Reconstruction of stenotic external auditory canal with a postauricular chondrocutaneous flap

Reconstruction of the external auditory canal: The tragal flap revisited and review of contemporary reconstructive techniques

BACKGROUND

Primary malignancies arising in the external auditory canal (EAC) are rare and usually are treated surgically. We review techniques to reconstruct the EAC following ablative surgery, and introduce a rarely utilized tragal skin flap which has particular advantages for reconstruction of limited anterior EAC defects.

METHODS

The terms "tragal flap", "external auditory canal", "preauricular tragal flap", "reconstructive techniques" were searched on PubMed and Google Scholar.

RESULTS

Our review identified one description of a tragal flap to reconstruct the EAC following resection of a malignancy. We add an additional case of a preauricular tragal flap to reconstruct the anterior EAC following resection of a recurrent basal cell carcinoma located in the EAC that led to a circumferential defect.

CONCLUSION

There are several surgical techniques that can be utilized to reconstruct the EAC. We describe a novel tragal flap used to reconstruct the anterior EAC following resection of a recurrent tumor.

Current Treatments for Congenital Aural Atresia

Congenital aural atresia is an ear malformation evident at birth, involving various degrees of failed external ear canal development. A true external ear canal is desirable, as devices that replace the canal are inconvenient and expensive. Therefore, an optimal surgical technique is required. Here, we review useful preoperative and operative techniques. Surgical correction is often not the preferred treatment; the hearing outcome is no better than the outcomes afforded by bone-conduction devices, and surgery may be associated with recurrence or complications such as meatal stenosis. Preoperative evaluation and appropriate management are important. Several means of preventing meatal stenosis are discussed in this review.

[Acquired atresia and stenosis of the external acoustic meatus]

Acquired atresia of the external acoustic meatus is a rare pathological condition characterized by obliteration of the medial part of the external acoustic canal by a soft fibrous plug. The present article presents an overview of a series of cases of acquired atresia and stenosis of the external acoustic meatus with the description of etiology, pathogenesis, and methods for the treatment of this condition. In the majority of the cases, atresia develops at the final stage of granulation external otitis with or without an accompanying dermatological pathology. Another common cause of the acquired atresia of the external acoustic meatus is the fracture of the temporal bone as well as extensive ear surgery, radiation therapy and a neoplasm in the auditory passage. The surgical strategy for the management of the acquired atresia and stenosis of the external acoustic meatus consists, besides the excision of the fibrous plug, of the application of the cutaneous flaps and/or transplants to cover the bare parts of the bone portion of the affected external canal. In spite of such treatment, the state of the external acoustic canal remains unstable, and a relapse of its atresia and stenosis can not be wholly excluded.

Paraumbilical perforator flap for reconstruction of the external auditory meatus: A case report

We herein present a technique of using the umbilical stalk for reconstruction of the external auditory meatus. A 49-year-old female presented with locally aggressive melanoma affecting her mastoid region. She underwent radical excision including the skin and soft tissues around the external ear with simultaneous lymph node clearance. The resultant defect measured 15 cm × 8 cm in diameter and was 2.5 cm deep. This was reconstructed with a similarly sized microvascular paraumbilical perforator flap that included the umbilical stalk. In the post-operative course there was complete flap survival but a prolonged wound dehiscence near the auditory meatus that required revision surgery. At 15-months follow-up, the patient was melanoma-free and the auditory meatus was patent. Hearing was also preserved. The umbilical stalk is one of the few skin covered tubed structures in the human body that may be used without major donor morbidity to "replace like with like," the auditory channel.

Two-stage aural atresia and stenosis surgery with the use of synthetic skin substitute

CONCLUSION

With this technique, patency rates achieved in congenital external ear canal (EAC) atresia/stenosis and improvement in hearing were evaluated as 'good' and 'satisfactory', respectively.

OBJECTIVES

We aimed to test the efficacy of a novel two-stage technique in preventing restenosis following atresioplasty.

PATIENTS AND METHODS

Nine patients with congenital EAC atresia/stenosis comprised our cases. We performed 10 atresioplasties using the two-stage technique described below. In the first stage, the ear canal is drilled and its wall is covered with a synthetic skin replacement that induces proliferation of a soft tissue; in the second stage this is lined underneath with split thickness skin graft. Operations were complemented with tympanoplasties in five of the patients.

RESULTS

Nine (91%) of 10 operations carried out with the technique were largely successful in terms of patency. The achieved average hearing gain was air conduction/bone conduction (Ac/Bc): 31.33/9.44 dBHL (21.89 in the air-bone gap), while the postoperative air-bone conduction gap was changed to <30 dBHL in eight (88.9%) of the patients.

Reconstruction of the ear after skin and perichondrium loss

Because no two auricular defects are exactly the same, the choice of a suitable method for ear reconstruction is essential. Location and size of the defect influence the choice of technique needed for reconstruction. The method of reconstruction varies if there is skin loss, skin and perichondrium loss, or full-thickness loss. The skin surrounding the defect should be examined to determined if it is lacerated, burned, or scarred to decide whether or not it can be used in reconstruction. A plan of treatment should be decided and explained fully to the patient. A small area of skin loss can be closed by undermining of the edges and direct closure. If this cannot be performed because the defect is too large, the perichondrium is then examined to decide whether or not it is intact.

Prevention of postoperative meatal stenosis with anteriorly and inferiorly based periosteal flaps in congenital aural atresia surgery

OBJECTIVE

The objective of this study was to evaluate postoperative meatal stenosis after surgery for congenital aural atresia using anteriorly and inferiorly based periosteal flaps (AIPFs). These were compared with the groups that did not use these flaps.

STUDY DESIGN

This was a retrospective clinical study.

SETTING

The study was conducted at the tertiary referral hospital.

PATIENTS

There were 133 patients (151 ears) who had undergone surgical correction for congenital aural atresia from November 1987 to March 1999.

INTERVENTION

The anterior approach surgical method was used to correct the congenital aural atresia.

MAIN OUTCOME MEASURE

A comparison between the 2 groups, 1 using the AIPFs and the other that did not use the AIPFs, was performed to evaluate both the incidence and the interval of postoperative meatal stenosis. The correlation between the age of the first operation to correct congenital aural atresia and the incidence of postoperative meatal stenosis was also investigated.

RESULTS

Meatal stenosis was the most common postoperative complication (23.8%) found. The incidence of meatal stenosis was much lower in the group using AIPFs (n = 105) than in the group that did not (n = 46) (19.0% versus 35.0%). The interval for the development of postoperative meatal stenosis showed similar distribution in both groups. In age distribution, the younger the age of the first operation, the more frequent the occurrence of postoperative meatal stenosis.

CONCLUSION

AIPF is an effective surgical method for reducing the incidence of postoperative meatal stenosis.

Reconstruction of congenital stenosis of external auditory canal with a postauricular chondrocutaneous flap

We describe here a new surgical technique for treatment of congenital stenosis of the external auditory canal using a postauricular chondrocutaneous flap. Our technique prevents recurring stenosis by cartilage support and provides a sufficient extension of the canal. The chondrocutaneous flap is safely elevated, easily reaches the canal, and has ample blood supply. It is beneficial for its self-cleaning function that the remnant canal, which contains cerumen glands, is used as part of the reconstructed canal. Six patients with congenital stenosis of the external auditory canal were treated by our procedure. In these patients, three patients were treated by a postauricular approach and the others were treated by an endaural approach. All patients had very satisfactory results.