Microtia Repair

Teri Junge, cst, csfa, med, fast

The term actually means small and the term anotia means lack of the ear. Microtia has become a “catch-all” term that includes any type of deformity of the external ear. Microtia occurs in approximately 1:6,000 births, is more common in males (approximately 63% of the patients are male and 37% are female), and is more likely to occur on the right side (approximately 58% of deformities occur on the right side) however the defect may be bilateral (approximately 9% of patients are affect- ed bilaterally). Microtia can occur as an isolated deformity or can occur in conjunction with other birth defects (related or not) which can include middle and inner ear prob- lems resulting in reduced or absence of hearing on the affected side.

Possible C auses icrotia is thought to be a random event; although it has LEARNING O BJECTIVES been linked to increased maternal age. Other possible s Examine the possible causes of causes are intrauterine tissue ischemia (possibly from an microtia Martery that was compressed in the womb), maternal medication use s Identify the grades of severity (such as the drug thalidomide/Thalomid® which is an immunomodu- related to this condition latory agent used to treat multiple myeloma and erythema nodosum s Review the anatomy of the external leprosum and/or the drug isotretinoin/Accutane® which is a retinoid that is used to treat acne), evidence of a first trimester of pregnancy ear, middle ear and inner ear rubella (German measles) episode, and genetic factors. Microtia has s Evaluate the steps taken during an been associated with several syndromes such as Goldenhar Syndrome autologous rib graft procedure and Treacher-Collins Syndrome. A syndrome is a cluster of deformi- s Compare and contrast the ties that often occur together. conservative approach with the Goldenhar Syndrome involves deformities of the face and usually surgical operation affects one side only. Characteristics of Goldenhar Syndrome include varying degrees of microtia or anotia, the chin on the affected side is closer to the ear, the corner of the mouth on the affected side may be

JANUARY 2014 | The Surgical Technologist | 17 Anatomy R eview Word Element Definition There are three structural divisions of the ear. 1. acous/o hearing External Ear 2. audi/o hearing The visible portion of the external ear is also called the 3. labyrinth/o portion of inner ear pinna and the . The external ear continues through the meatus to the tympanic membrane. The important struc- 4. myring/o tures of the external ear that are involved when performing 5. ot/o ear a reconstructive procedure are the: 6. tympan/o eardrum • Helix • Triangular fossa higher than the unaffected side, the eye on the affected • Antihelix side may be missing, deformed, or contain benign growths • Concha (such as dermoid cysts). Goldenhar Syndrome is a form of • Scaphae oculoauricular dysplasia. • Tragus Treacher-Collins Syndrome is an inherited craniofacial • Lobule defect that is caused by a defective protein called treacle (a • External auditory meatus protein involved in transcription of ribosomal DNA) and • External auditory canal which contains the ceruminous the significance ranges from mild to severe. Characteris- glands tics of Treacher-Collins Syndrome include varying degrees The function of the external ear is to collect and funnel of microtia or anotia, micrognathia (small jaw), a large sound waves into the ear canal. mouth, coloboma (a full-thickness defect of the eyelid in which there is a hole or a gap), scalp hair growth that Middle Ear extends to the checks, and chiloschisis/palatoschisis (cleft The middle ear begins at the tympanic membrane and ends lip/cleft palate). at the oval window. The three ossicles; the malleus, incus, and stapes are enclosed within the middle ear, as is the Severity opening to the eustachian tube. Additionally, access to the Microtia is described as typically occurring in 4 grades. tympanic antrum, which in turn communicates with the Atypical anomalies that do not fit into the grading scale mastoid air cells, is provided through the attic (also known can also occur. as the epitympanic recess). Several physiologic activities Grade 1 – The pinna is smaller than normal and may occur within the middle ear. have a slightly noticeable malformation. The normal char- acteristics of the external ear are present and well defined. Microtia has become a “catch-all” term that The acronym FLK which represents the term “funny look- ing kid” may be seen on the chart of a newborn or child includes any type of deformity of the external when a dysmorphic feature, such as a slightly malformed ear. Microtia occurs in approximately 1:6,000 ear, is suspected, but has not yet been fully researched and identified. births ... . Microtia can occur as an isolated defor- Grade 2 – The pinna is less developed than in grade mity or can occur in conjunction with other birth 1 and the structures such as the helix and antihelix show less definition. defects (related or not) which can include mid- Grade 3 – The pinna is basically absent however a ver- dle and inner ear problems resulting in reduced or tical skin remnant often remains. The remnant consists of cartilage that is not organized and the patient usually has absence of hearing on the affected side. a well-formed ear lobe. Grade 4 – Complete absence of the auricle (anotia).

18 | The Surgical Technologist | JANUARY 2014 The ossicles are attached to one another via small liga- Table 1 Process of Hearing ments and conduct vibrations from the tympanic membrane to the oval window. Several tiny muscles control/constrict the Step 1 Sound waves enter the external ear movements of the ossicles and help to obtund certain noises (such as from chewing crunch food). The two main muscles Step 2 Tympanic membrane vibrates of the middle ear are the tensor tympani and the stapedius. The eustachian tube, also called the pharyngotympanic Step 3 Vibrations are transferred through the middle tube, connects the middle ear cavity with the nasopharynx. ear by the ossicles The eustachian tube functions to drain mucus from the middle ear and provide aeration of the cavity. The eusta- Stapes moves the membrane covering the chian tube opens to equalize atmospheric pressure in the Step 4 oval window setting in motion the fluids middle ear and closes to protect the middle ear from loud within the bony labyrinth noises and retrograde infection that may result from con- taminates ascending from the nasopharynx. Step 5 Movement of the fluid within the cochlea sets The air spaces of the tympanic antrum function to pro- in motion the hair cells of the organ of Corti vide acoustic resonance, dissipate sound, and reduce the weight of the cranium. Step 6 Movement of the hair cells against the tecto- rial membrane initiates a nerve impulse Inner Ear Vibrational movement of the stapes against the oval win- Step 7 Nerve impulse is transmitted via the VIIIth dow, also known as the fenestra ovalis, sets in motion the cranial nerve fluids within the labyrinth. The labyrinth consists of the vestibule, the semicircular canals and the cochlea. The ves- Step 8 Impulse is interpreted in the temporal lobe of tibule contains receptors for equilibrium and movement the brain of the fluid within the two bony chambers of the vestibule affects balance. Fluid movement within the three semicir- Conservative/Nonsurgical A pproach cular canals, influences proprioception (sense of position) A prosthetic device can be constructed and applied to the and balance during movement (dynamic equilibrium) and side of the head at the location of the ear. If an earlobe is when still (static equilibrium). Fluid within the bony laby- present, the prosthesis can be constructed around it. The rinth is called perilymph; inside of the bony labyrinth is the main reason for using a prosthesis is to avoid undergoing a membranous labyrinth that contains a fluid called endo- surgical procedure. Negative qualities of prosthetic are lymph. The vestibulocochlear nerve (cranial nerve VIII) is that it must be removed and cleaned daily, it may become responsible for transmission of sound and balance informa- detached unexpectedly (especially during sporting activi- tion from the inner ear to the temporal lobe of the brain for ties), it will not change coloration according to the amount interpretation. The vestibular branch of the VIIIth cranial of sun exposure, will not grow with a child, and will show nerve serves the vestibule and the labyrinth and the cochle- signs of wear that will require replacement. ar branch serves the cochlea. The organ of Corti, also known as the organ of hear- History of S urgical I nterventions ing, is located within the cochlea. The organ of Corti is The first reported microtia repairs occurred in the late 1500s comprised of ciliated receptor cells that move against the and involved the use of cheek or scalp flaps. Homologous tectorial membrane as the fluid in the middle ear moves. rib graft (particularly from the mother) procedures began Movement of the tectorial membrane initiates the impulses to emerge in the late 1920s; however, there was a problem that move along the cochlear branch of the VIIIth cranial with tissue resorption and the technique has been aban- nerve for interpretation in the temporal lobe of the brain. doned. The autologous rib graft procedure, which is still in The process of hearing is outlined in Table 1. use today, originated in the 1940s. A major advantage of the

JANUARY 2014 | The Surgical Technologist | 19 autologous rib graft procedure is that the graft will grow care is exercised to remain outside of the pleura while with the child. In an attempt to avoid the thoracic portion securing the graft. The cartilage that will represent the of the autologous rib graft procedure, a variety of inor- main framework of the graft is taken from a section of the ganic implants have been tried. Unfortunately, migration false ribs and the cartilage that will become the helical rim and extrusion of the implants are problematic. Examples of is taken from the floating rib cartilage and the chest wound implanted materials that have been tried include Vitallium, is closed. The surgeon will remove the perichondrium from polyethylene and Teflon. the cartilage using a periosteal elevator (such as a freer), a scalpel, and a chisel, and then sculpt the main framework Autologous R ib G raft P rocedure O verview of the graft to closely resemble the template. The helical rim Microtia repair is typically described in three to four stages. is fashioned in much the same way as the main framework In preparation for stage one, a template is drawn from the and the rim is attached to the main framework with non- opposite (intact) ear and then reversed to be used of the absorbable suture (such as silk) or stainless steel wire. Once the cartilaginous framework (graft) is complete, it is set aside while the incision is made and the pocket is developed at the recipient site. The graft is inserted, the wound is closed, and a wound vacuum/drainage device is employed. A bulky wound dressing is applied and left is place for five to seven days. Additionally, a temporary protective device may be applied to keep very young children from disrupting the wound and to protect the wound while the patient is sleep- ing. The patient is restricted from using a hair dryer, swimming, and participating in contact sporting activities for four to six weeks. Stage two of the reconstruction involves transposition of the earlobe (if one is present) and can be performed in conjunction with stage one. Unfortunately, the risk of vascular compro- mise increases and the esthetic outcome may not The autologous rib graft procedure, which is still in use today, be as precise, if performed at the same time as originated in the 1940s. A major advantage of the autologous the first stage. Ideally, the earlobe transposition is performed when healing from the first stage rib graft procedure is that the graft will grow with the child. is complete. According to the age of the patient, the transposition may be performed under local anesthesia. Any existing lobular tissue is moved into position as a flap to maintain the integrity of affected side. If the defect is bilateral, a sibling or other the vascular structures, any unusable tissue is removed, the model may be used to draw the template. Measurements, wound is sutured, and a light dressing is applied. or a second template, are used to determine the location of Stage three of the reconstruction allows for elevation the new auricle. The lateral canthus, alar nasal cartilage, and (sometimes referred to as lifting) of the posterior aspect the corner of the mouth are used as landmarks to estimate of the newly created framework of the ear. Because skin the position the graft. grafting is often necessary, stage three is performed under Stage one of the reconstruction is performed under gen- general anesthesia. The donor site for the skin graft may eral anesthesia and involves securing the cartilaginous graft be the lower abdomen, the buttocks, or another location from the donor site on the contralateral chest wall. Great determined to be appropriate by the surgeon.

20 | The Surgical Technologist | JANUARY 2014 Any of the stages of the reconstruction may be com- References bined, as appropriate. If a fourth stage is needed, it may 1. Bonilla, A. (2011). Pediatric microtia surgery. Retrieved Octo- ber 11, 2011. http://emedicine.medscape.com/article/995953- include laser treatments to remove any scalp hair remain- overview#aw2aab6b2b1aa ing on the newly created ear and minor additional proce- 2. Brent, B. (2011). Microtia-atresia: Possible cause & incidence (etiology). Retrieved April 9, 2012. http://www.microtia.us.com/microtia-atresia- dures such as creation of a tragus and/or a false conical possible-cause-and-incidence.html shaped entry to simulate the auditory meatus and external 3. Cohen, BJ. (2005). Memmler’s the human body in health and disease (10th ear canal. ed). United States: Lippincott Williams & Wilkins. 4. FLK. (nd). The American heritage® abbreviations dictionary (3rd edition). Retrieved October 11, 2011. http://dictionary.reference.com/browse/FLK About the A uthor 5. Haldeman-Englert, C. (2011). Treacher-Collins syndrome. Retrieved Octo- ber 10, 2011. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002624 Teri Junge, cst, csfa, med, fast, cur- 6. National Craniofacial Association. (2011). Goldenhar syndrome. Retrieved rently serves as the surgical technology October 10, 2011. http://www.faces-cranio.org/Disord/Golden.htm program director at the San Joaquin 7. Romo, T. (2008). About microtia: Postoperative care. Retrieved October 12, 2011. http://www.earreconstruction.com/postop.html Valley College, Fresno campus. She has 8. United States National Library of Medicine. (2012). Isotretinoin. Retrieved been in that role for 11 years, a surgical April 9, 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000532 9. United States National Library of Medicine. (2012). Thalidomide.Retrieved technologist since 1974 and enjoys writing for publication. April 9, 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001053

The Accreditation Review Council on Education in Surgical Technology and Surgical Assisting (ARC STSA) is pleased to announce the launch of our 2014 Scholarship Program in service to the Surgical Technology and Surgical Assisting student and educator communities.

Annually, since 2005, the ARC STSA Board of Directors has awarded multiple scholarships of up to $1,000 in at least two separate categories, Student Scholarship and Educator Scholarship. In 2014, the ARC STSA will award a total of up to $5,000 in combined scholarships.

All eligible applicants are strongly encouraged to apply before the February 28th deadline. For eligibility requirements and to apply visit arcstsa.org today!

Scholarship recipients will be announced at the 2014 AST National Conference in Denver, CO and will be posted on our website, arcsta.org, by June 16, 2014.

JANUARY 2014 | The Surgical Technologist | 21 FEBRUARY 2012 THE VOLUME 44 NO 2

TECHNOLOGIST WRITE A CE Official JO urnal O f the a ssO ciatiO n O f s urgical t echnO l O gists, i nc. CE EXAM A Crash Course in Microbiology We are always looking for CE authors and surgical procedures that haven’t been written about or the latest advancements on a commonplace surgery. You don’t have to be a writer to contribute to the Journal. We’ll help you every step of the way, AND you’ll earn CE credits by writing a CE article that gets published! Here are some guidelines to kick start your way on becoming an author: Earn CE Credits at Home 1. An article submitted for a CE must have a unique thesis or angle and be relevant to the surgical You will be awarded continuing educa- technology profession. tion (CE) credits toward your recertifica- 2.  The article must have a clear message and be accurate, thorough and concise. tion after reading the designated arti- 3. It must be in a format that maintains the Journal’s integrity of style. cle and completing the test with a score of 4. It must be an original topic (one that hasn’t been published in the Journal recently.) 70% or better. If you do not pass the test, it will be returned along with your payment. How to Get Started Send the original answer sheet from the The process for writing a CE can be painless. We are here to assist you every step of the way and journal and make a copy for your records. If make sure that you are proud of your article. possible use a credit card (debit or credit) for •  W rite to [email protected], and state your interest in writing, and what topic you would like to payment. It is a faster option for processing of author. credits and offers more flexibility for correct •  Submit an outline of your proposed topic for review. Once the outline is returned to you for payment. When submitting multiple tests, approval, begin writing your manuscript. Getting your outline approved will save you time and you do not need to submit a separate check effort of writing a manuscript that may be rejected. for each journal test. You may submit multiple •  Submit manuscript, as well as any art to illustrate your authored topic. You will be notified upon journal tests with one check or money order. receipt of receiving the manuscript and as well as any changes, additions or concerns. Members this test is also available online Things to remember: at www.ast.org. No stamps or checks and it •  Length: Continuing education articles should run a minimum of 2,000 words and a maximum of posts to your record automatically! 5,000 words. •  References: Every article concludes with a list of ALL references cited in the text. All articles that Members: $6 per credit include facts, history, anatomy or other specific or scientific information must cite sources. (per credit not per test) •  Copyright: When in doubt about copyright, ask the AST Editor for clarification. Nonmembers: $10 per credit •  Author’s Responsibility: All articles submitted for publication should be free from plagiarism, (per credit not per test plus the $400 nonmember should properly document sources and should have attained written documentation of copyright fee per submission) release when necessary. AST may refuse to publish material that they believe is unauthorized

use of copyrighted material or a manuscript without complete documentation. After your credits are processed, A ST will Don’t delay! Become an author today. Write to us at [email protected] send you a letter acknowledging the number of credits that were accepted. Members can also check your CE credit status online with Other Topics your login information at www.ast.org. •  Finding My Calling – We encourage surgical techs to share their stories about how they found their 3 WAYS TO SUBMIT YOUR CE CREDITS calling and entered this profession. Inspire others with your story about how you fell in love with Mail to: AST, Member Services, 6 West Dry Creek this profession. Finding My Calling articles should be a minimum of 500 words and include a photo Circle Ste 200, Littleton, CO 80120-8031 of the author. Fax CE credits to: 303-694-9169 •  On a Mission – Served on a medical mission? Share your experiences with your fellow surgical E-mail scanned CE credits in PDF format to: techs and show everyone how you made a difference, and how the trip made a difference in your [email protected] life. On a Mission articles should be a minimum of 500 words and include photos of your mission trip. For questions please contact Member Services - [email protected] or 800-637-7433, option 3. •  Other Topics – Want to write an article that isn’t presented here? Be our guest! We welcome other Business hours: Mon-Fri, 8:00a.m. - 4:30 p.m., MT article topics as long as they are relevant and timely to the profession.

22 | The Surgical Technologist | JANUARY 2014 Microtia Repair 361 January 2014 1 CE credit - $6

1. Microtia is defined as: 5. Movement of the hair cells against the 8. Following the operation, the bulky a. Lack of ear tectorial membrane initiates a nerve wound dressing is left in place for b. Small ear impulse is which step of the process of ______. c. Inner ear hearing? a. 5 to 7 days d. External ear a. Step 4 b. 6 to 8 weeks b. Step 5 c. 3 to 4 days 2. Microtia is more common in: c. Step 6 d. 1 month a. Infants d. Step 7 b. Elderly 9. Laser treatments may be necessary in c. Males 6. In preparation for stage one of a micro- which stage? d. Females tia repair, and the patient’s other ear a. Stage 1 is in intact, a template is drawn from b. Stage 2 3. There are four grades of severity ______. c. Stage 3 describing microtia. In which grade is a. The opposite ear d. Stage 4 the pinna less developed? b. A sibling a. Grade 1 c. His or her mother 10. The autologous rib graft procedure b. Grade 2 d. A friend originated in the: c. Grade 3 a. 1920s d. Grade 4 7. In stage one, the surgeon will remove the b. 1930s perichondrium from the cartilage using c. 1940s 4. The visible portion of the ear can be a periosteal elevator, a scalpel and a d. 1950s called: ______. a. Auricle a. Retractor b. External ear b. Chisel c. Pinna c. Ear Knife d. All of the above d. Iris Scissors

Microtia Repair 361 January 2014 1 CE credit - $6 Make It Easy - Take CE Exams Online NBSTSA Certification No. a b c d a b c d AST Member No. 1 ■ ■ ■ ■ 11 You■ must ■have a■ credit■ card to ■ My address has changed. The address below is the new address. 2 ■ ■ ■ ■ 12 purchase■ test■ online.■ We■ accept Visa, MasterCard and American Name 3 ■ ■ ■ ■ 13 ■ ■ ■ ■ Express. Your credit card will Address 4 ■ ■ ■ ■ 14 only■ be charged■ ■ once ■you pass ■ ■ ■ ■ ■ ■ ■ ■ City State Zip 5 15 the test and then your credits will be automatically recorded Telephone 6 ■ ■ ■ ■ 16 ■ ■ ■ ■ 7 ■ ■ ■ ■ 17 to your■ account.■ ■ ■ ■ Check enclosed ■ Check Number Log on to your account on 8 ■ ■ ■ ■ 18 ■ ■ ■ ■ ■ Visa ■ MasterCard ■ American Express the AST homepage to take 9 ■ ■ ■ ■ 19 ■ ■ ■ ■ Credit Card Number advantage of this benefit. 10 ■ ■ ■ ■ 20 ■ ■ ■ ■ Expiration Date

JANUARY 2014 | The Surgical Technologist | 23