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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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