Acquired Ear Defects

Four main mechanisms causing defect

1)trauma

2)tumor

3)hematoma/infection

4)Burns – frostbite/thermal

Cancer of the external ear

SCC 60% of ear malignancy and BCC 40 % melanoma – 5-10%
Tumours of the ear tend to be aggressive with SCC having the highest rate of recurrence on the ear (5-18%)

Location-

Helix- 60%
Remaining found in the antihelix, triangular fossa, concha, posterior auricular skin

Surgical Rx better than rads for ca of the ear with large series high recurrence rate with rads

Mets

Nodal involvement with primary SCC of the ear are 5-20%

Drainage follows embryology
On Anterior surface:

1)Superior 1/3rd to parotid nodes

2)Posterior 2/3rd to superficial and deep cervical lymph glands

On posterior surface
Mastoid and retroauricular nodes in addition to cervical nodes

Trauma

Principles of management of the acutely traumatised ear

1)clean and minimal debridement

2)begin at known structures and progress to unknown

3)close skin and delay reconstruction

4)repair primarily after wedge excision if the wound is small and peripheral

5)when immediate closure not feasible -> regular dressings as ear has remarkable ability for secondary epithelialization

6)skin graft only if perichondrium intact

7)reattach small avulsed pieces as composite grafts especially in kids

Human bites most common mechanism
most common organisms are S aureus, Eikenella corrodens, Haemophilus influenzae, and beta-lactamase-producing oral anaerobic bacteria species.
Dog bites - Pasteurella multocida and Staphylococcus aureus are the most common aerobic organisms
Cat bites - P multocida is the most common pathogen in infected cat bite wounds.

Hematomas

Occur in blunt trauma to the ear when blood accumulates between the cartilage and the perichondrium presenting as a fluctuance over the ear with bluish discolouration
These should be drained with copious irrigation with incision designed to be hidden in the scapha.
Once the hematoma is drained the skin an perichondrium should be coapted to the underlying cart frameworkwith tie over sutured to prevent recurrent fluid accumulation below the perichondrium which may servea nidus for further cartilage formation leading to a loss of definition of the auricles cartilage frame work and creating a “cauliflower ear”

Frostbite

Frostbite
Below -7C the sensibility of the exposed tissue is diminished
Frost bite occurs when the exposed tissue has actual freezing of ECF with ice crystal formation

The key points in mx are

1)Rapid rewarming with sterile water soaked gauze 38-42C

2)Avoid further trauma injury to tissue

3)Use of topical Abs

The rewarming is painful and requires analgesia
No tissue should be debrided initially until wound is fully demarcated

Burns

Ears involved in 90 % of facial burns
Superficial andSPT cleansed and treated with topical abs
Deep PT and FT treated with mafenide (sulfamylon)ointment
Avoid further injury with pressure care etc
Ear usually allowed to heal with recon delayed
May need early debridement and ssg to avoid severe deformitie
Common but catastrophic complication of auricular burn injuries is suppurative chondritis of the auricle, observed in 25% of patients with facial burns
This complication is seen 3-5 weeks following the burn and is impossible to predict.
It presents as a dull pain gradually increasing in severity and refractory to opioid analgesics.
The ear appears erythematous, warm, and swollen, with exquisite tenderness.
Causative pathogens are of mixed flora, with Pseudomonas aeruginosa present in 95% of incidents.
The use of prophylactic Sulfamylon cream has decreased the incidence of chondritis from 29-19% of auricular burn cases.
Once diagnosed, suppurative chondritis can be treated with the local instillation of gentamicin, neomycin, and polymyxin antibiotics 2-5 times per day.

Suppurative chondritis

earlier the complication is recognized and treated, the greater the likelihood of successful results.
Still, even with early and appropriate treatment, the extent of the ultimate ear deformity is unpredictable.
When suppurative chondritis is diagnosed, immediate incision and drainage of the abscess is done.
The location of the drainage incision is selected carefully so as not to compromise future reconstruction.
Place drainage incision in the scapha parallel to the helix. Additional incisions, if needed, may be made in the posterior auricular sulcus.
Planning the incisions allows for the maintenance of an adequate blood supply to the helical skin, a consideration of major importance for future reconstruction.
Sulfamylon or saline soak dressings are then applied to the ear and are changed every 8 hours.
Pressure dressings are carefully avoided around the infected ear
Systemic antibiotics do not seem to influence the course of infected ears, but they are widely used in the acute phase.
Transdermal iontophoretic antibiotic drug delivery is highly effective and is considered the treatment of choice by some centers.
Débridement of necrotic cartilage is indicated relatively early. There is no sharp demarcation between necrotic and viable cartilage, and one should always be conservative during the initial débridement. Often, a second or third débridement will be necessary if the infection spreads into the remaining cartilage.
It is not until the acute infection is completely eliminated that the plans for reconstruction begin - usually wait for 6 to 9 months.

Reconstruction of the ear can be divided into segmental site of loss and the reconstruction planned accordingly

Cutaneous defects

The presence of supple and well vascularized skin is essential for ear recon
As the skin over the ear is tightly adherent to the surface there are few instances when the skin and subcut tissue are lost and the perichondrium is alive

Partial thickness loss of the ear can be treated with

1)wedged resection and closure

2)local flaps

3)excision of the cartilage and skin grafting the opp cutaneous surface

4)open treatment and healing by secondary intention

Flaps may be pre or post auricular and may be axial or random pattern and may be used in a crane principle

Where the amputated part is of satisfactory condition:

Composite defects <1.5cm may be sutured back as a graft.
Requirements for a successful reattachment of a composite graft include cooling of the severed part during transport, reattachment within 2-2.5 hours of injury, and strict atraumatic technique during reimplantation.
Use of corticosteroids has been shown to significantly enhance composite graft survival in some studies.
For larger defects, consider the pocket principle

Composite defects

May require cartilage support
Unlike congenital defects, usually harvested from the same or the opposite ear. Ear cartilage probably warps less and resists trauma better than rib cartilage not required -

Marginal defects

Small defects

Small defects of the helix may be closed by wedge resection or as a modified star excision
Wedge becomes less desirable when the defect size is greater than 15mm as this results in a small auricle , buckling and distortion of the remaining cartilage framework
For larger defects the proper relation between the peripheral and central defects should be restabilised with an increase in the peripheral tissue and decrease in the central tissue

This principle underlies the three main techniques for reconstruction of larger peripheral defects

1)the Antia –Buchchondrocutaneous helical rim advancement

2)tunnelled procedure by converse

3)tubed pedicle

Chondrocutaneous advancement flap (Antia and Buch PRS 1967)

Single staged procedure free the helix from the scapha via an incision in the helical sulcus extending thru the anterior skin and cartilage
The post medial skin superficial to the perichondrium is undermined and the helix is advanced as a chondro-cutaneous component based on the posterior skin flap
The cephalic component is elevated on a pre-auricular and rotated backward into the defect in a V-Y fashion
The ear will appear smaller and may need a wedge resection of the other ear to match the size
Technique works equally well for reconstruction of the upper and middle 1/3rd helical rim
For smaller defects, only the caudal segment needs to be advanced.
Limitation : As the helical defect reaches 25-30 mm in length significant distortion occurs thus not good for lesions greater than 3cm

Modifications for conchal scaphal defects

Modification by Swee Tan (PRS 1999)

chondrocutaneous "horns" on each side of the defect are removed preserving posterior perichondrium and skin
best used when the defect extends into the scaphoid fossa

Another option in the management of helical-scaphal defects is to combine an Antia-Buch procedure with a postauricular pull-through flap.
This technique results in a sinus tract between the anterior and posterior aspects of the ear which is of little cosmetic or functional concern.
Fata (PRS 1997)
designed primarily for marginal lesions extending beyond the helix in which wound dimensions exceed the limits of wedge excision and primary closure

Converse Tunnel flap

For defects30 –35mm, a staged procedure is required
Margins of the defect are opened and parallel incisions are made in the retroauricular skin overlying the mastoid
The flap then sutured to the ear
A tunnel is created and a costal cartilage graft place and sutured to the margins of the ear
The edge of the auricular defect is sutured to the mastoid skin incision, effectively burying the cartilage graft for 2-3 months.
At the second stage, the retroauricular skin is elevated with the cartilage graft and this is then folded over the cartilage graft to complete the reconstruction
Secondary defects are skin grafted
This procedure allows reasonable reconstruction of larger defects of the helical rim and scapha and does not lead to diminution of the ear size

Tubed Pedicle

Consider distal tube if local skin not available ie from supraclavicular skin

Technique

Three stages all 2-3 weeks apart. Reconstruction with a tube pedicle is an excellent technique when adjacent skin is available

Stage I

The defect is measured ad a bipedicled flap outlined on the mastoid skin
The anterior margin being adjacent to the auricular cephalic sulcus
The length of the flap is that of the defect with an additional 0.5cm at each end to allow for shrinkage during transfer
The width of the flap is 1.5 –2.0 cm depending on the thickness of the helical rim to be reconstructed
Flap raised at the level of the subcut tissue taking care to preserve the subdermal plexus
Length width ratio in this area is 3-6 to 1
The flap is tubed and the donor skin closed directly

Stage 2

The caudal limb of the tubed pedicle is divided and the inferior margin of the defect is minimally pared
The pedicle is then inset for 1-2 cm incorporating a V-Y on thelimb to prevent notching
The donor is closed directly
The cephalic portion is divided and the tube openedalong its length to allow inset

Mastoid flap

A similar technique based on a post auricular mastoid flap transferred to the helical defect leaving an exposed area posteriorly
The contour of the flap is then reconstituted as the raw surface of the flap heals and tubes on itself. The advantage is that the flap creates a natural thin helix which is difficult with the tubed pedicle flap

Pocket Principle

When the severed part is available in good condition and the post auricular skin undamaged the ideal salvage procedure is the pocket principle

Dermabrade the detached part – anterior and posterior
Reattach it in its correct anatomic position,
Bury it under a layer of postauricular skin in the subcutaneous tissue.

The ear is then inserted with traction sutures on the helical rim to help flatten and stretched out the segment for better contact with the side of the pocket
Remove the segment from the pocket after 10-14 days
Dermadrabed portion will reepithelialise spontaneously if removed from the pocket before 3 weeks.

Non-marginal defects

Usually post tumor excision
Grafts most commonly used
Other methods – posterior pull-through flap, postauricular flaps

Posterior pull through flap

Postauricular chondrocutaneous island flap. Vessels identified by transillumination or Doppler (Ohsumi PRS 1995)

Upper third reconstruction

Important functional use - for the use of glasses

Antia-Buch chondrocutaneous advancement flaps

Small helical rim defects

Cephaloauricular flap (Crikelair 1956)

Intermediate sized defects are reconstructed with a superiorly or inferiorly based cephaloauricular flap (extended mastoid flap) - described by Crikelair

Conchal cartilage graft (Adams 1955)

Reconstructed with contralateral concha cartilage grafts
The cartilage graft needs to be anchored to the remnant of the helical root by a suture and then covered with a post auricular flap
If not enough skin is available adjacent to the defect to cover the graft then a compound pedicle flap is an alternative

Davis Conchal transposition flap (Davis 1974)

Entire conchae can be raised based as a composite flap based on a small anterior pedicle of the helical crus

Variation by Park – based on posterior auricular artery – either inferiorly or posteriorly based

Compound pedicle flap (Orticochea)

Best for upper and middle 1/3rd defects

First stage

A compound flap is outlined containing the external anterior skin, cartilage and the retroauricular skin
The pedicle of this flap is outlined on the outer border of this flap situated on the outer border of the helix and has to be 1 cm wide
The pedicle composed of the skin of the external edge and of the anterior and posterior aspects of the helix and the scapha
The cartilage is cut inside the pedicle to allow easier rotation of the flap
The flap is rotated from the concha to the place to be reconstructed and skin sutured
The donor area is grafted

Second stage

The helix is corrected first by adjustment of the pedicle
The lobule is pulled downward to make the auricle the same length as the opposite side
For this an incisions made along theedge of the lobule cutting the cartilage and allowing the lobule to descend

Superficial mastoid fascial flap (Yoshimura 1998)

Combination of a postauricular skin flap transferred anteriorly with a mastoid fascial flap for the posterior surface, and these two flaps are then used to sandwich a fabricated costal cartilage framework

Middle third reconstruction

Minor defects

reducing flaps (ie Antia Buch)
Wedge excisions

Larger defects

Mastoid flap
Converse tunnel flap

Lower third reconstruction

Reconstruction of the lower third defect that have more than lobule are a challenge as they need to have cartilage and the lobule
Complex lower 1/3 defects may require reconstruction with a modified “valise handle” technique (Brent).
Multistaged procedure
contralateral conchal cartilage buried in mastoid – used later to reconstruct inferior antihelical fold. Posterior surface is skin grafted
Tubed pedicle is used for helical rim

Ear lobe deformities

Traumatic clefts are the most common acquired defects of the lobe
Pardue describes a technique that permits the continued use of earrings after repair of the cleft. A tiny flap of adjacent skin is rolled into the superior aspect of the cleft and the torn edges are excised and reapproximated.
Wedge excision – often complicated by a notch at the margin
Z plasty – to avoid notching
Total lobule reconstruction is done generally with local flaps folded over itself to produce lobule

1)Helical rim advancement (Brent)

2)superiorly based inverted Y auriculomastoid flap doubled on itself (Brent)

Often unsatisfactory due to wound contraction

3)Converse – bilobed flap that’s folded on itself

4)Alanis – reconstruction with a retroauricular vertical banner flap that is folded onto itself

Ear replantation

First successful complete ear replatation reported by Pennington 1980
depends on the presence of either the superficial temporal or posterior auricular arteries for microvascular anastomosis.
Use of the superficial temporal vessels can be associated with risk of vasospasm that can result in reconstructive failure. Meticulous dissection and handling of tissues is requisite to avoid this complication.
Consider a side to side anastamoses to the STA to preserve the temp parietal fascial flap as salvage option.
most frequent complication is venous congestion of the anastomosed segment, affecting over 50% of patients. The use of leech therapy is usually curative. Leeches relieve venous congestion, allowing time for neovascularization to supply venous drainage.
If the likelihood of a successful replantation is low, Jenkins propose dissection of the cartilage and skin from the amputated part, reattachment of the cartilage to the side of the head, and coverage with a temporoparietal fascial flap which is in turn covered with the saved ear skin as a full-thickness graft. The temporoparietal flap nourishes both the underlying cartilage and overlying skin.

Total Auricular Reconstruction

Essential components for total auricular reconstruction include

1)the adequate and reliable skin cover

2)creation of an acceptable framework

3)provision of skin cover for the posteromedial skin after ear elevation

Different to reconstruction for microtia :

1)often scarring with little elasticity and adjacent tissue loss and thus additional methods of cutaneous coverage need to be considered

2)no microtic vestige to be unfurled for extra skin

Soft tissue cover

1)Tissue expansion- of the pre-existing post auricular skin

-Expanded skin from the post auricular area is thin pliable well vascularized and non hair bearing