(A) Anterior branch of the great auricular nerve
(B) Arnold's branch of the vagus nerve
(C) Auriculotemporal nerve
(D) Lesser occipital nerve
(E) Posterior branch of the great auricular nerve

The correct response is Option D.

Branches of the lesser occipital nerve supply sensation to the upper cranial surface of the ear and skin of the anterior and superior surfaces of the external auditory canal. The anterior branch of the great auricular nerve (which forms from branches of cervical nerve roots C2-3 within the cervical plexus) supplies sensation to the lower half of the lateral surface of the ear, while the posterior branch innervates the lower portion of the cranial surface of the ear. The auriculotemporal nerve provides sensation to the anterosuperior surface of the external ear. Arnold's nerve, which is a branch of the vagus nerve, supplies sensation to the skin of the concha and posterior ear canal.

References
1. Allison GR. Anatomy of the auricle. Clin Plast Surg. 1990;17:209-212.
2. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66:675-679.
3. Posnick JC, Zimbler AG, Grossman JA. Normal cutaneous sensibility of the face. Plast Reconstr Surg. 1990;86:429-433.

The most likely cause of isolated unilateral microtia in a neonate is maldevelopment of mesenchymal proliferations around which pharyngeal cleft(s) during which trimester?

The correct response is Option A.

The external ear develops during the end of the first trimester from six mesenchymal proliferations around the first pharyngeal cleft. These proliferations arise from the tissues of the first and second pharyngeal arches and are known as auricular hillocks. They slowly enlarge and eventually fuse to form the external ear. This process occurs between four and one half weeks and 10 weeks of intrauterine development as other facial structures are being formed.

Although the external ear, along with other facial structures, grows during the second trimester of fetal development, it has already been formed during the first trimester. Tissues around the second pharyngeal cleft contribute to the formation of the muscles of facial expression, the tonsils, the hyoid bone, and other structures but are not involved in the formation of the external ear.

References
1. Johnson MC. Embryology of the head and neck. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;4:2451-2495.
2. Sadler TW, ed. Langman's Medical Embryology. Baltimore, Md: Williams & Wilkins; 1990:328-337.

A 25-year-old man has complete loss of the upper two-thirds of the right ear two years after sustaining a burn injury to the ear. On examination, the ear lobe and lower part of the conchal cartilage are viable and have adequate skin coverage; the ear canal is open. Scarred skin surrounds the ear remnant.

Which of the following is the most appropriate operative procedure for correction of this patient's deformity?

(A) Creation of the upper ear with a rib cartilage framework and coverage with a local skin flap
(B) Creation of the upper ear with a rib cartilage framework and coverage with a pre-expanded local skin flap
(C) Creation of the upper ear with a rib cartilage framework and coverage with a temporoparietal fascial flap and a split-thickness skin graft
(D) Creation of the upper ear with a Silastic framework and coverage with a local skin flap
(E) Creation of the upper ear with a Silastic framework and coverage with a temporoparietal fascial flap and a split-thickness skin graft

The correct response is Option C.

The most appropriate surgical procedure for correction of this patient's deformity is creation of the upper ear using a rib cartilage graft and coverage with a temporoparietal fascia flap and a split-thickness skin graft. These procedures will most likely result in a satisfactory outcome for this difficult reconstructive problem. The rib cartilage can be carved into an appropriate framework and covered with a thin temporoparietal fascia flap; a thin split-thickness skin graft can be used to create the intricate detail of the external ear. When successful, this reconstruction will be durable and long-lasting.

Local skin is the coverage material of choice in classic microtia reconstruction; however, when the ear remnant is surrounded by scarred skin, as in this patient with a burn injury, it will not stretch adequately to cover the framework and show detail. Skin expansion will fail because scarred skin expands poorly.

Silastic frameworks can give good early results but are not long-lasting. Because even the most minor trauma or wound problem can lead to total loss of the reconstruction, Silastic frameworks are not a good choice for reconstruction.

References
1. Bhandari PS. Total ear reconstruction in post burn deformity. Burns. 1998;24:661-670.
2. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094-2152.

A 17-year-old high school wrestler had the sudden onset of swelling of the right ear 24 hours ago. Initial attempts at aspiration of the ear were unsuccessful. On current physical examination, there is a hematoma involving the upper half of the right ear.

Which of the following is the most appropriate management?

(A) Placement of an ice pack on the ear followed by observation
(B) Aspiration of the hematoma after liquefaction
(C) MRI of the ear for delineation of the cartilage fracture followed by surgical repair
(D) Surgical drainage of the hematoma followed by placement of through-and-through sutures with gauze bolsters
(E) Debridement of the skin over the hematoma followed by insertion of the ear cartilage into a postauricular skin flap

The correct response is Option D.

Separation of the skin of the external ear from the cartilage, and the subsequent development of a hematoma because of a shearing type injury, is a known injury in wrestlers and boxers. If not treated correctly it can result in a chronically scarred ear with no definition, commonly referred to as "cauliflower ear."

Appropriate management of the acute hematoma in this patient is surgical drainage and placement of through-and-through sutures with gauze bolsters to coapt the separated skin to the underlying cartilage. These bolsters are left in place for seven to 10 days. Drainage and suturing can be accomplished under local anesthesia if the patient is cooperative; this procedure will typically allow the skin of the avulsed ear to adhere to the underlying cartilage and prevent the development of the deformity described previously.

Placement of an ice pack followed by observation would only delay appropriate treatment of this patient's injury. Waiting for the hematoma to liquefy and then aspirating it will not prevent chronic scarring because the skin of the avulsed ear will not adhere correctly to the delicate cartilage framework. An MRI is not necessary and will only delay the appropriate treatment. Debridement of the viable ear skin would be contraindicated because it would only complicate the injury and its management.

References
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094-2152.
2. Starck WJ, Kaltman SI. Current concepts in the surgical management of traumatic auricular hematoma. J Oral Maxillofac Surg. 1992;50:800-802.

Six months after undergoing bilateral otoplasty for correction of prominent ears, a 27-year-old man has recurrent prominence of the upper half of the left ear. At follow-up examination one month after surgery, the ears appeared symmetric.

Which of the following is the most likely cause of this patient's recurrent deformity?

(A) Disruption of the conchal-mastoid sutures
(B) Disruption of the sutures used to create the antihelical fold
(C) Inadequate excision of cartilage from the concha
(D) Inadequate excision of skin from the posterior ear
(E) Incorrect placement of the postoperative dressing

The correct response is Option B.

The most likely cause of this patient's recurrent prominence of the upper half of the left ear is inadequate placement of sutures used in the creation of the antihelical fold. Lack of formation of the antihelical fold is one of the most common causes of prominent ears. Surgical creation of the fold can be accomplished with permanent sutures alone, cartilage incision or resection combined with sutures, or abrasion of the lateral ear cartilage with or without sutures. When used alone, sutures are usually very effective in the creation of the antihelical fold in children because their ear cartilage is soft and pliable. In adults, who have less pliable cartilage, sutures can be used alone to create a fold, but frequently other techniques must be performed to allow the cartilage to bend. When sutures are used alone, they must be permanent and precisely placed, or relapse can occur.

Excision of conchal cartilage, skin resection, placement of conchal-mastoid sutures, and placement of the postoperative dressing, while all vital aspects of otoplasty for prominent ears, are less likely to be involved in recurrence of the deformity than the inadequate creation of the antihelical fold, which is most commonly associated with recurrence of the deformity.

References
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094-2152.
2. Mustarde JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg. 1967;39:382.