Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Microtia Repair Ter i Ju nge , c st, c sfa, m e d , fa st The term microtia actually means small ear and the term anotia means lack of the ear. Microtia has become a “catch-all” term that includes any type of deformity of the external ear. Microtia occurs in approximately 1:6,000 births, is more common in males (approximately 63% of the patients are male and 37% are female), and is more likely to occur on the right side (approximately 58% of deformities occur on the right side) however the defect may be bilateral (approximately 9% of patients are affected bilaterally). Microtia can occur as an isolated deformity or can occur in conjunction with other birth defects (related or not) which can include middle and inner ear problems resulting in reduced or absence of hearing on the affected side. M P ossible C auses icrotia is thought to be a random event; although it has been linked to increased maternal age. Other possible causes are intrauterine tissue ischemia (possibly from an artery that was compressed in the womb), maternal medication use (such as the drug thalidomide/Thalomid® which is an immunomodulatory agent used to treat multiple myeloma and erythema nodosum leprosum and/or the drug isotretinoin/Accutane® which is a retinoid that is used to treat acne), evidence of a first trimester of pregnancy rubella (German measles) episode, and genetic factors. Microtia has been associated with several syndromes such as Goldenhar Syndrome and Treacher-Collins Syndrome. A syndrome is a cluster of deformities that often occur together. Goldenhar Syndrome involves deformities of the face and usually affects one side only. Characteristics of Goldenhar Syndrome include varying degrees of microtia or anotia, the chin on the affected side is closer to the ear, the corner of the mouth on the affected side may be LEARNING O B J ECTI V ES s E xamine the possible causes of microtia s Identify the grades of severity related to this condition s Review the anatomy of the external ear, middle ear and inner ear s Evaluate the steps taken during an autologous rib graft procedure s Compare and contrast the conservative approach with the surgical operation JANUARY 2014 | The Surgical Technologist | 17 Word Element Definition 1. acous/o hearing 2. audi/o hearing 3. labyrinth/o portion of inner ear 4. myring/o eardrum 5. ot/o ear 6. tympan/o eardrum higher than the unaffected side, the eye on the affected side may be missing, deformed, or contain benign growths (such as dermoid cysts). Goldenhar Syndrome is a form of oculoauricular dysplasia. Treacher-Collins Syndrome is an inherited craniofacial defect that is caused by a defective protein called treacle (a protein involved in transcription of ribosomal DNA) and the significance ranges from mild to severe. Characteristics of Treacher-Collins Syndrome include varying degrees of microtia or anotia, micrognathia (small jaw), a large mouth, coloboma (a full-thickness defect of the eyelid in which there is a hole or a gap), scalp hair growth that extends to the checks, and chiloschisis/palatoschisis (cleft lip/cleft palate). S everity Microtia is described as typically occurring in 4 grades. Atypical anomalies that do not fit into the grading scale can also occur. Grade 1 – The pinna is smaller than normal and may have a slightly noticeable malformation. The normal characteristics of the external ear are present and well defined. The acronym FLK which represents the term “funny looking kid” may be seen on the chart of a newborn or child when a dysmorphic feature, such as a slightly malformed ear, is suspected, but has not yet been fully researched and identified. Grade 2 – The pinna is less developed than in grade 1 and the structures such as the helix and antihelix show less definition. Grade 3 – The pinna is basically absent however a vertical skin remnant often remains. The remnant consists of cartilage that is not organized and the patient usually has a well-formed ear lobe. Grade 4 – Complete absence of the auricle (anotia). 18 | The Surgical Technologist | JANUARY 2014 A natomy R eview There are three structural divisions of the ear. External Ear The visible portion of the external ear is also called the pinna and the auricle. The external ear continues through the meatus to the tympanic membrane. The important structures of the external ear that are involved when performing a reconstructive procedure are the: • Helix • Triangular fossa • Antihelix • Concha • Scaphae • Tragus • Lobule • External auditory meatus • External auditory canal which contains the ceruminous glands The function of the external ear is to collect and funnel sound waves into the ear canal. Middle Ear The middle ear begins at the tympanic membrane and ends at the oval window. The three ossicles; the malleus, incus, and stapes are enclosed within the middle ear, as is the opening to the eustachian tube. Additionally, access to the tympanic antrum, which in turn communicates with the mastoid air cells, is provided through the attic (also known as the epitympanic recess). Several physiologic activities occur within the middle ear. Microtia has become a “catch-all” term that includes any type of deformity of the external ear. Microtia occurs in approximately 1:6,000 births ... . Microtia can occur as an isolated deformity or can occur in conjunction with other birth defects (related or not) which can include middle and inner ear problems resulting in reduced or absence of hearing on the affected side. The ossicles are attached to one another via small ligaments and conduct vibrations from the tympanic membrane to the oval window. Several tiny muscles control/constrict the movements of the ossicles and help to obtund certain noises (such as from chewing crunch food). The two main muscles of the middle ear are the tensor tympani and the stapedius. The eustachian tube, also called the pharyngotympanic tube, connects the middle ear cavity with the nasopharynx. The eustachian tube functions to drain mucus from the middle ear and provide aeration of the cavity. The eustachian tube opens to equalize atmospheric pressure in the middle ear and closes to protect the middle ear from loud noises and retrograde infection that may result from contaminates ascending from the nasopharynx. The air spaces of the tympanic antrum function to provide acoustic resonance, dissipate sound, and reduce the weight of the cranium. Inner Ear Vibrational movement of the stapes against the oval window, also known as the fenestra ovalis, sets in motion the fluids within the labyrinth. The labyrinth consists of the vestibule, the semicircular canals and the cochlea. The vestibule contains receptors for equilibrium and movement of the fluid within the two bony chambers of the vestibule affects balance. Fluid movement within the three semicircular canals, influences proprioception (sense of position) and balance during movement (dynamic equilibrium) and when still (static equilibrium). Fluid within the bony labyrinth is called perilymph; inside of the bony labyrinth is the membranous labyrinth that contains a fluid called endolymph. The vestibulocochlear nerve (cranial nerve VIII) is responsible for transmission of sound and balance information from the inner ear to the temporal lobe of the brain for interpretation. The vestibular branch of the VIIIth cranial nerve serves the vestibule and the labyrinth and the cochlear branch serves the cochlea. The organ of Corti, also known as the organ of hearing, is located within the cochlea. The organ of Corti is comprised of ciliated receptor cells that move against the tectorial membrane as the fluid in the middle ear moves. Movement of the tectorial membrane initiates the impulses that move along the cochlear branch of the VIIIth cranial nerve for interpretation in the temporal lobe of the brain. The process of hearing is outlined in Table 1. Table 1 Process of Hearing Step 1 Sound waves enter the external ear Step 2 Tympanic membrane vibrates Step 3 Vibrations are transferred through the middle ear by the ossicles Step 4 Stapes moves the membrane covering the oval window setting in motion the fluids within the bony labyrinth Step 5 Movement of the fluid within the cochlea sets in motion the hair cells of the organ of Corti Step 6 Movement of the hair cells against the tectorial membrane initiates a nerve impulse Step 7 Nerve impulse is transmitted via the VIIIth cranial nerve Step 8 Impulse is interpreted in the temporal lobe of the brain C onservative / N onsurgical A pproach A prosthetic device can be constructed and applied to the side of the head at the location of the ear. If an earlobe is present, the prosthesis can be constructed around it. The main reason for using a prosthesis is to avoid undergoing a surgical procedure. Negative qualities of prosthetic ears are that it must be removed and cleaned daily, it may become detached unexpectedly (especially during sporting activities), it will not change coloration according to the amount of sun exposure, will not grow with a child, and will show signs of wear that will require replacement. H istory of S urgical I nterventions The first reported microtia repairs occurred in the late 1500s and involved the use of cheek or scalp flaps. Homologous rib graft (particularly from the mother) procedures began to emerge in the late 1920s; however, there was a problem with tissue resorption and the technique has been abandoned. The autologous rib graft procedure, which is still in use today, originated in the 1940s. A major advantage of the JANUARY 2014 | The Surgical Technologist | 19 care is exercised to remain outside of the pleura while securing the graft. The cartilage that will represent the main framework of the graft is taken from a section of the false ribs and the cartilage that will become the helical rim is taken from the floating rib cartilage and the chest wound is closed. The surgeon will remove the perichondrium from the cartilage using a periosteal elevator (such as a freer), a scalpel, and a chisel, and then sculpt the main framework of the graft to closely resemble the template. The helical rim A utologous R ib G raft P rocedure O verview is fashioned in much the same way as the main framework Microtia repair is typically described in three to four stages. and the rim is attached to the main framework with nonIn preparation for stage one, a template is drawn from the absorbable suture (such as silk) or stainless steel wire. opposite (intact) ear and then reversed to be used of the Once the cartilaginous framework (graft) is complete, it is set aside while the incision is made and the pocket is developed at the recipient site. The graft is inserted, the wound is closed, and a wound vacuum/drainage device is employed. A bulky wound dressing is applied and left is place for five to seven days. Additionally, a temporary protective device may be applied to keep very young children from disrupting the wound and to protect the wound while the patient is sleeping. The patient is restricted from using a hair dryer, swimming, and participating in contact sporting activities for four to six weeks. Stage two of the reconstruction involves transposition of the earlobe (if one is present) and can be performed in conjunction with stage one. Unfortunately, the risk of vascular compromise increases and the esthetic outcome may not The autologous rib graft procedure, which is still in use today, be as precise, if performed at the same time as the first stage. Ideally, the earlobe transposition originated in the 1940s. A major advantage of the autologous is performed when healing from the first stage rib graft procedure is that the graft will grow with the child. is complete. According to the age of the patient, the transposition may be performed under local anesthesia. Any existing lobular tissue is moved into position as a flap to maintain the integrity of the vascular structures, any unusable tissue is removed, the affected side. If the defect is bilateral, a sibling or other wound is sutured, and a light dressing is applied. model may be used to draw the template. Measurements, Stage three of the reconstruction allows for elevation or a second template, are used to determine the location of (sometimes referred to as lifting) of the posterior aspect the new auricle. The lateral canthus, alar nasal cartilage, and of the newly created framework of the ear. Because skin the corner of the mouth are used as landmarks to estimate grafting is often necessary, stage three is performed under the position the graft. general anesthesia. The donor site for the skin graft may Stage one of the reconstruction is performed under genbe the lower abdomen, the buttocks, or another location eral anesthesia and involves securing the cartilaginous graft determined to be appropriate by the surgeon. from the donor site on the contralateral chest wall. Great autologous rib graft procedure is that the graft will grow with the child. In an attempt to avoid the thoracic portion of the autologous rib graft procedure, a variety of inorganic implants have been tried. Unfortunately, migration and extrusion of the implants are problematic. Examples of implanted materials that have been tried include Vitallium, polyethylene and Teflon. 20 | The Surgical Technologist | JANUARY 2014 Any of the stages of the reconstruction may be combined, as appropriate. If a fourth stage is needed, it may include laser treatments to remove any scalp hair remaining on the newly created ear and minor additional procedures such as creation of a tragus and/or a false conical shaped entry to simulate the auditory meatus and external ear canal. A bout the A uthor Teri Junge, cst, csfa, med, fast, currently serves as the surgical technology program director at the San Joaquin Valley College, Fresno campus. She has been in that role for 11 years, a surgical technologist since 1974 and enjoys writing for publication. R eferences 1. Bonilla, A. (2011). Pediatric microtia surgery. Retrieved October 11, 2011. http://emedicine.medscape.com/article/995953overview#aw2aab6b2b1aa 2. Brent, B. (2011). Microtia-atresia: Possible cause & incidence (etiology). Retrieved April 9, 2012. http://www.microtia.us.com/microtia-atresiapossible-cause-and-incidence.html 3. Cohen, BJ. (2005). Memmler’s the human body in health and disease (10th ed). United States: Lippincott Williams & Wilkins. 4. FLK. (nd). The American heritage® abbreviations dictionary (3rd edition). Retrieved October 11, 2011. http://dictionary.reference.com/browse/FLK 5. Haldeman-Englert, C. (2011). Treacher-Collins syndrome. Retrieved October 10, 2011. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002624 6. National Craniofacial Association. (2011). Goldenhar syndrome. Retrieved October 10, 2011. http://www.faces-cranio.org/Disord/Golden.htm 7. Romo, T. (2008). About microtia: Postoperative care. Retrieved October 12, 2011. http://www.earreconstruction.com/postop.html 8. United States National Library of Medicine. (2012). Isotretinoin. Retrieved April 9, 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000532 9. United States National Library of Medicine. (2012). Thalidomide. Retrieved April 9, 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001053 The Accreditation Review Council on Education in Surgical Technology and Surgical Assisting (ARC STSA) is pleased to announce the launch of our 2014 Scholarship Program in service to the Surgical Technology and Surgical Assisting student and educator communities. Annually, since 2005, the ARC STSA Board of Directors has awarded multiple scholarships of up to $1,000 in at least two separate categories, Student Scholarship and Educator Scholarship. In 2014, the ARC STSA will award a total of up to $5,000 in combined scholarships. All eligible applicants are strongly encouraged to apply before the February 28th deadline. For eligibility requirements and to apply visit arcstsa.org today! Scholarship recipients will be announced at the 2014 AST National Conference in Denver, CO and will be posted on our website, arcsta.org, by June 16, 2014. JANUARY 2014 | The Surgical Technologist | 21 WRITE A CE FEBRUARY 2012 THE VOLUME 44 NO 2 T E C H N O L O G I S T Official JOurnal Of the assOciatiOn Of surgical technOlOgists, inc. CE EXAM A Crash Course in Microbiology We are always looking for CE authors and surgical procedures that haven’t been written about or the latest advancements on a commonplace surgery. You don’t have to be a writer to contribute to the Journal. We’ll help you every step of the way, AND you’ll earn CE credits by writing a CE article that gets published! Here are some guidelines to kick start your way on becoming an author: 1. An article submitted for a CE must have a unique thesis or angle and be relevant to the surgical technology profession. 2. The article must have a clear message and be accurate, thorough and concise. 3. It must be in a format that maintains the Journal’s integrity of style. 4. It must be an original topic (one that hasn’t been published in the Journal recently.) How to Get Started The process for writing a CE can be painless. We are here to assist you every step of the way and make sure that you are proud of your article. • Write to [email protected], and state your interest in writing, and what topic you would like to author. • Submit an outline of your proposed topic for review. Once the outline is returned to you for approval, begin writing your manuscript. Getting your outline approved will save you time and effort of writing a manuscript that may be rejected. • Submit manuscript, as well as any art to illustrate your authored topic. You will be notified upon receipt of receiving the manuscript and as well as any changes, additions or concerns. Things to remember: • Length: Continuing education articles should run a minimum of 2,000 words and a maximum of 5,000 words. • References: Every article concludes with a list of ALL references cited in the text. All articles that include facts, history, anatomy or other specific or scientific information must cite sources. • Copyright: When in doubt about copyright, ask the AST Editor for clarification. • Author’s Responsibility: All articles submitted for publication should be free from plagiarism, should properly document sources and should have attained written documentation of copyright release when necessary. AST may refuse to publish material that they believe is unauthorized use of copyrighted material or a manuscript without complete documentation. Don’t delay! Become an author today. Write to us at [email protected] Other Topics • Finding My Calling – We encourage surgical techs to share their stories about how they found their calling and entered this profession. Inspire others with your story about how you fell in love with this profession. Finding My Calling articles should be a minimum of 500 words and include a photo of the author. • On a Mission – Served on a medical mission? Share your experiences with your fellow surgical techs and show everyone how you made a difference, and how the trip made a difference in your life. On a Mission articles should be a minimum of 500 words and include photos of your mission trip. • Other Topics – Want to write an article that isn’t presented here? Be our guest! We welcome other article topics as long as they are relevant and timely to the profession. 22 | The Surgical Technologist | JANUARY 2014 Earn CE Credits at Home You will be awarded continuing education (CE) credits toward your recertification after reading the designated article and completing the test with a score of 70% or better. If you do not pass the test, it will be returned along with your payment. Send the original answer sheet from the journal and make a copy for your records. If possible use a credit card (debit or credit) for payment. It is a faster option for processing of credits and offers more flexibility for correct payment. When submitting multiple tests, you do not need to submit a separate check for each journal test. You may submit multiple journal tests with one check or money order. Members this test is also available online at www.ast.org. No stamps or checks and it posts to your record automatically! Members: $6 per credit (per credit not per test) Nonmembers: $10 per credit (per credit not per test plus the $400 nonmember fee per submission) After your credits are processed, AST will send you a letter acknowledging the number of credits that were accepted. Members can also check your CE credit status online with your login information at www.ast.org. 3 WAYS TO SUBMIT YOUR CE CREDITS Mail to: AST, Member Services, 6 West Dry Creek Circle Ste 200, Littleton, CO 80120-8031 Fax CE credits to: 303-694-9169 E-mail scanned CE credits in PDF format to: [email protected] For questions please contact Member Services [email protected] or 800-637-7433, option 3. Business hours: Mon-Fri, 8:00a.m. - 4:30 p.m., MT Microtia Repair 361 J a n u a r y 2 0 1 4 1 CE credit - $6 1. a. b. c. d. Microtia is defined as: Lack of ear Small ear Inner ear External ear 8. Following the operation, the bulky wound dressing is left in place for _________. a. 5 to 7 days b. 6 to 8 weeks c. 3 to 4 days d. 1 month 5. Movement of the hair cells against the tectorial membrane initiates a nerve impulse is which step of the process of hearing? a. Step 4 b. Step 5 c. Step 6 d. Step 7 2. Microtia is more common in: a. Infants b. Elderly c. Males d. Females 3. There are four grades of severity describing microtia. In which grade is the pinna less developed? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 4. The visible portion of the ear can be called: a. Auricle b. External ear c. Pinna d. All of the above 9. Laser treatments may be necessary in which stage? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 6. In preparation for stage one of a microtia repair, and the patient’s other ear is in intact, a template is drawn from _________. a. The opposite ear b. A sibling c. His or her mother d. A friend 10. The autologous rib graft procedure originated in the: a. 1920s b. 1930s c. 1940s d. 1950s 7. In stage one, the surgeon will remove the perichondrium from the cartilage using a periosteal elevator, a scalpel and a __________. a. Retractor b. Chisel c. Ear Knife d. Iris Scissors Make It Easy Take CE Exams Online Microtia Repair 361 J a n u a r y 2 0 1 4 1 CE credit - $6 NBSTSA Certification No. AST Member No. 1 ■ ■ ■ ■ ■ My address has changed. The address below is the new address. 2 ■ ■ ■ ■ Name 3 ■ ■ ■ ■ Address 4 ■ ■ ■ ■ 5 ■ ■ ■ ■ 6 ■ ■ ■ ■ 7 ■ ■ ■ ■ 8 ■ ■ ■ ■ 9 ■ ■ ■ ■ a b c d have a■credit■ card to 11 You■must ■ purchase test ■ ■ online. ■ We ■ accept 12 Visa, MasterCard and American ■ ■ ■ ■ 13 Express. Your credit card will ■ ■once ■ 14 only■be charged you pass ■ then ■ your ■credits 15 the■test and recorded ■ ■ ■ 16 will■be automatically to your account. ■ ■ ■ ■ 17 Log on to your account on ■ ■ ■ ■ 18 the AST homepage to take ■ ■of this ■benefit. ■ 19 advantage 10 ■ ■ ■ ■ 20 City Telephone ■ Check enclosed ■ Check Number ■ Visa ■ MasterCard ■ American Express Credit Card Number Expiration Date State Zip a b c d JANUARY 2014 ■ | ■ ■ The Surgical Technologist ■ | 23