15_ Sie_Microtia.pdf

8/16/2019 15_ Sie_Microtia.pdf

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Microtia and aural atresia:

An integrated approach tomanagement

Kathleen Sie, MD

Craig Murakami, MD

Pacific RimOtolaryngology Head and Neck Surgery Update 2010

Microtia and atresia: Overview

Microtia

Treatment choices for families to consider

Atresia

Microtia

Development of treatment plan

Surgical techniques Microtia

Atresia


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Microtia*

* Always look for the canal

Microtia (unilateral): Timetable

(Amplification)

Accommodations

Consider mandibular surgery

Dental/OMFSassessment

School age (8-12 yrs)

(Amplification)

AccommodationsReview options

Start microtia repair

Audiogram

Dental assessment

Early school (5-7 yrs)

(Amplification)

Discuss options

Answer questions

Review of photos

Ear specific audio

CT scan (t-bones)

C spine x-rays

Dental assessment

Preschool (3-5 yrs)

(Early intervention)

(Amplification)

Discuss options

Microtia and atresia

Monitor S/L

Monitor hearing

Middle ear

Toddler (1-3 yrs)

(Early intervention)

(Amplification)

Hearing

Renal US

Infancy (0-12 months)

Intervention Assessment Age


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Microtia and atresia:Management options

1. Do nothing

2. Bone conductionhearing aid

3. Softband

4. BAHA

5. Atresia repair*

Atresia/ conductivehearing loss (unilateral)

1. Do nothing

2. Prostheticmanagement

3. Staged surgicalreconstruction

Microtia

OptionsCondition

Atresia (unilateral):Management options

Complex surgery

Less predictable result

Modest hearing benefit

Ongoing care

Cosmesis

No device

Atresia repair*

Cosmesis

Device required

Soft tissue issuesInsurance coverage

Simple surgery

Predictable

Excellent hearing result

BAHA

Cosmesis

Comfort

No surgeryBCHA

Unilateral HLMinimize risk(?)Do nothing

Disadvantages Advantages Approach


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Aural atresia:

Classification systems*

Mastoidpneumatization

OW/FP

FP-VII relationship

Inner ear

Feature

Poor

Abnormal/absent

Abnormal

Abnormal

Normal

Normal

Normal

Normal

MajorMinor

De la Cruz2

1

1

1

1

1

1

1

1

10

Stapes

OW

Middle ear space

Facial nerve normal

Malleus-incus present

Mastoid well aerated

Incus stapes connection

RW normal

Appearance outer ear

Total

Jahrsdoerfer

* Do not live by the classification system alone

Autogenous rib reconstruction and BAHA

Position of BAHA

Should be about 3 cm posterior to hairline

Timing of BAHA procedure relative to microtiamanagement

Controversial

Presence 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 microtiamanagement

Expect ABG about 30 dB Patients may be able to accommodate hearing aid Post operative activity limitations

Avoid strenuous activity for 1 month Avoid water exposure for 3 months

Possible issues with otorrhea Variable ability to use ear level amplification Revision rate – approximately 25%

Microtia: Management options

Appearance

Donor sitesMultiple surgeries

Autogenous tissue

Minimal maintenanceBecomes sensate

Atresiarepair

Rib cartilage

(autogenous)

Reconstructed

Foreign body

More challenging to do

atresiarepair

Less donor site

morbidity

Less variability in

carving

MEDPOR®

Multiple procedures

Removal of remnant

and soft tissue

Ongoing prosthetic care

Daily maintenance

Use restrictions

Appearance

Secure retentionImplant

retained

Insecure

Ongoing prosthetic care

Daily maintenance

Use restrictions

Appearance Adhesi ve

retainedProsthetic

Disadvantages AdvantagesDetailsType


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Microtia and atresia:

Development of treatment plan

Educate family about timeline and overall options

Stress importance of language development duringinfancy

CT scan of temporal bones at about 5 years of age

Review options for hearing interventions

Ascertain preferences for microtia management

Develop treatment plan

Microtia and atresia:

Developing the treatment plan

1. Do nothing

2. Bone conductionhearing aid

3. Softband

4. BAHA

5. Atresia repair*

1. Do nothing

2. Prostheticmanagement

3. MEDPOR ®

4. Staged ribreconstruction

Atresia optionsMicrotia options

* Favorable candidates ; determine timing


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HISTORY

1937 Gillies maternal rib graft

1959 Tanzer autologous rib-solid block

1966 Cronin silastic

1974 Brent autologous rib

1991 Reinisch MEDPOR ®

1994 Nagata stacked autologous rib


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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 oftragus

Microtia: Stage I

Creation of template


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Microtia: Stage IRib harvesting


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# 69 Beaver Blade

Floating 9th Rib

Synchondrosis between 7 th and 8th Ribs


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Single drain goes beneath the framework

Microtia : Stage IILobule Transposition


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Micro Z-plasty

Microtia: Stage IIIPostauricular skin grafting


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Atresia repair: Surgical stages

Approach Lateral work External auditory canal Atretic plate

Reconstruction Middle ear

Ossiculoplasty

Tympanic membrane Skin graft

External auditory canal Skin graft

External auditory meatus Tragus

Atresia repair: Surgical technique

Approach

Tragal incision

Postauricular approach

Lateral EAC

Periosteal incisions

Harvest fascia

Expose cortex/cribiform

Expose glenoid

Adequate excision of soft tissue

Kenalog injectionintraoperatively

Put 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 graft Donor site

Contralateral ear

Groin; primary closure

Size

The bigger the better

About 7 x 3 cm ellipse

Excise one corner to graftTM

Create tube Interrupted and running

sutures

6-0 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: Outcomes

Pre op Post op

6 weeks

Post op

6 months

Post op

12 months

Atresia repair: Complications

Revision ifassociated with CHL

Creation of sulcus

Tuck fascia graft

TM lateralization

Layered closureLayered closure ofpostauricularincision

Fistula

RevisionPosition pinna

during closure

EAC ectasia

Steroid injectionSteroid injectionEAC stenosis

Steroid injection

Packing

Adequate excision ofsoft tissue

EAM collapse

ManagementPreventionComplication


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Atresia repair: Complications

Silver nitrate

Gentian violet

Careful positioning of skingrafts

Epithelial approximation

Mucosalization

A whole other topicFacial nerve monitorLow threshold toterminate the procedure

Facial palsy

Don’t drill on plateSNHL

Revision surgery

Amplification

BAHA

Candidacy

All of the above

CT scan in room

Ossiculoplasty

Persistent CHL

ManagementPreventionComplication

Improving outcomes with atresia repair

Pre op

Patient selection

Manage expectations (patient,family, and surgeon)

Operative

Schedule adequate time in OR

Meticulous surgical technique

Approximation of epithelium

Post op

Activity limitations

Embrace the details!!


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Microtia and aural atresia

Family education starts in infancy

Manage expectations

Surgical challenges

Rewarding outcomes

Case presentations


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Severe class 2 microtia



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Traumatic avulsion


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Traumatic avulsion


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Lobule reconstruction



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Cryptotia


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Documents

15_ Sie_Microtia.pdf