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Microtia and aural atresia: An integrated approach to

management

Kathleen Sie, MDCraig Murakami, MD

Pacific RimOtolaryngology Head and Neck Surgery Update 2010

Microtia and atresia: Overview

MicrotiaTreatment choices for families to consider

AtresiaMicrotiaDevelopment of treatment plan

Surgical techniquesMicrotiaAtresia

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Microtia*

* Always look for the canal

Microtia (unilateral): Timetable

(Amplification)AccommodationsConsider mandibular surgery

Dental/OMFS assessment

School age (8-12 yrs)

(Amplification)AccommodationsReview optionsStart microtia repair

AudiogramDental assessment

Early school (5-7 yrs)

(Amplification)Discuss options

Answer questionsReview of photos

Ear specific audioCT scan (t-bones)C spine x-raysDental assessment

Preschool (3-5 yrs)

(Early intervention)(Amplification)Discuss options

Microtia and atresia

Monitor S/LMonitor hearingMiddle ear

Toddler (1-3 yrs)

(Early intervention)(Amplification)

HearingRenal US

Infancy (0-12 months)

InterventionAssessment Age

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Microtia and atresia: Management options

1. Do nothing2. Bone conduction

hearing aid3. Softband4. BAHA5. Atresia repair*

Atresia/ conductive hearing loss (unilateral)

1. Do nothing2. Prosthetic

management3. Staged surgical

reconstruction

MicrotiaOptionsCondition

Atresia (unilateral): Management options

Complex surgeryLess predictable resultModest hearing benefitOngoing care

CosmesisNo device

Atresia repair*

CosmesisDevice requiredSoft tissue issuesInsurance coverage

Simple surgeryPredictable Excellent hearing result

BAHA

CosmesisComfort

No surgeryBCHA

Unilateral HLMinimize risk(?)Do nothing

DisadvantagesAdvantagesApproach

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Aural atresia: Classification systems*

Mastoid pneumatization

OW/FP

FP-VII relationship

Inner ear

Feature

Poor

Abnormal/absentAbnormal

Abnormal

Normal

Normal

Normal

Normal

MajorMinor

De la Cruz211111111

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StapesOWMiddle ear spaceFacial nerve normalMalleus-incus presentMastoid well aeratedIncus stapes connectionRW normalAppearance outer earTotal

Jahrsdoerfer

* Do not live by the classification system alone

Autogenous rib reconstruction and BAHA

Position of BAHAShould be about 3 cm posterior to hairline

Timing of BAHA procedure relative to microtiamanagement

ControversialPresence of BAHA may interfere with 3rd stage, depending upon the microtia surgeon

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Atresia repair: Preoperative counseling

Cannot get complete closure of air bone gap

Timing of atresia repair depends upon plan for microtiamanagementExpect ABG about 30 dBPatients may be able to accommodate hearing aidPost operative activity limitations

Avoid strenuous activity for 1 monthAvoid water exposure for 3 months

Possible issues with otorrheaVariable ability to use ear level amplificationRevision rate – approximately 25%

Microtia: Management options

AppearanceDonor sitesMultiple surgeries

Autogenous tissueMinimal maintenanceBecomes sensateAtresia repair

Rib cartilage (autogenous)

Reconstructed

Foreign bodyMore challenging to do atresia repair

Less donor site morbidityLess variability in carving

MEDPOR®

Multiple procedures Removal of remnant and soft tissueOngoing prosthetic careDaily maintenanceUse restrictions

AppearanceSecure retention

Implant retained

InsecureOngoing prosthetic careDaily maintenanceUse restrictions

AppearanceAdhesive retained

ProstheticDisadvantagesAdvantagesDetailsType

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Microtia and atresia: Development of treatment plan

Educate family about timeline and overall optionsStress importance of language development during infancyCT scan of temporal bones at about 5 years of ageReview options for hearing interventionsAscertain preferences for microtia managementDevelop treatment plan

Microtia and atresia: Developing the treatment plan

1. Do nothing2. Bone conduction

hearing aid3. Softband4. BAHA5. Atresia repair*

1. Do nothing2. Prosthetic

management3. MEDPOR®

4. Staged rib reconstruction

Atresia optionsMicrotia options

* Favorable candidates ; determine timing

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HISTORY

1937 Gillies maternal rib graft 1959 Tanzer autologous rib-solid block1966 Cronin silastic1974 Brent autologous rib1991 Reinisch MEDPOR®

1994 Nagata stacked autologous rib

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Microtia: Factors in decision making

Bony structuresOrbitZygomaMandible

Soft tissue considerationsHair lineAtrophy

Atresia/ hearing optionsSocial considerations

Patient expectationsFamily expectations

Microtia: Factors in decision making

Timing of microtiareconstruction

Context of overall management of HFMOverall growth

Patient preferenceAesthetic outcomeDonor site morbidity

Ongoing access to care

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Microtia: Staged autogenous rib reconstruction

Stage I: Rib graft implantation

Stage II: Transfer of lobule

Stage III: Release of ear with FTSG

Stage IV: Atresia repair and creation of tragus

Microtia: Stage I Creation of template

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Microtia: Stage I Rib harvesting

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# 69 Beaver Blade

Floating 9th Rib

Synchondrosis between 7th and 8th Ribs

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Single drain goes beneath the framework

Microtia : Stage II Lobule Transposition

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Micro Z-plasty

Microtia: Stage III Postauricular skin grafting

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Atresia repair: Surgical stagesApproach

Lateral workExternal auditory canalAtretic plate

ReconstructionMiddle ear

OssiculoplastyTympanic membrane

Skin graftExternal auditory canal

Skin graftExternal auditory meatusTragus

Atresia repair: Surgical technique

ApproachTragal incisionPostauricular approachLateral EACPeriosteal incisionsHarvest fasciaExpose cortex/cribiformExpose glenoid

Adequate excision of soft tissueKenalog injection intraoperativelyPut on some relaxing music

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Atresia repair: Identifying the middle ear

Atresia repair: Ossiculoplasty

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Atresia repair: Tympanic membrane

Atresia repair: Skin graftDonor site

Contralateral earGroin; primary closure

SizeThe bigger the betterAbout 7 x 3 cm ellipseExcise one corner to graft TM

Create tubeInterrupted and running sutures6-0 chromic on spatulatedneedle (TG140-8)Invert tube

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Atresia repair: Skin graft to TM

Atresia repair: Skin graft to EAC

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Atresia repair: OutcomesPre op Post op

6 weeks

Post op6 months

Post op12 months

Atresia repair: Complications

Revision if associated with CHL

Creation of sulcusTuck fascia graft

TM lateralization

Layered closureLayered closure of postauricularincision

Fistula

RevisionPosition pinnaduring closure

EAC ectasia

Steroid injectionSteroid injectionEAC stenosis

Steroid injectionPackingAdequate excision of soft tissue

EAM collapse

ManagementPreventionComplication

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Atresia repair: Complications

Silver nitrateGentian violet

Careful positioning of skin graftsEpithelial approximation

Mucosalization

A whole other topicFacial nerve monitorLow threshold to terminate the procedure

Facial palsyDon’t drill on plateSNHL

Revision surgeryAmplificationBAHA

CandidacyAll of the aboveCT scan in roomOssiculoplasty

Persistent CHL

ManagementPreventionComplication

Improving outcomes with atresia repair

Pre opPatient selectionManage expectations (patient, family, and surgeon)

OperativeSchedule adequate time in ORMeticulous surgical techniqueApproximation of epithelium

Post op Activity limitations

Embrace the details!!

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Microtia and aural atresia

Family education starts in infancyManage expectationsSurgical challengesRewarding outcomes

Case presentations

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Severe class 2 microtia

Severe class 2 microtia

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Severe class 2 microtia

Traumatic avulsion

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Traumatic avulsion

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Lobule reconstruction

Lobule reconstruction

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Lobule reconstruction

Lobule reconstruction

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Cryptotia

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