Download Prominent Ear

Prominent Ear
Embryology
Clinical
 Characterized by ear prominence
 Features
1. Absent antihelical fold
2. Conchal hypertrophy
3. Lobule protrusion
 Measurements
1. conchoscaphal angle >90
2. cephalic-auricular angle >34
3. >2cm projection of helical rim over scalp
 Look for another anomalies – Stahls ear, macrotia, or syndromic facial deformity.
 In macrotia, consider reduction techniques (Antia-Buch)
Axial sections of plastic models of three groups of protruding ears. In group I, the
antihelix has failed to develop fully. In group II, the protrusion is caused by a large or
abnormally angulated concha. Group III shows characteristics of both groups I and II,
which combine to produce the abnormality.
Causes
1. secondary to deformational forces – 2 theories
a. in utero - embryonic arrest during the final convolutions of the ear - failure
of the anithelix to fold, widens the conchoscaphal angle, and flattens
superior crus.
b. Post natal – due to aberrant insertion of the intrinsic or extrinsic auricular
muscles or imbalance of muscle actions.
i. Strong pull of well formed antitragus
ii. muscular or neurologic deficiency of the posterior auricular muscle
(Smith, Takashima 1980)
 High level of circulating maternal estrogens in neonates makes the
auricular cartilage soft and malleable. Shortly after birth, the
competing muscle forces can affect the shape of the ear.
 As estrogen levels diminish, the cartilage acquires more elastic
resilience, a more retentive memory, and the shape of the cartilage is
altered permanently.
 Support for a postnatal event points out that the incidence of
prominent ears increases postnatally.
2. familial tendencies reported
Indications
 Most operate after 5 to allow for ear to achieve most of its growth although Gosain
PRS 2004 finds that ear growth will not be affected if otoplasty done at earlier age.
 Child experiencing psychosocial issues at school. Better to wait until a child is at an
age of awareness of his or her prominent ears and wants them corrected.
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Studies have found otoplasty to significantly reduce peer ridicule and to increase
self-esteem
Non-Surgical techniques
 Successful only in neonates and infants
 Matsuo 1990 - described a molding device of malleable plastic material that he
secured to the ear with Steri-Strips.
 Commencement of treatment as early as possible is a key to success
 excellent results if commenced within the first 2-3 months of life
 Splinting may last days to months
SURGERY
Aims (McDowell 1968)
(1) correction of upper 1/3rd protrusion;
(2) helix of both ears should be seen lateral to the antihelix from the
front view;
(3) helix should have a smooth and regular contour throughout;
(4) no disturbance of the postauricular sulcus;
(5) avoiding the plastered-down postoperative appearance;
(6) achieve symmetry
(7) avoiding the sharp antihelical fold.
This can be achieved by:
1. Upper third – absent or weak antihelix – exaggerate antihelix
2. Middle third – concha recessed by excision or sutures
3. Lobule – resect or reposition the cartilaginous tail or retrolubular skin
SURGICAL TECHNIQUES
Grouped into
1. excision of cartilage
2. molding the ear with sutures
3. molding the ear with scoring or sculpting the cartilage
4. combination of any of the above
also grouped by the particular exposure
posterior (medial) approach (Luckett)
anterior (lateral) approach
open otoplasty in which an incision is made through the posterior ear to enter the
anterior aspect of the ear
Historical
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Dieffenbach (1845) and Ely (1881) – excise skin and conchal cartilage from
postauricular sulcus
Morestin (1903) was first to use suture techniques – conchal-scaphal and conchalmastoid sutures
Luckett (1910) identified that an undeveloped/ unfolded antihelix is the main issue
and excised a crescent shaped segment of skin and cartilage from the entire vertical
length of the ear and sutured the edges to create a fold. Tended to create a sharp
antihelix.
Pierce 1930 created the antihelical fold by posteriorly scoring the crest of the
antihelix which was modified by Converse (1955) and Tanzer (1962)
Mustarde (1963) introduced the suture method
Kaye (1967) combined anterior scoring(Stenstrom) with suture technique(Mustarde)
Excisional techniques
 Variations of the original Luckett technique to create antihelical fold
 Not shown to affect ear growth
 Conchal bowl reduction by excising a cartilaginous ellipse beneath the antihelical
body.
 Bauer(PRS 2002) – recommend chondrocutaneous reduction of the conchal bowl
(shadow zone)through an anterior incision to address redundant skin there
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For stiffer (adult) cartilage , may need partial thickness or even full thickness excision
Conchal spring - released in the area of the isthmus inferiorly and superior helical
root
Suture technique
 Mustarde suture technique - molding the antihelical fold with full thickness mattress
sutures placed on the cranial cartilaginous surface
 Furnas conchal mastoid sutures – reduce the conchal bown into the postauricular
sulcus
 Fossa-fascial sutures –used to treat the prominent upper pole, more commonly seen in
the constricted ear. Deirect suturing of the cartilage of the triangular fossa or the
scaphoid fossa to the deep temporal fascia
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Hatch suture (Spira 1999) -
Hatch suture used to bring the root of the helix closer to the scalp
Cartilage scoring
 based on the observation by Gibson and Davis (BJPS 1958) that disruption of a
balanced cross-section of costal cartilage caused warping away from the site of
disruption (Gibson’s principle)
 Fry (BJPS 1966) attributed this to interlocked stresses released by incision of the
prichondrium.
 Chongchet (1963) using Gibson’s principle, replaced the traditional posterior scoring
with anterior scoring of the antihelix via a posterior cartilage splitting incision.
 Stenstrom (1963) achieved the same but using a specially designed rasp
 Dingman otoabrader is used most commonly for closed scoring.
 Full-thickness cartilaginous scoring incision, when fully healed, will often produce a
sharp edge, instead of the desired gentle curve.
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In the very young (<3 years), suture often will suffice due to the very malleable
cartilage (scoring not required). Skin excision is generally not required and should not
be done
Reducing the prominent lobule
 Resection of cauda helicus
 Excision of posterior lobule skin – fish-tail, squid shape or Z-plasty
o Problem is enchroachment to the ear-ring area
Squid shape skin excision to address prominent lobule (Baeur 2002)
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Helical tail to conchal suture (Webster) – free tail of helix posteriorly but leave it
attached to anterior skin. Rotate tail medially over the posterior surface of the concha
and secure with sutures
DAVID GILETT TECHNIQUE
Markings before scrub
Minimal skin excision posteriorly dumbbell shaped
Anteriorly a line where the proposed antehelical fold will lie and then 3 lines
perpendicular to that radiaiting out
Local anaesthetic injected
Posterior incision skin only
then tunnel posteriorly with tenotomies in a subperichondral plane
Colorado monopolar skin and subcut fat excision
Avoid handling the skin edge
Then strip the post skin and fat subperichonrally up to the helical rim
Pass a bent 19 gauge needle and make 3 longitudinal passes
Needle passes from post into the ant through a gap between the conchal bowl and the tail
of the helix
Pass proline through the marks made anteriorly the mark where the mustarde sutures with
mersilene will lie
Dressings are acroflavin wool in the scaphoid fossa, triangular fossa, and the conchal
bowl
Acroflavin wool wrapped in jellonet and cut radially and placed behind the ear
Wool around the ear
Then bandage ears high to low
Then fastanet to hold
Post Op Care
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Head bandage for 10-14 days
Night head band for 6 weeks
Avoid vigorous activites for 1 month
COMPLICATIONS
Early and late
Early
a. Pain
i. warn patients of the importance of the symptom
ii. suspected if the patient complains of excessive post-op pain
b. Hematoma(0.8%)
i. Avoid hypertension
c. Pruritis
d. Infection
e. Perichondritis (0.7%)
i. May follow undetected hematoma or cellulitis
ii. hospitalization, intravenous antibiotics
iii. Failure to control chondritis early can lead to major cartilage loss and deformity
of the ear.
f. Cartilage necrosis
g. skin ulceration
i. follows tight dressings or wide undermining
h. Oedema
Late
b. Patient dissatisfaction
i. Under-correction
ii. Over-correction
c. Unsightly scars
i. Keloids – 2% in Caucasians, 11% in Blacks – probably more likely with
posterior skin
d. Dysethesias
e. Asymmetry
f. Recurrence (5-18% after open and 8-24% after Mustarde)
i. Mean recurrence 8% in most papers
ii. In closed scoring techniques, due to:
1. Insufficient "breaking" of the cartilage spring
2. incorrect placement or insufficient number of sutures.
a. Spira uses 4 sutures minimum in antihelix and 2 sutures in concha
mastoid.
3. cutting needle
4. Excessive removal of skin on the posterior ear surface.
5. The noncompliant patient.
g. Suture reactions – sinuses, ganulomas, wound infection, extrusion
i. Incidence with suture techniques 15%
ii. Gault PRS 2001 raises a separate postauricular fascial flap to cover the sutures
(double breasted) – reduces suture complications to zero.
Gault fascial flap
Specific aesthetic issues
a. Sharp ridges
b. A vertical post (lack of the normal curvature of the superior crus)
c. Irregular contours
d. Antihelical roll too small, too sharp (deep scoring) or malpositioned
e. Excessively large scapha
f. Narrow ear
g. Telephone deformity
i. caused by overaggressive setback of the middle third of the helical rims by
creation of a severe antihelical fold without attention to correction of the position
of the lobule and with or without incomplete correction of the uppermost pole of
the helix; or overresection of skin in middle 1/3rd
h. Obliterated postauricular sulcus
i. Protruding lobule
j. obliterated external ear canal
i. occurs when the conchal bowl setback is done too aggressively and the conchal
bowl actually rolls in the sagittal plane, pushing the tragus laterally and
narrowing the outer eighth of the external auditory canal
k. postperichondritis deformity.
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