Ear Reconstruction - Microtia - Trauma Flashcards
A 25-year-old woman has facial asymmetry. She says that she has had progressive loss of soft-tissue volume on the right side of the face since age 10 years that became stabilized four years ago. Examination shows significant subcutaneous atrophy of the right side of the face without bony asymmetry. She also has hypopigmentation of the iris on the affected side.
Which of the following is the most appropriate management?
(A) Bone graft augmentation of the midface
(B) Alloplastic augmentation
(C) Reconstruction with a microvascular serratus anterior free flap
(D) Reconstruction with a microvascular parascapular free flap
(E) Reconstruction with a superficial temporal fascia flap
The correct response is Option D.
This 25-year-old woman has Romberg’s hemifacial atrophy characterized by progressive unilateral loss of facial soft tissue. The underlying skeleton is also affected in patients with severe forms of the disease. Surgery should be delayed until the condition becomes stabilized, which is indicated by the cessation of facial atrophy. When this has occurred, a microvascular parascapular flap can be deepithelialized and customized to fit the dimensions of the defect, and then transferred and buried subcutaneously.
Skeletal augmentation with either bone graft or alloplast is not appropriate because the bones of the face are not affected. The serratus anterior flap would only atrophy over time, and the superficial temporal fascia flap would not provide the necessary volume.
Which of the following hormones is responsible for the success of molding therapy of ear deformities in the neonatal period?
(A) Estrogen
(B) Growth hormone
(C) Progesterone
(D) Prolactin
(E) Thyroid
The correct response is Option A.
At birth, the neonate’s ears are soft and pliable, which makes molding therapy of ear deformities more successful during the neonatal period. This pliability is thought to be due to the effect of maternal estrogen, which increases the amount of hyaluronic acid, a major constitute of ear cartilage. After six weeks, the infant’s estrogen level begins to fall, and the ears becomes firmer and less malleable. Because breast-fed infants have higher levels of estrogen for a longer time, their ears may be moldable for a longer period.
The other hormones have no effect on the pliability of cartilage in the newborn period.
Several studies reported success with different molding methods. One reported an 87% rate of success after treating 92 ears with soft putty and taping. The deformities treated included lop, prominent, Stahl’s, and constricted ears. Another study used flexible plastic tubing and wire to form splints and reported good results in 19 neonates. Children treated after three months of age showed little significant improvement. In both studies, complications were minimal.
A 35-year-old man has persistent enophthalmos 18 months after undergoing open reduction of a fracture of the orbital floor and zygoma. Forced duction testing shows no restriction of eye motion. Which of the following is the most likely cause of this patient’s enophthalmos?
(A) Fat atrophy
(B) Fibrosis of the extraocular muscles
(C) Herniated contents of the orbit within the maxillary sinus
(D) Inadequate fracture reduction
(E) Scar contracture
The correct response is Option D.
Persistent enophthalmos following facial trauma is primarily caused by increased bony orbital volume secondary to inadequate fracture reduction. An appropriate anatomic reduction should be the initial goal of surgery; bone grafting may be required to restore orbital volume to normal levels.
Fat atrophy, extraocular muscle fibrosis, herniation of orbital contents, and scar contracture can also contribute to the discrepancy between traumatic and nontraumatic orbital volume, but are less likely to contribute to postoperative enophthalmos than inadequate fracture reduction. In addition, extraocular muscle fibrosis and/or scarring would typically be associated with limited motion of the globe on forced duction testing.
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 21-year-old man sustains a complete amputation of the right ear at the level of the external auditory canal in a motor vehicle collision. There are no other injuries. Which of the following procedures will provide the best aesthetic result?
(A) Delayed total ear reconstruction with a rib cartilage graft
(B) Dermabrasion of the epidermis of the amputated ear, burial of the ear in a subcutaneous postauricular pocket, followed by removal and coverage with a skin graft or flap
(C) Removal of the skin of the amputated ear, reattachment of the ear cartilage, and immediate coverage with a temporoparietal fascial flap and skin graft
(D) Composite grafting of the amputated ear followed by surface cooling
(E) Microsurgical ear replantation
The correct response is Option E.
Successful microsurgical replantation of the ear provides superior aesthetic results while eliminating the need for other complex reconstructive procedures. However, this technique is associated with increased operative time and the need for multiple blood transfusions. Hospitalization is typically prolonged, and failure rates associated with the procedure are high.
Delayed reconstruction results in only moderate cosmetic improvement, and secondary reconstruction does not sufficiently recreate the intricate architecture of the external ear.
Primary nonvascularized replantation of the ear produces a good appearance initially because of the survival of the avulsed cartilage; however, late distortion of the cartilage frequently limits the overall aesthetic result. Techniques used for nonvascularized replantation include primary reattachment of the ear with surface cooling, dermabrasion of the ear, and partial or complete burial of the ear in a postauricular skin pocket, followed by coverage of the filleted cartilage with a temporoparietal fascial flap and skin graft.
A 6-year-old girl with prominent ears due to overdeveloped conchae and effaced antihelical folds is scheduled to undergo otoplasty by a combination of methods including Stenstrom cartilage abrasion. In this technique, which of the following surfaces of the auricular cartilage is abraded?
(A) Anterior surface of the antihelix
(B) Anterior surface of the conchal bowl
(C) Lateral border of the helix
(D) Posterior surface of the antihelix
(E) Posterior surface of the conchal bowl
The correct response is Option A.
Classic congenital prominence of the ears is caused by an overdeveloped or excessively deep conchal bowl; an underdeveloped, effaced, or absent antihelical fold; or both. Surgical correction of prominent ears commonly calls for a combination of procedures, including the Mustardé technique for placement of mattress sutures to create an antihelical fold, partial excision of the conchal bowl, placement of concha-mastoid sutures for setback of the conchal bowl, and Stenstrom cartilage abrasion.
Stenstrom cartilage abrasion requires partial thickness scoring, scratching, or abrading of the anterior surface of the antihelix. This causes the cartilage to bend away from the abraded surface, creating or accentuating an antihelical fold.
To correct prominent ears, projection of the conchal bowl usually needs to be reduced by excision or by setback with placement of concha-mastoid sutures, not by scoring the anterior or posterior surface. Because the helix is normal in prominent ears, it should not be abraded.
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 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.
A 70-year-old man who underwent total resection of the right ear followed by radiation because of squamous cell carcinoma one year ago comes to the office for consultation regarding reconstruction of the ear. He says he needs the ear to support his eyeglasses. Medical history shows chronic obstructive pulmonary disease. Which of the following reconstruction techniques is most appropriate in this patient?
(A) Fixation of autogenous cartilage under local flaps
(B) Implantation of osseointegrated auricular prostheses
(C) Placement of porous polyethylene framework and coverage with a radial forearm free flap
(D) Placement of silicone rubber (Silastic) framework and coverage with a temporoparietal flap
(E) Tissue expansion and placement of porous polyethylene framework
The correct response is Option B.
Ear reconstruction techniques are needed to address a variety of congenital, traumatic, and ablative defects. Both an intricate framework and stable covering are needed to obtain a consistent and aesthetically pleasing reconstruction. Cartilage has been the framework of choice for many years, but this involves some donor morbidity. Silastic and porous polyethylene frameworks offer synthetic alternatives but can become infected or exposed. Covering can be accomplished by local tissue if available, expanded tissue, and local or distant skin flaps.
Prosthetic ears have been available for many years but were limited by the harsh adhesives necessary to keep them in place. The use of osseointegrated titanium implants for the retention of dental prostheses opened a new possibility for implant fixation in other areas of the body.
Several recent studies document the recommended indications for autogenous versus prosthetic techniques. One study of 98 patients recommends autogenous reconstruction for pediatric microtia patients and prosthetic reconstruction for traumatic or ablative defects in adults. In addition, prosthetic ears are also recommended for severe soft tissue hypoplasia, low or unfavorable hairline, and failed autogenous reconstruction. Another study of 55 patients recommended autogenous reconstruction for classic microtia, relatively normal lower one third of the ear, patient preference, and noncompliant patients. The principal indications for osseointegrated implants were major cancer extirpation, poor local tissue, absence of the lower half of the ear, salvage following unsuccessful surgery, and poor operative risk patients.
In this case of an older patient with medical problems and poor local tissue, the fastest and safest option is a prosthetic ear implant. His radiation would preclude tissue expansion or a temporoparietal flap. A rib donor site would have significant morbidity in a patient with chronic obstructive pulmonary disease. A free flap is also high risk in this patient, with its longer anesthetic time and need for anticoagulation.
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.
The antihelix and antitragus of the external ear arise from which of the following embryologic structures?
A) First branchial arch
B) First branchial groove
C) First pharyngeal pouch
D) Second branchial arch
E) Second branchial groove
Development of the six branchial arches occurs within the walls of the anterior foregut during the fourth week of gestation, as neural crest cells migrate into the future head and neck region and alternating ridges and depressions develop. A series of clefts forms during embryologic development to create the branchial grooves externally and the pharyngeal pouches internally.
The auricle arises from the first (mandibular) and second (hyoid) branchial arches and is further defined by the development of six hillocks, which appear on these arches during the sixth week of gestation. The anterior (first through third) hillocks give rise to the tragus, root of the helix, and superior helix. The posterior (fourth through sixth) hillocks give rise to the posterior helix, antihelix, antitragus, and lobule. Meckel’s cartilage is derived from the first branchial arch; it ossifies to form the malleus and incus. The external acoustic meatus develops from the first branchial groove. The middle ear and eustachian tube are formed from the first pharyngeal pouch. Reichert’s cartilage is also derived from the second branchial arch and ossifies to form the stapes. The second, third, and fourth branchial grooves are obliterated within the cervical sinus during the later stages of development.
Which of the following congenital ear deformities is characterized by absence of the superior auriculocephalic sulcus?
(A) Cryptotia
(B) Cup ear deformity
(C) Lop ear
(D) Microtia
(E) Prominent ear deformity
The correct response is Option A.
Cryptotia (“hidden ear”) is a congenital deformity of the cartilage of the scapha and antihelix. In neonates who have this deformity, the upper pole of the ear is buried beneath the scalp, and the superior auriculocephalic sulcus is absent. Conservative management is most appropriate initially; surgical release should be performed when the child is older.
Infants with the cup ear deformity have hooding of the scapha and helix and flattening of the antihelix. Lop ear is characterized by protrusion of the ear and folding of the superior helix. Microtia is a hypoplastic condition that manifests as varying degrees of ear absence, from anotia (complete ear absence) to a smaller than normal ear with normal morphology. The prominent ear deformity involves widening of the conchoscaphal angle, increased auriculocephalic distance, and loss of the antihelical fold.
A 55 year old woman is referred to the office by her primary physician because she has had a painful, chronic area of scabbing on the right ear for the past three months. Physical examination shows a 2 x 1-mm area of skin ulceration on the superior helix of the ear. Surrounding inflammation and exposed cartilage are noted. Which of the following is the most appropriate initial step in management?
(A) Daily wound dressing with bacitracin ointment and avoidance of pressure on the ear
(B) Excision with 5-mm margins and coverage with a retroauricular trap door flap
(C) Excision with 5-mm margins and reconstruction with an Antia €‘Buch advancement flap
(D) Excisional biopsy and primary wound closure
(E) Injection of triamcinolone and daily topical application of hydrocortisone cream
The correct response is Option D.
The patient described most likely has a benign condition referred to as chondrodermatitis nodularis helicis, an inflammation of the cartilage of the ear that often leads to a painful open area. This condition can mimic a skin cancer on physical examination. Unless the area is clearly benign, biopsy is warranted to rule out skin cancer. Recurrence rate for this condition is high. Excisional biopsy and primary wound closure will give a pathological confirmation and may suffice as treatment.
Daily wound dressing with bacitracin ointment or injection of triamcinolone and daily topical application of hydrocortisone cream are both inappropriate because neither would give the appropriate tissue diagnosis. Excision and reconstruction or coverage with a flap are unwarranted given no pathological diagnosis.
Chondrodermatitis nodularis helicis is a condition of unknown etiology predominantly found in older men and often is associated with trauma from sleeping. It begins as an area of cartilage inflammation and then ulcerates through the skin. The treatment is excision of the cartilage and closure of the skin. Recurrence rates remain high. Preventive measures to decrease the recurrence rate include avoidance of sleeping on the affected ear.
A healthy 7-year-old boy with anotia undergoes reconstruction of the right ear via implantation of a high-density porous polyethylene prosthesis. Compared with use of autologous cartilage, which of the following is the most likely result of this procedure?
A) Higher incidence of contour deformities
B) Higher incidence of extrusion
C) Increased likelihood of malposition
D) Lower incidence of infection
E) More resorption of the implant over time
High density porous polyethylene (Medpor) is an alloplastic implant material that is nonresorbable and highly biocompatible. It has an intramaterial porosity with a pore size between 125 and 250 μm, which permits extensive fibrovascular ingrowth throughout the implant. Although limited bony ingrowth may occur in select clinical circumstances, the material should not be considered truly osteoconductive. This bony and fibrovascular ingrowth can make this type of material somewhat difficult to remove. Studies have shown less underlying bone resorption occurs with high density polyethylene than with other implant materials.
As an alloplastic material, it should not be placed in contaminated wound beds, because it can get easily infected, and should always be positioned in areas of adequate soft tissue cover to prevent extrusion. The incidence of extrusion is higher in microtia reconstruction and nasal dorsum augmentation for this reason.
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 58-year-old woman is scheduled to undergo bilateral upper eyelid blepharoplasty. Preoperatively, the surgeon plans to resect skin, a strip of orbicularis oculi muscle, and a small amount of orbital fat. During the dissection, there is concern that the levator tendon has been lacerated just above the tarsal plate. This can be confirmed by visualizing which of the following structures through the laceration?
(A) Capsulopalpebral fascia
(B) Müller’s muscle
(C) Orbital septum
(D) Retro-orbicularis oculi fat
(E) Whitnall ligament
The correct response is Option B.
Superior to the tarsus, the layers of the eyelid are the conjunctiva, Müller’s muscle, levator tendon, orbital fat, orbital septum, retro-orbicularis oculi fat, orbicularis oculi muscle, and skin. Because the Müller’s muscle lies just below the levator tendon, visualization of this muscle confirms laceration of the tendon.
The conjunctiva is located deep to the Müller’s muscle. In this procedure, the conjunctiva would not be visualized unless the Müller’s muscle had been lacerated also. The orbital septum and retro-orbicularis oculi are anterior and superior to the levator tendon. The Whitnall ligament also is superior to the levator tendon.
A 2-week-old neonate has bilateral prominent ears with lopped superior poles. Which of the following is the most appropriate management?
(A) Observation
(B) Molding the ears using tape and splinting
(C) Injection of a corticosteroid
(D) Otoplasty at age 2 years
(E) Otoplasty at age 6 years
The correct response is Option B.
In this neonate with bilateral prominent ears, immediate management should include molding of the ears with tape and splinting. Circulating maternal estrogens are still present until the age of 6 months, allowing for successful molding of the soft, malleable ear cartilage in infants with cryptotia and prominent ears. Molding can also be performed in newborns with lop ear and Stahl’s ear during the neonatal period. Complete correction without surgery is a realistic expectation.
Because the concept of body image typically begins to form at about school age, ear reconstruction, if required, should ideally be performed between the ages of 5 and 6 years. The normal ear is within 6 to 7 mm of its full vertical height by the age of 6 years, allowing for the construction of an ear that is symmetrical to the normal ear.
Observation alone is inadequate in a child with ear deformities, and injection of a corticosteroid is inappropriate management. Otoplasty should not be performed at the age of 2 years because ear growth is not complete.
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.
A 2-month-old boy is brought to the office by his parents for consultation regarding congenital lop ear. On the basis of the physical examination, nonoperative correction of the deformity with thermoplastic splinting is planned. The parents ask how long their son will be required to wear the splint. The physician tells the parents that if their son wears the splint as directed, the most likely length of time between application of the device to full correction of the deformity is which of the following?
(A) One week
(B) Two months
(C) Four months
(D) Eight months
(E) One year
The correct response is Option B.
Nonsurgical treatment of various congenital auricular deformities has been reported in children of neonatal age. More recently, this has also been achieved in children who are several years of age. The splints are made from a malleable thermoplastic material and are applied to the ear by hand until a normal form is attained. Remodeling can be performed once per week until a desired correction is achieved. In one study involving 290 patients, 70% of cases could be treated with good results. The average time for treatment was 1.9 months (range, one week to four months). All patients showed remarkable improvement within the first one to two weeks after beginning the treatment. Young age, cooperation of the parents and patient, elasticity of the cartilage, and type of deformity are all contributing factors in the time required for treatment.
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.
Microtia is an auricular deformity most commonly found in patients with which of the following syndromes?
A) Apert
B) Binder
C) Crouzon
D) Pfeiffer
E) Treacher Collins
Treacher Collins syndrome is characterized by bilateral abnormalities of structures within the first and second branchial arches. Treacher Collins syndrome has anomalies in structures derived from the first branchial arch, groove, and pouch. It is considered to be autosomal dominant in its inheritance with variable expressivity. Features include a convex facial profile with a retrusive lower jaw and chin, down-slant of the palpebral fissures, lower eyelid colobomas, partial absence of eyelid cilia, absent or malformed external ears, hypoplasia of the malar bones, and variable cleft palate.
Binder syndrome is characterized by nasomaxillary hypoplasia. Apert, Crouzon, and Pfeiffer syndromes are all craniosynostotic syndromes that result in mid-facial hypoplasia and a concave facial profile of varying degrees. These syndromes do not typically present with microtia.
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.
In a child with microtia, growth of the reconstructed ear is primarily dependent on which of the following factors?
(A) Age of the child
(B) Presence of the perichondrium
(C) Preservation of intercostal muscle
(D) Type of fixation
(E) Type of rib graft
The correct response is Option B.
An intact perichondrium is most crucial for growth of the reconstructed ear. If the perichondrium is present, the reconstructed auricular framework will grow at a rate similar to that of the normal ear. The age of the child and timing of reconstruction are secondary considerations because the auricle reaches near normal size at approximately 6 years of age. Preservation of the intercostal muscle attached to the graft does not influence future growth of the reconstructed ear, nor does the type of fixation used. Only rib cartilage should be used for grafting, and bone should not be included.
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.
A 27-year-old man is brought to the emergency department two hours after sustaining a laceration of the left ear in a fight. Physical examination shows a 3-cm laceration that extends from the helix to the conchal bowl. A ring block is performed. The wound is cleaned and suturing is begun. The patient grimaces and withdraws during suturing of the section of the laceration that extends to the concha. The most likely cause is inadequate anesthesia of which of the following nerves?
A ) Auricular branch of the vagus (X)
B ) Auriculotemporal
C ) Great auricular
D ) Lesser auricular
E ) Lesser occipital
The correct response is Option A.
The majority of the external ear can be readily anesthetized by placing a ring of local anesthetic around the ear. The exception is the concha and the posterior auditory canal. These structures are innervated by the Arnold nerve, the auricular branch of the vagus nerve (X), which travels along the ear canal. This nerve, and therefore the concha and the posterior auditory canal, is not successfully anesthetized with a ring block of the ear. If anesthesia is needed in this area, local infiltration is required.
A 21-year-old man comes to the office for consultation because he thinks his ears protrude. He appears self-conscious about his ears and wears his hair long to hide them. He repeatedly looks in the mirror during his evaluation. On examination, postauricular measurement shows a helical rim-to-head distance of 12 mm at the superior pole, 17 mm at the midpoint, and 23 mm at the lobule bilaterally. Which of the following is the most appropriate next step in management?
A ) Referral for psychological evaluation
B ) Re-evaluation in 1 year
C ) Resection of the conchal bowl
D ) Scoring of the anterior cartilage
E ) Conchal-mastoid suturing
The correct response is Option A.
The patient described exhibits traits consistent with body dysmorphic disorder (BDD). DSM-IV describes BDD as a preoccupation with an appearance that is either imagined or is a slight physical anomaly. The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The degrees of emotional distress and behavioral impairment, rather than the size or nature of the physical defect, may be more accurate indicators. Although possibly more difficult to diagnose in the cosmetic surgery patient population, plastic surgeons should evaluate for possible underlying psychiatric disorders. Psychiatric illnesses are not absolute contraindications for surgery; however, cosmetic surgery is unlikely to benefit those with BDD, psychoses, or eating disorders.
Normal helical rim-to-head measurements for each third of the ear are 10 to 12 mm at the helical apex, 16 to 18 mm at the midpoint, and 20 to 22 mm at the lobule.
The antihelix and antitragus of the external ear arise from which of the following embryologic structures?
(A) First branchial arch
(B) First branchial groove
(C) First pharyngeal pouch
(D) Second branchial arch
(E) Second branchial groove
The correct response is Option D.
Development of the six branchial arches occurs within the walls of the anterior foregut during the fourth week of gestation, as neural crest cells migrate into the future head and neck region and alternating ridges and depressions develop. A series of clefts forms during embryologic development to create the branchial grooves externally and the pharyngeal pouches internally.
The auricle arises from the first (mandibular) and second (hyoid) branchial arches and is further defined by the development of six hillocks, which appear on these arches during the sixth week of gestation. The anterior (first through third) hillocks give rise to the tragus, root of the helix, and superior helix. The posterior (fourth through sixth) hillocks give rise to the posterior helix, antihelix, antitragus, and lobule.
Meckel’s cartilage is derived from the first branchial arch; it ossifies to form the malleus and incus. The external acoustic meatus develops from the first branchial groove. The middle ear and eustachian tube are formed from the first pharyngeal pouch. Reichert’s cartilage is also derived from the second branchial arch and ossifies to form the stapes. The second, third, and fourth branchial grooves are obliterated within the cervical sinus during the later stages of development.
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 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 28-year-old man comes to the office because of fever and increasing pain 1 week after partial amputation of the right ear when he was bitten during a fight. The wound was irrigated and repaired in the emergency department. Temperature is 100.4 °F (38.0 °C). Examination shows erythema and swelling of the entire ear and a small area of dehiscence containing pus along the posterior suture line. Which of the following is the most important step in management?
A ) Application of wet-to-dry dressings
B ) Completion of the amputation with sparing of cartilage in a remote subdermal pocket
C ) Intravenous antibiotic therapy
D ) Irrigation, debridement, and packing the wound open
E ) Oral antibiotic therapy
The correct response is Option D.
Auricular chondritis and perichondritis is a serious surgical infection requiring immediate surgical intervention as the primary course of treatment in traumatic cases. Culture swabs should also be obtained and will guide antibiotic therapy for associated cellulitis; however, broad spectrum coverage initially is appropriate. Chondritis complicating elective otoplasty is sometimes handled in a more stepwise approach, sometimes initiating intravenous antibiotics while removing a few sutures to allow drainage and/or insertion of a small irrigating catheter. Without a reasonable response in these cases, then standard open irrigation and debridement are done with removal of all sutures, and repeat otoplasty correction is deferred until several months after resolution of the infection.
Antibiotics alone, orally or intravenously, for localized suppurative chondritis are likely to be ineffective without surgical treatment. Likewise, topical dressings without formal opening of the suture line for wide exposure and drainage of the infected cartilage would also be ineffective.
Completing the amputation when the tissues still appear viable is overaggressive at this stage. If and when the majority of the tissue appears unable to sustain sufficient circulation to support its viability, then discarding precious tissue is justified. Salvaging the cartilage framework component in a remote subdermal pocket may be useful; however, the cartilage is infected in this scenario and would require caution, including thorough debridement and lavage with antibiotic solution and close monitoring of the bank.
A 25-year-old man has complete loss of the upper two-thirds of the right ear two years after sustaining a burn injury to the ear. On examination, the ear lobe and lower part of the conchal cartilage are viable and have adequate skin coverage; the ear canal is open. Scarred skin surrounds the ear remnant.
Which of the following is the most appropriate operative procedure for correction of this patient’s deformity?
(A) Creation of the upper ear with a rib cartilage framework and coverage with a local skin flap
(B) Creation of the upper ear with a rib cartilage framework and coverage with a pre-expanded local skin flap
(C) Creation of the upper ear with a rib cartilage framework and coverage with a temporoparietal fascial flap and a split-thickness skin graft
(D) Creation of the upper ear with a Silastic framework and coverage with a local skin flap
(E) Creation of the upper ear with a Silastic framework and coverage with a temporoparietal fascial flap and a split-thickness skin graft
The correct response is Option C.
The most appropriate surgical procedure for correction of this patient’s deformity is creation of the upper ear using a rib cartilage graft and coverage with a temporoparietal fascia flap and a split-thickness skin graft. These procedures will most likely result in a satisfactory outcome for this difficult reconstructive problem. The rib cartilage can be carved into an appropriate framework and covered with a thin temporoparietal fascia flap; a thin split-thickness skin graft can be used to create the intricate detail of the external ear. When successful, this reconstruction will be durable and long-lasting.
Local skin is the coverage material of choice in classic microtia reconstruction; however, when the ear remnant is surrounded by scarred skin, as in this patient with a burn injury, it will not stretch adequately to cover the framework and show detail. Skin expansion will fail because scarred skin expands poorly.
Silastic frameworks can give good early results but are not long-lasting. Because even the most minor trauma or wound problem can lead to total loss of the reconstruction, Silastic frameworks are not a good choice for reconstruction.
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.
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.
Microtia is an auricular deformity most commonly found in patients with which of the following syndromes?
A ) Apert
B ) Binder
C ) Crouzon
D ) Pfeiffer
E ) Treacher Collins
The correct response is Option E.
Treacher Collins syndrome is characterized by bilateral abnormalities of structures within the first and second branchial arches. Treacher Collins syndrome has anomalies in structures derived from the first branchial arch, groove, and pouch. It is considered to be autosomal dominant in its inheritance with variable expressivity. Features include a convex facial profile with a retrusive lower jaw and chin, down-slant of the palpebral fissures, lower eyelid colobomas, partial absence of eyelid cilia, absent or malformed external ears, hypoplasia of the malar bones, and variable cleft palate.
Binder syndrome is characterized by nasomaxillary hypoplasia. Apert, Crouzon, and Pfeiffer syndromes are all craniosynostotic syndromes that result in mid-facial hypoplasia and a concave facial profile of varying degrees. These syndromes do not typically present with microtia.
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.
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 healthy 7-year-old boy with anotia undergoes reconstruction of the right ear via implantation of a high-density porous polyethylene prosthesis. Compared with use of autologous cartilage, which of the following is the most likely result of this procedure?
(A) Higher incidence of contour deformities
(B) Higher incidence of extrusion
(C) Increased likelihood of malposition
(D) Lower incidence of infection
(E) More resorption of the implant over time
The correct response is Option B.
High density porous polyethylene (Medpor) is an alloplastic implant material that is nonresorbable and highly biocompatible. It has an intramaterial porosity with a pore size between 1 25 and 250 micrometers
which permits extensive fibrovascular ingrowth throughout the implant. Although limited bony ingrowth may occur in select clinical circumstances, the material should not be considered truly osteoconductive. This bony and fibrovascular ingrowth can make this type of material somewhat difficult to remove. Studies have shown less underlying bone resorption occurs with high €‘density polyethylene than with other implant materials. As an alloplastic material, it should not be placed in contaminated wound beds, because it can get easily infected, and should always be positioned in areas of adequate soft tissue cover to prevent extrusion. The incidence of extrusion is higher in microtia reconstruction and nasal dorsum augmentation for this reason.
A 24-year-old man undergoes total auricular reconstruction using a porous polyethylene implant covered with a temporoparietal fascia flap and a skin graft after sustaining burns to the face and ear. On follow-up examination one month later, there is a 1 * 1-cm area of necrosis of the flap; a small area of implant is exposed beneath the eschar.
Which of the following is the most appropriate next step in management?
(A) Initiation of frequent dressing changes and allowing the wound to heal secondarily
(B) Removal of the implant and allowing the wound to heal secondarily
(C) Removal of the implant and immediate replacement with a smaller porous polyethylene implant
(D) Removal of the implant and immediate replacement with a rib cartilage graft
(E) Removal of the implant and immediate replacement with a Silastic implant
The correct response is Option A.
Excellent results have been reported with the use of porous polyethylene implants covered with temporoparietal fascial flaps for ear reconstruction in patients with burns. In the past, Silastic implantation was associated with an unacceptably high complication rate, frequently resulting in removal of the implant. Adequate soft-tissue coverage of any type of alloplastic implant, whether porous polyethylene or Silastic, is essential.
Because porous polyethylene allows for ingrowth of tissue, small areas of implant exposure can be managed with frequent dressing changes and either allowing the wound to heal secondarily or covering the wound with a skin graft after granulation tissue has formed over the implant. Although removal is an option, the surgeon should wait for a minimum of six months before inserting another implant or a cartilage graft.
A 1-month-old healthy female presents to your office with left sided microtia. Which of the following is the least appropriate method for ear construction?
A) Osseointegrated implant
B) Porous polyethylene
C) Costal cartilage
D) Tissue engineered cartilage
The least appropriate method for ear construction is tissue engineered cartilage. Tissue engineered cartilage has not yet been translated to clinical use. Costal cartilage is the most common method of auricular construction, followed by porous polyethylene. Osseointegrated implants are more appropriate for older adults and for salvage following failed cartilage or porous polyethylene.
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 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 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 50-year-old man is brought to the emergency department 90 minutes after he sustained injuries in a motor vehicle collision. Physical examination shows a severe abrasion injury to the right ear with partial degloving of the superior helical rim extending into the concha. The skin over the upper third of the ear is missing at variable depths. Which of the following is the most appropriate initial step in management?
(A) Conservative debridement and topical wound care
(B) Debridement and coverage with a local flap
(C) Debridement and skin grafting
(D) Debridement, coverage with a temporoparietal fascia flap, and skin grafting
(E) Resection and primary wound closure
The correct response is Option A.
The patient described has a partial-thickness injury involving the upper third of the ear. It is often not clear initially if the perichondrium is viable in this situation. Although the patient may require coverage of the exposed cartilage with a flap, initial management is most often conservative. The most appropriate initial step is conservative debridement and topical wound care including dressing changes until the devitalized tissues demarcate. This management allows for a full assessment of the extent of the injury. It is important that the dressings prevent desiccation and infection of the exposed perichondrium.
Debridement followed by immediate skin grafting is not appropriate because skin graft take is often unreliable if the cartilage is exposed. Also, the extent of tissue injury caused by shearing and blunt trauma is difficult to assess initially because of the soiled and edematous tissues of the fresh trauma.
Debridement, coverage with a temporoparietal fascia flap, and skin grafting is effective in providing a bed for skin grafting but is not the most appropriate initial step in management.
Resection and closure of a defect of this size can be performed, often with an Antia €‘Buch flap after wedge resection with a pentagonal design. However, this procedure will reduce the size of the ear and, therefore, is not appropriate.
Six months after undergoing bilateral otoplasty for correction of prominent ears, a 27-year-old man has recurrent prominence of the upper half of the left ear. At follow-up examination one month after surgery, the ears appeared symmetric.
Which of the following is the most likely cause of this patient’s recurrent deformity?
(A) Disruption of the conchal-mastoid sutures
(B) Disruption of the sutures used to create the antihelical fold
(C) Inadequate excision of cartilage from the concha
(D) Inadequate excision of skin from the posterior ear
(E) Incorrect placement of the postoperative dressing
The correct response is Option B.
The most likely cause of this patient’s recurrent prominence of the upper half of the left ear is inadequate placement of sutures used in the creation of the antihelical fold. Lack of formation of the antihelical fold is one of the most common causes of prominent ears. Surgical creation of the fold can be accomplished with permanent sutures alone, cartilage incision or resection combined with sutures, or abrasion of the lateral ear cartilage with or without sutures. When used alone, sutures are usually very effective in the creation of the antihelical fold in children because their ear cartilage is soft and pliable. In adults, who have less pliable cartilage, sutures can be used alone to create a fold, but frequently other techniques must be performed to allow the cartilage to bend. When sutures are used alone, they must be permanent and precisely placed, or relapse can occur.
Excision of conchal cartilage, skin resection, placement of conchal-mastoid sutures, and placement of the postoperative dressing, while all vital aspects of otoplasty for prominent ears, are less likely to be involved in recurrence of the deformity than the inadequate creation of the antihelical fold, which is most commonly associated with recurrence of the deformity.
A 7-year-old girl has conchal valgus and underfolding of the antihelix. The cranioauricular angle is 45 degrees. Which of the following is most appropriate for correction of this patient’s deformity?
(A) Conchoscaphoid suturing
(B) Customized splinting
(C) Flag flap transfer
(D) Helical release with skin grafting
(E) Posterior scoring of the antihelical cartilage
The correct response is Option A.
Prominent ear deformities affect 5% of the general population and are characterized by conchal valgus with a cranioauricular angle greater than 40 degrees and underfolding of the antihelix. Conchal hypertrophy is a rare finding. Several options exist for management of prominent ears during childhood, including conchoscaphoid (MustardŽ) or conchomastoid suturing, anterior scoring of the cartilage at the antihelical fold, resection of the concha, and resection of postauricular skin.
Although a customized splint can be applied for management of minor deformities of the auricular cartilage, including prominent, lop, cup, and Stahl’s ears, it is only effective during the neonatal period unless the deformity is associated with hypoplasia.
Flag flap transfer is useful for correction of a lop ear deformity.
Helical release with split-thickness skin grafting is appropriate management for cryptotia. In this technique, the superior portion of the auricle is buried beneath the skin.
As mentioned above, anterior, not posterior, scoring of the antihelical cartilage is a recognized technique for management of prominent ears.
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 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.
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.
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.
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) Following completion of the ear reconstruction
B) During elevation of the carved-rib framework
C) During placement of the carved-rib framework
D) During rotation of the earlobe
E) Prior to the ear reconstruction
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.
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.
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 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.
Which of the following structures provides sensation to the upper cranial surface of the ear?
(A) Anterior branch of the great auricular nerve
(B) Arnold’s branch of the vagus nerve
(C) Auriculotemporal nerve
(D) Lesser occipital nerve
(E) Posterior branch of the great auricular nerve
The correct response is Option D.
Branches of the lesser occipital nerve supply sensation to the upper cranial surface of the ear and skin of the anterior and superior surfaces of the external auditory canal. The anterior branch of the great auricular nerve (which forms from branches of cervical nerve roots C2-3 within the cervical plexus) supplies sensation to the lower half of the lateral surface of the ear, while the posterior branch innervates the lower portion of the cranial surface of the ear. The auriculotemporal nerve provides sensation to the anterosuperior surface of the external ear. Arnold’s nerve, which is a branch of the vagus nerve, supplies sensation to the skin of the concha and posterior ear canal.
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-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.
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 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.
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 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 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 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.
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.
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 45-year-old male presents with a 1.5 cm defect in the upper third of the helix following excision of a basal cell carcinoma. The defect involves the helical rim but spares the scapha. The patient is concerned about maintaining a natural ear contour and is eager to avoid a standing deformity. Which of the following is the most appropriate reconstructive option for this defect?:
A. Scapha wedge excision with primary closure
B. Bilobe flap reconstruction
C. Full-thickness skin grafting
D. Composite graft from the contralateral ear
E. Chondrocutaneous advancement flap (Antia-Buch flap)
Correct Answer:
E. Chondrocutaneous advancement flap (Antia-Buch flap)
Rationale:
The chondrocutaneous advancement flap, or Antia-Buch flap, is extremely helpful in reconstruction of small- to medium-sized upper third helical defects. While such a reconstruction may make a slightly smaller ear, it is usually well tolerated. A postoperative photograph of the patient in this scenario is shown. Scapha wedge excision with primary closure and full-thickness skin grafting would leave an unacceptable standing deformity. Bilobe flaps are of limited utility in the upper third of the ear. Composite grafts may be useful for smaller helical defects, especially in younger patients; however, in defects of this size, the success rate is poor.
Reference(s):
1. Thorne CH. Ear reconstruction. In: Thorne CH, Chung KC, Gosain AK, et al., eds. Grabb and Smith’s Plastic Surgery. 7th ed. Lippincott Williams & Wilkins; 2014:283-294.
2. Tay S, Nikkhah D, Teo TC. The Antia-Buch flap revisited. Clin Otolaryngol. 2017;42(4):951-953. doi:10.1111/coa.12489
A 7-year-old boy is brought to the clinic by his parents due to concerns about the prominence of his ears. On examination, the child has underdeveloped antihelical folds bilaterally, with no significant conchal hypertrophy or lobule malposition. The parents are interested in surgical correction and want to know the most appropriate technique for addressing the underdeveloped antihelical fold without compromising the integrity of the cartilage. Which of the following techniques would be most suitable for this patient?
A. Furnas technique
B. Spira technique
C. Stenström technique
D. Mustardé technique
E. Siegert technique
The correct answer is option D.
The Mustardé suture technique is a technique that recreates the antihelical fold with mattress sutures between the scaphoid and conchal fossa and without scoring the cartilage. One can consider the prominent ear as being comprised of varying contributions from three sources: underdeveloped antihelical fold, conchal hypertrophy, and lobule malposition. While scoring techniques were popularized in the 1960s and 1970s, more recent concerns about the integrity of the cartilage and risk for infection have led to surgeons favoring suture techniques. Suture techniques, with or without resection of the lobule or conchal bowl, can address all three aspects of the prominent ear. The Furnas technique uses sutures to fix the conchal bowl to the mastoid periosteum to address a hypertrophic conchal bowl. The Spira technique combines a wedge excision of the lobule with a deep dermal-to-periosteum suture to reposition the lobule, and it also uses a conchamastoid suture to address a hypertrophic conchal bowl. The Stenström technique is not a suture technique; it relies on abrasion of the anterior surface of the antihelix, which induces bending of the cartilage away from the disruption. The Siegert technique is used for lobuloplasty.
Reference(s)
Ordon A, Wolfswinkel E, Shauly O, Gould DJ. Aesthetic otoplasty: principles, techniques and an integrated approach to patient-centric outcomes. Aesthetic Plast Surg. 2019;43(5):1214-1225. doi:10.1007/s00266-019-01441-2
Choi JY, Jung SC, Sykes JM. Clinical outcome and patients’ satisfaction study after otoplasty using hybrid techniques in adult patients. J Craniofac Surg. 2017;28(5):1278-1281. doi:10.1097/SCS.0000000000003744
Siegert R. Correction of the lobule. Facial Plast Surg. 2004;
