For each deformity of the ear, select the corresponding anatomic site in the photograph shown on page 44 (A-E).

(A) Concha cavum
(B) Helical rim
(C) Scapha
(D) Superior crus of the antihelix
(E) Triangular fossa

1 Effacement of this structure most commonly results in prominence of the ear.

2 Hypertrophy of this structure most commonly results in prominence of the middle third of the ear.

The correct response for Item 1 is Option D and for Item 2 is Option A.

In children with congenital ear prominence, the superior and middle thirds of the ear are most likely to be affected. The most likely cause of a prominent superior third of the ear is absence or effacement of the superior crus of the antihelix. As a result, the conchoscaphal angle is greater than 90 degrees and the helix is positioned more than 12 to 15 mm from the temporal region. The cephaloauricular angle is also increased, typically measuring more than 25 degrees. Appropriate management involves scoring and suturing of the cartilage to recreate the natural roll of the antihelix.

In contrast, prominence of the middle third of the ear is most likely caused by hypertrophy of the concha cavum. In affected patients, the concha cavum has a depth of more than 1.5 cm. The middle third of the ear is located more than 16 to 18 mm from the mastoid region. Options for correction include excision and/or reduction of the concha or setback with concha-mastoid sutures.

The scapha is the concave region between the helical rim and antihelix, and the triangular fossa is the concave area between the superior and inferior crura of the antihelix. Although the helical rim, scapha, and triangular fossa lie in the superior third of the ear, they do not typically cause prominent ears.

References
1. Bauer BS, Patel PK. Congenital deformities of the ear. In: Bentz ML, ed. Pediatric Plastic Surgery. Stamford, Conn: Appleton & Lange; 1998:359.
2. Spira M. Otoplasty: what I do now – a 30-year perspective. Plast Reconstr Surg. 1999;104:834-840.

A 77-year-old man has a 12-mm squamous cell carcinoma on the lateral margin of the right helix. He is scheduled to undergo excision of the lesion with confirmation of margins by frozen section, followed by immediate reconstruction. Which of the following flaps is most appropriate for ear reconstruction?

(A) Antia-Buch flap
(B) Postauricular flap
(C) Temporoparietal fascial flap
(D) Temporalis muscle flap

The correct response is Option A.

The Antia-Buch flap is most appropriate for reconstruction of this patient’s ear defect. The lesion can be excised easily because of its location on the lateral rim and of the size of the auricle. Following excision, the resultant defect is effectively reconstructed using the Antia-Buch flap, which is a local flap that uses tissue from the helical rim based on the postauricular skin to reconstruct the helical margin. It is a reliable, single-stage procedure that is acceptable aesthetically. The surgeon may need to excise a “dog ear”-shaped area of tissue from the conchal bowl and incise and advance the helical margins separately. However, because the two ears are not viewed simultaneously, moderate differences in ear size are frequently unnoticed.

A postauricular flap does not provide thin, contoured, helical-type tissue and requires several procedures for adequate coverage. The temporoparietal fascial flap provides thin, pliable soft-tissue coverage for a cartilage or alloplastic framework, as in patients undergoing microtia reconstruction. A temporalis muscle flap is excessively bulky and is not appropriate for ear reconstruction because it would obliterate the intricate detailing of the ear.

References
1. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg. 1967;39:472.
2. Elsahy NI. Reconstruction of the ear after skin and cartilage loss. Clin Plast Surg. 2002;29:201-212.
3. Low DW. Modified chondrocutaneous advancement flap for ear reconstruction. Plast Reconstr Surg. 1998;102:174-177.
4. Park C, Lew DH, Yoo WM. An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 1999;104:1295-1306.

A 14-year-old boy sustains an avulsion injury involving the entire pinna when he is bitten by a dog. The amputated part has been preserved on iced saline gauze. Following administration of antibiotics, tetanus toxoid, and rabies prophylaxis, microsurgical replantation of the ear is to be performed. Anastomosis of the arteries is most appropriate at which of the following anatomic locations on the ear?

(A) Anterior surface
(B) Inferior surface
(C) Posterior surface
(D) Superior surface

The correct response is Option C.

In patients undergoing microsurgical replantation of the ear, the tissues are debrided first, and dissection is performed to locate the appropriate vessels for replantation, with visualization provided by an operating microscope. Because the large arteries to the ear enter on the posterior aspect of the pinna, anastomosis is most appropriate on the posterior surface. These arteries include branches of the external carotid artery, the anterior auricular branch of the superficial temporal artery, and a branch of the occipital artery. In contrast, the smaller branches are located on the anterior surface.

References
1. Park C, Lineaweaver WC, Rumly TO, et al. Arterial supply of the anterior ear. Plast Reconstr Surg. 1992;90:38-44
2. Pick TP, Howden R, eds. Gray’s Anatomy: Descriptive and Surgical. New York, NY: Bounty Books; 1977.

A 15-year-old boy undergoes reconstruction of a 15-mm2 traumatic defect of the right ear with a graft harvested from the contralateral ear. On examination two days after the procedure, the graft appears dusky. A photograph is shown above. Which of the following is the most appropriate next step in management?

(A) Hyperbaric oxygen therapy
(B) Application of leeches
(C) Release of the sutures
(D) Debridement of the graft

The correct response is Option A.

In this 15-year-old boy who exhibits duskiness at the graft site two days after undergoing composite grafting of the ear, the most appropriate next step is initiation of hyperbaric oxygen therapy. This will provide oxygenation during the critical ischemia period for the graft and thus is likely to improve the outcome. Hyperbaric oxygen therapy enhances antimicrobial activity by facilitating the oxidative burst of polymorphonuclear neutrophils. It increases the hyperoxygenation of tissue to a level that is 10 to 15 times greater than normal. In addition, it stimulates angiogenesis and blunts the ischemia-reperfusion injury response.

Application of leeches is appropriate if arterial input is adequate but venous outflow is insufficient, as in patients undergoing microsurgical replantation who demonstrate thrombosis of the vein, or if a suitable vein does not exist for anastomosis. However, duskiness of the ear is an indication of arterial insufficiency, and leeches would fail to attach if they were applied.

Because a composite graft receives its vascularity through diffusion from the surrounding wound bed, releasing the sutures would inhibit the “take” of the graft to the bed. Similarly, performing debridement two days after grafting is excessive. Instead, the composite graft should be left in place for a minimum of two weeks in order to demonstrate healing and incorporation, as long as infection does not develop.

References
1. McClane S, Renner G, Bell PL, et al. Pilot study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of reattached auricular composite grafts in the New Zealand White rabbit. Otolaryngol Head Neck Surg. 2000;123:539-542.
2. Nichter LS, Morwood DT, Williams GS, et al. Expanding the limits of composite grafting: a case report of successful nose replantation assisted by hyperbaric oxygen therapy. Plast Reconstr Surg. 1991;87:337-340.
3. Renner G, McClane SD, Early E, et al. Enhancement of auricular composite graft survival with hyperbaric oxygen therapy. Arch Facial Plast Surg. 2002;4:102-104.
4. Zhang F, Cheng C, Gerlach T, et al. Effect of hyperbaric oxygen on survival of the composite ear graft in rats. Ann Plast Surg. 1998;41:530-534.

A 24-year-old man has pain and swelling of the left ear after injuring the ear in a fight. Physical examination shows obliteration of the normal contours of the lateral surface of the ear. Which of the following is the most appropriate management?

(A) Application of a pressure dressing for several days, followed by evacuation of clotted blood
(B) Needle aspiration of the ear
(C) Needle aspiration of the ear and application of a pressure dressing
(D) Incision and drainage of the skin and perichondrium and application of a pressure dressing
(E) Excision of thickened tissue and placement of suction-drainage catheters

The correct response is Option D.

Hematoma formation is the primary complication of blunt trauma to the ear. The mechanism of injury involves disruption of blood vessels in the perichondrium, leading to hemorrhage. The blood fills the space between the perichondrium and cartilage, distorting the contour of the lateral ear into a convex shape and blocking the vascular supply to the cartilage, which is derived from the perichondrium. Necrosis or infection of the cartilage results.

Prompt treatment involves removing the accumulated blood while maintaining pressure on the affected area for several days to prevent recurrence. To accomplish this, an incision is made through the skin and perichondrium on the inner side of and parallel to the antihelix, which will conceal the scar. The blood is drained and the wound is inspected for further bleeding. When the surgeon is assured that the bleeding has stopped, a pressure dressing and a head dressing are applied.

Late treatment of a cauliflower ear deformity involves excision of the thickened tissue, including fibrous tissue and new cartilage, followed by application of a pressure dressing.

Simple needle aspiration of the blood is likely to result in development of seroma.

References
1. Elsahy NI. Acquired ear defects. Clin Plast Surg. 2002;29:175-186.
2. Schuller DE, Dankle SD, Strauss RH, et al. A technique to treat wrestlers’ auricular hematoma without interrupting training or competition. Arch Otolaryngol Head Neck Surg. 1989;15:202-206.

A 21-year-old man sustains a complete amputation of the right ear at the level of the external auditory canal in a motor vehicle collision. There are no other injuries. Which of the following procedures will provide the best aesthetic result?

(A) Delayed total ear reconstruction with a rib cartilage graft
(B) Dermabrasion of the epidermis of the amputated ear, burial of the ear in a subcutaneous postauricular pocket, followed by removal and coverage with a skin graft or flap
(C) Removal of the skin of the amputated ear, reattachment of the ear cartilage, and immediate coverage with a temporoparietal fascial flap and skin graft
(D) Composite grafting of the amputated ear followed by surface cooling
(E) Microsurgical ear replantation

The correct response is Option E.

Successful microsurgical replantation of the ear provides superior aesthetic results while eliminating the need for other complex reconstructive procedures. However, this technique is associated with increased operative time and the need for multiple blood transfusions. Hospitalization is typically prolonged, and failure rates associated with the procedure are high.

Delayed reconstruction results in only moderate cosmetic improvement, and secondary reconstruction does not sufficiently recreate the intricate architecture of the external ear.

Primary nonvascularized replantation of the ear produces a good appearance initially because of the survival of the avulsed cartilage; however, late distortion of the cartilage frequently limits the overall aesthetic result. Techniques used for nonvascularized replantation include primary reattachment of the ear with surface cooling, dermabrasion of the ear, and partial or complete burial of the ear in a postauricular skin pocket, followed by coverage of the filleted cartilage with a temporoparietal fascial flap and skin graft.

References
1. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2094.
2. King GM. Microvascular ear transplantation. Clin Plast Surg. 2002;29:233-248.
3. Turpin IM. Microsurgical replantation of the external ear. Clin Plast Surg. 1990;17:397.

A 6-year-old boy has prominent ears. Physical examination shows an obtuse concha-mastoid angle. The antihelical fold is normal. Which of the following is the most appropriate management?

(A) Use of a headband splint at night
(B) Use of Mustardé sutures
(C) Setback of the concha using concha-mastoid sutures
(D) Excision of excess skin
(E) Resection of the concha

The correct response is Option C.

Because prominent ears can be caused by an enlarged conchal bowl, an obtuse concha-mastoid angle, or loss of the antihelical fold, appropriate management should be based on the cause of the deformity. This 6-year-old boy has ear prominence caused by an obtuse concha-mastoid angle. Conchal setback is recommended in children to correct the enlarged conchal bowl and obtuse concha-mastoid angle deformities. This is accomplished using concha-mastoid sutures, which are mattress sutures placed between the posterior conchal wall and the mastoid periosteum to create a more acute concha-mastoid angle and decrease the height of the protruding concha.

In contrast, elliptical conchal excision may be required to perform conchal setback in adults, whose ear cartilage is typically stiff.

Ear prominence resulting from loss of the antihelical fold is best corrected by abrading or scoring the antihelix and placing Mustardé mattress sutures between the conchal eminence and the scaphoid eminence.

Splinting is effective only in infants because of the pliability of the ear cartilage in this age group.

Excess skin may need to be excised following placement of concha-mastoid sutures, but this is unlikely to produce adequate setback if performed alone. This technique is appropriate instead to decrease the prominence of the lobule or superior helix.

References
1. Furnas DW. Otoplasty for prominent ears. Clin Plast Surg. 2002;29:273-288.
2. Yotsuyanagi T, Yokoi K, Sawada Y. Nonsurgical treatment of various auricular deformities. Clin Plast Surg. 2002;29:327-332.

Each of the following deformities is commonly associated with microtia EXCEPT

(A) cervical spine abnormalities
(B) inner ear abnormalities
(C) macrostomia
(D) mandibular hypoplasia
(E) preauricular pits

The correct response is Option B.

Patients with microtia have partial or complete absence of the external ear structures due to abnormal embryologic development of portions of the first, or mandibular, and second, or hyoid, branchial arches. This typically occurs during the fourth to twelfth week of intrauterine development and affects the auditory ossicles, external auditory canal, middle ear cavity, and tympanic membrane. Several abnormalities can occur in conjunction with microtia. Orbital auricular vertebral syndrome, also known as Goldenhar syndrome, and the Tessier No. 7 cleft also result from abnormalities in the development of the first and second branchial arches. Orbital auricular vertebral syndrome is characterized by microtia, cervical spine abnormalities, mandibular hypoplasia, preauricular pits and sinuses, and hemifacial microsomia. The Tessier No. 7 cleft manifests as microtia, macrostomia, and preauricular sinuses.

Because the external auditory meatus and internal ear are derived from different structures, the internal ear is usually well constructed in patients with microtia. Likewise, patients with orbital auricular vertebral syndrome have abnormalities of the middle and external ear but not the inner ear.

References
1. Kawamoto HK Jr, Patel PK. Atypical facial clefts. In: Bentz ML, ed. Pediatric Plastic Surgery. Stamford, Conn: Appleton & Lange; 1998:175-225.
2. Kurihara K. Congenital deformities of the external ear. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;1:776-779.