Two-Step External Ear Canal Construction in Atresia as Part of Auricular Reconstruction

Microtia and cholesteatoma: Implications for the reconstructive surgeon

Infection after reconstructive surgery for microtia is a technical challenge. This can be a sign of cholesteatoma formation by entrapment of epithelium in the middle or outer ear, specifically when the patient does not respond to first choice antibiotic therapy and debridement.

Two patients with microtia presented themselves with severe infections after ear reconstruction. In both cases cholesteatoma was diagnosed as the cause of the infection. After cholesteatoma management an additional surgical procedure was necessary to improve the esthetic outcome. The plastic surgeon should identify possible signs of cholesteatoma after reconstruction of the auricle.

Periosteal Flap Technique for Elevation of the Pinna in Microtia

IMPORTANCE

For optimal aesthetic construction of the auricle in patients with severe microtia, it is important to construct an exquisite framework and place it in the correct natural position. In addition to its accurate vertical and sagittal positioning, normal elevation is of utmost importance because this determines the auricular width from the common anterior view in interpersonal communication. Many techniques have been described to stabilize the constructed auricle in the elevated position. Some of the techniques are prone to relapse (eg, simple skin transplantation), while others are intricate (eg, using cartilage, huge pedicled flaps, and free skin grafts).

OBSERVATIONS

The objective of the study was to describe a simple and reliable periosteal flap technique and present our experience in 158 patients with complete unilateral or bilateral ear deformity (with possible defects of the external auditory meatus) who were operated on between February 3, 2005, and August 27, 2012. Principles of the technique include elevating the framework from the posterior aspect, stabilizing it with autogenous rib cartilage, covering this with a novel periosteal flap, and skin grafting.

CONCLUSIONS AND RELEVANCE

The periosteal flap technique proved to be straightforward and reliable. All flaps had unrestricted microcirculation. Good and stable projection of the auricle was achieved in all patients.

Complication rate of autologous cartilage microtia reconstruction: a systematic review

Background:

Autologous cartilage has been widely accepted as the frame material of ear reconstruction for patients with microtia. Although rare, there are multiple complications related with the surgical reconstruction techniques. The authors performed a systematic review of the English literature of microtia reconstruction to determine significant surgical factors that are predictors of postoperative complications.

Methods:

A PubMed search using the terms “ear reconstruction” and “microtia” was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, surgical techniques, the incidence of all kinds of complications, and the specific postoperative morbidity. Patient cohorts were pooled, and the incidence of complications was calculated. Significant predictors such as the use of tissue expander, simultaneously mid-ear reconstruction, with/without skin graft, and different fascia coverage were analyzed by chi-square test.

Result:

Of 320 articles found, 60 met the inclusion criteria. Totally 9415 patients with microtia were analyzed in this review with 1525 cases with complications. The overall complication incidence is 16.2% in average with a range of 0–72.9%. There was no significant difference when comparing the overall complication rate between with/without preexpansion 2-stage and multiple-stage techniques or with/without mid-ear reconstruction simultaneously.

Conclusion:

Although there is little agreement in literature regarding risk factors for complications, the authors were able to demonstrate several significant predictors by systematically analyzing 60 articles. Improved knowledge of the incidence of different complications related with various surgical methods can help surgeons provide improved preoperative counseling and take measures to minimize the risk.

Combined reconstruction of congenital auricular atresia and severe microtia

OBJECTIVES

Due to their embryologic developments, auricular atresia and severe microtia are in most cases combined malformations. The aims of this study were to develop a surgical technique for combined esthetic and functional reconstruction with a minimum of operations and to evaluate the results.

STUDY DESIGN

Prospective clinical evaluation.

PATIENTS AND METHODS

Fifty-two patients with third-degree microtia and congenital aural atresia with a sound-conducting block of about 50 dB were treated as described here. In the first operation, autogenous cartilage is harvested and the auricular framework fabricated and implanted. In addition, the tympanic membrane and the external ear canal are prefabricated and stored in a subcutaneous pocket. In the second step, the elevation of the new framework is combined with the operation for atresia utilizing the prefabricated tympanic membrane and external ear canal. In the third step, the cavum conchae is deepened and the external ear canal opened and covered with a skin graft.

RESULTS

Seventy-six percent of the patients had a final conducting hearing loss of 30 dB or less. No restenosis of the new external ear canal was observed. The esthetic results of the constructed auricles are shown.

CONCLUSION

With this combination of plastic surgery for the auricle and functional surgery for the middle ear, no additional operations are necessary, and the prefabrication of the external ear canal and the tympanic membrane gives stable and reliable results. Therefore, we think that this combined technique offers the best chance for an optimal esthetic and functional rehabilitation of patients with these malformations.

Congenital aural atresia reconstruction: a surgical procedure with a long history

BACKGROUND

Pinna deformities, combined with congenital aural atresia, have been a matter of serious debate in the literature as they are associated with major aesthetic and functional problems that are difficult to manage. These problems have been described as early as 2000 BC. The aim of the present article is to approach the whole problem as one (pinna malformation and aural atresia) and present the history as well as the current approaches in reconstruction.

METHODS

Extensive literature search and medical history books were used as scientific sources.

RESULTS

For many centuries, the prevalent view was that any surgical attempts to reconstruct the pinna and the ear canal were of little value. In addition, the aesthetic result of these early surgical procedures was mostly unacceptable. Over time, new surgical techniques and synthetic materials were used, leading to satisfactory and lasting aesthetic and functional results in selected patients, improving their quality of life, while reducing the complication rate. However, many cases are still challenging for plastic surgeons and ENT surgeons alike.

CONCLUSIONS

Despite significant progress in the field, surgery for pinna deformities combined with congenital aural atresia still remains one of the most challenging and risky procedures. Accurate audiological evaluation of newborns as well as assessment of their craniofacial development is necessary and can help the plastic surgeons and otologists choose proper candidates for surgical repair and a suitable and age-appropriate therapeutic plan. History and repeated failures have taught us that close multidisciplinary approach is of paramount importance.

Controversies in aural atresia repair

PURPOSE OF REVIEW

To discuss recent controversies regarding the management of aural atresia.

RECENT FINDINGS

Management of unilateral atresia is less controversial. Candidacy for successful repair is based on high-resolution computed tomography findings and atresia grading. The bone-anchored hearing aid is a viable alternative strategy for hearing improvement. Stability of hearing results following atresia repair improves with the number of atresiaplasties performed. Development of image-guided surgery may provide benefit in atresia surgery. New unrecognized rare complications of aural atresia and atresia repair including salivary fistula and middle ear cholesteatoma are now being recognized and are manageable.

SUMMARY

Management of aural atresia continues to be difficult and surrounded by controversy. New studies and cases series may shed light on these management issues.

Satisfactory surgical option for congenital microtia with defects of external auditory meatus (EAM) and middle ear

CONCLUSIONS

Improved appearance and hearing and increased efficiency are achievable for congenital microbia with defects of external auditory meatus (EAM) and middle ear. First the site of the external auditory meatus (EAM) orifice must be located according to the results of the temporal CT scan, then the auricle can be reconstructed employing the three-stage method. At the third stage, the EAM and middle ear can be reconstructed at the same time.

OBJECTIVE

To select the best approach for reconstruction of congenital microtia with defects of the EAM and middle ear.

PATIENTS AND METHODS

This study analyzed 498 cases (528 ears) of auricle reconstruction by the three-stage method and 77 cases (91 ears operation/120 ears) of EAM and middle ear reconstruction.

RESULTS

For auricular reconstructions, the effects of reconstructed auricles were classified into four grades according to their structure verisimilitude and the bilateral symmetry. The majority of patients/families were satisfied. For 52 ears with normal movement of stapes, reconstructions of EAM and middle ear improved hearing by 15-50 dB, but long-term improvement was not ideal. In bilateral patients, 20 of 24 ears with reconstructed EAMs exhibited relapse of stenosis or atresia. For patients whose EAMs were reconstructed first, scar developed around the orifice and affected the skin flap and later auricle reconstruction, while reconstructing the auricle first sometimes resulted in the location of the EAM orifice deviating from an ideal position.

Advances in the treatment of microtia

PURPOSE OF REVIEW

Creating the fine details of the ear in a patient with a congenital absent ear is extremely challenging. Each component of the multidisciplinary team that manages the ear reconstruction, hearing restoration, and associated craniofacial anomalies of these patients has seen recent progress.

RECENT FINDINGS

Population studies have provided new insights into the etiology of microtia. Novel techniques for costal cartilage harvest, implantation, and positioning add to the techniques of Brent and Nagata, which remain the gold standard for microtia repair. Advances in the use of alloplasts and tissue-engineered cartilage appear promising.

SUMMARY

Technical advances in combined aural atresia/microtia reconstruction, bone-anchored prosthetics, bone-anchored hearing aides, and use of alloplastic implants provide numerous options to patients and practitioners. Implantable, tissue-engineered auricular frameworks appear to be a promising option for the future.

Round Window Stimulation with an Implantable Hearing Aid (Soundbridge®) Combined with Autogenous Reconstruction of the Auricle – A New Approach

BACKGROUND

Congenital malformations of the auricle are often combined with atresia of the outer ear canal and malformations of the ossicles, representing aesthetic as well as functional deficits. Optimal treatment should therefore address both aspects equally. This report describes a new approach, combining the reconstruction of the auricle with implantation of an active middle ear hearing aid, stimulating the round window membrane.

METHOD

A 33-year-old male patient, with bilateral ear microtia, fibrous atresia of the external ear canals and malformation of the ossicles due to Treacher Collins-Franceschetti syndrome was included in the study. In stage one, the cartilage framework of the new auricle, made of autogenous rib cartilage, was fabricated and implanted. During stage two, the auricle was elevated, a retro-auricular sulcus was formed and a Vibrant MED-EL Soundbridge device was implanted. The transducer was coupled to the round window membrane.

RESULTS

Both functional and aesthetical results were favourable. Aided thresholds were between 15 and 30 dB in the frequency range of 0.75-6 kHz, monosyllabic word understanding at 65 dB SPL increased from 0 to 80%.

DISCUSSION

Combining aesthetic and functional rehabilitation, autogenous reconstruction of a new auricle together with the implantation of an active middle ear hearing aid, coupled to the round window membrane, is a promising new approach.

Permanence of diced cartilage, bone dust and diced cartilage/bone dust mixture in experimental design in twelve weeks

Bone dust and diced cartilage are used for contour restoration because their minimal donor site morbidity. The purpose of this study is to investigate permanence of bone dust, diced cartilage and bone dust/diced cartilage mixture in rabbits over 12 weeks. New Zealand white rabbits were used for this study. There were three groups in the study: Group I: 1 mL bone dust. Group II: 1 mL diced cartilage. Group III: 0.5 mL bone dust + 0.5 mL diced cartilage mixture. They were placed into subcutaneous tissue of rabbits and removed 12 weeks later. The mean volumes of groups were 0.23 +/- 0.08 mL in group I, 0.60 +/- 0.12 mL in group II and 0.36 +/- 0.10 mL in group III. The differences between groups were found statistically significant. In conclusion, diced cartilage was found more reliable than bone dust aspect of preserving its volume for a long period in this study.

Navigation-Assisted Construction of an External Ear Canal Using an Autogenous Foreskin Graft

Classic microtia is combined with external ear canal atresia and middle ear malformation. In order to evaluate whether an operation to improve hearing ability and the use of computer-assisted surgery are indicated, preoperative high-resolution navigation CT is mandatory. We combined atresia surgery and tympanoplasty with auricular reconstruction in the case of an 8-year-old boy with bilateral microtia, aural atresia and malformation of the middle ear. After creating an auricle framework with rib cartilage and transplanting it under the skin of the mastoid plane, we shifted it forward in the second step, and the new auditory canal was drilled under computer-assisted navigation and facial nerve monitoring. In the same operation, tympanoplasty was accomplished, and a silastic cylinder, wrapped into pieces of rib cartilage, was inserted into the constructed canal and removed 2 months later. For lining the new auditory canal, we used the patient's prepuce, harvested by elective circumcision.

Microtia reconstruction: an update

Reconstruction of the microtic ear remains one of the most challenging procedures encountered by the reconstructive surgeon. The use of autogenous rib cartilage continues to be the gold standard for microtia repair. Numerous refinements and modifications in the original technique described by Tanzer have paved the way for exceptional results in experienced hands. However, ideal results are not always achieved, and there continue to be drawbacks with the standard approach to reconstruction with autogenous rib cartilage. In an attempt to circumvent these shortcomings, surgeons have developed alternative or adjuvant techniques to repair the microtic ear, including the use of tissue expansion, alloplastic implants, and osseointegrated prostheses. Finally, greater emphasis is being placed on early atresia repair in appropriate candidates.