Monday, September 17, 2007

Prominent Ear Deformity

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. Mustard√©’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.

(Photos from first reference article)

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."

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.

  • 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
  • After prominent ear correction (Looking after your child at home)--Information Leaflet by Birmingham Children's Hospital


Sid Schwab said...

A highly informative post; lots of work on your part. Otoplasty, it would seem, is one of the more creative and artistic endeavors in a plastic surgeon's bag of tricks.

Val said...

Have you noticed Steven Colbert's right ear? He needs your help, Ramona. :)