(A) Cryptotia
(B) Cup ear deformity
(C) Lop ear
(D) Microtia
(E) Prominent ear deformity

The correct response is Option A.

Cryptotia ("hidden ear") is a congenital deformity of the cartilage of the scapha and antihelix. In neonates who have this deformity, the upper pole of the ear is buried beneath the scalp, and the superior auriculocephalic sulcus is absent. Conservative management is most appropriate initially; surgical release should be performed when the child is older.

Infants with the cup ear deformity have hooding of the scapha and helix and flattening of the antihelix. Lop ear is characterized by protrusion of the ear and folding of the superior helix. Microtia is a hypoplastic condition that manifests as varying degrees of ear absence, from anotia (complete ear absence) to a smaller than normal ear with normal morphology. The prominent ear deformity involves widening of the conchoscaphal angle, increased auriculocephalic distance, and loss of the antihelical fold.

Reference
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2099.

Which of the following congenital ear deformities is characterized by absence of the superior auriculocephalic sulcus?

(A) Cryptotia
(B) Cup ear deformity
(C) Lop ear
(D) Microtia
(E) Prominent ear deformity

The correct response is Option A.

Cryptotia ("hidden ear") is a congenital deformity of the cartilage of the scapha and antihelix. In neonates who have this deformity, the upper pole of the ear is buried beneath the scalp, and the superior auriculocephalic sulcus is absent. Conservative management is most appropriate initially; surgical release should be performed when the child is older.

Infants with the cup ear deformity have hooding of the scapha and helix and flattening of the antihelix. Lop ear is characterized by protrusion of the ear and folding of the superior helix. Microtia is a hypoplastic condition that manifests as varying degrees of ear absence, from anotia (complete ear absence) to a smaller than normal ear with normal morphology. The prominent ear deformity involves widening of the conchoscaphal angle, increased auriculocephalic distance, and loss of the antihelical fold.

Reference
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2099.

A 25-year-old woman has facial asymmetry. She says that she has had progressive loss of soft-tissue volume on the right side of the face since age 10 years that became stabilized four years ago. Examination shows significant subcutaneous atrophy of the right side of the face without bony asymmetry. She also has hypopigmentation of the iris on the affected side.

Which of the following is the most appropriate management?

(A) Bone graft augmentation of the midface
(B) Alloplastic augmentation
(C) Reconstruction with a microvascular serratus anterior free flap
(D) Reconstruction with a microvascular parascapular free flap
(E) Reconstruction with a superficial temporal fascia flap

The correct response is Option D.

This 25-year-old woman has Romberg's hemifacial atrophy characterized by progressive unilateral loss of facial soft tissue. The underlying skeleton is also affected in patients with severe forms of the disease. Surgery should be delayed until the condition becomes stabilized, which is indicated by the cessation of facial atrophy. When this has occurred, a microvascular parascapular flap can be deepithelialized and customized to fit the dimensions of the defect, and then transferred and buried subcutaneously.

Skeletal augmentation with either bone graft or alloplast is not appropriate because the bones of the face are not affected. The serratus anterior flap would only atrophy over time, and the superficial temporal fascia flap would not provide the necessary volume.

References
1. Longaker MT, Siebert JW. Microvascular free-flap correction of severe hemifacial atrophy. Plast Reconstr Surg. 1995;96:800-809.
2. Ruff GL. Progressive hemifacial atrophy: Romberg's disease. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;5:3135-3143.

A 35-year-old man has persistent enophthalmos 18 months after undergoing open reduction of a fracture of the orbital floor and zygoma. Forced duction testing shows no restriction of eye motion. Which of the following is the most likely cause of this patient's enophthalmos?

(A) Fat atrophy
(B) Fibrosis of the extraocular muscles
(C) Herniated contents of the orbit within the maxillary sinus
(D) Inadequate fracture reduction
(E) Scar contracture

The correct response is Option D.

Persistent enophthalmos following facial trauma is primarily caused by increased bony orbital volume secondary to inadequate fracture reduction. An appropriate anatomic reduction should be the initial goal of surgery; bone grafting may be required to restore orbital volume to normal levels.

Fat atrophy, extraocular muscle fibrosis, herniation of orbital contents, and scar contracture can also contribute to the discrepancy between traumatic and nontraumatic orbital volume, but are less likely to contribute to postoperative enophthalmos than inadequate fracture reduction. In addition, extraocular muscle fibrosis and/or scarring would typically be associated with limited motion of the globe on forced duction testing.

References
1. Manson PN, Grivas A, Rosenbaum A, et al. Studies on enophthalmos: II: the measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg. 1986;77:203-214.
2. Manson PN. Reoperative facial fracture repair. In: Grotting JC, ed. Reoperative Aesthetic and Reconstructive Plastic Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995;1:677-759.
3. Pearl RM. Treatment of enophthalmos. Clin Plast Surg. 1992;19:99.

A 7-year-old girl has conchal valgus and underfolding of the antihelix. The cranioauricular angle is 45 degrees. Which of the following is most appropriate for correction of this patient's deformity?

(A) Conchoscaphoid suturing
(B) Customized splinting
(C) Flag flap transfer
(D) Helical release with skin grafting
(E) Posterior scoring of the antihelical cartilage

The correct response is Option A.

Prominent ear deformities affect 5% of the general population and are characterized by conchal valgus with a cranioauricular angle greater than 40 degrees and underfolding of the antihelix. Conchal hypertrophy is a rare finding. Several options exist for management of prominent ears during childhood, including conchoscaphoid (MustardŽ) or conchomastoid suturing, anterior scoring of the cartilage at the antihelical fold, resection of the concha, and resection of postauricular skin.

Although a customized splint can be applied for management of minor deformities of the auricular cartilage, including prominent, lop, cup, and Stahl's ears, it is only effective during the neonatal period unless the deformity is associated with hypoplasia.

Flag flap transfer is useful for correction of a lop ear deformity.

Helical release with split-thickness skin grafting is appropriate management for cryptotia. In this technique, the superior portion of the auricle is buried beneath the skin.

As mentioned above, anterior, not posterior, scoring of the antihelical cartilage is a recognized technique for management of prominent ears.

References
1. Caouette-Laberge L, Guay N, Bortoluzzi P, et al. Otoplasty: anterior scoring technique and results in 500 cases. Plast Reconstr Surg. 2000;105:504-515.
2. Guyuron B, DeLuca L. Ear projection and the posterior auricular muscle insertion. Plast Reconstr Surg. 1997;100:457-460.

Which of the following is the most appropriate management of a 1-year-old boy who has isolated microtia on the left?

(A) Fabrication of a costal cartilage framework at age 3 years
(B) Implantation of a Silastic framework at age 4 years
(C) Placement of a bone-conduction hearing aid at age 5 years
(D) Creation of an ipsilateral ear canal at age 6 years
(E) Autologous ear reconstruction at age 7 years

The correct response is Option E.

Although the recommended age of surgery may vary among individual patients with microtia, autologous ear reconstruction is typically performed once the child reaches 5 years of age; most children are between the ages of 6 and 7 years at the time of surgery, at which time there is typically sufficient rib cartilage for reconstruction. The ear attains 85% of its total growth by age 3 years and has almost fully developed by ages 5 to 7 years; however, minimal changes in the width of the ear and its distance from the scalp can be seen until age 10 years.

Hearing in the affected ear should be assessed as soon as possible. When necessary, a bone-conduction hearing aid, whether external or implantable, should be initially used by age 1 year.

Implantation of a Silastic framework is not the first choice for management of congenital microtia. Creation of an ear canal is typically performed for unilateral microtia when the patient is age 13 to 19 years and should not be initiated until reconstruction of the external auricle has been completed.

References
1. Adamson JE, Horton CE, Crawford HH. The growth pattern of the external ear. Plast Reconstr Surg. 1965;36:466-470.
2. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg. 1999;104:319-334.
3. Nagata S. Microtia: auricular reconstruction. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000:1023-1056.

A 20-year-old man has severe right ear pain 24 hours after undergoing bilateral otoplasty. Which of the following is the most likely cause?

(A) Chondritis
(B) Excessively tight dressings
(C) Hematoma
(D) Nerve injury
(E) Otitis externa

The correct response is Option C.

Severe unilateral pain in the ear occurring within the first 24 hours after surgery is most consistent with the development of a hematoma resulting from increased pressure on the surrounding soft tissue. If the hematoma is not evacuated urgently, more severe complications, such as pressure necrosis of the overlying skin or underlying cartilage and fibrosis of the soft tissues, may result.

Chondritis, an uncommon complication of otoplasty, is characterized by pain, swelling, and tenderness of the affected ear. This condition initially presents several days after surgery and is best managed with intravenous antibiotic therapy. Surgical exploration is indicated in those patients diagnosed with suppurative chondritis.

Excessively tight dressings and head wraps would be detected soon after surgery, as the effects of the anesthesia dissipate, and would be associated with bilateral pain.

Patients who sustain injuries to the great auricular nerve during otoplasty would experience paresthesia and dysesthesia of the involved ear several weeks following surgery.

Otitis externa would not develop as soon as 24 hours after surgery.

References
1. Furnas DW. Complications of surgery of the external ear. Clin Plast Surg. 1990;17:305-318.
2. Preuss S, Eriksson E. Prominent ears. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000:1057-1065.

A 2-week-old neonate has bilateral prominent ears with lopped superior poles. Which of the following is the most appropriate management?

(A) Observation
(B) Molding the ears using tape and splinting
(C) Injection of a corticosteroid
(D) Otoplasty at age 2 years
(E) Otoplasty at age 6 years

The correct response is Option B.

In this neonate with bilateral prominent ears, immediate management should include molding of the ears with tape and splinting. Circulating maternal estrogens are still present until the age of 6 months, allowing for successful molding of the soft, malleable ear cartilage in infants with cryptotia and prominent ears. Molding can also be performed in newborns with lop ear and Stahl's ear during the neonatal period. Complete correction without surgery is a realistic expectation.

Because the concept of body image typically begins to form at about school age, ear reconstruction, if required, should ideally be performed between the ages of 5 and 6 years. The normal ear is within 6 to 7 mm of its full vertical height by the age of 6 years, allowing for the construction of an ear that is symmetrical to the normal ear.

Observation alone is inadequate in a child with ear deformities, and injection of a corticosteroid is inappropriate management. Otoplasty should not be performed at the age of 2 years because ear growth is not complete.

References
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094.
2. Furnas DW. Otoplasty for protruding ears, cryptotia, or Stahl's ear. In: Evans GR, ed. Operative Plastic Surgery. New York, NY: McGraw-Hill Inc; 2000:417.
3. Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17:383-395.

An 8-year-old boy has a third crus, flattening of the antihelix, and malformation of the scaphoid fossa. These findings are most consistent with which of the following?

(A) Constricted ear
(B) Cryptotia
(C) Prominent ear
(D) Stahl's ear
(E) Telephone ear deformity

PHOTO

Reproduced with permission of McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2095.

The correct response is Option D.

This child has findings consistent with Stahl's ear, a rare congenital anomaly of unknown cause characterized by the presence of a third crus, flattening of the antihelix, and malformation of the scaphoid fossa. This condition is often difficult to correct surgically.

Constricted ear manifests as hooding of the helix and scapha. In patients with cryptotia, the upper pole of the ear cartilage is buried beneath the skin, and the superior auriculocephalic sulcus is absent. Prominent ears can be associated with several factors, including incomplete development of the antihelix, enlargement of the concha, widening of the conchoscaphal angle (ie, greater than 90 degrees), and protrusion of the ear lobe. The telephone ear deformity results from either excessive reduction of the concha or inadequate correction of prominent upper and lower poles of the ear during an otoplasty procedure.

References
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094-2095.
2. Spira M. Otoplasty: what I do now Ð a 30-year perspective. Plast Reconstr Surg. 1999;104:834.