. Local skin flaps such as Elsahy’s two bipedicled flaps from the medial ear may be used.

Question 18

What is the Antia-Buch reconstruction technique?

Answer 18

Antia-Buch technique of helical rim advancement can be used for defects up to 2.5 cm. The helical rim is separated from the scapha through an incision in the helical sulcus. This extends from the lower edge of the defect to the upper lobule, including skin, perichondrium, and cartilage. The posteromedial skin is left intact, whereas the chondrocutaneous flap is advanced. V-Y advancement of the root helix and trimming scaphal cartilage allow for additional coverage

Question 19

Describe the Converse tunnel procedure.

Answer 19

The Converse tunnel procedure is used for helical rim defects greater than 3 cm. A cartilage strut is tunneled under
postauricular skin. Three weeks later, the strut is lifted on an anteriorly based flap and inset into the defect.

Question 20

Describe the tubed pedicle technique.

Answer 20

The tubed pedicle technique is used for helical reconstruction. A bipedicled flap is elevated and fashioned into a
tube. This is sewn to the edge of the defect. A second stage is performed to elevate the flap.

Question 21

What are reconstructive options for the conchal bowl and helical root?

Answer 21

1. Healing by secondary intention.
2. Full-thickness skin grafts can be placed onto perichondrium.
3. If the perichondrium is not present, the cartilage should be excised and skin graft placed onto medial ear skin.

Question 22

How large of a defect can be closed primarily (ie, Tanzer excision)?

Answer 22

A defect of 2 cm or less can be closed using a wedge excision technique with star-shaped pattern to allow for closure without excessive excision of the helical rim. This is commonly referred to as a Tanzer’s excision.

Question 23

What is a Banner flap?

Answer 23

This is a postauricular flap from the superior auriculocephalic sulcus. It is used in conjunction with a cartilage graft for upper one-third defects.

Question 24

What are the reconstructive options for defects of the middle one-third of the ear?

Answer 24

1. Defects limited to helical rim are closed by Antia-Buch technique.
2. Wedge excision with primary closure (ie, Tanzer’s excision) (<2 cm).
3. Cartilage graft with postauricular or temporoparietal flap/skin graft (ie, Dieffenbach’s flap or Converse tunnel technique) (>2 cm).
4. Contralateral chondrocutaneous composite flap (>2 cm).

Question 25

What is a Dieffenbach flap?

Answer 25

This is a postauricular flap with contralateral cartilage support, which is used to reconstruct defects of the middle one-third. Cartilage graft is sutured into the defect with postauricular skin advanced over for skin coverage. The flap is then divided 2 to 3 weeks later

Question 26

Is cartilage required for lobular reconstruction?

Answer 26

Although the lower ear is not composed of cartilage, reconstruction with cartilage provides better support. Wedge excision and primary closure can be performed by defects <50%. Local preauricular and postauricular flaps with cartilage struts are used for defects >50%.

Question 27

What is a split earlobe and how is this treated?

Answer 27

Split earlobe results from a traumatic earring injury or heavy earring use. Straight line closure will result in a
notched earlobe. A wedge excision and zigzag repair can prevent notching.

Question 28

Describe the use of the temporoparietal fascial flap in ear reconstruction.

Answer 28

This flap is the superficial temporal fascia, which is based on the superficial temporal vessels. It is tunneled to the ear for tissue coverage and covered with skin graft. It is a thin and pliable flap that preserves external topography. This is used when local skin flaps are not available.

Question 29

What is the management of partial ear amputation?

Answer 29

Partial amputation even with a wide small pedicle has good prognosis with debridement and primary closure. Partial amputation with a narrow pedicle and a large amount of cartilage to support has a poor prognosis with primary repair.

Question 30

Describe the approach to total ear amputation.

Answer 30

Cartilage banking or the “pocket principle” is rarely used at this time due to cartilage degradation and deformity.
Microvascular replantation should be attempted. If this is not possible, staged reconstruction should be performed

Question 31

What should be done if no sufficient venous outflow can be established for an ear replantation?

Answer 31

Leech therapy.

Question 32

Describe total ear reconstruction options.

Answer 32

Ear reconstruction involves multiple stages. First a framework is created using the contralateral ear as a model and contralateral costal cartilages 6 to 8 for the structure. This is placed in a subcutaneous pocket. The cartilage framework is then lifted with overlying skin and the posterior defect is covered with skin graft. After 2 to 3 weeks, the ear is rotated into anatomic position.