Ear Reconstruction Flashcards
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
A) 3 days
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? (the upper part of the retroauricular sulcus is absent) A) Cryptotia B) Microtia C) Pixie ear D) Prominent ear E) Stahl ear
A) Cryptotia
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
C) Scapha cartilage and conchal cartilage
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
D ) Ear molding
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
B ) Costochondral ear reconstruction at 7 years of age
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
B ) Inadequate reduction of the cavum conchae
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
E ) Recurrence
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%).
