Microtia: epidemiology and genetics

Characterising the speech phenotype in individuals with craniofacial microsomia: a scoping review protocol

INTRODUCTION

Asymmetric mandibular hypoplasia, microtia, tongue and laryngeal anomalies, and soft palate and facial nerve dysfunction are clinical features observed in children with craniofacial microsomia (CFM). Despite involvement of all these structures in hearing and speech, there is limited evidence reporting speech outcomes in this population. Systematic reviews of clinical and surgical interventions related to CFM have been published, but no methodological review of speech outcomes exists. This scoping review will summarise what is known about speech production in individuals with CFM as well as illustrate gaps in the existing body of literature that will guide future research.

METHODS/ANALYSIS

This review will follow the methodological framework for scoping reviews first reported by Arksey & O'Malley and revised by Levac and others. Databases searched will include Ovid MEDLINE, EMBASE, CINAHL, PsycINFO and grey literature. Articles reporting any parameter of speech production in individuals with CFM will be considered for inclusion. Articles published in a language other than English will be excluded. Articles will be screened in three stages: (1) title review, (2) abstract review and (3) full text review. Ten per cent of articles will be rescreened by a second reviewer. Reference lists will be hand reviewed to identify additional relevant articles. Data charting will capture article metadata, study population and design, CFM diagnostic criteria, speech outcome measurement and key findings. The Preferred Reporting Systems for Systematic Reviews and Meta-Analyses Protocols-Extension for Scoping Reviews checklist will guide reporting of results. Descriptive analysis and data visualisation strategies will be used.

ETHICS AND DISSEMINATION

Institutional review board approval is not required for a scoping review, as it does not directly involve human subjects. Results will be disseminated through peer-reviewed publication as well as conference presentation.

Search for a genetic cause in children with unilateral isolated microtia and congenital aural atresia

PURPOSE

Microtia describes a spectrum of auricular malformations ranging from mild dysplasia to anotia. A vast majority of microtia patients demonstrate congenital aural atresia (CAA). Isolated microtia has a right ear predominance (58-61%) and is more common in the male sex. Isolated microtia is a multifactorial condition involving genetic and environmental causes. The aim of this study is to describe the phenotype of children with unilateral isolated microtia and CAA, and to search for a common genetic cause trough DNA analysis.

METHODS

Phenotyping included a complete clinical examination. Description on the degree of auricular malformation (Weerda classification-Weerda 1988), assessment for hemifacial microsomia and age-appropriate audiometric testing were documented. Computerized tomography of the temporal bone with 3-D rendering provided a histopathological classification (HEAR classification-Declau et al. 1999). Genetic testing was carried out by single nucleotide polymorphism (SNP) microarray.

RESULTS

Complete data are available for 44 children (50% was younger than 33 days at presentation; 59.1% boys; 72.7% right ear). Type III microtia was present in 28 patients. Type 2b CAA existed in 32 patients. All patients had a normal hearing at the non-affected side. Genome wide deletion duplication analysis using microarray did not reveal any pathological copy number variant (CNV) that could explain the phenotype.

CONCLUSIONS

Type III microtia (peanut-shell type) in combination with a type 2b CAA was the most common phenotype, present in 23 of 44 (52.3%) patients with isolated unilateral microtia. No abnormalities could be found by copy number variant (CNV) analysis. Whole exome sequencing in a larger sample with a similar phenotype may represent a future diagnostic approach.

3D printed bionic ear and microtia-anotia: Medical and forensic implications

Advances in science and technology result in continuous upgrading of the medical and clinical fields. These upgrades have been beneficial to many patients suffering from congenital and developmental diseases causing compromised functionality as well as the structural integrity of the affected organs. One such congenital anomaly is the microtia-anotia spectrum, which results in deformities of the external ear, affecting the hearing capability of an individual. The collaboration and integration of electronics in human biology are exemplified by the development of a 3D printed cyborg bionic ear from the patient's own cells, which is implanted to ameliorate microtia and improve the patient's hearing capacity. Since the late nineteenth century, forensic scientists have explored the external ear, establishing the significance of ear biometrics in the identification process. Similarly, ear prints can also play an important role in identifying the felon of a crime. In this regard, we examine the structure and functionality of implanted ears. This communication is an attempt to enlighten investigators on the forensic importance and limitations of the use of bionic ears for identification.

Angular and Linear Accelerations, Ear, and the Skeletal Muscle

The ear serves two vital functions of hearing and maintaining balance. It achieves these roles within three major compartments: the outer, the middle, and the inner ear. Embryological development of the ear and its associated structures have been studied in some animal models. Yet, the role of skeletal muscle in ear development and its related structures is largely unknown. Research suggests the outer ear and parts of the inner ear may require skeletal muscle for normal embryogenesis. Here, we describe the role of skeletal muscle in the development of the ear and its associated structures. Moreover, we report the possible consequences of defect in the skeletal muscle of the ear and the clinical correlates of such consequences.

The Alberta Congenital Anomalies Surveillance System: a 40-year review with prevalence and trends for selected congenital anomalies, 1997-2019

INTRODUCTION

Current published long-term provincial or territorial congenital anomaly data are lacking for Canada. We report on prevalence (per 1000 total births) and trends in 1997-2019, in Alberta, Canada, for selected congenital anomalies. Associated risk factors are also discussed.

METHODS

We used data from the Alberta Congenital Anomalies Surveillance System (ACASS) to calculate the prevalence and perform chi-square linear trend analyses.

RESULTS

From 1997 to 2019, the overall prevalence of neural tube defects was stable, at 0.74 per 1000 total births. The same was true for spina bifida (0.38), orofacial clefts (1.99), more severe CHDs (transposition of the great arteries, 0.38; tetralogy of Fallot, 0.33; and hypoplastic left heart syndrome, 0.32); and gastroschisis (0.38). Anencephaly, cleft palate and anorectal malformation significantly decreased with a prevalence of 0.23, 0.75 and 0.54 per 1000 total births, respectively. Significantly increasing trends were reported for anotia/microtia (0.24), limb reduction anomalies (0.73), omphalocele (0.36) and Down syndrome (2.21) and for hypospadias and undescended testes (4.68 and 5.29, respectively, per 1000 male births).

CONCLUSION

Congenital anomalies are an important public health concern with significant social and societal costs. Surveillance data gathered by ACASS for over 40 years can be used for planning and policy decisions and the evaluation of prevention strategies. Contributing genetic and environmental factors are discussed as is the need for continued surveillance and research.

Factors associated with nonsyndromic anotia and microtia, Texas, 1999-2014

BACKGROUND

Few risk factors have been identified for nonsyndromic anotia/microtia (A/M).

METHODS

We obtained data on cases and a reference population of all livebirths in Texas for 1999-2014 from the Texas Birth Defects Registry (TBDR) and Texas vital records. We estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) for A/M (any, isolated, nonisolated, unilateral, and bilateral) using Poisson regression. We evaluated trends in prevalence rates using Joinpoint regression.

RESULTS

We identified 1,322 cases, of whom 982 (74.3%) had isolated and 1,175 (88.9%) had unilateral A/M. Prevalence was increased among males (PR: 1.3, 95% CI: 1.2-1.4), offspring of women with less than high school education (PR: 1.3, 95% CI: 1.1-1.5), diabetes (PR: 2.0, 95% CI: 1.6-2.4), or age 30-39 versus 20-29 years (PR: 1.2, 95% CI: 1.0-1.3). The prevalence was decreased among offspring of non-Hispanic Black versus White women (PR: 0.6, 95% CI: 0.4-0.8) but increased among offspring of Hispanic women (PR: 2.9, 95% CI: 2.5-3.4) and non-Hispanic women of other races (PR: 1.7, 95% CI: 1.3-2.3). We observed similar results among cases with isolated and unilateral A/M. Sex disparities were not evident for nonisolated or bilateral phenotypes, nor did birth prevalence differ between offspring of non-Hispanic Black and non-Hispanic White women. Maternal diabetes was more strongly associated with nonisolated (PR: 4.5, 95% CI: 3.2-6.4) and bilateral A/M (PR: 5.0, 95% CI: 3.3-7.7). Crude prevalence rates increased throughout the study period (annual percent change: 1.82).

CONCLUSION

We identified differences in the prevalence of nonsyndromic A/M by maternal race/ethnicity, education, and age, which may be indicators of unidentified social/environmental risk factors.

Changes of Age-related Auricular Cartilage Plasticity and Biomechanical Property in a Rabbit Model

OBJECTIVES

Ear molding is an emerging technique that can correct auricular deformities. Treatment initiation time is the most important prognostic determinant of ear molding. Here, we aimed to examine why auricular cartilage plasticity appeared to diminish with age. Thus, we characterized age-related changes in the biomechanical, biochemical, and morphological properties of auricular cartilage.

METHODS

New Zealand rabbits were used as the experimental animal. We examined immature [postnatal 0 day (P0), 5 days (P5), 15 days (P15)], young [2 months (2M)], and mature [6 months (6M)] rabbits. Rabbits' ears were splinted and folded using adhesive fixation strips. Folding duration ranged from 1 day to 5 days to 10 days. Photographs were taken to calculate the retained fold angle. Cartilage morphology and extracellular matrix (ECM) content were examined histologically (using hematoxylin-eosin, Safranin O, elastic Van Gieson, and Masson's trichrome). Water content, DNA content, and cell density were also analyzed. Biomechanical properties were measured using a Nano indenter.

RESULTS

Immature ears had smaller angles after strip removal, and the angled deformation lasted a longer time. Cartilage matrix compositions, including glycosaminoglycan (GAG), elastin fiber, and collagen, increased over development. The water content, DNA content, and cell density decreased with age. Young's modulus was significantly higher in mature cartilage.

CONCLUSIONS

Here, we successfully established an animal model of ear molding and demonstrated that immature cartilage was associated with better plasticity. We also found that the cartilage's biomechanical property increased with the accumulation of ECM. The biomechanical change could underlie age-related shape plasticity.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:88-94, 2023.

Integrated microtia and aural atresia management

Objectives

To present recommendations for the coordinated evaluation and management of the hearing and reconstructive needs of patients with microtia and aural atresia.

Methods

A national working group of 9 experts on microtia and atresia evaluated a working document on the evaluation and treatment of patients. Treatment options for auricular reconstruction and hearing habilitation were reviewed and integrated into a coordinated care timeline.

Results

Recommendations were created for children with microtia and atresia, including diagnostic considerations, surgical and non-surgical options for hearing management and auricular reconstruction, and the treatment timeline for each option. These recommendations are based on the collective opinion of the group and are intended for otolaryngologists, audiologists, plastic surgeons, anaplastologists, and any provider caring for a patient with microtia and ear canal atresia. Close communication between atresia/hearing reconstruction surgeon and microtia repair surgeon is strongly recommended.

In vitro elastic cartilage reconstruction using human auricular perichondrial chondroprogenitor cell-derived micro 3D spheroids

Morphologically stable scaffold-free elastic cartilage tissue is crucial for treating external ear abnormalities. However, establishing adequate mechanical strength is challenging, owing to the difficulty of achieving chondrogenic differentiation in vitro; thus, cartilage reconstruction is a complex task. Auricular perichondrial chondroprogenitor cells exhibit high proliferation potential and can be obtained with minimal invasion. Therefore, these cells are an ideal resource for elastic cartilage reconstruction. In this study, we aimed to develop a novel in vitro scaffold-free method for elastic cartilage reconstruction, using human auricular perichondrial chondroprogenitor cells. Inducing chondrogenesis by using microscopic spheroids similar to auricular hillocks significantly increased the chondrogenic potential. The size and elasticity of the tissue were maintained after craniofacial transplantation in immunodeficient mice, suggesting that the reconstructed tissue was morphologically stable. Our novel tissue reconstruction method may facilitate the development of future treatments for external ear abnormalities.

Development of an interdisciplinary microtia-atresia care model: A single-center 20-year experience

Objectives

Microtia and aural atresia are congenital ear anomalies with a wide-ranging spectrum of phenotypes and varied functional and psychosocial consequences for patients. This study seeks to analyze the management of microtia-atresia patients at our center over a 20-year period and to propose recommendations for advancing microtia-atresia care at a national level.

Methods

We performed a retrospective analysis of data from patients presenting to the Massachusetts Eye and Ear (Boston, MA) for initial otolaryngology consultation for congenital microtia and/or aural atresia between 1999 and 2018.

Results

Over the 20-year study period, 229 patients presented to our microtia-atresia center at a median age of 7 years. The severity of microtia was most commonly classified as grade III (n = 87, 38%), 61% (n = 140) of patients had complete atresia, the median Jahrsdoerfer grading scale score was 6 (range 0-10), and 81 patients (35%) underwent surgery for microtia repair. For hearing rehabilitation, 30 patients (64%) underwent bone conduction device implantation and 17 patients (36%) underwent atresiaplasty. The implementation of an interdisciplinary, longitudinal care model resulted in an increase in patient (r = 0.819, p < .001) and surgical volume (microtia surgeries, r = 0.521, p = .019; otologic surgeries, r = 0.767, p < .001) at our center over time.

Conclusion

An interdisciplinary team approach to microtia-atresia patient care may result in increased patient volume, which could improve aesthetic and hearing outcomes over time by concentrating care and surgical expertise. Future work should aim to establish standardized clinical consensus recommendations to guide the creation of high-quality microtia-atresia care programs.

Level of Evidence

4.

3D-printed high-density polyethylene scaffolds with bioactive and antibacterial layer-by-layer modification for auricle reconstruction

High-density polyethylene (HDPE) is a promising material for the development of scaffold implants for auricle reconstruction. However, preparing a personalized HDPE auricle implant with favorable bioactive and antibacterial functions to promote skin tissue ingrowth is challenging. Herein, we present 3D-printed HDPE auricle scaffolds with satisfactory pore size and connectivity. The layer-by-layer (LBL) approach was applied to achieve the improved bioactive and antibacterial properties of these 3D printed scaffolds. The HDPE auricle scaffolds were fabricated using an extrusion 3D printing approach, and the individualized macrostructure and porous microstructure were both adjusted by the 3D printing parameters. The polydopamine (pDA) coating method was used to construct a multilayer ε-polylysine (EPL) and fibrin (FIB) modification on the surface of the 3D HDPE scaffold via the LBL self-assembly approach, which provides the bioactive and antibacterial properties. The results of the in vivo experiments using an animal model showed that LBL-coated HDPE auricular scaffolds were able to significantly enhance skin tissue ingrowth and ameliorate the inflammatory response caused by local stress. The results of this study suggest that the combination of the 3D printing technique and surface modification provides a promising strategy for developing personalized implants with biofunctional coatings, which show great potential as a scaffold implant for auricle reconstruction applications.

The Enigmatic Etiology of Oculo-Auriculo-Vertebral Spectrum (OAVS): An Exploratory Gene Variant Interaction Approach in Candidate Genes

The clinical diagnosis of oculo-auriculo-vertebral spectrum (OAVS) is established when microtia is present in association with hemifacial hypoplasia (HH) and/or ocular, vertebral, and/or renal malformations. Genetic and non-genetic factors have been associated with microtia/OAVS. Although the etiology remains unknown in most patients, some cases may have an autosomal dominant, autosomal recessive, or multifactorial inheritance. Among the possible genetic factors, gene−gene interactions may play important roles in the etiology of complex diseases, but the literature lacks related reports in OAVS patients. Therefore, we performed a gene−variant interaction analysis within five microtia/OAVS candidate genes (HOXA2, TCOF1, SALL1, EYA1 and TBX1) in 49 unrelated OAVS Mexican patients (25 familial and 24 sporadic cases). A statistically significant intergenic interaction (p-value < 0.001) was identified between variants p.(Pro1099Arg) TCOF1 (rs1136103) and p.(Leu858=) SALL1 (rs1965024). This intergenic interaction may suggest that the products of these genes could participate in pathways related to craniofacial alterations, such as the retinoic acid (RA) pathway. The absence of clearly pathogenic variants in any of the analyzed genes does not support a monogenic etiology for microtia/OAVS involving these genes in our patients. Our findings could suggest that in addition to high-throughput genomic approaches, future gene−gene interaction analyses could contribute to improving our understanding of the etiology of microtia/OAVS.

Auricular reconstruction via 3D bioprinting strategies: An update

Image 1.

Experience of the 'Ear Glove' in children with microtia

INTRODUCTION

Microtia is a congenital condition which can be found in isolation or as part of a syndrome. The key factors to consider when treating a child with microtia are hearing, speech and language development, cosmesis, and the psychological impact on the patient as well as the family. As children age and become more self-aware, the anxiety about transition from primary to secondary school can often be a trigger for carers and child to want a cosmetic solution at a younger age. Any form of cosmetic surgery ideally requires a child with an understanding of what is involved, as well as sufficient growth and anatomy to provide soft tissue resources for surgery. An additional issue for some children with microtia is the concern about adding to their already 'different' appearance by using a bone conduction solution/hearing implant. We present the outcomes of a novel non-surgical prosthesis 'Ear Glove' offered to pediatric patients with microtia.

METHODS

Children with microtia are seen in the multidisciplinary outpatient clinic and reviewed by the team which includes an Otolaryngologist, Audiologist, Plastic surgeon and Maxillofacial prosthetist. When discussing cosmesis, all reconstruction options are explored. These include a 'no treatment' option, both adhesive and implant-retained prosthetic ears, and autologous and/or MedporⓇ ear reconstruction (age appropriate). All children who chose to undergo the adhesive non-surgical prosthetic option 'Ear Glove' for microtia were identified by our prosthetic department (n = 9), and their outcomes reviewed.

RESULTS

Nine children have been fitted with the 'Ear Glove', with all 9 achieving excellent symmetry and aesthetics. Seven patients continue to successfully use their prostheses either daily or for special occasions. Two of these patients also decided to undergo bone anchored hearing implant surgery. One patient opted to change his treatment plans and chose 'no treatment' after feeling he preferred his 'little' ears. Finally, one patient reported the daily use of adhesive to be a deterrent. No skin reactions to the adhesive were reported in any patient.

CONCLUSIONS

The 'Ear Glove' is increasingly being used by microtia patients in our department to good effect. This non-surgical alternative allows young patients to appreciate the cosmetic results of the surgical options before committing to an invasive procedure.

Characteristics of sound localization in children with unilateral microtia and atresia and predictors of localization improvement when using a bone conduction device

This study aimed to determine the characteristics of sound localization in children with unilateral microtia and atresia (UMA) and the influence of a non-surgical bone conduction device (BCD). Hearing benefits were evaluated by the word recognition score (WRS), speech reception threshold, the international outcome inventory for hearing aids (IOI-HA), and the Speech, Spatial, and Qualities of Hearing Test for Parent (SSQ-P). Sound localization was measured using broadband noise stimuli randomly played from seven loudspeakers at different stimulus levels [65, 70, and 75 dB sound pressure levels (SPLs)]. The average unaided WRS and speech-to-noise ratio (SNR) for UMA patients was 18.27 ± 14.63 % and -5 ± 1.18 dB SPL, and the average aided WRS and SNR conspicuously changed to 85.45 ± 7.38 % and -7.73 ± 1.42 dB SPL, respectively. The mean IOI-HA score was 4.57 ± 0.73. Compared to the unaided condition, the mean SSQ-P score in each domain improved from 7.08 ± 2.5, 4.86 ± 2.27, and 6.59 ± 1.4 to 8.72 ± 0.95, 7.61 ± 1.52, and 8.55 ± 1.09, respectively. In the sound localization test, some children with UMA were able to detect sound sources quite well and the sound localization abilities did not deteriorate with the non-surgical BCD. Our study concludes that for children with UMA, the non-surgical BCD provided a definite benefit on speech recognition and high satisfaction without deteriorating their sound localization abilities. It is an efficient and safe solution for the early hearing intervention of these patients.

Surgical Microtia Reconstruction in Hemifacial Microsomia Patients: Current State and Future Directions

Background:

Hemifacial microsomia (HFM) is one of the most common congenital craniofacial disorders. Among many other features, microtia is present in the large majority of these patients. However, mainly due to the unilateral hypoplastic anatomy, microtia reconstruction among this patient population remains a reconstructive challenge for plastic surgeons. Given that no clear standards exist, an evidence-based synthesis of the literature was devised.

Methods:

A systematic search of Pubmed, Medline, and Embase was carried out, in accordance with the PRISMA guidelines. Studies discussing surgical microtia reconstruction for HFM patients were retained. Qualitative data regarding study design, challenges addressed, specific recommendations, and their respective strengths/limitations were extracted from each. Retrieved recommendations were consolidated and assigned a level of evidence grade.

Results:

Although only 11 studies were included in this review, these provided 22 main recommendations regarding the eight HFM-specific challenges identified, which were of either grade C (n = 5) or D (n = 17). Included studies addressed construct location (n = 7), the low hairline (n = 6), soft tissue construct coverage (n = 6), earlobe reconstruction (n = 6), construct projection (n = 5), anomalies of the relevant neurovascular systems (n = 2), retroauricular construct coverage (n = 2), and sizing of the construct (n = 2).

Conclusions:

Given the many persisting reconstructive challenges regarding surgical microtia reconstruction for HFM patients, the authors present a comprehensive and evidence-based consolidation of recommendations specific to these challenges. The authors hope this systematic review can appropriately guide plastic surgeons and will ultimately improve care for this patient population.

Evaluation and Nonsurgical Treatment of Neonatal Ear Anomalies: A Case Report

BACKGROUND

Inspection and evaluation of the neonate's ears are important parts of the neonatal examination. Neonates display a wide variety of ear size and configuration. In many cases, ear molding techniques obviate the need for future surgical correction. This article provides a review of the fetal ear development and describes common physical examination findings of the newborn's external ear. A case report reviews a successful nonsurgical treatment of a minor ear deformity.

CLINICAL FINDINGS

Newborn infant with near absent to very thin bilateral helical rims and otherwise normal bilateral ear shape and structures.

PRIMARY DIAGNOSIS

Bilateral Stahl's ear deformity.

INTERVENTIONS

The EarBuddies product was applied to bilateral ears in an outpatient pediatric plastic surgery clinic. This product remained in place for 8 weeks.

OUTCOMES

The family was pleased with the overall progress and shape of their child's ears. At 18 months of age, the family has no desire to pursue surgical correction of their child's ears.

PRACTICE RECOMMENDATIONS

Assessment of the newborn's external ear is part of a routine admission examination. Careful attention to abnormal or unusual findings allows for prompt evaluation and nonsurgical intervention.

Epidemiological Study of Neonatal Congenital Microtia in Shandong Province, China, 2011-2020

OBJECTIVE

Congenital microtia is a common congenital disease in newborns. The specific cause of congenital microtia is currently unknown. The main objective of this study is to elucidate the epidemiological characteristics of congenital microtia and explore the possible etiology of congenital microtia.

METHODS

Part of the newborn data from 2011 to 2020 in Shandong Province Birth Defects Monitoring Hospitals were randomly selected. The software GraphPad Prism 9 was used to analyze the data and draw figures.

RESULTS

A total of 4247 infants were diagnosed with congenital malformation among 149,525 newborns randomly selected from the Shandong Province Birth Defects Monitoring Hospitals. Among them, a total of 115 infants were diagnosed with congenital microtia. The mean incidence of microtia during 10 years was 76.14±21.93 per 100,000 infants. The mean incidence of microtia in infants with congenital malformation was 2.67±0.75%. The average incidence of male and female infants with microtia during 10 years were 86.93±23.22 and 64.18±32.71 per 100,000 infants, respectively. In terms of maternal age, the older the mother, the higher the incidence of microtia. In terms of the place of residence, rural infants have a higher incidence of microtia than urban infants.

CONCLUSIONS

The average incidence of microtia was 76.14±21.93 per 100,000 infants in Shandong Province, China, 2011-2020. The female-to-male incidence ratio was 1.45:1. The authors recommend that women choose to give birth at the age of 25 to 29. They hope that the government will take measures to improve the medical and health conditions in rural areas and improve parenting knowledge in rural areas. This can effectively reduce the prevalence of microtia in infants.

[Genetic characteristics of microtia-associated syndromes in neonates]

Microtia is the second most common maxillofacial birth defect in neonates and has an prevalence rate of 3.06/10 000 in China, and 20%-60% of microtia cases is associated with a certain type of syndrome. This article elaborates on the clinical phenotypes and genetic characteristics of three microtia-associated syndromes (MASs) with high prevalence, high incidence rate of ear deformity, and definite genetic etiology, i.e., oculo-auriculo-vertebral spectrum, branchio-oto-renal spectrum disorder, and Treacher-Collins syndrome, and summarizes another three common MASs, so as to provide a reference for the genetic diagnosis of neonatal MAS.

Key Genes Identified in Nonsyndromic Microtia by the Analysis of Transcriptomics and Proteomics

As one of the common birth defects worldwide, nonsyndromic microtia is a complex disease that results from interactions between environmental and genetic factors. However, the underlying causes of nonsyndromic microtia are currently not well understood. The present study determined transcriptomic and proteomic profiles of auricular cartilage tissues in 10 patients with third-degree nonsyndromic microtia and five control subjects by RNA microarray and tandem mass tag-based quantitative proteomics technology. Relative mRNA and protein abundances were compared and evaluated for their function and putative involvement in nonsyndromic microtia. A total of 3971 differentially expressed genes and 256 differentially expressed proteins were identified. Bioinformatics analysis demonstrated that some of these genes and proteins showed potential associations with nonsyndromic microtia. Thirteen proteins with the same trend at the mRNA level obtained by the integrated analysis were validated by parallel reaction monitoring analysis. Several key genes, namely, LAMB2, COMP, APOA2, APOC2, APOC3, and A2M, were found to be dysregulated, which could contribute to nonsyndromic microtia. The present study is the first report on the transcriptomic and proteomic integrated analysis of nonsyndromic microtia using the same auricular cartilage sample. Additional studies are required to clarify the roles of potential key genes in nonsyndromic microtia.

Contemporary management of microtia

Microtia techniques have evolved to improve aesthetic outcomes, reduce donor site morbidities, and reduce complications. Patients with microtia commonly have aural atresia associated with conductive hearing loss. We present the evolution of our technique for microtia reconstruction and considerations for hearing management in these patients. Keywords: Microtia, aural atresia, autologous rib reconstruction, contemporary management.

Cartilage tissue engineering by extrusion bioprinting utilizing porous hyaluronic acid microgel bioinks

3D bioprinting offers an excellent opportunity to provide tissue-engineered cartilage to microtia patients. However, hydrogel-based bioinks are hindered by their dense and cell-restrictive environment, impairing tissue development and ultimately leading to mechanical failure of large scaffoldsin vivo. Granular hydrogels, made of annealed microgels, offer a superior alternative to conventional bioinks, with their improved porosity and modularity. We have evaluated the ability of enzymatically crosslinked hyaluronic acid (HA) microgel bioinks to form mature cartilagein vivo. Microgel bioinks were formed by mechanically sizing bulk HA-tyramine hydrogels through meshes with aperture diameters of 40, 100 or 500µm. Annealing of the microgels was achieved by crosslinking residual tyramines. Secondary crosslinked scaffolds were stable in solution and showed tunable porosity from 9% to 21%. Bioinks showed excellent rheological properties and were used to print different objects. Printing precision was found to be directly correlated to microgel size. As a proof of concept, freeform reversible embedding of suspended hydrogels printing with gelation triggered directly in the bath was performed to demonstrate the versatility of the method. The granular hydrogels support the homogeneous development of mature cartilage-like tissuesin vitrowith mechanical stiffening up to 200 kPa after 63 d. After 6 weeks ofin vivoimplantation, small-diameter microgels formed stable constructs with low immunogenicity and continuous tissue maturation. Conversely, increasing the microgel size resulted in increased inflammatory response, with limited stabilityin vivo. This study reports the development of new microgel bioinks for cartilage tissue biofabrication and offers insights into the foreign body reaction towards porous scaffolds implantation.

Predicting the Risk of Microtia From Prenatal Factors: A Hospital-Based Case-Control Study

Background

Although a wide range of risk factors for microtia were identified, the limitation of these studies, however, is that risk factors were not estimated in comparison with one another or from different domains. Our study aimed to uncover which factors should be prioritized for the prevention and intervention of non-syndromic microtia via tranditonal and meachine-learning statistical methods.

Methods

293 pairs of 1:1 matched non-syndromic microtia cases and controls who visited Shanghai Ninth People's Hospital were enrolled in the current study during 2017-2019. Thirty-nine risk factors across four domains were measured (i.e., parental sociodemographic characteristics, maternal pregnancy history, parental health conditions and lifestyles, and parental environmental and occupational exposures). Lasso regression model and multivariate conditional logistic regression model were performed to identify the leading predictors of microtia across the four domains. The area under the curve (AUC) was used to calculate the predictive probabilities.

Results

Eight predictors were identified by the lasso regression, including abnormal pregnancy history, genital system infection, teratogenic drugs usage, folic acid supplementation, paternal chronic conditions history, parental exposure to indoor decoration, paternal occupational exposure to noise and maternal acute respiratory infection. The additional predictors identified by the multivariate conditional logistic regression model were maternal age and maternal occupational exposure to heavy metal. Predictors selected from the conditional logistic regression and lasso regression both yielded AUCs (95% CIs) of 0.83 (0.79-0.86).

Conclusion

The findings from this study suggest some factors across multiple domains are key drivers of non-syndromic microtia regardless of the applied statistical methods. These factors could be used to generate hypotheses for further observational and clinical studies on microtia and guide the prevention and intervention strategies for microtia.

Ipsilateral hemifacial microsomia with dextrocardia and pulmonary hypoplasia: A case report

BACKGROUND

Hemifacial microsomia (HFM) is a rare congenital malformation characterized by a combination of various anomalies, including the face, ears, eyes, and vertebrae. Prenatal diagnosis for HFM is possible, and quite accurate ultrasound can detect obvious defects. The etiology is still unknown, although some hypotheses have been proposed, including gene mutation, chromosome anomaly, and environmental risk factors. However, there are few reports of pulmonary hypoplasia and dextrocardia in HFM.

CASE SUMMARY

A 2-year-old boy presented to the ear reconstruction department of our hospital complaining of deviation of the face to the right side and auricular anomaly. Physical examination revealed facial asymmetry, preauricular skin tags, and concha-type microtia with stricture of the external auditory canal on the right side. Head magnetic resonance imaging showed bilateral semicircular canal dysplasia and bilateral internal auditory canals stenosis. Audiometric examination showed bilateral severe sensorineural hearing loss. Chest radiography and computed tomography showed dextrocardia and right pulmonary hypoplasia.

CONCLUSION

This case presented a rare finding and an unusual association of 3 malformations, ipsilateral HFM, pulmonary agenesis, and dextrocardia.

Pearl Syndrome With an Unusual Association of Spina Bifida and Congenital Cholesteatoma

We report a case of a one-day-old female with congenital facial nerve palsy, bilateral microtia, congenital heart disease, spina bifida, and congenital cholesteatoma. The newborn was brought by the mother with complaints of abnormally looking ear and a facial droop toward the left side, following which a two-dimensional echocardiography was done showing the atrial septal defect and ventricular septal defect. Computed tomography of the temporal bone showed the presence of congenital cholesteatoma in the left ear. MRI of the lumbosacral spine was suggestive of spina bifida occulta. Brainstem evoked response audiometry was suggestive of sensorineural hearing loss. Such a combination of symptoms is very rare, and therefore this case is being reported.

Ear Abnormalities Among Children with Fetal Alcohol Spectrum Disorder: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and conduct meta-analysis on studies that report the type and prevalence of functional and structural ear abnormalities among children with prenatal alcohol exposure and/or fetal alcohol spectrum disorder (FASD).

STUDY DESIGN

MEDLINE, PubMed, Embase, Web of Science, PsycINFO, ERIC, CINAHL, and Maternity and Infant Care were searched from 1806 through March 2021. Reference lists of relevant articles were manually searched. Studies reporting on functional and/or structural ear abnormalities among children (<18 years) with prenatal alcohol exposure and/or FASD were eligible. Data extraction and quality assessment were performed by one reviewer and independently checked by another. A random effects meta-analysis was conducted.

RESULTS

A total of 31 studies met the inclusion criteria and 25 were included in the meta-analyses, representing a total of 843 children with prenatal alcohol exposure and 1653 children with FASD. Functional ear abnormalities with the highest pooled prevalence were chronic serous otitis media (88.5%; 95% CI, 70.4%-99.3%), abnormal auditory filtering (80.1%; 95% CI, 76.5%-84.3%), and unspecified conductive hearing loss (68.0%; 95% CI, 51.9%-82.2%). Structural ear abnormalities with the highest pooled prevalence were microtia (42.9%; 95% CI, 26.8%-59.7%), railroad track ear (16.8%; 95% CI, 8.1%-27.7%), and misplaced ear (12.3%; 95% CI, 7.6%-17.9%).

CONCLUSIONS

Our findings highlight the importance of examining the ears during assessment for FASD, and the need for public health messaging regarding the harms of prenatal alcohol exposure.

Bioprinting and regeneration of auricular cartilage using a bioactive bioink based on microporous photocrosslinkable acellular cartilage matrix

Tissue engineering provides a promising strategy for auricular reconstruction. Although the first international clinical breakthrough of tissue-engineered auricular reconstruction has been realized based on polymer scaffolds, this approach has not been recognized as a clinically available treatment because of its unsatisfactory clinical efficacy. This is mainly since reconstruction constructs easily cause inflammation and deformation. In this study, we present a novel strategy for the development of biological auricle equivalents with precise shapes, low immunogenicity, and excellent mechanics using auricular chondrocytes and a bioactive bioink based on biomimetic microporous methacrylate-modified acellular cartilage matrix (ACMMA) with the assistance of gelatin methacrylate (GelMA), poly(ethylene oxide) (PEO), and polycaprolactone (PCL) by integrating multi-nozzle bioprinting technology. Photocrosslinkable ACMMA is used to emulate the intricacy of the cartilage-specific microenvironment for active cellular behavior, while GelMA, PEO, and PCL are used to balance printability and physical properties for precise structural stability, form the microporous structure for unhindered nutrient exchange, and provide mechanical support for higher shape fidelity, respectively. Finally, mature auricular cartilage-like tissues with high morphological fidelity, excellent elasticity, abundant cartilage lacunae, and cartilage-specific ECM deposition are successfully regenerated in vivo, which provides new opportunities and novel strategies for the fabrication and regeneration of patient-specific auricular cartilage.

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Comprehensive proteomic characteristics of the acellular cartilage matrix.

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Bioactive bioink based on ACMMA, GelMA, and PEO promoted cell behavior.

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Bioactive bioink contained biomimetic ECM components and microporous structure.

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Higher biomechanics was provided by alternately bioactive bioink and PCL strands.

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Mature auricle cartilage with high shape fidelity and good mechanics was regenerated.

Proposed clinical approach and imaging studies in families with oculo-auriculo-vertebral spectrum to assess variable expressivity

A diagnosis of oculo-auriculo-vertebral spectrum (OAVS) is established when microtia is present in association with hemifacial hypoplasia (HH) and/or ocular, vertebral, and/or renal malformations. There is no consensus on which imaging studies should be used to rule out variable expressivity and distinguish "sporadic" from "familial" patients. This observational and descriptive study was performed in a Mexican population of 51 patients (32 males, 19 females, 0-18 years old) with microtia/OAVS, and their available parents. A clinical history, genealogy, and physical examination were obtained from all included patients, as were a computed tomography (CT) scan of the ear, audiological evaluation, orthopantomography, complete spine radiography, and renal ultrasound. The same approach was completed in their available parents (51 mothers and 40 fathers), excluding the CT scan and audiological evaluation. By genealogy, 53% of patients were classified as "sporadic"; of the "familial" patients, at least 79.1% had suggestion of a multifactorial inheritance. In the available parents, orthopantomography, complete spine X-ray, and renal ultrasound identified the following OAVS-related manifestations: HH (16.2%, n = 14/86), vertebral alterations (10.9%, n = 10/91), and renal anomalies (2.2%, n = 2/90). Our evaluation of the parents allowed three patients to be reclassified from "sporadic" to "familial" (5.8%, n = 3/51). Our proposed clinical and imaging approach allowed the identification of variable expressivity that more clearly distinguished between "sporadic" and "familial" OAVS patients, which is of utmost importance in providing proper genetic counseling to these families.

Tissue engineering of human ear pinna

Auricular deformities (Microtia) can cause physical, social as well as psychological impacts on a patient's wellbeing. Biofabrication of a complex structure such as ear pinna is not precise with currently available techniques. These limitations can be overcome with the help of tissue engineering. In this article, the authors presented molding and three dimensional (3D) printing to generate a flexible, human size ear pinna. The decellularization of goat ear cartilage protocol and bioink alkaline digestion protocol was followed to yield complete removal of all cellular components without changing the properties of the Extra Cellular Matrix (ECM). Decellularized scaffold used in molding technology and 3D printing technology Computer-Aided Design /Stereolithography (CAD/STL) uses bioink to construct the patient-specific ear. In vivo biocompatibility of the both ear pinnae showed demonstrable recellularization. Histology and scanning electron microscopy analysis revealed the recellularization of cartilage-specific cells and the development of ECM in molded and 3D printed ear pinna after transplantation. Both the techniques provided ideal results for mechanical properties such as elasticity. Vascular Associated Protein expression revealed specific vasculogenic pattern (angiogenesis) in transplanted molded pinna. Chondrocyte specific progenitor cells express CD⁹⁰⁺ which highlighted newly developed chondrocytes in both the grafts which indicated that the xenograft was accepted by the rat. Transplantation of molded as well as 3D ear pinna was successful in an animal model and can be available for clinical treatments as a medical object to cure auricular deformities.

Evaluation of reconstructed auricles by convolutional neural networks

The difficulty in determining which structures are crucial to ensure a natural-looking ear has been plaguing surgeons for many years. This preliminary study explores the feasibility of training convolutional neural network (CNN) models to evaluate a reconstructed auricle as accurate as a human would. By visualizing the attention of trained models, the criteria for the design of a natural-looking auricle can be established. A total of 400 pictures were evaluated by 20 volunteers, and 20 labeled datasets were generated, which were then used to train ResNet models that had been pre-trained on ImageNet. The saliency maps and occlusion maps of each trained model were calculated to capture the attention of models. The average accuracy of the 20 models was 0.8245 ± 0.0356 (>0.80), and the evaluation results of the trained model and the medical student showed a significant correlation (P < 0.05). For the attention visualization of auricles labeled as normal, distribution of the highlighted portions corresponded to a linear contour of the helix, the inferior crura of the antihelix, and the contour of the concha. A CNN can provide an evaluation of a reconstructed auricle in a manner similar to that of a medical student. Saliency maps generated by the CNN demonstrate the subjective view, which was consistent with professional opinion.

Clinical effect evaluation and complication analysis of different auricle reconstruction of congenital microtia

This study compared the clinical efficacy and complications of autogenous rib cartilage stent and Medpor stent auricle reconstruction in patients with congenital microtia. A total of 300 patients with congenital microtia were selected as the research objects. 150 patients in the auricle reconstruction group with autologous rib cartilage stent and 150 patients in the auricle reconstruction group with Medpor stent were selected. Postoperative follow-up was conducted to observe whether the shape, color, size, and position of the reconstructed auricle were good, and to compare whether the cranial auricle Angle was consistent with the healthy lateral auricle, so as to judge whether the reconstructed auricle was successful. The incidence of postoperative complications, such as infection and stent exposure was recorded. The postoperative satisfaction and quality of life scores were compared between the two groups. Two operation methods of the auricle reconstruction effect showed no obvious difference (P>0.05), but the incidence of auricle reconstruction scaffold exposing Medpor stenting was significantly higher than those of autologous rib cartilage auricle reconstruction. The satisfaction and quality of life scores of patients in the autologous rib cartilage group were significantly higher than those in the Medpor stent group (P<0.05). Although there was no significant difference between auricle reconstruction with autologous rib cartilage scaffold and Medpor stent implantation in the improvement rate of microtia, there were fewer complications after autologous rib cartilage stent implantation, but higher patient satisfaction and quality of life. (The registry of clinical trial is: Chinese Clinical Trial Register, ChiCTR2100052010, https://www.chictr.org.cn/).

Psychosocial status of patients with unilateral and bilateral microtia before auricular reconstruction surgery

OBJECTIVE

Microtia can profoundly influence health-related quality of life. The aim of this study was to investigate the psychosocial status of children and adolescents with unilateral and bilateral microtia before reconstruction surgery.

METHODS

Eighty-six patients with microtia from Peking Union Medical College Hospital (54 with unilateral microtia and 32 with bilateral microtia) responded to structured interviews before reconstruction surgery. The 3 clinically validated questionnaires were the Piers-Harris Children's Self-concept Scale (PHCSS), the Social Anxiety Scale for Children (SASC), and the Children's Loneliness Scale (CLS). Scores from the PHCSS and SASC were compared with Chinese norms. The total scores of the unilateral and bilateral groups were compared for all three questionnaires.

RESULTS

Males with unilateral and bilateral microtia had significantly different PHSCC scores than norms (both P < 0.05), and male patients overall had a total score that was 10.61 ± 2.20 points lower than female patients overall. Patients who were 7-9 years-old in the unilateral group and 10 to 13 years-old in the bilateral group had lower total PHSCC scores than norms of the same age (both P < 0.05). There was no significant difference between patients and norms in the 14-16 years-old group. The SASC scores of patients were significantly higher than the norms (P < 0.05). The CLS score was significantly lower in the unilateral group than in the bilateral group (50.17 ± 14.63 vs. 61.38 ± 13.24, P < 0.05), but these two groups did not significantly differ in PHCSS and SASC scores.

CONCLUSION

Compared to Chinese norms, children with unilateral and bilateral microtia had lower self-concept, especially males and those who were 7-13 years-old. Patients with microtia also had increased social anxiety and loneliness. Patients with bilateral microtia were more likely to report loneliness than those with unilateral microtia.

Management of patients with unilateral microtia and aural atresia: recent advances and updates

PURPOSE OF REVIEW

The management of patients with unilateral microtia and aural atresia is complex. Recent literature suggests significant strides in hearing habilitation and ear reconstruction.

RECENT FINDINGS

Several options of hearing management are available and are associated with improved outcomes. Timelines for hearing habilitation and ear reconstruction vary by institution. We offer our timeline as a reference. Three dimensional (3D) printed models are increasingly used for training and reconstruction. Bioprinting is on the horizon, though safety and effectiveness studies are pending. Lastly, application of qualitative methods has provided a foundation on which to improve communication between physicians and patients and their families. Better understanding of the patient and family experiences will provide opportunities to target interventions to improve care.

SUMMARY

Current developments include expanding options for hearing management, changing approaches to timing of atresiaplasty, utilization of 3D printed models, and focus on patient and family experience to improve reconstructive outcomes.

An anthropometric study of the external ear in the Thai population

Auricular dimensions are important data for the treatment of auricular deformities, either congenital or acquired. Many previous studies have shown that the auricular dimension varies among ethnic groups; however, there are currently no available data for the Thai population. The objective of this investigation was to provide normative values regarding the adult ear dimensions in Thailand. A total of 200 Thai volunteers between the ages of 18 and 70 years (80 men, 120 women) were enrolled in this study. We measured six dimensions, including the auricular, lobular, and conchal length and width and the auricular projection at the superaurale and tragal levels. Moreover, we calculated the auricular, lobular, and conchal indices. The selected dimensions of the external ears were shown as means ± standard deviations. These parameters were then compared between the right and left sides, men and women and participants aged ≥50 and <50 years. We found that men have a significantly larger and more projected ear than women do. The length of the entire auricles and the length of the earlobe were also significantly longer in the population ≥50 years than those <50 years. This study provides normative data of the external ear dimension and projection in the adult Thai population. These data can be used to reconstruct the ear and face more appropriately for Thai individuals.

A homozygous missense variant in laminin subunit beta 1 as candidate causal mutation of hemifacial microsomia in Romagnola cattle

Hemifacial microsomia (HFM) was diagnosed in a 9‐day‐old Romagnola calf. The condition was characterized by microtia of the left ear, anotia of the right ear, asymmetry of the face, and deafness. Magnetic resonance imaging revealed agenesis of the right pinna and both tympanic bullae, asymmetry of the temporal bones and temporomandibular joints, and right pontine meningocele. Brainstem auditory evoked responses confirmed the impaired auditory capacity. At gross post mortem examination, there was agenesis and hypoplasia of the right and the left external ear, respectively. No histological abnormalities were detected in the inner ears. A trio whole‐genome sequencing approach was carried out and identified a private homozygous missense variant in LAMB1 affecting a conserved residue (p.Arg668Cys). Genotyping of 221 Romagnola bulls revealed a carrier prevalence <2%. This represents a report of a LAMB1‐related autosomal recessive inherited disorder in domestic animals and adds LAMB1 to the candidate genes for HFM.

Utility of 3D CT Rib Study in Presurgical Planning of Autologous Ear Graft for Pinna Reconstruction in Microtia

Purpose  The aim of this study was to demonstrate the utility of three-dimensional computed tomography (3D) CT rib study in presurgical planning to select the autologous rib cartilage graft for pinna reconstruction.

Materials and Methods  Total of 35 patients of microtia for autologous rib graft from April 2017 to February 2020 were evaluated in this study. All patients had a plain low-dose multislice CT chest. The length of costal cartilages of sixth to ninth ribs bilaterally and width and height of sixth and seventh rib costal cartilage synchondrosis were measured in 3D reconstructed true size coronal images with best possible length displayed. All patients had high-resolution computed tomography (HRCT) temporal studies done to evaluate for associated anomalies in external canal, middle ear cavities, and inner ear structures. Eleven patients had simultaneous HRCT temporal bone done after plain CT chest and rest who had done recent prior study were reviewed without repetition of study.

Results  There were 19 males and 16 females for 3D CT rib study. Average age of the participants was 16.5 years. The average width of synchondrosis of sixth and seventh rib was 15.4 mm on right side and 14.7 mm on left side, average height of synchondrosis was 28.5 mm on right side and 30.7 mm on left side. Average length of the eighth rib costal cartilage was 88.6 mm on the right side and 90.5 mm on the left side. Average length of the ninth rib was 63.2 mm on the right side and 58.2 mm on the left side. Costal cartilage calcifications were present in 9 patients.

Conclusion  Preoperative 3D CT rib study provides accurate measurements of rib stock for sculpting autologous ear graft.

Effectiveness of Bone Conduction Hearing Aids in Young Children with Congenital Aural Atresia and Microtia

Background

The aim of this study was to assess the effectiveness of bone conduction hearing aids in children under 2 years old who have congenital microtia and atresia.

Material/Methods

This prospective study involved 42 children under 2 years old with congenital microtia and atresia who were divided into 2 groups: 21 with unilateral defect and 21 with bilateral defect. All children were provided with bone conduction hearing aids on a softband. Air and bone auditory thresholds were assessed by auditory brainstem responses (ABRs). The LittlEARS questionnaire was used to evaluate auditory development at baseline and after 6 months of hearing aids use. Behavioral observation audiometry (BOA) was used to assess auditory thresholds and compare aided and unaided hearing.

Results

After 6 months of hearing aid use, the total score of the LittlEARS questionnaire in children with unilateral defect was 24±5.60, while children with bilateral defect achieved a result of 26.29±6.17. Hearing thresholds in both groups with bone conduction hearing aids improved significantly and approached the normal level.

Conclusions

Our results confirm that bone conduction hearing aids provide an effective method of auditory rehabilitation for children with conductive and mixed hearing loss caused by microtia and atresia. Using bone conduction hearing aids in such children is crucial for proper hearing, speech, and language development.

Tissue Engineering the Pinna: Comparison and Characterization of Human Decellularized Auricular Biological Scaffolds

Decellularization is one of the promising techniques in tissue engineering used to create a biological scaffold for subsequent repopulation with the patient's own cells. This study aims to compare two different decellularization protocols to optimize the process of auricle decellularization by assessing and characterizing the decellularization effects on human auricular cartilage. Herein, 12 pairs (8 females, 4 males) of freshly frozen adult human cadaveric auricles were de-epithelialized and defatted leaving only the cartilaginous framework. An auricle from each pair was randomly assigned to either protocol A (latrunculin B-based decellularization) or protocol B (trypsin-based decellularization). Gross examination of the generated scaffolds demonstrated preservation of the auricles' contours and a change in color from pinkish-white to yellowish-white. Hematoxylin and eosin staining demonstrated empty cartilaginous lacunae in both study groups, which confirms the depletion of cells. However, there was greater preservation of the extracellular matrix in auricles decellularized with protocol A as compared to protocol B. Comparing protocol A to protocol B, Masson's trichrome and Safranin-O stains also demonstrated noticeable preservation of collagen and proteoglycans, respectively. Additionally, scanning electron micrographs demonstrated preservation of the cartilaginous microtopography in both study groups. Biomechanical testing demonstrated a substantial decrease in Young's modulus after decellularization using protocol B (1.3 MPa), albeit not significant (P-value > 0.05) when compared to Young's modulus prior to decellularization (2.6 MPa) or after decellularization with protocol A (2.7 MPa). A DNA quantification assay demonstrated a significant drop (P-value < 0.05) in the DNA content after decellularization with protocol A (111.0 ng/mg) and protocol B (127.6 ng/mg) in comparison to before decellularization (865.3 ng/mg). Overall, this study demonstrated effective decellularization of human auricular cartilage, and it is concluded that protocol A provided greater preservation of the extracellular matrix and biomechanical characteristics. These findings warrant proceeding with the assessment of inflammation and cell migration in a decellularized scaffold using an animal model.

Satisfaction and health-related quality of life of patients with microtia following reconstructive surgery using the Nagata technique

Objective

This study aimed to investigate the functional outcomes, satisfaction, and quality of life of patients with microtia following reconstructive surgery.

Methods

This cross-sectional study was conducted using retrospective data of patients with microtia following reconstructive surgery using the Nagata technique. Data were obtained from the medical records of patients who underwent reconstructive surgery at the Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, Dr. Cipto Mangunkusumo Hospital between 2014 and 2018. All eligible patients were referred to participate in this study between November 2018 and March 2019. The hearing function was assessed by a professional audiologist after surgery. Patient satisfaction was evaluated by interview using a previously developed questionnaire, while quality of life was assessed using the EuroQol-5D-Young questionnaire.

Results

Thirty-one eligible subjects were included in the study. Pain and discomfort were the most commonly reported factors related to the quality of life following surgery. Approximately 67.7% of the patients were satisfied; 19.4% were very satisfied, and 12.9% reported acceptance of their surgical outcomes. The most common complication was infection (n = 8). Most patients did not experience any problems in their lives after microtia surgery.

Conclusions

The highest rate of satisfactory outcomes was observed for the lobule subunit, which was assumed to be associated with the use of the Z-plasty technique. The most common complication was infection, as environmental hygiene was the most important factor. Thus, further concern for maintaining good hygiene is necessary to improve the quality of reconstructive surgery. The level of satisfaction with microtia reconstructive surgery was adequate. Most patients had a good health-related quality of life without experiencing any problems.

Long-term aesthetics, patient-reported outcomes, and auricular sensitivity after microtia reconstruction: A systematic review

BACKGROUND

Auricular reconstruction for microtia is most frequently performed using autologous costal cartilage (ACC) or porous polyethylene (PPE) implants. Short-term results are generally promising, but long-term results remain unclear. Long-term outcomes were explored in this systematic review, and minimal reporting criteria were suggested for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included if postsurgical follow-up was at least 1 year. Outcome reporting was split into separate publications, and results on complications were reported previously. This publication focused on long-term aesthetic, patient-reported, and sensitivity outcomes.

RESULTS

Forty-one publications reported on these outcomes. Both materials led to aesthetically pleasing results and high rates of patient satisfaction. ACC frameworks grew similarly to contralateral ears, and the anterior surface of auricles regained sensitivity. Furthermore, postoperative health-related quality of life (HRQoL) outcomes were generally good. Data synthesis was limited due to considerable variability between studies and poor study quality. No conclusions could be drawn on the superiority of either method due to the lack of comparative analyses.

CONCLUSION

Future studies should minimally report (1) surgical efficacy measured using the tool provided in the UK Care Standards for the Management of Patients with Microtia and Atresia; (2) complications including framework extrusion or exposure, graft loss, framework resorption, wire exposure and scalp/auricular scar complications and (3) HRQoL before and after treatment using the EAR-Q patient-reported outcome measure (PROM).

Long-term complications of microtia reconstruction: A systematic review

BACKGROUND

Microtia is a rare disorder characterized by malformation or even complete absence of the auricle. Reconstruction is often performed using autologous costal cartilage (ACC) or porous polyethylene implants (PPE). However, the long-term outcomes of both methods are unclear.

OBJECTIVE

This systematic review aimed to analyze long-term complications and suggest minimal reporting criteria for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included provided that the follow-up period was at least one year. This publication focused on long-term complications reported in patients with a postoperative follow-up period of at least one year.

RESULTS

Twenty-nine publications reported on complications during long-term follow-up. Overall long-term complication rates were not reported. The incidence of individual complications during long-term follow-up was less than 10% after ACC reconstruction and less than 15% in PPE reconstruction. Framework resorption and wire exposure were reported even after an extended follow-up of more than five years after ACC reconstruction, while reports on the extended long-term results of PPE reconstruction are limited. Data synthesis was limited due to heterogeneity and poor study quality.

CONCLUSIONS

Future studies should report on long-term complications including framework exposure or extrusion, graft loss, framework resorption, wire exposure and scalp and auricular scar complications. We recommend a surgical follow-up of at least five years.

1.5T magnetic resonance imaging in evaluating fetal head and abdomen malformations: a preliminary study

OBJECTIVE

Magnetic resonance imaging (MRI) is increasingly used in the diagnosis of fetal malformations. The purpose of this study was to determine the diagnostic value of 1.5T MRI in fetal head and abdominal malformations.

METHODS

A total of 132 pregnant women admitted to Shijiazhuang NO.4 Hospital were included and divided into a control group (CG; n=63) and a research group (RG; n=69) according to different prenatal examination methods. Patients in CG were given ultrasound, while those in RG underwent 1.5T MRI examination. The image quality of 1.5T MRI in different amniotic fluid, different gestational weeks with normal amniotic fluid and different fetal positions with normal amniotic fluid were compared. The detection rate and diagnostic value of the two methods were also compared, with the histological and pathological results as the gold standard.

RESULTS

The image quality of 1.5T MRI was not affected by different gestational age with normal amniotic fluid, different fetal positions with normal amniotic fluid, or different amniotic fluid, indicating the feasibility of 1.5T MRI in fetal malformation examination. Histopathological diagnosis revealed 39 cases of head and abdominal deformities in CG and 50 cases in RG. Based on the results of ultrasound examination, there were 32 cases of deformities and 31 of non-deformities in CG. In RG, 1.5T MRI revealed 48 malformations and 21 non-malformations. The sensitivity, specificity, accuracy, missed diagnosis and misdiagnosis rates were 82.05%, 75.00%, 79.37%, 17.95% and 25.00% respectively in CG where ultrasonography was performed, and were 96.00%, 94.74%, 95.65%, 4.00% and 5.26% respectively in RG where 1.5T MRI was performed. The data identified significant differences in sensitivity, accuracy and missed diagnosis between RG and CG.

CONCLUSION

1.5T MRI is effective in diagnosing fetal head and abdominal malformations.

Invitro and Invivo Study of PCL-Hydrogel Scaffold to Advance Bioprinting Translation in Microtia Reconstruction

BACKGROUND

Bioprinting has shown promise in the area of microtia reconstruction. However clinical translation has been challenged by the lack of robust techniques to control delivery of stem cells. Hybrid printing allowing multiple materials, both cell and support, to be printed together may overcome these challenges.

OBJECTIVE

This study assesses the degradation behavior and tissue compatibility of hybrid scaffolds (PCL-Hydrogel) compared to single material Polycaprolactone (PCL) scaffolds in-vitro and in-vivo. Sheep demonstrate similar fascial anatomy to humans. This is the first reported study using a sheep model to study hybrid scaffolds for microtia.

METHODS

PCL and PCL-Hydrogel samples of increasing porosity were subjected to an accelerated enzymatic degradation assay to study degradation behavior in-vitro. In addition, a 6-month study using Merino-Dorset sheep was conducted to compare the biological reaction of the host to PCL and PCL-hydrogel scaffolds.

RESULTS

In-vitro degradation showed homogenous degradation of the scaffold. PCL presented the dominating influence on degradation volume compared to hydrogel. In-vivo, there was no evidence of skin irritation or infection over 6 months in both control and test, though PCL-hydrogel scaffolds showed higher levels of tissue ingrowth.

CONCLUSION

Homogenous degradation pattern of porous scaffolds may create less surrounding tissue irritation. Hybrid scaffolds had good biological compatibility and showed better tissue ingrowth than PCL alone.

Ten-year trends in the incidence of microtia: a nationwide population-based study from Taiwan

PURPOSE

Few studies have explored population-based incidence rates of microtia using nationwide data. The aim of this study was to analyze the 10-year secular trends in the incidence of microtia and/or anotia in Taiwan from 2008 to 2017 using nationwide population-based data.

METHODS

Patient data were retrieved from Taiwan's National Health Insurance Dataset, after identifying 1152 children aged ≤ 1 year with a first-time diagnosis of microtia or anotia between January 2008 and December 2017. The annual microtia-anotia incidence rate was the sum of new microtia-anotia cases in a year divided by total infant population in the year. Furthermore, we used the annual percent change (APC) to study the secular trend in microtia-anotia incidence rate.

RESULTS

The annual incidence rate of microtia-anotia averaged across the 10-year period was 57.7 per 100,000 infants (standard deviation = 8.6). The annual incidence rates of microtia and anotia were 53.3 and 4.4 per 100,000 infants, respectively, during this period. Furthermore, female infants had a higher incidence than males (63.3 vs. 52.4 per 100,000). The incidence of microtia-anotia gradually decreased between 2008 and 2017 with an APC of - 5.64% (95% CI - 9.31 ~ - 1.18%, p = 0.004). Since 2011, females had a significantly higher annual incidence rate of microtia-anotia than males.

CONCLUSIONS

The incidence of microtia-anotia was 57.7 per 100,000 infants in Taiwan, which declined during the study period 2008-2017. The female-to-male incidence ratio was 1.21:1.

Heterogeneity of Accompanying Phenotypes and Genomic Variants Involved in Microtia

OBJECTIVES

The symptoms associated with microtia are ever-changing and not to stick to 1 pattern. The symptoms associated with microtia are constantly changing and are not set in stone. The aim of this article was to describe the various phenotypes from multiple systems found in microtitis patients included in the DatabasE of genomiC varIation and Phenotype in Humans using Ensembl Resources database, and to analyze possible pathogenic mutations.

METHODS

DatabasE of genomiC varIation and Phenotype in Humans using Ensembl Resources is an interactive web-based database, which incorporates a suite of tools designed to aid the interpretation of genomic variants. The term "microtia" was used as the search term, and the data extracted from the DatabasE of genomiC varIation and Phenotype in Humans using Ensembl Resources for this study was updated until October 2020. Pearson chi-squared test was used to test associations between types of genomic variants and the pathogenicity of variants.

RESULTS

Of the 386 cases enrolled in the study, 99% (n = 382) had 1 or more associated abnormalities. The most frequently detected abnormalities were those of the face and neck (n = 362 [93.8% of all cases]); musculoskeletal system (n = 337 [87.3%]); and nervous system (n = 334 [86.5%]), followed by abnormalities of limbs (n = 252 [65.3%]); the eye (n = 212 [54.9%]); and the integument (n = 200 [51.8%]). Besides, a total of 479 genomic variants were determined, including sequence variants and copy number variants (loss and gain). The pathogenicity of loss-type variants was significantly higher among other types (P < 0.001). Twelve sharing variants had more than 5 repeats, and the repeated fragments were concentrated on chromosome 3, 7, 9, 10, 11, 15, 17, 18, and 22.

CONCLUSIONS

Identification of the relation between phenotypes and genotypes will facilitate the uncovering of the mechanism of microtia and the study of potential therapeutic targets.

Congenital Aural Atresia: What the Radiologist Needs to Know?

Congenital aural atresia (CAA) is characterized by hypoplasia or aplasia of external auditory canal associated with auricular deformity. It also embodies a spectrum of temporal bone abnormalities including anomalies of middle ear, ossicles, facial nerve, oval window, round window, mastoid pneumatization, temporomandibular joint and occasionally inner ear and vascular anomalies. The management in such patients is variable and consists of rehabilitative hearing aids or surgical correction depending on various patient factors like associated temporal bone abnormalities, degree of hearing impairment and laterality. Surgical management if planned, depends on the extent of associated temporal bone anomalies and hence necessitates comprehensive knowledge about the normal and abnormal anatomy of these structures. High resolution computed tomography (HRCT) is the optimal investigation which provides required anatomical information and plays a pivotal role in deciding the management strategy. This pictorial review aims to review the spectrum of anomalies involving critical structures in CAA on HRCT along with their clinical significance.

Postoperative outcomes of autologous rib graft for microtia repair in children: A NSQIP study

OBJECTIVE

To compare the effect of surgical specialty and patient factors on 30-day postoperative outcomes and complications for children undergoing autologous costochondral grafting for microtia reconstruction.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was searched from 2012 through 2017 for patients who underwent autologous rib grafting (CPT 21230). The group was further filtered for coexisting ICD 9 or 10 code for microtia (744.23, Q17.2) as an indication for surgery. Outcomes analyzed included patient demographics, medical comorbidities, admission type (inpatient vs. outpatient), operative time, surgeon specialty, length of hospital stay (LOS), complications, and readmission.

RESULTS

A total of 375 pediatric patients were identified of which 157 were female and 218 were male. Mean age at time of surgery was 9.6 years. Postoperative complications and readmission occurred in 5.6% and 3.5% of patients, respectively. Surgical site infection was the most common complication. Average operative time was 246.9 min. When comparing Otolaryngology to Plastic Surgery with multivariate analysis, there was no difference in admission type (OR 1.00, p = 0.993), complication rate (OR 0.91, p = 0.744), readmission (OR 0.68, p = 0.576), operative time (p = 0.471) or total LOS (p = 0.266).

CONCLUSION

The present study demonstrated postoperative complications and readmission rates following microtia repair as reported by the NSQIP-P database. Overall complication and readmission rates were low. No significant risk factors were identified on multivariate analysis. There were no differences between surgical specialty for complication rate, operative time, hospital stay or readmission when accounting for demographic data and comorbidities.