SurgExperiences 105

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.


"Harree! Harree! Step Right Up! Get your Handbook of Medical Eponyms at Inside Surgery.

If you are thinking about going into medicine as a career, read this post by EM Physician-Backstage Pass. She notes this regarding the specialties, "Also important is, finding a specialty that fits your personality. If you want to be an involved parent, surgery isn't for you. If you want to have a comfortable lifestyle, you might wanna rethink primary care. If you like to interact with people, radiology/pathology may not bring you satisfaction." An earlier post discusses choosing surgery as a specialty.

Pin-Chieh Chiang takes you through the experience of Getting Caught Unprepared and the grilling your surgery attending can (and often does) give you as a medical student (or resident). Anyone who has been there knows it is not fun as Anna Burkhead posts about ”Pimping” in Getting Grilled! These Signs and helpful tips in Sleeve (Up) by Dr. Schwab over at Surgeonsblog will help you find your way. And through it all, take Someonetc's advice and Don't Forget to Breathe.

While you're learning, may I suggest take you use Dr. Bruce Campbell as someone to emulate. Read his post, How to Avoid Becoming Another Ionitch, and learn how he relates to his patients. And don't be like this cardiac surgeon who falsified his expertise (courtesy of Dr. Kevin).

More from the medical students as Ali Tabatabaey argues for and against surgery as a specialty. For in Surgery is Addictive, "Once you’ve tasted it you just want more. You crave bigger cuts and more complex operations. The simple appendectomy won’t be enough anymore; Deeper cuts, more blood, bigger sutures … ha ha ha (evil laugh)! Wow! I guess it’s got all the characteristics of a true addiction." and the against in The Lure of Surgery Can Be Fleeting-- Wow! What an experience. If you feel that you’re unwillingly being seduced into mastering the art of “the Blade” instead of the science of medicine, there is nothing like a back breaking seven-hour session at the operating room to change your mind back!

Chris (I Made a Difference) in Iraq writes about the First Night as the SOD (surgeon on duty) and how he survived it. Chris you have my deep respect.

Vanessa Ruiz is a graduate student in Biomedical Visualization at the University of Illinois at Chicago, one of the few medical illustration programs in the nation. Check out her recent post, "I don't like Wearing a Helmet, it Ruins my Hair" on her blog Street Anatomy. In it, she tells you why she now always wears a helmet when riding her bicycle.

Don't you just love going to carnivals or festivals. Well, TC over at Donorcycle writes about why she enjoys being in the operating room in Why I <3 Surgery. I can relate, as can most if not all of you.

The food at festivals in the USA is not "lite" but is often tasty. We like to bless our food before we eat and Dr. Campbell has the perfect "muscular" invocation. Don't I wish I could try the brisket Doc Shazam's butcher made. This man truly knows his craft in The Butcher's Silver Skin - Part 3. ...mmm good!

Buckeye Surgeon reviews a case of necrotizing pancreatitis (NP) in Acute Abdomen and other thoughts. This kind of case seems to be the Curses of the new surgeon in town, as described by Dr. Schwab. And why Respectful Insolence "One Reason I Don't Do General Surgery Anymore". NP is one disease that "distinguishes general surgeons from all other specialties."

NP get more attention as Aggravated DocSurg writes in Dr. Phibes meets the Pancreas, Hospital stays are long, complications are frequent, and the one thing required above all else in the patient with necrotizing pancreatitis is found in very short supply in our pharmacy: patience. But it is with a hefty dose of patience on the part of the surgeon, patient, and family that we manage to get the majority of these folks back on their feet. And then, it's Hammer time for all! (image of Hammer from his post, it makes me want to get up and dance)

Any time you have a gunshot wound patient, "don't be caught out" if you don't find the expected. Keep looking, as Bongi explains-- what the hell!!! i thought. but of course all i said was "hmmm?"

Ready to cool down? Then head over to The Ether Way where Mitch Keamy discusses Deep Hypothermic Circulatory Arrest for Aortic Arch Surgery….A .Global Brain Ischemia Situation.

May need to eat some more fair food. You will certainly need the energy to keep up with MakeMineTrauma. She takes us through a night of call with an orthopedic doc in her post-Stomped, Beat Up and Whooped! Day 1, then follows up with a second edition of same Day 2. The food's not the only thing that needs a stick or IM rod in MMT's case.

More skewering as Someonetc in his post Think before you shoot... discusses the placement of percutaneous pins (K-wires).

Midwife with a Knife reminds us that the proper tools are very helpful in her post, Forceps are Your Friends. MakeMineTrauma spent part of her night looking for the proper tools. TBTAM's post In Defense of the Hysterectomy covers the correct indications and why the choice should be between the patient and her doctor. And if you are still hungry, try TBTAM's recipe for Fig and Plum Tarts.

Check out Harvest provided by Bongi at other things amanzi. Yes, TC we need to be "green and recycle", but sometimes it requires much and not all can be given--check out Dr. Oliver's post on the question "Can skin from gastric bypass surgery be donated to children for skin grafts?"

Don't get lost as you head over to Dr Wes' to read Lost in Transition. He reminds us about the side effects of drugs (Versed) given during procedures as he tells of the $400 grocery shopping trip of one patient post-procedure. Not a good time to do anything that involves your pocketbook. If you haven't had any Versed, then enjoy the carnival game.

Now pour yourself a glass of Arkansas' own Weiderkehr Wine, coffee, or tea. Relax and enjoy the reading. Or maybe you're ready for some Karaoke. If so head over to Dr. Val's (Let's pick on anesthesiology) for the words and link to a youtube video of a young anesthesiologist singing a song about what his profession does during surgery to the tune of Total Eclipse of the Heart by Bonnie Tyler. [I passed this by my friend Dr Dan the Diprovan Man who loved it. No disrespect is intended. It's just for fun.]

Thanks Jeffrey for asking me to host this Carnival. The next one will be held over at IntraopOrate, Oct 14th.

Volunteer Firefighters

This evening our local volunteer fire department, West Pulaski Fire Department, is holding its annual catfish dinner to raise money. We always go. We feel it is important to support them, as well feel fortunate to have them available. We live just (less than 3 miles by the road, even closer as the crow flies) outside the city limits. The money raised helps them buy new equipment or replace worn out equipment/gear.

A volunteer fire department (VFD) is an organization of men and women who have joined forces to perform fire suppression and other related emergency services for a local jurisdiction. According to the National Volunteer Fire Council, "There are just over a million active firefighters in the US, of which just over three-fourths are volunteer firefighters. Nearly half the volunteers serve in communities with less than 2,500 population."

The term "volunteer" refers to a group of part-time or on-call firefighters who have other occupations when not engaged in occasional firefighting or response to other emergencies. Although they may have "volunteered" to become members, and to respond to the call for help, they are compensated as employees during the time they are responding to or attending an emergency scene, and possibly even for training drills. An on-call firefighter would probably be expected to volunteer time for other non-emergency duties as well (training, fundraising, equipment maintenance, etc).

So we'll be there this evening to support our local "volunteer" firefighters. They serve very good catfish

Electric Burns to the Mouth

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.


Electrical injuries to the mouth are most commonly caused when a child bites into a cord, touches the male ends of a "live" but improperly connected cord, or sucks on the female end of an extension cord that is plugged into the wall. The vast majority of the patients is younger than three years. The burn injury usually occurs in the area of the oral commissure (corner of the mouth) affecting the commissure and adjacent upper and lower lip. [Children with electric burns should have a thorough systemic evaluation to rule out other system injuries.] 

Components of both an arc burn and a contact burn make up the mechanism of injury. Arc burns result from electrolyte-containing saliva ( the small pool of drool at the corner of the mouth or the moist mucosa lining of the mouth) bridging the polarity gap of the wires and causing an arc or flash. The contact component of the burn occurs as the current passes from the electrical source through the mouth and to the ground through the path of least resistance.

The tissue injury results from direct thermal changes at the entrance and exit site. Temperatures can reach as high as 3000°C (5400°F). Alternating current at low voltage is more dangerous than direct current. Alternating current produces tetanic spasm and can freeze the patient to the power source with subsequent prolongation of contact. Nerve, blood vessels, and muscle offer little resistance and show the greatest destruction. Tendon, fat and bone tissue have highest resistance and show less destruction. 

The burn most often invades both upper and lower lip and the oral commissure. There is usually a significant tissue defect in this area. They are usually full thickness burns involving muscle destruction. The extent of tissue necrosis is not immediately known as it may progress for some time after injury. Patient observation reveals that these wounds are usually not as painful as they appear. Tetanus prophylaxis must be verified and boosters given if indicated.

Immediately after injury, the wound margins appear coagulated without an apparent margin of necrosis. Blood vessels are cauterized by the heat, so little or no bleeding is present. At approximately six hours, the wound is covered with whitish fibrin, a surrounding rim of erythema, and edema of the local tissue. The edema has a tendency to increase, as well as a progressive thrombosis, so after 24 hours there is usually a significant margin indicating the area of tissue necrosis. Bleeding from the labial artery has been reported to occur from these wounds between 1 and 2 weeks after injury as the eschar sloughs. The healing process follows the formation of the eschar, and takes 1 to 2 weeks. At that time, the eschar will slough from the wound, leaving a scar that has a tendency to contract.

The treatment concept

Surgical intervention immediately after injury is not indicated, because the extent of tissue necrosis cannot be defined precisely. For this reason the initial treatment is conservative. Topical antibiotic ointment should be used to prevent infection and assure wound healing. Some of the more severely injured patients were also treated with oral penicillin. Reconstructive procedures were planned after the healing was completed and after the degree of functional and/or aesthetic deformity was established (usually 6 months post-injury).

Attention must be paid not only to the existing deformity, but also to the functional impairment. After the healing process, the size of the tissue defect is most often substantially decreased because of scar contracture. The oral commissure is often narrowed and shortened, causing functional impairment and aesthetic deformity. Sometimes functional impairment and deformity is evident only during movement of the lips and cheeks (smiling or opening the mouth). Defects of the vermilion in the area of the commissure and adjacent upper and lower lips present a difficult reconstructive problem. However, it is more difficult to correct functional impairment and obtain perfect symmetry during movements. Both form and function must be considered when planning a reconstructive procedure.

During the six months post-injury, special attention should be paid to the scar formed in the area of the commissure. Vigorous scar massage should be done using vitamin E cream, kenalog cream, or Mederma to soften the scar as much as possible. Massage is performed by the patient (or parent for the child) five to seven times per day, for 2 to 3 minutes each time. Some suggest the use of splints to prevent contracture of the commissure.

Planning of the reconstructive procedure depends on the size, shape, and location of the defect, as well as the texture of the scar and the condition of the surrounding tissue. The surgeon must determine which design and which tissue to include into the local flap reconstructive procedure. The reconstructive procedure for recreating the commissure may be combined with that for reconstructing the vermilion on one or both lips adjacent to the commissure. Staged procedures are required in cases where defects of the vermilion are substantial. In these cases, the commissure is reconstructed first, followed by reconstruction of the lip 6 to 12 months later.

Reconstruction of the oral commissure, when performed simultaneously with reconstruction of the adjacent vermilion of the upper and/or lower lip, is based on recruiting a mucosal flap from the cheek and transferring it to the commissure and the adjacent lip defects that require reconstruction of the vermilion. The operation starts with precise measurements to determine the position of the commissure after reconstruction and anticipates postoperative scar contracture. The length of the oral fissure on the affected side is determined according to the measurements taken on the normal side. The commissure on the affected side is extended an additional 2 mm laterally to allow for postoperative scar contracture, which will narrow the commissure, bringing it up to the length of the normal side. It is also essential to position the commissure exactly at the same level as on the normal side. The incision is usually carried through the skin and muscle to completely remove the scar and to save the intact mucosa adjacent to the commissure. The design of the mucosal pedicle flap may vary, depending on how much tissue is necessary for reconstruction of the vermilion and closure of the lip defects. (photo from third reference article).

References

• Burns, Electrical by Richard F Edlich, MD PhD--eMedicine Article
• Electric Burns of the Lip--Pediatric Dentistry, "just for kids"
• Oral Commissure Burns in Children; Plastic & Reconstructive Surgery. 97(4):738-744, April 1996; Canady, John W. M.D.; Thompson, Sue Ann Ph.D.; Bardach, Janusz M.D.
• Bardach, J. Local Flaps and Free Skin Grafts in Head and Neck Reconstruction. St. Louis: Mosby, 1992.
• Safe Uses of Extension Cords
• Reducing the Risk of Burns--Cincinnati Children's Hospital

(Grand)baby Quilt

A nurse I work with has been admiring the quilts I have given several new mothers for their babies. As I didn't know her when she was having babies, she never received one. Well a couple of months ago, she commented that she needed one for her grandbabies. Sucker that I am, I made her one. This one has an "orphan" album block for the center then is surrounded with blocks in a "sunshine and shadow" pattern. When I gave it to her, I told her she had to keep it at her house for the grandbabies to use there. It is 38" X 44" in size.

Macrostomia

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

 
The word macromastia simply means "abnormal largeness of the mouth". It is much too simple a word.

Congenital macrostomia or transverse facial cleft or Tessier No 7 is a rare congenital craniofacial anomaly. Transverse facial clefts account for only 1 in 100 to 1 in 300 of all patients with facial clefts. It is estimated to occur in 1 in 80,000 live births. Males are more frequently affected than females. Bilateral involvement is rare. When unilateral, the left side is most frequently affecte.

It has been termed as hemifacial microsomia, craniofacial microsomia, first and second branchial arch syndrome and otomandibular dysostosis. Clinical expression is variable. A preauricular skin tag can be present in microform cases. In it’s complete form, cleft begins as a macrostomia at the oral commissure and continuous across the cheek toward a microtic ear (photo of extreme case). All soft tissues may be underdeveloped on affected site. Osseous manifestations also cover a wide range.

Unilateral first and second branchial arch syndrome is almost always sporadic in occurrence. Facial features begin to develop during the fourth week of embryonic life and differentiation of structures progresses through the eighth to ninth week. This link shows an animation of the normal development of the face. Some evidence suggests that disturbance in the embryonic blood supply, the stapedial artery that provides temporary blood supply to this area in the embryo, during mesechymal ingrowth could result in first arch deformities in the developing face.

Regardless of the cause, the mouth deformity is one of muscle, subcutaneous tissue, and skin. The deformity is particularly evident when the affected child cries or laughs because the absence of the orbicularis oris muscle allows a wide gapping of the commissure. Supernumerary auricular cartilage anterior to the tragus and anomalies in the ipsilateral (same side) ear lobule are present in almost all individuals with this syndrome.

The operative technique for repair should be designed to reconstruct the muscular continuity of the orbicularis, preserve the rounded commissure with vermillion, and minimize scar formation. The standard correction uses an overlapping myoplasty at the commissure and a Z-plasty for the skin closure. Some would argue that a better scar is obtained by the straight line method. 

References

• A Rare Craniofacial Cleft: Tessier No. 7: A Retrospective Analysis; Journal of Ankara Medical School Vol 24, No 2, 2002 63-68; Serdar Gökrem, Orhan Murat Özdemir, Arda Katırcıoğlu, Zeynep Şen, Atilla Ersoy, Zeki Can, Murat Emiroğlu, Serdar Gültan
• Common Craniofacial Anomalies: The Facial Dysostoses; Plastic & Reconstructive Surgery. 110(7):1714-1726, December 2002; Hunt, Jeremy A. M.D.; Hobar, P. Craig M.D.
• Anatomical classification of facial, cranio-facial and latero-facial clefts; J. Maxillofac. Surg. 4: 69, 1976; Tessier, P
• Manifestations of Craniofacial Syndromes by Ted L Tewfik, MD, FRCSC--eMedicine Article
• Picture of the Month; Arch Pediatr Adolesc Med, Vol 153, Aug 1999, pp 889-890; Mendez, Robero MD, et al
• Macrostoma Repair: 15-Year Experience; Plastic & Reconstructive Surgery. 119(2):757-758, February 2007; Lezama-Reus, Marco A. M.D.; Moreno-Penagos, Gregorio M.D.; Ramirez-Ledesma, Sergio G. M.D.; Lozano-Gutierrez, Marco A. M.D.; Ramos-Valdelamar, Francisco M.D.
• Straight Line Closure of Congenital Macrostomia; Indian J Plastic Surg, July-December 2004 Vol 37 Issue 2; Schwarz, Richard; Sharma, Digvijay
• Normal Lip Anatomy--wonderful slides

Thyroglossal Duct Cyst

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Thyroglossal duct cysts(TGDC) are the second most common neck masses. Approximately 7% of the adult population has thyroglossal remnants, with an equal sex distribution.

Thyroglossal duct cysts are cysts that are left over when the thyroid migrates from the base of the tongue into the neck before birth, leaving behind an epithelial trace known as the thyroglossal tract. This tract usually disappears during the 5th-10th gestational week. Incomplete atrophy of this tract, or retained epithelial cysts, creates the basis for the origin of TGDC. A thyroglossal remnant can be a cyst, a tract (or duct), a fistula, or an ectopic thyroid within a cyst or duct. The cyst usually lies in the middle of the neck in front of the "Adam's Apple".

Thyroglossal duct cysts usually show up in the first ten years of life, but may be found in older children or even adults. Most of the time it is a benign cyst that usually contains mucous or even pus-like fluid. (The incidence of primary carcinoma within the thyroglossal duct (TGD)varies in the literature, and ranges from 0.7%–1.6%. These figures pertain to patients of all ages, but in the pediatric population this cancer is even scarcer.)

Thyroglossal duct cysts are usually in the middle of the neck and seem to move up and down during swallowing. Because thyroid tissue may be inside the cyst, it is important to make sure that the thyroid gland has developed normally (and that not all the thyroid tissue is within the cyst). This is done by assessing the thyroid function by using blood tests (TSH, T3, T4), ultrasound exam, thyroid scans, or an MRI.

Once these tests have been completed, excision of the cyst may be performed as an outpatient procedure. The common surgical procedure used to excise TGDC is the Sistrunk procedure, consisting of excision of the TGDC, the central portion of the body of the hyoid bone, and a core of tissue around the thyroglossal tract to open into the oral cavity at the foramen cecum. This allows the excision of all possible TGD remnants without actually visualizing them. The recurrence rate of thyroglossal remnants is 6%–10%.

If the only thyroid tissue found in the patient is located in the thyroglossal duct cyst, the treatment options are as follows:

1. Remove the thyroglossal duct cyst and thyroid tissue, and start lifelong thyroid hormone replacement therapy (under a specialist's supervision)
2. Attempt to keep the ectopic thyroid tissue in place, while stopping further growth of the tissue with medications (thyroxine - a thyroid hormone). Unfortunately, if the ectopic thyroid gland continues to cause symptoms in the patient (breathing or swallowing problems, bleeding or repeated infections), it will ultimately be recommended for removal.
3. For those patients unable to tolerate surgery and who have failed a thyroid hormone trial, radiation therapy may be an option.

References

• Thyroglossal Duct Cyst--Children's Hospital Web-Article
• Thyroglossal Duct Cyst--University of Virginia Health System Web-Article
• Thyroglossal Dust Cyst Excision--Pediatric Otolaryngology Web-site
• Evaluation of neck masses in children. American Family Physician, 51:1904–191, 1995; Park YW
• Thyroglossal Duct Cyst; American Family Physician, Sept, 1990 by Mark Girard, Salvatore A. Deluca
• Hypothyroidism Following Removal of a "Thyroglossal Duct Cyst"; Plastic & Reconstructive Surgery. 68(6):930-932, December 1981; Conklin, William T. M.D.; Davis, Robert M. M.D.; Dabb, Richard W. M.D.; Reilly, Charles M. M.D.
• The surgical treatment of cysts of the thyroglossal tract; Ann Surg 71:121–129, 1920; Sistrunk WF
• Thyroglossal Duct Carcinoma in Children: Case Presentation and Review of the Literature --MedScape Article by Asaf Peretz; Esther Leiberman; Joseph Kapelushnik; Eli Hershkovitz

Tagged

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

 I've been tagged by IntraopOrate, "seems like such a gentle soul." Wow! Let me just say that I really like reading these when other folks get tagged, but was not looking forward to being tagged (and would like to not get tagged again for say six months to a year). I, like IntraopOrate, am not sure I can find 8 folks who haven't been tagged, so I apologize in advance but hope you will humor me!

The rules:
1. Post these rules before you give your facts.
2. List 8 random facts about yourself.
3. At the end of your post, choose (tag) 8 people and list their names, linking to them.
4. Leave a comment on their blog, letting them know they've been tagged.

1. I was born in Missouri. My mother says that's why I'm so stubborn. Missouri used to be known as the "Show Me" state. That's me--show me "how" or show me as in "prove it".

2. I played basketball in high school. This was back when girls played half-court, not full-court basketball. I think they changed to full court the year after I graduated. Mostly I sat on the bench, but I loved being on the team.

3. I grew up in a farming community and have picked cotton and hauled hay for extra money.

4. I have completed 3 Marathons. When Little Rock began their Marathon, I felt like I had to do at least the first one. Notice I said completed--I am not fast. The first one I ran/walked. The next two I walked. Finished all in less than 6 hours (not fast). Now I volunteer in the Medical Tent.

5. IntraopOrate will like this one. I once got to assist Dr. Tom Starzl in an organ harvest. I was a first year general surgery resident at OVMC. Dr. Starzl was very nice. I still remember that patient, mostly though because he was my youngest brother's age at the time.

6. I come from a very large family. My mother had eight children--4 boys and 4 girls (I'm the third), seven with my father and one with my step-father. My father had two children with a previous marriage. My step-father had five children when my mother married him. Only my mother's children lived in our house.

7. My father died in a car accident when I was eight.
8. I have never had any plastic surgery other than this described by Dr. Smak.

Now, the tough part--to tag eight people.
1. Let's start with Dr. Smak, a female family practice doctor
2. Then maybe another female doc--Denver Doc.
3. Then Vanessa over at Street Anatomy. Check out the x-rays of models in blue jeans.
4. Then T at Notes of an Anesthesioboist, a female anesthesiologist.
5. Now for the guys, Chris in Iraq (I Made a Difference).
6. Dr. Wes-- I enjoy his views.
7. Dr. Paul Auerbach over at Medicine for the Outdoors. The adventures he and his friends have.
8. Mitch Keamy over at The Ether Way.
So there you have it. Have a blessed day!

Ear Lacerations, Abrasions, and Avulsions

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.



As mentioned before, the location of the ear in a prominent, unprotected position on the side of the head makes it susceptible to injuries. Many of us remember Mike Tyson biting the ear of Evander Holyfield in their fight in Las Vegas on June 28, 1997.  It is a form of an open injury to the ear. These injuries include lacerations (with and without cartilage exposure) and avulsions. Sharp trauma to the ear causes lacerations to the pinna’s cartilaginous framework. This requires minimal debridement and suturing of the perichondrium and skin in alignment with the remaining natural landmarks. Because the blood supply in this area is excellent, primary closure is usually successful, and even tenuous flaps will generally survive.

Lacerations of the auricle require careful realignment to maintain the contour of the auricle. I like to use a mixture of Lidocaine with epinephrine and Marcaine without epinephrine for a local block. The Marcaine will provide some longer lasting pain control. With the local in place, the wound can be more thoroughly inspected and cleansed. Lacerations involving only the skin may be repaired using basic suture techniques.

Lacerations involving all layers of the auricle require more extensive repair. Each of the layers--cartilage, perichondrium and skin--has to carefully examined for necrosis. The necrotic tissue is sharply debrided, being careful to preserve as much "good" tissue as possible. The cartilage is reapproximated and the perichondrium is sutured over the cartilage with a small-gauge 5-0 or 6-0 absorbable suture (vicryl or dexon). If possible, sutures through cartilage should be avoided. The skin is repaired as above. After repair, a pressure dressing is applied for 48 hours to minimize edema and prevent formation of a hematoma (and to prevent the late complication--cauliflower ear).

Abrasions are a frictional contact injury which result in partial loss of the covering epidermis (skin) of the ear. The affected area may show punctate bleeding, formation of hemorrhagic blebs and even exposure of the underlying dermis or perichondrium. As with lacerations, these wounds should be infiltrated with local so that a thorough inspection and cleansing can be done. All foreign bodies must be removed to prevent infection or "tattooing". A topical antibiotic ointment or cream is applied to prevent surface contamination and secondary infection. A protective dressing may be applied for the first 24 hours. The patient should be instructed to return promptly if pain, fever or swelling develops. Such symptoms usually signal the development of perichondritis, which requires immediate aggressive management. Superficial abrasions generally heal within one to two weeks.

The majority of Avulsion injuries to the ear are from bites. They may be partial (some part still attached) or complete (piece of tissue completely free). When partial, then the ear should be repaired as a laceration. If complete, then reattachment should be done as soon as possible. For best results, complete avulsion injuries should be treated with microvascular reattachment. If this option is not available (or feasible) then the pocket principle may be used. It was first described by Mladick, et al in 1971.

Pocket principle (below three photos from the 5th reference article)-
-Avulsed tissue should be debrided and the surface dermabraded

-The tissue is then anatomically reattached
-The ear is then buried in post-auricular pocket


-After 2-4 weeks, the pocket is opened and the ear removed
-Ear is then allowed to re-epithelialization or is skin grafted.

The pros for the Pocket Principle are 1) provides immediate blood supply, 2) preserves skin/cartilage relationship. The cons are that 1) the aesthetic results are variable, and may be poor if left buried too long and 2) there may be granulation tissue formation.

Lacerations of the pinna can progress to severe chondritis or perichondritis and so along with suturing must be treated antibiotics. Human bites contaminate the wound with the oral flora of the mouth. "Unfortunately, no well-controlled studies have investigated using antibiotics to prevent infection in human bite wounds. Uncontrolled studies have involved cephalosporins and generally do not indicate a benefit of prophylactic antibiotics. Once a human bite is infected, beta-lactamase–producing staphylococci must be addressed. Eikenella corrodens may not be covered by first-generation cephalosporins. Additionally, Eikenella species are resistant to clindamycin, penicillinase-resistant semisynthetic penicillins, and metronidazole. A broad-spectrum antibiotic, rather than combination therapy, is the usual choice for infected bite wounds. A recent in vitro study of 50 infected human bites by Talan et al indicated that amoxicillin-clavulanic acid and moxifloxacin demonstrated excellent activity against common isolates"--Dr McNamara

References

• Ear, Reconstruction and Salvage by Steven P Davison, DDS, MD --eMedicine Article
• Bite Wounds of the Head and Neck; Brian H. Weeks, M.D.; June 24, 1999; Department of Otolaryngology- Head and Neck Surgery V.A. Hospital (Power Point )
• Cuts and Wounds of the External Ear--University of Virginia Health System
• Initial management of auricular trauma; American Family Physician, May 15, 1996 by Dennis Lee, Neil Sperling
• THE POCKET PRINCIPLE: A New Technique for the Reattachment of a Severed Ear Part; Plastic & Reconstructive Surgery, 48(3):219-223, September 1971; Mladick, Richard MD, Horton, Charles MD, Adamson, Jerome MD, Cohen, Bernard MD
• Bites, Human by Robert M McNamara, MD--eMedicine Article

Thanks Kate!

Recently I discovered Kate's Quilting Blog. Kate's profile states that she is "A quilt and fibre artist living outside London, trying to cope with all her fabric addictions and raise three kids at the same time. Some days you eat the bear, some days..." If you like quilting give her a visit. It is full of information, photos, and links.

She holds a weekly giveaway to "It's just a bit of fun, and a way to say thank you to everyone who visits and leaves comments and also a way to say thanks to all the generous ladies out there in quiltblog land who take the time and energy to share their work online and bring me so much inspiration!" And this week I won these lovely Flying Geese! It will be fun deciding how to use them.

Here is a Flying Geese quilt I posted back in the summer. It was sent to a soldier via the Quilts of Valor Organization (QOV).
I do love "flying geese". Thanks Kate!

Cauliflower Ear

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.


Cauliflower ear is an acquired deformity of the outer ear. It is not related to the vegetable--cauliflower and I have not been able to find why it came to be called such. Though there is some similarity between how the two look. 

Because of it's location, the ear is vulnerable to blunt trauma. A blunt blow to the external ear can cause bruising between the cartilage and the layer of connective tissue around it (perichondrium). When blood collects in this area, the external ear becomes swollen and purple. The collected blood (hematoma) can cut off the blood supply to the cartilage, allowing that portion of the cartilage to die, leading in time to a deformed ear. This deformity is common among wrestlers, boxers, and rugby players.

The cartilage of the ear has no other blood supply except that supplied by the overlying skin. When the skin is pulled from the cartilage, and/or separated from the cartilage by blood (as with accumulated blood from injury called a hematoma) or infection, the cartilage is deprived of important nutrients. Ultimately, the cartilage dies and the risk of infection is increased. Left untreated, the ear cartilage begins to contract on itself forming a shriveled up outer ear classically known as the cauliflower ear deformity. Once there is cartilage death and scarring (fibrosis), the resulting deformity is very difficult to reconstruct (if at all possible). Often the victim is left with a permanent deformity.

Common causes of cauliflower ear deformity include previous trauma, relapsing polychondritis, perichondritis, and Hansen’s disease. These are very diverse diseases, which vary significantly in their therapeutic strategies. With no history of trauma, these other causes should not be overlooked.

Treatment
"The review found no trials of good quality to demonstrate that any one technique, which removes the hematoma and prevents its recurrence, gives the best cosmetic outcome. The literature however generally suggests that treatment is better than leaving a hematoma untreated. Well designed studies are required."--4th reference below.

With that said, it is generally accepted that the hematoma needs to be evacuated. This may be done by incising the skin and removing the blood with suction or by inserting a needle and aspirating. After the hematoma is empty, a compression dressing is applied and left on for 3 to 7 days to prevent the hematoma from coming back. (photo set from sixth reference article)

The dressing keeps the skin and perichondrium in their normal positions, allowing blood to reach the cartilage again. Sometimes through-and-through ear sutures over dental gauze rolls or insertion of a Penrose drain plus a pressure dressing is used. Because these injuries are prone to infection, an oral antibiotic effective against staphylococci (eg, cephalexin 500 mg TID X 5 days).

When treated aggressively and promptly, the cauliflower ear deformity is unlikely. Any delay in diagnosis leads to more difficulty in managing this problem and the risk of deformity is greater.

Prevention

Wearing the right headgear when playing sports - especially contact sports - is a must. Helmets can not only save you from developing cauliflower ear but protect you from serious head injury as well. Always wear a helmet if you are biking, blading, riding your scooter, or playing any sport where helmets or other forms of headgear are recommended or required (like football, baseball, hockey, boxing, or wrestling). Products like Impact can add more protection when playing sports like rugby.

References

• Bilateral Cauliflower Ear Deformity: An Unusual Presentation of Cutaneous Rosai-Dorfman Disease; Plastic & Reconstructive Surgery. 113(3):967-969, March 2004; Oo, Kenneth K. K. M.B., B.S.; Pang, Yoke T. F.R.C.S., F.A.M.S.; Thamboo, Thomas P. M.B., Ch.B.
• Relapsing Polychondritis, MedScape Article posted 02/24/2004; Peter D. Kent; Clement J. Michet, Jr; Harvinder S. Luthra
• External Ear Trauma--Merck Medicus
• Interventions for acute auricular haematoma; Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004166. DOI: 10.1002/14651858.CD004166.pub2; Jones SEM, Mahendran S
• Cauliflower Ear--MedicineNet.com article
• Management of Auricular Hematoma Using a Thermoplastic Splint; Arch Otolaryngol Head Neck Surg.2000;126:888-890; Henderson,JM, Salama, AR, Blanchaert Jr, RH
• Wrestlers Cauliflower Ear; Care &Prevention; Anthony Donatelli, M.D.

SurgExperience 105

I have been invited by Jeffrey (Monash Medical Student) to host the next edition of surgexperiences. As Jeffrey puts it, "I am excited. Surgexperiences has traveled from Melbourne, Australia (101, 102), to Mexico (103), then to Mpumalanga, a certain province in South Africa (104). On 30 Sept, it will hit Little Rock, the capital and the most populous city of the State of Arkansas." That's in the USA. [above quilt made by me]
As you can see, it is a new carnival (or grand rounds) focusing on surgical and/or surgery-related blogs. You can send your submissions here or email me directly at the link on the left side-bar. It will be published on September 30th. Please have all submissions in by September 28th. I thank you in advance.


Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Girlfriend

My 14 year old female Labrador, Girlfriend, died today. She had quit eating for a couple of days. [Well, she would still eat hot dogs, but not her dog food.] Not a good sign in a Labrador. So I had taken her to her veterinarian yesterday who discovered that she had a low Hct and bleeding in her abdomen from a splenic tumor. [She had just had her yearly exam in mid-July.] So she was scheduled for exploratory surgery this morning. It was bad. The splenic tumor (Canine Hemangiosarcoma) had seeded metastasis all over her abdomen. Her liver was nearly destroyed due to mets. Bill (Dr. Ormsby) called me to give me the news. I asked if I could come and be with her as he gave her the euthanasia injection, and that is what we did. I guess it was a "good death" for her. She was surrounded by people who loved and cared for her.

All this going on and she had never whimpered, never complained. Even Monday evening she had wanted to go on our daily walk which I let her do (though I shortened it and really slowed the pace). She continued to shadow me as I went from room to room at home doing chores or just getting something from another room. My husband called her my "six foot radius" dog, because she hated not being with me. She had such heart! I really miss her.

My heart-felt thanks to the good folks

at Town and Country Animal Hospital.

Stahl's Ear

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.



Stahl's ear is a rare congenital auricular malformation in which an abnormal "third crus" traverses the upper pole of the scapha. This results in a deformation that flattens and steers the helical rim posteriorly and superiorly. This deformity was originally described by Stahl in the nineteenth century. It is more prevalent in Oriental societies, especially Japan. It is seen bilaterally in 20% of cases. It is also known as Spock's ear or Vulcan Ear.

In 1889, Binder stated that Stahl's ear has a hereditary tendency; however, this has never been substantiated. There is some evidence that this deformity is caused by an error in the development of the helix and scapha, approximately in the third embryologic month.

In this ear deformity, the main feature is that the free margin of the helix is longer than the outer margin of the auricula, and the helix does not fold in. This situation is just the opposite of the normal ear shape. When the deformity is marked, there is flattening of the helix and significant posterosuperior protrusion of the rim. There is no superior crus, but the inferior crus is usually present. The anomaly can be difficult to correct, and a number of different treatment options have been suggested.

Non-surgical Taping &Splinting

There are some who are able to correct this deformity with splinting and taping.



Neonatal auricular cartilage lacks elasticity. The moldability of auricular cartilage during the prenatal and neonatal periods is believed to be associated with the increased concentration of maternal estrogen. Estrogen relaxes the cartilage, ligaments and connective tissue of the fetus to pass through the birth canal. Ear molding takes advantage of this transient increase in estrogen. Researchers agree that, ideally, correction should be initiated within the first week of life. Early referral is critical. Maternal estrogen decreases within the first six weeks.


Ear molding relies on early splinting for correction of congenital auricular deformities. Splints or ear molds have been fabricated from dental impression materials including vinyl polysiloxane, guttapercha, triad, or thermoplastic material. Surgical tape has been used to secure the splint, obtain the correct helical and antihelical shape, and to position the auricle closer to the scalp. The splint is worn 24 hours a day, with removal and cleaning during bath time. The parents’ compliance with taping instructions is vital to the success of the technique. The duration of splinting ranges from six to 12 weeks. Treatment is completed when the splint can be removed for several days without relapse. Possible complications include skin irritation and ulceration.

Surgical Treatment
For reconstruction, a full-thickness, wedge-shaped (varying from triangular to trapezoidal), third crus excision is needed. Often small triangular excision (one or more) along the rim are needed to narrow the scapha, to prevent a dog-ear deformity and to get an adequate rotation of the helical rim. Full-thickness excisions are made according to the planned drawings. Auricular cartilage is sutured with 5-0 monofilament nylon, and skin is closed with 6-0 monofilament nylon sutures. Gentle pressure dressings are applied to the ears after the operation. Left photo set from 4th reference article, right photo set from 6th reference article)

References

• Plastic Surgery Update, Winter 2006--Children's Hospital of Pittsburgh
• Correction of deformational auricular anomalies by moulding – results of a fast-track service; Swee Tan, Anna Wright, Anna Hemphill, Kari Ashton and Joan Evans; Journal of the New Zealand Medical Association, 12-September-2003, Vol 116 No 1181 (molding technique photos from this article)
• Aesthetic Otoplasty--Wedge Excision of a Flattened Helix to Create a Helical Curl; Peter F. Maurice, MD, MS; Karl J. Eisbach, MD; ARCH FACIAL PLAST SURG/VOL 7, MAY/JUNE 2005
• BILATERAL STAHL'S EAR: A RARELY SEEN ANOMALY.; Plastic & Reconstructive Surgery; 115(1):345-346, January 2005; Tatlidede, Soner M.D.; Gonen, Emre M.D.; Bas, Lutfu M.D.
• The third crus of the antihelix and another minor anomaly of the external ear; Plast. Reconstr. Surg. 58: 192, 1976; Fischl, RA
• A Novel Surgical Method of Repair for Stahl's Ear: A Case Report and Review of Current Treatment Modalities; Plastic & Reconstructive Surgery; 103(2):566-569, February 1999; Kaplan, Hilton M. M.B., B.Ch.; Hudson, Don A. F.R.C.S.

Museum of Bags and Purses

This post is simply on something that fascinates me--bags and purse. There is now a museum in Amsterdam showcases the history of bags and purses. Tassem Museum has a very informative web site. It isn't in English, but you can still enjoy the photos. I have made a few, but they don't compare to these.

Prominent Ear Deformity

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.
 

Prominent ears are relatively common, with an incidence in whites of about 5 percent. It is inherited as an autosomal dominant trait. Despite its benign physical presence, numerous studies attest to the psychological distress, emotional trauma, and behavioral problems this deformity can inflict on children. Names such as Dumbo, Jug Ears, and Wing Nut have been used. Surgeons who treat this deformity must have a thorough understanding of the anatomy of the normal ear and of the prominent ear deformity.

The main anatomical basis of the prominent ear are as follows:
(1) conchal hypertrophy or excess (upper pole, lower pole, or both)
(2) inadequate formation of the antihelical fold (the root, superior crus, inferior crus, or all)
(3) a conchoscaphal angle greater than 90 degrees
(4) a combination of conchal hypertrophy and underdeveloped antihelical fold.Occasionally, conchal excess can be difficult to appreciate. A well-described technique for these difficult cases is to apply medially directed pressure along the helical rim. This maneuver allowsprominent conchal cartilage to be visualized. It is important to note that usually the prominent ear deformity is bilateral; however, Spira et al. point out that the cause of the defect maybe different for each side. Any procedure to correct a prominent ear should therefore address the underlying anatomical defect and attempt to correct it. Clearly, one approach will not work for all clinical presentations. (photo from second reference article)

The history of otoplasty correction surgery begins with Dieffenbach (1845). He is credited with the first otoplasty for the protruding ear (posttraumatic). Ely described his technique for elective correction of the prominent ear in 1881. He performed this as a two-stage procedure (each side performed at a separate sitting). Luckett introduced the important concept of restoration of the antihelical fold. Luckett corrected this deformity by using a cartilage-breaking technique consisting of skin and cartilage excision along the length of the antihelical fold combined with horizontal mattress sutures. Becker, in 1952, introduced the concept of conical antihelical tubing using a combination of cartilage incisions and suture techniques in an effort to soften the contour of the corrected prominent ear. This technique was later refined by Converse in 1955. Mustardé’s (1963) approach to the creation of antihelical tubing was to use permanent conchoscaphal mattress sutures.

The correction of prominent ears should keep in mind McDowell’s basic goals of otoplasty:

1. All upper third ear protrusion must be corrected.

2. The helix of both ears should be seen beyond the antihelix from the front view.

3. The helix should have a smooth and regular line throughout.

4. The postauricular sulcus should not be markedly decreased or distorted.

5. The helix to mastoid distance should fall in the normal range of 10 to 12 mm in the upper third, 16 to 18 mm in the middle third, and 20 to 22 mm in the lower third.

6. The position of the lateral ear border to the head should match within 3 mm at any point between the two ears.

LaTrenta suggests that three common anatomical goals must always be kept in mind: (1) production of a smooth, rounded, and welldefined antihelical fold; (2) a conchoscaphal angle of 90 degrees; and (3) conchal reduction or reduction of the conchomastoidal angle. Georgiade et al. add to this list the importance of lateral projection of the helical rim beyondthe lobule.

Timing of the Otoplasty

The ear is nearly fully developed by age 6-7 years, correction may be performed then. It has been shown by Balogh and Millesi that auricular growth was not halted after a 7 yr followup of 76 patients. Gosain (3rd reference) did a survey which shows that most surgeons still perform otoplasty when the patients are aged 5 years or older. In his prospective series of 12 patients whounderwent otoplasty at age 3 years or younger, recurrence rates remained in a range comparable to those of historical controls in which otoplasty was performed at later ages. No negative effect on subsequent ear growth following either unilateral or bilateralotoplasty was appreciated up to 71⁄2 years postoperatively.He suggests (rightly so in my mind) "that there may be significant psychosocial benefit to early intervention, particularly in light of changing norms for interaction with peers and daycare providers at ages considerably earlier than what had previously been thought of as “school age.”

Surgical Technique
There is a very nice algorithmic approach to otoplasty is given in the article (second reference) by Rohrich, etc. This is the procedure Dr Spira (reference 1, procedure sketch/photo from same article) employs when ear protrusion is caused by incomplete development of the antihelix with some degree of accompanying conchal enlargement, the most common situation encountered.

"With the patient under general anesthesia, full facial and adjacent hair preparation is carried out. Appropriate head drapes are stapled into place, and moist cotton pledgets are used to occlude the ear canals. The scapha is lightly folded onto the concha, and a row of ink marks is made on the anterior ear skin that run from just lateral to the superior portion of the superior crus of the antihelix down to the scapha near the tail of the helix. Two marks are made on the skin within the fossa triangularis for placement of sutures, to reshape the superior crus of the antihelix. An additional row of ink marks, representing the location of the horizontal mattress sutures that will reshape the entire antihelix, is placed just medial to the reformed antihelix in the lateral conchal area. If the concha is large or angulated, as in most cases, another row of marks is made just medial to the markings described above. This row represents conchal suture placement sites between the concha and mastoid periosteum. Two-percent Xylocaine with epinephrine 1:100,000 is lightly infiltrated subcutaneously with a 30-gauge needle, using approximately 1 cc on the anterior and posterior surfaces of the ear and in the postauricular sulcus and mastoid area. The opposite ear is marked in the same way. A 1 1/4-inch 25-gauge needle is lightly scraped on a scratch pad (the kind used to clean electrocautery tips) to remove its silicone coating.

The first ear is then addressed after being reassessed for symmetry. The prepared (abraded) needle is passed through an ink mark from the anterior to the posterior surface of the ear, A cotton-tipped applicator dipped in methylene blue is used to wet the distal end of the needle and its shaft; the needle is then withdrawn, marking the posterior skin and underlying cartilage. The ear is maintained on a light stretch while this marking procedure is carried out, and all previously made ink marks are temporarily tattooed in this fashion.

A 3-mm incision is made just below the eave of the helical rim, where the superior portion of the superior crus of the antihelix ends. The skin of the anterior ear over the proposed site of the antihelix is undermined subcutaneously, using either a Freer or a Cottle elevator. The anterior surface of the ear cartilage, along with the proposed antihelix, is lightly abraded with a Dingman otobrader from the antitragus below to the helical rim above. Care is taken not to extend the "scratch" through the cartilage, to prevent the creation of any sharp angles in the reconstructed antihelix.

Attention is directed to the posterior surface of the ear, where an incision is extended from superiorly near the helical rim above down to the level of the earlobe in a straight line; a minimal fusiform ellipse of the skin of the lobe is incised. It should be noted that skin removal is not planned over the majority of the back of the ear, in contradistinction to most other otoplasty techniques for protruding ears. The skin from the incision over the back of the ear is dissected laterally, almost to the helical rim, with small, curved, blunt-tipped scissors, exposing the methylene blue dye marks in the cartilage. Medial dissection is carried to the postauricular sulcus and then to the mastoid periosteum; the posterior auricular muscle is moved aside with blunt dissection.

A horizontal mattress suture (4-0 white Mersilene on a half-circle, round, noncutting needle) is placed between the upper scapha and the fossa triangularis, crossed once, and lightly tightened to test the positioning and contour of the new superior crus. The suture is left unknotted and long, and it is held together with a short strip of sterile paper tape. Similar horizontal mattress sutures are placed between the scapha and lateral concha and tested but not tied. Four sutures are generally sufficient. Care is taken not to pierce the anterior skin of the ear in the placement of sutures.

Attention is directed to the conchomastoid area. Two or three mattress sutures that are similar to those described above are placed between the concha and the mastoid area, beginning just medial to the concha-scapha sutures and extending through the mastoid periosteum. Tying of these sutures brings the concha closer to the mastoid area and reduces overall projection of the ear.

In cases where the concha is itself very large, and where placement of such a suture would rotate the posterior wall of the external meatus anteriorly and partially obliterate the meatus, a 1-cm-wide, laterally based flap of perichondrium and underlying cartilage is cut and sutured to the mastoid periosteum, as described above, to accomplish the same effect without compromising the external canal. The concha-scapha sutures are then tied, with individual adjustment made in knot position to recontour the main body of the antihelix and the superior crus in a pleasing configuration. Some bowstringing of the sutures will result; the space

created between concha and scapha will subsequently fill with fibrous tissue.

Attention now turns to the earlobe, which, if protuberant, requires a single suture from the dermis on the lateral side of the previously excised fusiform ellipse to the most inferior portion of the concha. One suture is usually all that is needed.

Next, the root of the helix is checked for outward angulation. If this is present and if the earlobe has not been set back, a postoperative "telephone ear" deformity may result. If the angle is too obtuse or if the patient wears glasses, a 4-mm incision in the sulcus, where the root of the helix abuts the scalp, exposes the underlying cartilage and

the deep temporalis fascia. The same type of suture described above is placed between the helical rim and the underlying temporalis fascia; when tied, this should bring the helical rim into a more pleasing position closer to the ear. The wound is irrigated with an antibiotic solution and checked for hemostasis.

No additional skin is excised, and the posterior sulcus is closed with a running suture of 4-0 chromic catgut. Because the postauricular skin is so redundant, care must be taken to ensure an even raw edge-to-raw edge closure. The incision at the root of the helix is closed with interrupted sutures of 4-0 catgut, as is the short incision made beneath the superior eave of the helix for abrasion of the cartilage. Drains are unnecessary.

The opposite ear is then treated surgically. Care is taken to correct for any differences in contour before surgery, and the number and placement of sutures are adjusted appropriately. The head drapes and cotton pledgets placed earlier are removed, and a dressing of inch-wide petroleum jelly gauze is packed into the conchal area and over both the anterior and posterior surfaces of the ear. Several gauze fluffs are placed over the ear, and a mastoidtype dressing is applied. The dressing is always secured with paper tape to the skin of the lateral cheek and forehead."

Complications

Early complications include hematoma, infection, chondritis, pain, bleeding, pruritus, and necrosis.
Late sequelae include unsightly scarring, patient dissatisfaction, suture problems, and dysesthesias.
Hematoma is heralded by the acute onset of severe, persistent, and often unilateral pain. If encountered, the head dressing should be removed and sutures released to drain the hematoma.If there is evidence of ongoing bleeding, reoperation and exploration are mandatory.

Infection is a potentially devastating complication of otoplasty, as it may lead to the development of chondritis and residual deformity. If redness, swelling, and drainage are encountered, treatment with intravenous antibiotics is recommended,as is the use of topical mafenide acetate cream. The usual pathogens are Staphylococcus, Streptococcus, and sometimes Pseudomonas.

Chondritis is a surgical emergency. If left untreated, it can result in deformity. Therefore, prompt débridement of devitalized tissue is necessary.
Residual deformity is, by far, the most common unsatisfactory result of otoplasty. It usually is apparent by 6 months postoperatively. It is manifested by one or more of thefollowing: a sharply ridged antihelical fold; lack of normal curvature of the superior crus; irregular contouring; a malpositioned or poorly constructed antihelical roll; an excessively large scapha; and a narrow ear.

Telephone Ear Deformity refers to relative prominence of the upper and lower poles. Reoperation is the only means of correction. Reverse telephone ear deformity occurs when the upper and lower thirds of the ear are set back and the antihelix and concha protrude.

References

• Otoplasty: What I Do Now-A 30-Year Perspective; Plastic & Reconstructive Surgery, 104(3):834-840, September 1999; Spira, Melvin M.D.
• Otoplasty; Plastic & Reconstructive Surgery, 115(4):60e-72e, April 1, 2005; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.; Gutowski, Karol A. M.D.
• Prominent Ears in Children Younger than 4 Years of Age: What Is the Appropriate Timing for Otoplasty?; Plastic & Reconstructive Surgery. 114(5):1042-1054, October 2004; Gosain, Arun K. M.D.; Kumar, Ajay M.D.; Huang, George M.D.
• Ear, Prominent Ear by Samuel J Lin, MD--eMedicine Article (very nice article)
• Ear Surgery, Otoplasty--American Society of Plastic Surgeons

Hummingbirds

I have been enjoying the hummingbirds this weekend. There have been up to a dozen at the feeders at times, mostly 4-6. I have refilled the feeders daily, as they empty them. I have had difficulty getting any decent photos of them. This is one (it's okay, not great). My brothers tell me that I should not keep my feeders out after Labor Day, but I feel like the birds know when to migrate and that they need the nourishment along the way.

The Audubon Society agrees: "Put up hummingbird feeders to provide sugar water as supplemental food, which is especially critical during the fall and winter, when the birds are migrating."

Flowers are the natural way to attract hummingbirds to your yard, but I am not a good enough gardener to have flowers this late in the season. So I need to use a man-made feeders filled with a mixture of water and ordinary table sugar (sucrose). Sugar, whether from a flower or a feeder, is essential for a hummingbird's diet. It provides the quick fuel for flight that it needs during waking hours; it is not "junk food." Human metabolism is not comparable to hummingbird metabolism (don't I wish it were)! Hummingbirds also eat insects and tiny spiders to provide protein for their diet (well, I'd rather have a steak for protein than spider).

A good formula for hummingbird food: 4 parts water to 1 part sugar (so 1/4 cup sugar to 1 cup water). The water should not be distilled, just use tap water. The sugar should be white table sugar. Do not use artificial colors (red dye does NOT help attract hummingbirds) or other additives. Never use honey or artificial sweeteners, for to do so may kill the birds. The ingredients can be mixed using cold water.

Any mixture of sugar and water will ferment and can host the growth of mold spores and/or bacteria. Because of this, the mixture must be discarded regularly (if not eaten by the hummingbirds) to avoid these problems. In moderate temperatures, such as 60-85 degrees F. (15-30 degrees C.) a mixture should last about 3 days. It will need to be changed more frequently at higher temperatures and less often at cooler temperatures. Regardless of the mixture's age, discard it immediately if you see cloudiness or you see mold growing in the feeder. Always clean a feeder thoroughly before refilling; do not "top off" a feeder which is low in mixture. Clean with warm water and detergent, and rinse very thoroughly.

other things amanzi: surgexperiences 104

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

other things amanzi: surgexperiences 104
It's up! Link over there for some good reading!

I have been invited by Jeffrey (Monash Medical Student) to host the next edition of surgexperiences. It is a new carnival (or grand rounds) focussing on surgical and/or surgery-related blogs. You can send your submissions here or email me directly at the link on the left side-bar. It will be published on September 30th. Please have all submissions in by September 28th. I thank you in advance.

Constricted Ear Deformity

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.
 

The constricted ear includes a spectrum of auricular anomalies in which the rim of the ear appears as if it has been tightened with a purse-string. Terms often used to describe this deformity include log ear, lidded helix, cup ear, canoe ear, and cockle shell ear. Significant constriction of the ear constitutes fewer than 10% of all ear anomalies in the United States, but very mild forms are so frequent as to be considered a normal variant. Scapha compression and mild helical lidding appear in 2-5% of a randomly examined clinic population. The incidence is 10-15% in blacks. (these photos from last reference article)

The four features of the completely developed anomaly are

• Lidding of the helix
• Compression or narrowing of the scapha and fossa triangularis with decreased ear size
• Protrusion of the ear
• Low ear position

A lop ear is a malformed auricle in which the characteristic major deformity is an acute downward folding and/or deficiency of the helix and scapha, usually at the level of the tuberculum auriculae (Darwin's tubercle). The deformity is associated with a malformed antihelix, usually at the superior crus.

A cup ear is essentially a malformed, protruding ear combining characteristics of both a lop ear and a prominent ear. Typical features are 1) an overdeveloped, deep, cup-shaped concha, 2) a deficient superior part of the helical margin and antihelical crura, and 3) apparently small vertical height. The body of the antihelix is often wider than normal, and whether it is unfolded or fully developed tends to exaggerate the cupping deformity. In some cases the helical margin or helical fold drapes forward and over the scapha like a hood.

Tanzer's Classification of Constricted Ears
Type I--Helical involvement only
Type IIA--Involvement of the helix and scapha, with no supplemental skin needed
Type IIB--Helical and scaphal involvement, with supplemental skin needed at auricular margin
Type III--Extreme cupping deformity with involvment of the helix, scapha, antihelix, and conchal wall (Some, like Cosman, dismiss this group as forms of microtia.)

The goals of surgical correction should include obtaining symmetry and correcting the intra-auricular anatomy. The degree of intervention is based on the severity of the deformity and may range from simple repositioning, soft tissue rearrangement, or manipulation of the cartilage. Correction of Type I involves detaching the folded helix and reattaching it in an upright position. Correction of Type IIA involves adjusting the anterior helix, filleting the deformed helix and scapha, and reconstructing the upper pole of the ear with "banner" flaps of cartilage. Correction of Type IIB involves using a skin flap from the medial surface of the ear and various methods for expanding the ear cartilage. (photos from next to last reference article)

Sometimes surgical correction (with Type I or Type IIA) can be avoided by splinting during the early neonatal period. Good results have been reported in up to 85% of the patients when the treatment is continuous over the entire 4-week period. However, when treatment is partial or discontinuous, only 10% will have good results. Early initiation of treatment has proven to be more effective than later treatment. Strong parental cooperation and close follow-up are also important for success.
References

• Ear Constriction Deformity and Otoplasty Ear Plastic Surgery--Dr. Michael Bermant's website
• Non-surgical correction of a congenital lop ear deformity by splinting with Reston foam; Br J Plast Surg. 1982 Apr;35(2):181-2; Kurozumi N, Ono S, Ishida H.
• Splinting Therapy for Congenital Auricular Deformities with the use of Soft Material; J Perinatol. 1995 Jul-Aug;15(4):293-6; Merlob P, Eshel Y, Mor N
• Nonsurgical Correction of Congenital Auricular Deformities in Children Older than Early Neonates; Plastic & Reconstructive Surgery. 101(4):907-914, April 1998; Yotsuyanagi, Takatoshi M.D., Ph.D.; Yokoi, Katsunori M.D., Ph.D.; Urushidate, Satoshi M.D.; Sawada, Yukimasa M.D., Ph.D
• The Constricted Ear; Clin Plast Surg. 2002 Apr;29(2):289-99, viii; Paredes AA Jr, Williams JK, Elsahy NI
• Technique for Correction of Lop Ear; Plastic & Reconstructive Surgery. 85(4):615-620, April 1990; Elsahy, Nabil I. M.D.
• A Method of Treatment of Constricted Ears with a Conchal Cartilage Graft to the Posterior Auricular Plane; Plastic & Reconstructive Surgery. 92(4):621-627, September 1993; Ono, Ichiro M.D.; Gunji, Hironori M.D.; Sato, Morihiro M.D.; Kaneko, Fumio M.D. (photos of technique from this article)
• 5-Year Series of Constricted (Lop and Cup) Ear Corrections: Development of the Mastoid Hitch as an Adjunctive Technique; Plastic & Reconstructive Surgery. 102(7):2325-2332, December 1998; Horlock, N. F.R.C.S.; Grobbelaar, A. O. M.Med.(Plast.), F.C.S.(S.A.), F.R.C.S.(Plast.); Gault, D. T. F.R.C.S. (photos of spectrum from this article)

Microtia

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.



I have not seen any microtia cases in my practice. Most of these, appropriately so, are sent to Children's Hospitals so that a team (ENT, Plastic Surgeons, Audiologist, Speech Therapist, etc) can take care of them. I do find it amazing that this reconstruction can be done so well by those like Dr. Charles Thorne who has a great website on Microtia. I suggest you visit his site.

Severe forms of microtia most likely represent arrests in embryonic development occurring at approximately 6-8 weeks of gestation. Less extreme forms are likely the result of embryonic accidents at a later stage, around the third month of fetal development. Even with extremely small microtic remnants, a lobular component is almost always present, although vertically oriented and superiorly displace. Anotia, the severest of ear deformities, is extremely rare and represents complete failure of development.

The incidence of microtia varies with the extent of the deformity. Severe abnormalities occur in approximately 1 in 7000 to 1 in 8000 births. The occurrence is estimated to be 1 in 4000 for Japanese and as high as one in 900 to 1200 in Javajo Indian. Microtia is nearly twice as likely in male as in females. The right-to-left-to-bilateral ratio is 5:3:1. Ear deformities frequently occur in families of patients with mandibulofacial dysostosis (Treacher Collins syndrome). Many patients with microtia have evidence of the first and second branchial arch syndrome (craniofacial microsomia). In previous studies it is thought that this is multifactorial and there is approximately a 6 % risk of recurrence in first degree relatives.

In 1977 Tanzer proposed a clinical classification of auricular defects which is often used in publications since that time. He classified the congenital ear defects according to the approach necessary for their surgical correction.

I. Anotia
II. Complete hypoplasia (microtia)
A. With atresia of external auditory canal
B. Without atresia of external auditory canal
III. Hypoplasia of middle third of auricle
IV. Hypoplasia of superior third of auricle
A. Constricted (cup or lop) ear
B. Cryptotia
C. Hypoplasia of entire superior third
V. Prominent ear

The term aural atresia refers to the absence of the ear canal. Patients who have microtia usually, but not always, also have aural atresia. Patients who have aural atresia have no hearing on that side but usually have completely normal hearing in the normal ear. Patients who lack the ear canal also have structural abnormalities of the middle ear with absence of the eardrum and incomplete formation of the small middle ear bones, which allow conduction of hearing through the middle ear. Microtia and aural atresia tend to occur together because the outer ear and the middle ear evolve from a common embryologic origin.

"In most patients the only issue which should be addressed early in childhood is an evaluation of the hearing. At What Age Is the External Ear Reconstruction Initiated? This is an important question, which is undergoing some evolution. Up until recently, surgical reconstruction of the outer ear was recommended beginning at the age of six years. At this age the patients were thought to have sufficient cartilage in the rib cage to allow reconstruction of the ear. As surgical techniques have improved, however, it is clear that a better quality, more detailed, ear reconstruction is possible when the surgery is delayed to after the age of ten years. "--Dr. Charles Thorne

There are four elements needed to create the appearance of a "real" ear--a flaplike shape, a helix, a concha, and a lobule. A lack of these essential elements cannot be made up by the addition of small details. Position is also of prime importance. Three key dimensions of correct position include 1) the inclination of the long axis of the pinna, 2) the level on the face (high or low), and 3) the distance from the orbit.

A variety of surgical strategies have been devised for the reconstruction of the external ear. The stages depend largely on the severity of the patient’s deformity; the size, position, and quality of the microtic elements; and the surgeon’s preference. Tanzer advocated a four-stage reconstruction. In the first stage, the lobular remnant was transposed transversely to its correct anatomic position. In the second stage, costal cartilage from the sixth, seventh, and eighth contralateral ribs, was implanted beneath the mastoid skin, using a V-shaped postlobule incision. The sixth and seventh costal cartilages were used for the base and antihelix, and the eighth costal cartilage became the helical rim. The carved cartilage elements were coapted with fine-gauge wire. In the third stage, the construct was elevated from the head by advancement of postauricular skin and placement of a retroauricular, full-thickness skin graft. The concha and tragus were later (fourth stage) created with composite contralateral ear and skin/cartilage grafts. Tanzer later modified this sequence by combining the lobular transposition and placement of the cartilage framework into one stage, prefacing this modification with the admonition that if extensive mobilization or surgical manipulation of the lobule is necessary, it is best to use four separate stages to avoid vascular compromise of the lobular element.

Brent uses a three-stage or four-stage technique, similar to that of Tanzer, although with a slightly varied sequence. In the first stage, a pattern for the construct is made by placing a piece of x-ray film against the normal ear and tracing its anatomic landmarks. The template is then reversed and made several millimeters smaller throughout to accommodate for the thickness of the skin cover. The lobular component is altered depending on the quality and amount of residual lobular tissue. Lobule transposition is the second stage in Brent’s technique. He believes it is safer and easier to position the lobular remnant around an established construct. This stage is performed several months after the initial cartilage grafting.The lobule is rotated and often filleted to receive the end of the framework. The construct is elevated in the third stage to achieve projection of the helical rim. The ear position is stabilized by placing a piece of banked costal cartilage posteriorly beneath the framework in a fascial pocket. The retroauricular scalp is then advanced to minimize visible scarring. The remaining postauricular defect is closed with a “medium-thick” split-thickness skin graft. Tragus construction, conchal excavation, and symmetry adjustment are performed in the fourth stage. The tragus is formed using a composite skin/cartilage graft from the contralateral conchal vault through an anterior approach.

Nagata’s technique involves two stages. It was first introduced in 1993 and has undergone several possible technical refinements, depending on the type of microtia present (ie lobular, small concha, anotia, low hairline).In the first stage, the rib cartilage framework, which incorporates a tragal component, is placed in a subcutaneous pocket and the lobule is transposed. This first stage thus roughly corresponds to the first three stages in Brent’s sequence. Nagata uses the skin of the posterior lobule and mastoid to cover the conchal aspect of the construct. By converting the V-shaped posterior lobule incision used by Tanzer into a “W,” he also increases the surface area of skin available to cover the framework. Six months later the second stage is done. The construct is elevated and symmetry adjustments made.

Complications arising from surgical efforts to reconstruct the external ear may occur both at the ear reconstructive site and at the donor sites for tissue harvest. The complications associated with costal cartilage harvest include the immediate problems of the pneumothorax and atelectasis and the delayed issues of chest wall deformity and scarring. Complications at the ear reconstruction site include exposure of the cartilage framework due to overlying skin flap necrosis. This can be devastating to the reconstruction and may necessitate the complete removal of the framework. In cases of flap compromise, early intervention is mandatory for salvage of the reconstruction. More commonly, small areas of skin loss (less than 1 cm) may be dealt with conservatively with topical and systemic antimicrobial therapy, allowing the area to granulate and heal by secondary intent. Infection is not a common complication (0.5 percent), but it may stem from either construct exposure or pathogens in the vestigial external ear canal. As such, careful assessment of any pathologic findings in the middle ear, such as otitis or cholesteatoma, and preoperative cleaning of the canal are imperative. Hematoma is an infrequent complication (0.3 percent), but its occurrence can have devastating consequences. Long-term complications in the reconstructed ear primarily relate to extrusion of suture material and resorption of the cartilage framework, which may alter the shape and form of the auricular components.

Recent advances in implantology and prosthetic materials have lead to excellent results using osseo-integrated anchoring devices and ear prostheses. The weak link in this technology lies in the quality of the prosthesis itself, the lifelike appearance of which is wholly dependent on the artistry and skill of the anaplastologist. Patients undergoing this approach have been generally quite satisfied with the prostheses and wear them daily and for prolonged periods without difficulty.

References

• Surgical Procedures of the External Ear Canal and Ear; Dept. of Otolaryngology, UTMB, Grand Rounds; May 5, 1993; Kathleen McDonald M.D., Jeff Vrabec M.D., Melinda McCracken, M.S.
• Total reconstruction of the auricle: The evolution of a plan of treatment; Plast. Reconstr. Surg. 47: 523, 1971; Tanzer, R. C.
• Autogenous Rib Cartilage Reconstruction of Congenital Ear Defects: Report of 110 Cases with Brent's Technique; Plastic & Reconstructive Surgery. 104(7):1951-1962, December 1999; Osorno, Gabriel M.D.
• Auricular Reconstruction: Indications for Autogenous and Prosthetic Techniques; Plastic & Reconstructive Surgery. 107(5):1241-1251, April 15, 2001; Thorne, Charles H. M.D.; Brecht, Lawrence E. D.D.S.; Bradley, James P. M.D.; Levine, Jamie P. M.D.; Hammerschlag, Paul M.D.; Longaker, Michael T. M.D.
• Auricular Reconstruction for Microtia: Part II. Surgical Techniques; Plastic & Reconstructive Surgery. 110(1):234-251, July 2002; Walton, Robert L. M.D.; Beahm, Elisabeth K. M.D.
  
• Refinements in the Elevation of Reconstructed Auricles in Microtia; Plastic & Reconstructive Surgery. 117(7):2414-2423, June 2006; Tai, Yoshiaki M.D.; Tanaka, Shinsuke M.D.; Fukushima, Junichi M.D.; Kizuka, Yuichiro M.D.; Kiyokawa, Kensuke M.D.; Inoue, Yojiro M.D.; Yamauchi, Toshihiko M.D.

Dream Weavers Quilt

The image on the left was torn from an issue of Western Interiors magazine. The basket is a Hosig Di basket from the Wounaan and Embera people of Panama's Darien Rainforest. The article says the baskets are available through Rainforestbaskets.com.

I really liked the design and thought I would try to make a quilt using it. I did the sketch on the right. Designed it for a 50X70 inch quilt. It is machine pieced and quilted. It will be given to the Quilts of Valor Organization.

View of Full Quilt, 50 X 70 inches


Detail showing the quilting.

External Ear

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.



Reading Dr Rob on the physical exam of the ears, I noticed that there are a couple of young men who could use a setback otoplasty. But before we get to that procedure and other ear reconstruction procedures, let's start with the anatomy.

The external ear consists of the expanded portion which is called the auricula or pinna, and the external acoustic meatus (ear cannel). The pinna projects from the side of the head and serves to collect the vibrations of the air by which sound is produced. The ear canel leads inward from the bottom of the auricula and conducts the vibrations to the tympanic cavity.

The auricula is of an ovoid form, with its larger end directed upward. Its lateral surface is irregularly concave and directed slightly forward. The prominent rim of the auricula is called the helix. In the region where the helix turns downward, a small tubercle, Darwin's tubercle, is frequently seen. Another curved prominence, parallel with and in front of the helix, is called the antihelix; this divides above into two crura (leg-like part), between which is a triangular depression, the fossa triangularis (triangular fossa). The narrow-curved depression between the helix and the antihelix is called the scapha. The antihelix describes a curve around a deep cavity, the concha. In front of the concha, and projecting backward over the meatus, is a small pointed eminence, the tragus, (from the Latin tragos, goat). Opposite the tragus, and separated from it by the intertragic notch, is a small tubercle, the antitragus. Below this is the lobule, composed of tough areolar and adipose tissues, and wanting the firmness and elasticity of the rest of the auricula.

The backside (cranial surface) of the auricula presents elevations which correspond to the depressions on its front (anterior surface) and after which they are named, e. g., eminentia conchæ, eminentia triangularis, etc.

The cartilage of the auricula consists of a single piece. It provides the form to the external ear. It is absent from the lobule. It is also deficient between the tragus and beginning of the helix, the gap being filled up by dense fibrous tissue. The posterior (cranial) aspect of the cartilage exhibits a transverse furrow, the sulcus antihelicis transversus, which corresponds with the inferior crus of the antihelix and separates the eminentia conchæ from the eminentia triangularis. The skin is thin, closely adherent to the cartilage, and covered with fine hairs furnished with sebaceous glands, which are most numerous in the concha and scaphoid fossa.

Sensibility of the normal external ear is derived from several cranial and extracranial nerves. Cervical nerves (the great auricular nerve, C2 to C3) and the lesser occipital nerve (C2) innervate the posterior aspect of the auricle and lobule. In the majority of dissections, the lesser occipital nerves have been found to be dominant and innervate the superior ear and the mastoid region, whereas the inferior ear and a portion of the preauricular area are supplied by the great auricular nerve. The anterior surface and the tragus are supplied by the trigeminal nerve (auriculotemporal nerve V3). The auricular branch of the vagus nerve (Arnold’s nerve) provides sensibility to the external auditory meatus.

Two separate but intercommunicating arterial networks to the external ear are formed from the external carotid system. One network supplies the triangular fossa-scapha, and the other supplies the concha. The triangular fossascapha network is derived from one subbranch of the upper auricular branch of the superficial temporal artery and from branches of the posterior auricular artery, which come through the earlobe and triangular fossa and over the helical rim. The conchal network is derived from perforators (usually two to four vessels) of the posterior auricular artery. The superficial temporal artery also sends several small auricular branches to supply the anterior surface of the ear. The rich communications between the superficial temporal and postauricular arterial systems allow for either system to support the ear. Venous drainage flows through the posterior auricular veins into the external jugular, the superficial temporal, and the retromandibular veins.

The relationships, dimensions, and proportions of the external ear have been thoroughly reviewed by Tolleth. At birth the ear is the same size in both sexes, but by the end of the first year boys' ears are larger than girls'. The full width of a boy's ear develops by age 13 and the full length by age 15. In girls, width is complete at age 10 and length at age 13. Ear width is approximately 55 percent of length. The long axis of the ear is tilted posteriorly from the vertical axis of the face at an angle ranging from 2-30 degrees. The axis of the ear and the nasal bridge, although similar, are not identical. The angle between them approximates 15 degrees, with the ear more vertical. The helical rim protrudes 1 to 2 cm from the skull, with the projection increasing from superior to inferior. In a normal ear, the rim is positioned 10 to 12 mm from the mastoid at the superior helix, 16 to 18 mm from the mastoid at midear, and 20 to 22 mm from the mastoid in the lower third. Although these measurements are most commonly used as a reference in setback otoplasty to avoid the classic
“telephone” deformity, they must also be carefully assessed and reproduced for an anatomically correct ear reconstruction in patients with microtia.

References

• Grey's Anatomy, The External Ear (both photos from this link)
• Core Curriculum Syllabus: Review of Anatomy - Temporal Bone and Ear--Baylor College of Medicine
• Auricular Reconstruction for Microtia: Part I. Anatomy, Embryology, and Clinical Evaluation; Beahm, Elisabeth K. M.D.; Walton, Robert L. M.D.; Plastic & Reconstructive Surgery. 109(7):2473-2482, June 2002.
• Artistic anatomy, dimensions, and proportions of the external ear.; Tolleth, H; Clin. Plast. Surg. 5: 337, 1978.