Microtia: epidemiology and genetics

Impact of unilateral congenital aural atresia on academic Performance: A systematic review

BACKGROUND

Little is known about the academic performance of children with unilateral congenital aural atresia (CAA).

OBJECTIVE

of review: Our objective was to summarize what is known about the academic performance of children with hearing loss by unilateral congenital aural atresia, in order to provide pragmatic recommendations to clinicians who see children with this entity.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

We conducted a systematic search in PubMed Medline, EMBASE, and Cochrane Library combining the terms "atresia" and synonyms with "unilateral hearing loss" and synonyms. Date of the most recent search was 16 May 2018.

EVALUATION METHOD

Two independent authors identified studies, extracted data, and assessed risk of bias. This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational studies on the academic achievements of patients of any age with unilateral conductive hearing loss of any level due to congenital aural atresia were included. We considered grade retention, special education, individualized education plans, and parental report of school performance as outcome measures for academic achievement.

RESULTS

Two studies reporting on academic performance of patients with unilateral CAA, which both had a significant risk of bias. One study (n = 140) showed a grade retention rate of 3.6% (n = 5) in total. 15.7% (n = 22) needed special education, and 36.4% (n = 51) used an individualized education program. The second study, reporting on 67 patients with unilateral CAA, showed that 29.9% (n = 20) of the patients received school intervention, and 25.4% (n = 17) had learning problems.

CONCLUSION

Current evidence regarding the effect of unilateral congenital aural atresia on academic performance is sparse, inconclusive and has a significant risk of bias. High quality observational studies assessing the effects of aural atresia on academic performance in these patients should be initiated.

Tissue engineering the human auricle by auricular chondrocyte-mesenchymal stem cell co-implantation

Children suffering from microtia have few options for auricular reconstruction. Tissue engineering approaches attempt to replicate the complex anatomy and structure of the ear with autologous cartilage but have been limited by access to clinically accessible cell sources. Here we present a full-scale, patient-based human ear generated by implantation of human auricular chondrocytes and human mesenchymal stem cells in a 1:1 ratio. Additional disc construct surrogates were generated with 1:0, 1:1, and 0:1 combinations of auricular chondrocytes and mesenchymal stem cells. After 3 months in vivo, monocellular auricular chondrocyte discs and 1:1 disc and ear constructs displayed bundled collagen fibers in a perichondrial layer, rich proteoglycan deposition, and elastin fiber network formation similar to native human auricular cartilage, with the protein composition and mechanical stiffness of native tissue. Full ear constructs with a 1:1 cell combination maintained gross ear structure and developed a cartilaginous appearance following implantation. These studies demonstrate the successful engineering of a patient-specific human auricle using exclusively human cell sources without extensive in vitro tissue culture prior to implantation, a critical step towards the clinical application of tissue engineering for auricular reconstruction.

Simultaneous auricular reconstruction combined with bone bridge implantation-optimal surgical techniques in bilateral microtia with severe hearing impairment

BACKGROUND

Congenital bilateral microtia with external ear canal (EAC)/middle ear malformation lead to severe appearance defects, hearing impairment and language barrier. Here we report an optimal integrated surgical technique for BoneBridge implantation and auricular reconstruction, which reduce time span of operation, total cost and patients' suffering as well.

METHOD

Seven patients with bilateral external and middle ear malformation received 2-stage auricular reconstruction (age from 7 to 11 years old). In the 1st stage, 6th, 7th, and part of 8th autologous costal cartilage were used to make main body and C-shaped base part of the framework. In 2nd stage of the operation, dissect and lift the framework, isolate postauricular fascia and periosteum, put the BoneBridge subperiosteally and fixed with titanium screw. The C-shaped cartilage base was further attached to the framework and retroauricular fascial flaps and a full-thickness skin graft obtained from the donor site was used to cover posterior raw surface.

RESULTS

Patients were followed up for about 8 months post operation, all of them satisfied with the outcomes and symmetric shape on both sides about desirable 3D detail without adverse complications. Hearing test indicated the mean improvement of auditory threshold of 34.8 dB HL 3 weeks after BoneBridge implantation, with mean scores of speech recognition test ranging from 26% to 62%.

CONCLUSION

The combined 2-stage surgical techniques of simultaneous auricular reconstruction and BoneBridge implantation is safe and efficient for bilateral microtia with significant advantages in decreasing operation difficulties, shortening treatment span and relieving suffering for patients.

Renal ultrasound abnormalities in children with syndromic and non-syndromic microtia

OBJECTIVE

Renal abnormalities are commonly considered in the work up of pediatric patients with external ear malformations. However, there is little consensus regarding an appropriate renal screening protocol for patients with microtia. We sought to characterize renal abnormalities detected on ultrasonography in pediatric patients with microtia.

METHODS

We conducted a retrospective cohort study of pediatric patients diagnosed with microtia who underwent renal ultrasound from 1991 to 2014 at a single tertiary academic institution. Renal ultrasound reports and medical records were reviewed to assess for renal abnormalities and to determine whether patients required specialist follow-up or interventions. Audiograms and otolaryngology notes were used to determine patterns of hearing loss. The following additional information was recorded from the electronic medical records: patient sex, microtia grade (I-IV), microtia laterality, and known associated syndromes. Characteristics were compared between those who did and did not have renal ultrasound findings using Fisher's exact test. Univariate logistic regression analysis was performed to determine factors associated with renal ultrasound findings.

RESULTS

The majority of patients in this cohort were syndromic (n = 51, 64%) with grade III microtia (n = 46, 58%) and conductive hearing loss (n = 58, 72%). Syndromic children with microtia demonstrated a higher crude rate of renal ultrasound abnormalities (22%) than children with isolated microtia (7%). Of these patients, 69% required specialist follow-up. Univariate logistic regression analysis did not identify predictors that were significantly associated with renal ultrasound findings.

CONCLUSION

Fairly high rates of abnormalities in syndromic and non-syndromic patients may warrant screening renal ultrasound in all patients with microtia, especially given the high percentage of findings requiring renal follow-up. A prospective study to formally evaluate screening efficacy is needed.

Development of a New Patient-reported Outcome Measure for Ear Conditions: The EAR-Q

Background:

Patient-reported outcome measures are widely used to improve health services and patient outcomes. The aim of our study was to describe the development of 2 ear-specific scales designed to measure outcomes important to children and young adults with ear conditions, such as microtia and prominent ears.

Methods:

We used an interpretive description qualitative approach. Semi-structured qualitative and cognitive interviews were performed with participants with any type of ear condition recruited from plastic surgery clinics in Canada, Australia, United States, and United Kingdom. Participants were interviewed to elicit new concepts. Interviews were audio-recorded, transcribed, and coded using the constant comparison approach. Experts in ear reconstruction were invited to provide input via an online Research Electronic Data Capture survey.

Results:

Participants included 25 patients aged 8–21 years with prominent ears (n = 9), microtia (n = 14), or another condition that affected ear appearance (n = 2). Analysis of participant qualitative data, followed by cognitive interviews and expert input, led to the development and refinement of an 18-item ear appearance scale (eg, size, shape, look up close, look in photographs) and a 12-item adverse effects scale (eg, itchy, painful, numb).

Conclusions:

The EAR-Q in currently being field-tested internationally. Once finalized, we anticipate the EAR-Q will be used in clinical practice and research to understand the patient’s perspective of outcomes following ear surgery.

Applications and challenges of using 3D printed implants for the treatment of birth defects

Pediatric implants are a special subclass of a vast number of clinically used medical implants, uniquely designed to address the needs of young patients who are at the onset of their developmental growth stage. Given the vulnerability of the implant receiver, it is crucial that the implants manufactured for small children with birth-associated defects be given careful considerations and great attention to design detail to avoid postoperative complications. In this review, we focus on the most common types of medical implants manufactured for the treatment of birth defects originating from both genetic and environmental causes. Particular emphasis is devoted toward identifying the implant material of choice and manufacturing approaches for the fabrication of pediatric prostheses. Along this line, the emerging role of 3D printing to enable customized implants for infants with congenital disorders is presented, as well as the possible complications associated with prosthetic-related infections that is prevalent in using artificial implants for the treatment of birth malformations.

Early Familial Experiences With Microtia: Psychosocial Implications for Pediatric Providers

This study focuses on early experiences of families with a child with microtia to better inform their ongoing care by pediatric providers. Parents and children (n = 62; mean age of 6.9 ± 3.9 years) with isolated microtia participated in semistructured interviews in Spanish (66.1%) or English (33.9%). Qualitative analysis of responses used open coding to identify themes. Parents reported stressful informing experiences of the diagnosis with multiple negative emotions. Parents and children generally reported not understanding microtia etiology, while some families identified medical, religious, and folk explanations. Parental coping included learning about surgeries, normalization, perspective taking, and support from family, providers, religion, and others with microtia. Family communication centered on surgery and reassurance. Pediatricians of children with microtia need to understand families' formative psychosocial experiences to better promote positive family adjustment through clarifying misinformation, educating families about available treatment options, modeling acceptance, psychosocial screening, and providing resources.

Descriptive Analysis of the Arterial Supply to the Auricle in Patients with Unilateral Microtia

Background:

Microtia is a congenital auricular deformity that occurs in 1:5,000–10,000 births. It can cause severe impairment to the patient’s self-esteem and problems regarding social integration. Multiple measures have been described in attempt to better operative outcomes of these patients. We used computed tomography (CT) angiography to analyze the vascular pattern of the auricular region before surgery.

Methods:

Fourteen patients with unilateral microtia were included. All underwent CT angiogram plus tridimensional reconstruction. Both healthy and microtic auricles were analyzed descriptively in terms of main arterial supply, pattern, diameter of subbranches, and angulation. The sample was divided in 2 age groups for better understanding of the data.

Results:

Blood supply to the auricle was found to depend on 2 main vessels: temporal superficial artery (TSA) and its subbranches (superior, middle, and lower branch) and posterior auricular (PA) artery. In the microtic group, TSA was the dominant artery in 13 of 14 cases (92%). Superior, middle, and inferior branches were present in 4, 3, and 0 cases, respectively. Three of the microtic auricles presented supply from PA artery, from which in 1 case, it represented the only supply to the region.

Conclusions:

There is wide variability in the blood supply of both healthy and microtic auricles; however, we were able to identify some tendencies in our sample. Further research is needed to prove the benefit of a preoperative imaging study in these patients. Still, in our experience, we found it useful as a complement for surgical planning.

Characterization of congenital craniofacial anomalies in a specialized hospital of Risaralda, Colombia. 2010-2014

Introducción. Los defectos craneofaciales congénitos pueden causar un impacto en la vida de los niños y de sus familias cuando comprometen el rostro. Además, pueden estar acompañados de alteración de las funciones cerebrales o de la apariencia facial. No se tienen datos concluyentes sobre la presencia de estos defectos en el Eje Cafetero.Objetivo. Identificar la frecuencia de las malformaciones craneofaciales congénitas en un periodo de cuatro años en una institución privada de la ciudad de Pereira, en Risaralda, Colombia.Materiales y métodos. Estudio trasversal retrospectivo. La información fue recolectada a través del sistema de información de historias clínicas de pacientes que consultaron por primera vez en una institución privada de salud. El análisis estadístico fue realizado mediante el software R y Microsoft Excel versión 2007.Resultados. Entre enero del 2010 y diciembre del 2014 se atendieron 1 807 pacientes con malformaciones craneofaciales congénitas, lo que corresponde al 19.5% del total de las anomalías congénitas. La hendidura labio-palatina fue la más frecuente.Conclusiones. Aunque las malformaciones craneofaciales congénitas se presentan con frecuencia, se sabe muy poco de su etiología. El diagnóstico temprano puede prevenir futuras complicaciones que deterioren la salud o que generen un sobrecosto para el sistema de salud.

Auricular Retentive Prosthetic Conformer Post Brent's Stage III Surgery in Microtia Repair: A Clinical Report

Auricular reconstruction is an interdisciplinary approach where multiple specialties play a vital role in the treatment provided to the patient. This article provides a comprehensive interpretation of the process carried out for the fabrication of a custom-made prosthetic conformer for the management of postoperative contraction of a skin graft after ear reconstruction surgery-Brent stage III. The prosthesis is used as a precautionary measure and is simple, effective, and economical.

Parental preferences for the first consultation for microtia

OBJECTIVES

The aim of our study was to investigate subjective information concerning parental experiences and preferences with regard to the initial information that is provided right after the birth of a child with microtia. The analysis of these data is intended to help professionals improve the way in which such conversations are conducted. As a result, future parents may feel better informed and, hence, better fit to cope with challenges they may encounter having a child with microtia.

METHODS

A self-administered questionnaire was sent to 106 parents and caretakers of children with microtia who visited the annual International Microtia and Atresia Conference in the Netherlands, May 2016.

RESULTS

Eighty-seven questionnaires were returned (response rate 82%). Results revealed that 26% of the participants did not receive any information about the condition in the perinatal period. Participants who did receive information right after birth were informed by pediatricians and otolaryngolosits in most of the cases. Plastic surgeons and maxillofacial surgeons were the less commonly serving specialties in this role. A majority of the participants experienced their informing consultation as either being "terrible", or "bad". Parents desired more information about all domains regarding microtia. Development, clothing and appearance, and psychology were believed to be the least important domains.

CONCLUSIONS

Parents are dissatisfied with several aspects of the initial information that is provided right after the birth of a child with microtia. We believe that there is a need for correct information and patient- and family centered care administered by multiple disciplines.

Content Validity of Patient-Reported Outcome Instruments used with Pediatric Patients with Facial Differences

Objective:

The aim of this systematic review was to identify patient-reported outcome (PRO) instruments used in research with children/youth with conditions associated with facial differences to identify the health concepts measured.

Design:

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 2004 to 2016 to identify PRO instruments used in acne vulgaris, birthmarks, burns, ear anomalies, facial asymmetries, and facial paralysis patients. We performed a content analysis whereby the items were coded to identify concepts and categorized as positive or negative content or phrasing.

Results:

A total of 7,835 articles were screened; 6 generic and 11 condition-specific PRO instruments were used in 96 publications. Condition-specific instruments were for acne (four), oral health (two), dermatology (one), facial asymmetries (two), microtia (one), and burns (one). The PRO instruments provided 554 items (295 generic; 259 condition specific) that were sorted into 4 domains, 11 subdomains, and 91 health concepts. The most common domain was psychological (n = 224 items). Of the identified items, 76% had negative content or phrasing (e.g., “Because of the way my face looks I wish I had never been born”). Given the small number of items measuring facial appearance (n = 19) and function (n = 22), the PRO instruments reviewed lacked content validity for patients whose condition impacted facial function and/or appearance.

Conclusions:

Treatments can change facial appearance and function. This review draws attention to a problem with content validity in existing PRO instruments. Our team is now developing a new PRO instrument called FACE-Q Kids to address this problem.

Whole-exome sequencing for monozygotic twins discordant for hemifacial microsomia

Hemifacial microsomia (HFM) is the second most common congenital craniofacial malformation. Although many sporadic and familial cases have been studied to explore the etiology and pathogenesis of HFM, no common understanding has been reached. We aimed to further probe into the etiology of HFM through studying monozygotic twins. Here, we report two cases of pairs of monozygotic twins discordant for HFM, and performed whole-exome sequencing (WES) and bioinformatics analysis to help determine the underlying molecular mechanisms. We identified 93 and 83, and 101 and 104 genes containing rare germline mutations in the twins of the two pairs, respectively. No positive gene candidates were found among the samples, and none of the analyses results revealed a clear intersection with previously reported gene candidates. The pathogenesis of HFM twin pairs does not appear to be related to single nucleotide variants or small insertions/deletions. Thus, HFM may be caused by structure variations, epigenetic alterations, and/or instability of short repeat sequences, which requires further investigation in a larger cohort with sequencing technology for verification.

Clinical and cytogenomic findings in OAV spectrum

The oculoauriculovertebral spectrum (OAVS) is characterized by anomalies involving the development of the first and second pharyngeal arches during the embryonic period. The phenotype is highly heterogeneous, involving ears, eyes, face, neck, and other systems and organs. There is no agreement in the literature for the minimum phenotypic inclusion criteria, but the primary phenotype involves hemifacial microsomia with facial asymmetry and microtia. Most cases are sporadic and the etiology of this syndrome is not well known. Environmental factors, family cases that demonstrate Mendelian inheritance, such as preauricular appendages, microtia, mandibular hypoplasia, and facial asymmetry; chromosomal abnormalities and some candidate genes suggest a multifactorial inheritance model. We evaluated clinical, cytogenomic and molecularly 72 patients with OAVS, and compared our findings with patients from the literature. We found 15 CNVs (copy number variations) considered pathogenic or possibly pathogenic in 13 out of 72 patients. Our results did not indicated a single candidate genomic region, but recurrent chromosomal imbalances were observed in chromosome 4 and 22, in regions containing genes relevant to the OAVS phenotype or related to known OMIM diseases suggesting different pathogenic mechanisms involved in this genetically and phenotypic heterogeneous spectrum.

Low-set ears and associated anomalies in human foetuses

OBJECTIVES

To determine the prevalence of low-set ears (LSE) in a group of human foetuses, to analyse the associated anomalies, and to review the development mechanisms possibly involved.

METHODS

A total of 1759 human foetuses from spontaneous abortion were evaluated. Foetuses were obtained from the Foetuses and Embryos Collection of the Embryology Department of the Faculty of Medicine of the Autonomous University of Nuevo León. The Ethics Committee gave its approval for this study (EH-230-16). The position of the auricles was determined according to the standards recommended by the Elements of Morphology. Two study groups were created: foetuses with LSE and foetuses with normal ears. In both groups, a detailed examination of the external morphology was performed, followed by thoraco-abdominal micro dissection. Statistical analysis was performed.

RESULTS

Two hundred two of the foetuses presented LSE (1148 per 10,000). In this group, 68.8% did not present associated anomalies, while 31.2% had an associated anomaly. The most frequently affected organ was the heart (53.6%), followed by the digestive tract (23.9%), urinary system (16.9%), head and neck (4.2%), and limbs (1.4%). In the group of foetuses with normal ears, only 7.4% of the specimens had associated anomalies, which was a significant difference compared with the LSE group.

CONCLUSIONS

Based on the obtained results, we consider that LSE can be used as a sensitive indicator of major anomalies. It is recommended to include a systematic assessment of the position of the auricles in the initial clinical evaluation of any newborn.

Prevalence of Renal and Cervical Vertebral Anomalies in Patients with Isolated Microtia and/or Aural Atresia

Objective

The objective of this study was to determine whether patients with isolated microtia or aural atresia have an increased prevalence of renal or cervical vertebral anomalies.

Design

The study design was a retrospective medical record review.

Setting

The setting was the following four distinct institutions: an urban tertiary care children's hospital, two urban academic medical centers, and a staff-model health maintenance organization.

Participants

Patients diagnosed with microtia, aural atresia, or oculoauriculovertebral spectrum were identified. Patients with facial asymmetry, craniofacial microsomia, and other craniofacial abnormalities or syndromes were excluded.

Main Outcome Measures

Main outcome measures were the number of patients with isolated microtia or aural atresia who underwent a renal ultrasound or cervical spine X-ray, the results of those studies, and further evaluation or treatment for any abnormalities found.

Statistical Analysis

A binomial analysis using a one-sided 95% confidence level was performed.

Results

A total of 514 patients with isolated microtia and/or aural atresia were identified. Of these patients, 145 (28%) had undergone a renal ultrasound and 81 (16%) had undergone cervical spine X-rays. A total of 3 patients (2%) had minimal renal pelviectasis, all of which had resolved on repeat ultrasound and required no treatment. There were no structural renal abnormalities identified, and there were no cervical spine abnormalities identified.

Conclusions

The data suggest that there is no increased prevalence of structural renal or cervical vertebral anomalies in patients with isolated microtia and/or aural atresia. Therefore, these patients do not require routine screening renal ultrasound or cervical spine X-rays.

Evaluation of tracheobronchial branching abnormalities in patients with microtia using chest computed tomography

BACKGROUND

The objective of this study was to identify the characteristics and incidence of Tracheobronchial branching abnormalities in patients with microtia and to evaluate the risk of anesthesia.

METHODS

A total of 204 consecutive microtia patients and 465 nose cosmetic patients without microtia received a preoperative chest computed tomography. A retrospective study was performed with the clinical and imaging data from July 2016 to April 2017.

RESULTS

With the chest computed tomography images, a total of 7 cases were documented with Tracheobronchial branching abnormalities, including 6 cases among the microtia patients and 1 case among the cosmetic patients without microtia. The incidence of Tracheobronchial branching abnormalities was higher in microtia patients than the cosmetic patients without microtia (2.94% versus 0.22%, P < 0.01).

CONCLUSIONS

The incidence of Tracheobronchial branching abnormalities was high in patients with microtia. Preoperative diagnosis of tracheal bronchus can help anesthesiologists avoid complications. Microtia with Tracheobronchial branching abnormalities may involve a new syndrome previously undiscovered or just another extension with the very wide spectrum of microtia.

Evaluation of 4 Outcomes Measures in Microtia Treatment: Exposures, Infections, Aesthetics, and Psychosocial Ramifications

Background:

In craniofacial microsomia, microtia and canal atresia pose formidable reconstructive challenges. We review our institutional experience in treating microtia and atresia to identify variables associated with 4 outcomes measures: complications, surgical revisions, aesthetic outcomes, and psychosocial function.

Methods:

Craniofacial microsomia patients treated at the University of California Los Angeles Craniofacial Clinic between 2008 and 2014 greater than 13 years of age (n = 68) were reviewed for microtia and atresia treatment and outcomes.

Results:

In total, 91.2% of patients diagnosed with craniofacial microsomia presented with microtia, affecting 75 ears. Both a male and right-sided predominance were observed. Fifty-six patients (90.3%) underwent autologous external ear reconstruction at an average age of 8.5 years. Age, type of incision, and size of cartilage framework did not predict total number of surgeries or complications. Severity of ear anomalies correlated with increased number of surgeries (P < 0.001) and decreased aesthetic outcomes (P < 0.001) but not complications. In total, 87.1% of patients with microtia had documented hearing loss, of which the majority were conductive and 18.5% were mixed sensorineural and conductive. Hearing deficits were addressed in 70.4% of patients with external hearing aids, bone anchored hearing aids, or canaloplasty. Of all variables, improvement of psychosocial function was correlated only to hearing loss treatment of any type (P = 0.01).

Conclusions:

On evaluation of surgical and patient characteristics, severity of microtia predicted the total number of surgical revisions performed and aesthetic ratings. In addition, we found that the only factor that correlated with improved patient and parent-reported psychosocial outcomes was treatment of hearing loss.

Target sequencing of 307 deafness genes identifies candidate genes implicated in microtia

Microtia is a congenital malformation of the external ear caused by genetic and/or environmental factors. However, no causal genetic mutations have been identified in isolated microtia patients. In this study, we utilized targeted genomic capturing combined with next-generation sequencing to screen for mutations in 307 deafness genes in 32 microtia patients. Forty-two rare heterozygous mutations in 25 genes, including 22 novel mutations in 24 isolated unilateral microtia cases were identified. Pathway analysis found five pathways especially focal adhesion pathway and ECM-receptor interaction pathway were significantly associated with microtia. The low-frequency variants association study was used and highlighted several strong candidate genes MUC4, MUC6, COL4A4, MYO7A, AKAP12, COL11A1, DSPP, ESPN, GPR98, PCDH15, BSN, CACNA1D, TPRN, and USH1C for microtia (P = 2.51 × 10^-4). Among these genes, COL4A4 and COL11A1 may lead to microtia through focal adhesion pathway and ECM-receptor interaction pathway which are connected to the downstream Wnt signaling pathway. The present results indicate that certain genes may affect both external/middle and inner ear development, and demonstrate the benefits of using a capture array in microtia patients.

[Bone anchored auricular prosthesis for patients with grade III microtia]

The aim of the study was to assess the effectivity of auricular prosthesis on intraosseous implants in patient with grade III microtia. The study included 7 patients (5 males and 2 females) aged 18 to 45 years with hemifacial microsomia and grade III microtia operated in Central Research Institute of Dentistry and Maxillofacial Surgery in 2013-2016. Number and position of intraosseous implants was determined by reverse planning based on CT representing hard and soft facial structures. Patients were followed-up for 6-36 months. Good esthetic results were obtained by minimally invasive surgical procedure and short post-op rehabilitation. However these results required meticulous virtual planning and manufacturing of surgical template. The described method promotes very fast medical and social rehabilitation of patients with severe microtia.

Preoperative assessment of stapes implantations of the vibrant SoundBridge for congenital aural atresia patients

OBJECTIVE

The objective of this study is to retrospectively analyze the imaging characteristics of patients with congenital aural atresia who underwent Vibrant Soundbridge implantation, and to investigate the importance of preoperative evaluation of vibroplasty.

MATERIALS AND METHODS

The study included 16 patients with bilateral congenital aural atresia aged 6-25 years (mean age, 14.7 years). All patients underwent Vibrant Soundbridge implantations.

RESULTS

Among the 16 patients, 15 successfully underwent stapes implantation. The average height of the stapes of these 15 patients was 2.93 mm, which was significantly different from that of the control group with normal hearing (p ≤ .001). The average distance between the tympanic segment of the facial nerve and the stapes was 1.41 mm in patients in whom the oval window was occluded by the displaced facial nerve. In the non-occluded group, the average distance was 2.00 mm. No significant difference was observed between the two groups (p = .08).

CONCLUSION

The distance between the facial nerve and stapes, as well as the height of the stapes, could be important predictors of successful stapes implantation of Vibrant Soundbridge.

Otologic and Audiology Concerns of Microtia Repair

Microtia is a congenital auricular deformity that commonly presents with associated congenital aural atresia. The most acute concern in these patients is concomitant hearing loss at birth. A team-based approach by plastic surgeons and otologists is necessary to address both the otologic and audiologic concerns of microtia and atresia. Hearing rehabilitation is imperative; yet it should not compromise the aesthetic components of reconstruction and vice versa. Here, the authors propose a framework to evaluate and manage patients with microtia and atresia with the goal of optimizing functional and cosmetic outcomes.

Chorda tympani nerve dysfunction associated with congenital microtia

CONCLUSION

This is the first report to investigate the correlation between ear anomalies related to the development of specific ear structures and chorda tympani dysfunction (CTD) in congenital microtia. CTD is not always consistent with the severity of the ear anomaly or the presence of facial nerve paralysis (FNP).

OBJECTIVES

To investigate the relationship between the severity of ear anomalies and CTD as well as FNP in congenital microtia.

METHODS

A retrospective assessment was performed for all patients with microtia over the period 2010-2016. All ears were graded based on the severity of ear deformity using the Jahrsdoerfer system, based on findings on computed tomography of the temporal bone. Electrogustometry (EGM) was performed to evaluate CTD.

RESULTS

The group included 110 male and 62 female patients. The right ear was the most commonly affected (right 106, left 47). Eighteen patients (10.5%) had abnormal EGM thresholds. The mean (± SD) Jahrsdoerfer scores in the without CTD and positive for CTD groups were 6.53 ± 0.32 and 7.06 ± 0.37, respectively. In terms of sub-total points, there was no significant correlation between anatomic structure and CTD. There was no significant correlation between CTD and the presence of FNP.

Cost analysis of microtia treatment in the Netherlands

INTRODUCTION

Ear reconstruction for microtia is a challenging procedure. Although analyzing esthetic outcome is crucial, there is a paucity of information with regard to financial aspects of microtia reconstruction. This study was conducted to analyze the costs associated with ear reconstruction with costal cartilage in patients with microtia.

METHODS

Ten consecutive children with autologous ear reconstruction of a unilateral microtia were included in this analysis. All patients had completed their treatment protocol for ear reconstruction. Direct costs (admission to hospital, diagnostics, and surgery) and indirect cost (travel expenses and absence from work) were obtained retrospectively.

RESULTS

The overall mean cumulative cost per patient was €14,753. Direct and indirect costs were €13,907 and €846, respectively. Hospital admission and surgery cover 55% and 32% of all the costs, respectively.

DISCUSSION

This study analyzes the costs for autologous ear reconstruction. Hospital admission and surgery are the most important factors of the total costs. Total costs could be decreased by possibly decreasing admission days and surgical time. These data can be used for choosing and developing future treatment strategies.

Differential expression of long noncoding RNAs in congenital microtia

OBJECTIVE

To analyse lncRNA expression profiles in microtia using bioinformatics analysis.

METHODS

We examined lncRNA expression profiles in residual ear cartilage and normal ear cartilage from individual congenital microtia patients.

RESULTS

The gene chips used in this study included 30586 lncRNAs and 26109 mRNA probes. Intotal, 180 lncRNAs with differential expression weredetected in the residual ear cartilage compared with the normal cartilage, including 74 up-regulated and 106down-regulated lncRNAs. Signalling pathway analysis highlighted glyceride metabolism, osteoclast differentiation, andtumour growth. The results of qRT-PCR analysis were consistent with those of themicroarray.

CONCLUSION

Differential expression of lncRNAs occurs in microtia. These lncRNAs and related signalling pathways may play an important role in the occurrence and development ofmicrotia.

Microtia Reconstruction

Microtia reconstruction is a challenging endeavor that has seen significant technique evolution. It is important to educate patients and their families to determine the best hearing rehabilitation and ear reconstructive options. Microtia is often associated with aural atresia, hearing loss, and craniofacial syndromes. Optimal care is provided by multiple disciplines, including a reconstructive surgeon, an otologic surgeon, an audiologist, and a craniofacial pediatrician. Microtia management includes observation, prosthetic ear, autologous cartilage reconstruction, or alloplastic implant placement. Hearing management options are observation, bone conduction sound processor, or atresiaplasty with and without hearing aids. Appropriate counseling should be done to manage expectations.

Health-Related Quality-of-Life Instruments for Pediatric Patients with Diverse Facial Deformities: A Systematic Literature Review

BACKGROUND

Treatment for patients with diverse craniofacial conditions is complex and long-term. Craniofacial conditions profoundly influence health-related quality of life, and patient- and parent-reported outcomes provide a critical and complementary perspective on the multidisciplinary treatment of patients. However, little is known regarding the health-related quality of life among children with diverse craniofacial conditions. The purpose of this study was to systematically review the literature regarding patient- and parent-reported outcomes measures for patients with diverse craniofacial conditions.

METHODS

Articles from the PubMed, PsychINFO, CINAHL, Embase/MEDLINE, Scopus, and Web of Science databases that used patient- and/or parent-reported outcome instruments in patients with diverse craniofacial conditions were reviewed. Diagnoses included were cleft lip and/or palate, craniosynostosis, microtia, craniofacial microsomia, facial vascular malformations, and congenital nevi across pediatric populations (0 to 22 years of age).

RESULTS

Six hundred ninety articles were identified, and 155 were selected for inclusion. One hundred twenty different health-related quality-of-life tools were used to analyze factors such as physical, psychological, or social function. Of these, the 10 most common psychometrically tested tools were identified in 59 studies. Five tools had both parent and patient versions. Two tools were developed and validated for patients with diverse craniofacial conditions, but neither was developed for nonadolescent children.

CONCLUSIONS

Many parent- and patient-reported instruments are used to measure varying health-related quality of life factors in this population, but no tool exists that was developed and psychometrically tested in different facial deformities that measures comprehensive health-related quality of life issues across all pediatric ages. This study will guide the development of new tools to measure the parent and patient health-related quality-of-life perspective in patients with diverse craniofacial conditions.

Chondrocytes from congenital microtia possess an inferior capacity for in vivo cartilage regeneration to healthy ear chondrocytes

The remnant auricular cartilage from microtia has become a valuable cell source for ear regeneration. It is important to clarify the issue of whether the genetically defective microtia chondrocytes could engineer cartilage tissue comparable to healthy ear chondrocytes. In the current study, the histology and cell yield of native microtia and normal ear cartilage were investigated, and the biological characteristics of derived chondrocytes examined, including proliferation, chondrogenic phenotype and cell migration. Furthermore, the in vivo cartilage-forming capacity of passaged microtia and normal auricular chondrocytes were systematically compared by seeding them onto polyglycolic acid/polylactic acid scaffold to generate tissue engineered cartilage in nude mice. Through histological examinations and quantitative analysis of glycosaminoglycan, Young's modulus, and the expression of cartilage-related genes, it was found that microtia chondrocytes had a slower dedifferentiation rate with the decreased expression of stemness-related genes, and weaker migration ability than normal ear chondrocytes, and the microtia chondrocytes-engineered cartilage was biochemically and biomechanically inferior to that constructed using normal ear chondrocytes. This study provides valuable information for the clinical application of the chondrocytes derived from congenital microtia to engineer cartilage. Copyright © 2016 John Wiley & Sons, Ltd.

A Review of Current Regenerative Medicine Strategies that Utilize Nanotechnology to Treat Cartilage Damage

BACKGROUND

Cartilage is an important tissue found in a variety of anatomical locations. Damage to cartilage is particularly detrimental, owing to its intrinsically poor healing capacity. Current reconstructive options for cartilage repair are limited, and alternative approaches are required. Biomaterial science and Tissue engineering are multidisciplinary areas of research that integrate biological and engineering principles for the purpose of restoring premorbid tissue function. Biomaterial science traditionally focuses on the replacement of diseased or damaged tissue with implants. Conversely, tissue engineering utilizes porous biomimetic scaffolds, containing cells and bioactive molecules, to regenerate functional tissue. However, both paradigms feature several disadvantages. Faced with the increasing clinical burden of cartilage defects, attention has shifted towards the incorporation of Nanotechnology into these areas of regenerative medicine.

METHODS

Searches were conducted on Pubmed using the terms "cartilage", "reconstruction", "nanotechnology", "nanomaterials", "tissue engineering" and "biomaterials". Abstracts were examined to identify articles of relevance, and further papers were obtained from the citations within.

RESULTS

The content of 96 articles was ultimately reviewed. The literature yielded no studies that have progressed beyond in vitro and in vivo experimentation. Several limitations to the use of nanomaterials to reconstruct damaged cartilage were identified in both the tissue engineering and biomaterial fields.

CONCLUSION

Nanomaterials have unique physicochemical properties that interact with biological systems in novel ways, potentially opening new avenues for the advancement of constructs used to repair cartilage. However, research into these technologies is in its infancy, and clinical translation remains elusive.

Optimizing cell sourcing for clinical translation of tissue engineered ears

Background . Currently, the major impediment to clinical translation of our previously described platform for the fabrication of high fidelity, patient-specific tissue engineered ears is the development of a clinically optimal cell sourcing strategy. A limited autologous auricular chondrocyte (AuC) supply in conjunction with rapid chondrocyte de-differentiation during in vitro expansion currently makes clinical translation more challenging. Mesenchymal stem cells (MSCs) offer significant promise due to their inherent chondrogenic potential, and large availability through minimally invasive procedures. Herein, we demonstrate the promise of AuC/MSC co-culture to fabricate elastic cartilage using 50% fewer AuC than standard approaches.

METHODS

Bovine auricular chondrocytes (bAuC) and bovine MSC (bMSC) were encapsulated within 10 mg ml^-1 type I collagen hydrogels in ratios of bAuC:bMSC 100:0, 50:50, and 0:100 at a density of 25 million cells ml^-1 hydrogel. One mm thick collagen sheet gels were fabricated, and thereafter, 8 mm diameter discs were extracted using a biopsy punch. Discs were implanted subcutaneously in the dorsa of nude mice (NU/NU) and harvested after 1 and 3 months.

RESULTS

Gross analysis of explanted discs revealed bAuC:bMSC co-culture discs maintained their size and shape, and exhibited native auricular cartilage-like elasticity after 1 and 3 months of implantation. Co-culture discs developed into auricular cartilage, with viable chondrocytes within lacunae, copious proteoglycan and elastic fiber deposition, and a distinct perichondrial layer. Biochemical analysis confirmed that co-culture discs deposited critical cartilage molecular components more readily than did both bAuC and bMSC discs after 1 and 3 months, and proteoglycan content significantly increased between 1 and 3 months.

CONCLUSION

We have successfully demonstrated an innovative cell sourcing strategy that facilitates our efforts to achieve clinical translation of our high fidelity, patient-specific ears for auricular reconstruction utilizing only half of the requisite auricular chondrocytes to fabricate mature elastic cartilage.

[Congenital cysts and fistulae in children]

Cysts and fistulae of the face and neck in children are formed before birth and correspond to the persistence of embryonic remnants that occur due to coalescence defects of embryonic buds or due to epidermal inclusion. They represent the most common pathological malformation of the face and neck. They may be separated according to their location into laterocervical cysts and fistulas or median cysts and fistulas. Their discovery may occur prematurely at birth or later during growth or in adulthood. Their treatment always requires surgical excision, which must be complete in order to prevent recurrences.

Genetic Advances in the Understanding of Microtia

Microtia is a genetic condition affecting the external ears and presents clinically along a wide spectrum: minimally affected ears are small with minor shape abnormalities; extremely affected ears lack all identifiable structures, with the most extreme being absence of the entire external ear. Multiple genetic causes have been linked to microtia in both animal models and humans, which are improving our understanding of the condition and may lead to the identification of a unified cause for the condition. Microtia is also a prominent feature of several genetic syndromes, the study of which has provided further insight into the possible causes and genetic mechanisms of the condition. This article reviews our current understanding of microtia including epidemiological characteristics, classification systems, environmental and genetic causative factors leading to microtia. Despite our increased understanding of the genetics of microtia, we do not have a means of preventing the condition and still rely on complex staged, surgical correction.

Genetic Screening in Patients with Craniofacial Malformations

Craniofacial malformations include a variety of anomalies, including cleft lip with or without cleft palate, craniosynostosis, microtia, and hemifacial microsomia. All of these anomalies can be either isolated or part of a defined genetic syndrome. A clinical geneticist or genetic counselor should be a member of the craniofacial team to help determine which patients have isolated anomalies and which are likely to have a syndrome. They would then arrange for the appropriate genetic testing to confirm the diagnosis of the specific syndrome. The identification of the specific syndrome is important for the overall care of the patient (as it identifies risk for other medical problems such as congenital heart defect) that will have to be taken into account in the care of the craniofacial malformation. In addition, knowing the specific syndrome will allow the family to understand how this happened to their child and the recurrence risk for future pregnancies. With the advent of new technologies, there are now many types of genetic testing available (including, karyotype, fluorescence in situ hybridization, chromosomal microarrays, and next generation sequencing) and the medical geneticist and genetic counselor can determine which specific testing is needed for a given patient.

Characterization of pediatric microtia cartilage: a reservoir of chondrocytes for auricular reconstruction using tissue engineering strategies

The external ear is composed of elastic cartilage. Microtia is a congenital malformation of the external ear that involves a small reduction in size or a complete absence. The aim of tissue engineering is to regenerate tissues and organs clinically implantable based on the utilization of cells and biomaterials. Remnants from microtia represent a source of cells for auricular reconstruction using tissue engineering. To examine the macromolecular architecture of microtia cartilage and behavior of chondrocytes, in order to enrich the knowledge of this type of cartilage as a cell reservoir. Auricular cartilage remnants were obtained from pediatric patients with microtia undergoing reconstructive procedures. Extracellular matrix composition was characterized using immunofluorescence and histological staining methods. Chondrocytes were isolated and expanded in vitro using a mechanical-enzymatic protocol. Chondrocyte phenotype was analyzed using qualitative PCR. Microtia cartilage preserves structural organization similar to healthy elastic cartilage. Extracellular matrix is composed of typical cartilage proteins such as type II collagen, elastin and proteoglycans. Chondrocytes displayed morphological features similar to chondrocytes derived from healthy cartilage, expressing SOX9, COL2 and ELN, thus preserving chondral phenotype. Cell viability was 94.6 % during in vitro expansion. Elastic cartilage from microtia has similar characteristics, both architectural and biochemical to healthy cartilage. We confirmed the suitability of microtia remnant as a reservoir of chondrocytes with potential to be expanded in vitro, maintaining phenotypical features and viability. Microtia remnants are an accessible source of autologous cells for auricular reconstruction using tissue engineering strategies.

Microarray analysis of microRNA expression in mouse fetus at 13.5 and 14.5 days post-coitum in ear and back skin tissues

There is no information regarding the role of microRNAs in the development of the external ear in mammals. The purpose of this study was to determine the stage-specific expression of microRNA during external ear development in mice under normal conditions. GeneChip miRNA 3.0 arrays by Affymetrix were used to obtain miRNA expression profiles from mice fetal pinnae and back skin tissues at 13.5 days-post-coitum (dpc) and 14.5 dpc. Biological triplicates for each tissue were analyzed; one litter represents one biological replica, each litter had 16 fetuses on average. The results were analyzed with Affymetrix's Transcriptome Analysis Console software to identify differentially expressed miRNAs. The inquiry showed significant differential expression of 25 miRNAs at 13.5 dpc and 31 at 14.5 dpc, some of these miRNAs were predicted to target genes implicated in external ear development. One example is mmu-miR-10a whose low expression in pinnae is known to impact ear development by modulating Hoxa1 mRNA levels Garzon et al. (2006), Gavalas et al. (1998) [1], [2]. Other findings like the upregulation of mmu-miR-200c and mmu-miR-205 in the pinnae tissues of healthy mice are in agreement with what has been reported in human patients with microtia, in which down regulation of both miRNAs has been found Li et al. (2013) [3].

This study uncovered a spatiotemporal pattern of miRNA expression in the external ear, which results from continuous transcriptional changes during normal development of body structures.

All microarray data are available at the Gene Expression Omnibus (GEO) at NCBI under accession number GSE64945.

A distal 594 bp ECR specifies Hmx1 expression in pinna and lateral facial morphogenesis and is regulated by the Hox-Pbx-Meis complex

Hmx1 encodes a homeodomain transcription factor expressed in the developing lateral craniofacial mesenchyme, retina and sensory ganglia. Mutation or mis-regulation of Hmx1 underlies malformations of the eye and external ear in multiple species. Deletion or insertional duplication of an evolutionarily conserved region (ECR) downstream of Hmx1 has recently been described in rat and cow, respectively. Here, we demonstrate that the impact of Hmx1 loss is greater than previously appreciated, with a variety of lateral cranioskeletal defects, auriculofacial nerve deficits, and duplication of the caudal region of the external ear. Using a transgenic approach, we demonstrate that a 594 bp sequence encompassing the ECR recapitulates specific aspects of the endogenous Hmx1 lateral facial expression pattern. Moreover, we show that Hoxa2, Meis and Pbx proteins act cooperatively on the ECR, via a core 32 bp sequence, to regulate Hmx1 expression. These studies highlight the conserved role for Hmx1 in BA2-derived tissues and provide an entry point for improved understanding of the causes of the frequent lateral facial birth defects in humans.

Microtia e atresia congênita do canal auditivo em cão: relato de caso

RESUMO Descreve-se o caso de um cão, Pinscher, fêmea de 11 meses de idade, com alteração anatômica da orelha do lado direito. Após avaliação, foi realizado o diagnóstico clínico e o radiográfico de microtia com atresia do canal auditivo do lado direito. Como o animal não apresentava sinais de alterações no sistema vestibular ou otite, optou-se pelo acompanhamento clínico do caso. A microtia, caracterizada pela hipoplasia parcial ou completa da pina, assim como outras anomalias do conduto auditivo, é raramente descrita em medicina veterinária. De acordo com a revisão de literatura realizada, este é o primeiro relato ocorrido no Brasil de um cão com microtia e atresia congênita do canal auditivo sem a associação de síndrome vestibular.

The Association of External and Middle Ear Anomaly and Mandibular Morphology in Congenital Microtia

OBJECTIVE

To investigate the relationship between the severity of ear anomaly and mandibular dysplasia in congenital microtia.

STUDY DESIGN

Retrospective case review.

SETTING

Sapporo Medical University Hospital.

PATIENTS

Congenital microtia: 44 patients over a period of 4 years.

INTERVENTIONS

The height of the condylar process of the mandible was assessed by three-dimensional computed tomography (CT), and the patients were divided into three groups based on the ratio of the condylar process height on the affected side to that on the unaffected side: Group A, ≥1.00; Group B, 0.99 to 0.85; Group C, <0.85. Developmental abnormalities of the ear were evaluated using Jahrsdoerfer's scoring system on high-resolution CT scans.

MAIN OUTCOME MEASURES

Nonparametric statistical tests were used to determine correlations between the height of the condylar process of the mandible and Jahrsdoerfer's score.

RESULTS

The total Jahrsdoerfer's score for each group was 7.36 ± 2.23, 7.28 ± 0.10, and 4.52 ± 0.30, respectively; this value was significantly lower in Group C than in the other groups. In terms of subtotal points, oval window open, middle ear aeration, and mastoid pneumatization correlated significantly with mandibular dysplasia. Patients in Group C tended to have grade III microtia, by Marx's classification. Facial nerve weakness was not significantly correlated with mandibular dysplasia.

CONCLUSIONS

In congenital microtia, mandibular development correlated significantly with aeration of the middle ear space, pneumatization of the mastoid, and formation of the oval window, but not with the presence of a bony part of the external auditory canal or with ossicular development.

Genome-wide association scan suggests basis for microtia in Awassi sheep

Hereditary underdevelopment of the ear, a condition also known as microtia, has been observed in several sheep breeds as well as in humans and other species. Its genetic basis in sheep is unknown. The Awassi sheep, a breed native to southwest Asia, carries this phenotype and was targeted for molecular characterization via a genome-wide association study. DNA samples were collected from sheep in Jordan. Eight affected and 12 normal individuals were genotyped with the Illumina OvineSNP50(®) chip. Multilocus analyses failed to identify any genotypic association. In contrast, a single-locus analysis revealed a statistically significant association (P = 0.012, genome-wide) with a SNP at basepair 34 647 499 on OAR23. This marker is adjacent to the gene encoding transcription factor GATA-6, which has been shown to play a role in many developmental processes, including chondrogenesis. The lack of extended homozygosity in this region suggests a fairly ancient mutation, and the time of occurrence was estimated to be approximately 3000 years ago. Many of the earless sheep breeds may thus share the causative mutation, especially within the subgroup of fat-tailed, wool sheep.