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Thread: Pictures of Congenital Ear Deformities pictures - Ear Atlas

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    Default Pictures of Congenital Ear Deformities pictures - Ear Atlas

    History of the Procedure
    Many different approaches to setback otoplasty have been developed. Originally, the first operations were merely resection of skin from the posterior sulcus. Approximately 200 different techniques have now been described for setback otoplasty; each technique has strengths and weaknesses. Over the years, an evolution of operations has occurred, including those with and without sutures, with and without resection of cartilage, and with or without scoring of cartilage. With this many variations, no single "right" technique exists.

    Microtia as a modern operation was first pioneered by Tanzer from Dartmouth Medical School. Tanzer was the first to develop the technique of using a whole piece of rib cartilage to simulate the cartilaginous structure of the external ear. Burt Brent from Stanford, Calif, expounded upon Tanzer's work and has written extensively about microtia reconstruction.

    Problem
    The expression "beauty is in the eye of the beholder" is often quoted and still quite relevant. What constitutes a prominent ear? Ray Elliot stated in his 1990 review article in Clinics of Plastic Surgery, "the esthetic ear protrudes less than 2 cm when measured from the surface of the helix to the mastoid scalp at the midpoint of the ear's length."However, once this measurement achieves a distance of less than 1.2 cm, the ear has an equally displeasing "pinned back" appearance. The ear protrudes more at the lower pole and less so at the upper pole because of the shape of the skull. The scaphoconchal angle should have a natural soft roll and should not block the view of the helix anywhere along its course when viewed anteriorly.

    Frequency
    No statistics are available on the prevalence of protruding or prominent ears. Heredity plays a role in many deformities of the external ear.

    Etiology
    Most embryologic studies of the ear focus on the development of the 6 ear hillocks. These hillocks appear around the fundus of the first branchial groove by 38 days of gestation. As the groove closes and the first and second arches come together, the primitive ear is formed by day 50 of gestation. The first 3 hillocks come from the first branchial arch and the second 3 from the second branchial arch. Absence of hillocks 2-5 produces a frequent and typical microtia. Malformations of the ear can appear anywhere during this development.
    Pictures Congenital Deformities pictures Atlas attachment.php?s=5c75f7c6754228d55b1644c64215def5&attachmentid=1874&d=1441393123

    Presentation
    Most parents, while emotionally distressed when their baby is born with a portion of the external auricle missing or severely distorted, are unconcerned about protruding ears at birth. Patients tend to seek surgical opinion for protruding ear problems at two stages of life. Parents often seek medical advice for their children at the start of school because of the child's complaints of classmates' teasing. The jeer of "Dumbo" is difficult for a first grader. The second group of patients consists primarily of women in their twenties or early thirties. These patients also are embarrassed about their protruding ears.

    Indications
    For the child born without an external ear, the indications for surgical reconstruction are obvious. Parents are anxious to proceed as soon as possible to spare their child any embarrassment. Unlike cleft lip surgery, which is performed in the first few weeks of life, most experienced surgeons recommend waiting to do multistages at age 6-7 years. The more important question is not whether surgery is indicated, but which of the techniques for reconstruction is indicated for the individual. Even with microtia, the physiologic effects of an ear deformity are negligible. The aesthetic and psychological effects are significant.

    In the patient born with a prominent ear or deformity, the situation may be a little different. With the obtuse scaphoconchal angle and absent antihelical fold, distance from the helical rim varies. Many authorities believe the external ear should protrude no more than 2 cm from the surface of the helix to the mastoid scalp at the midpoint of the ear's length. This measurement is a guide and not an absolute rule. Much depends upon the patient's expectations as well as the surgeon's experience. Although congenital absence is almost always unilateral, patients with prominent ears usually require a bilateral operation.

    Children with protruding ears generally do well when operated on as early as age 5-6 years. A study from the Medical College of Wisconsin presented a series of 12 patients in whom otoplasty was performed before the age of 4 years with good results.Taunts from schoolmates begin at this time. Parents, not realizing how cruel kindergarten children can be, are often oblivious to this ridicule. Young girls reveal much less of this mental anguish because they are able to wear their hair long and cover their ears. They never wear a ponytail, lest a peer discovers their ears stick out.

    In this author's practice, a common indication for setback otoplasty is the approximately 20-year-old woman who is getting married and now wants to wear her hair in an upswept fashion. Boys do not have that option. Because of a genetic predisposition to protruding ears, some parents find that seeking plastic surgical consultation for their children is difficult. To admit his or her child is flawed, the parent must admit he or she is flawed.

    Medical Therapy
    Historically, prominent or protruding ears have been treated surgically. More recently, nonsurgical techniques have emerged to treat neonates immediately after delivery. The posterior helical rim is taped to the posterior retroauricular region with surgical tape. Tubular elastic net bandage or some type of ear wrap is used for reinforcement. To achieve the desired result, such techniques must begin in the first few weeks of life and take several weeks or months of constant and vigilant therapy.

    A protruding ear tends to become more apparent as the child ages, particularly in the neonatal period. Matsuo believes most prominent ear deformities are acquired and recommends careful positioning of babies in their cribs to keep the auricles from folding anteriorly.One preventive method is to lay babies in a prone position

    Epinephrine (Adrenalin, Bronitin, EpiPen) is a sympathomimetic catecholamine that acts as vasoconstrictor on alpha-adrenergic receptors in capillaries and decreases permeability of dilated capillaries to plasma. This vasoconstrictive action reduces absorption of local anesthetic, prolonging duration of action and decreasing risk of anesthetic's toxicity. Vasoconstrictive action also causes hemostasis in small vessels, relaxes smooth muscle of bronchioles, stomach, intestine, pregnant uterus, and urinary bladder wall. Use to prolong anesthetic effect and provide hemostasis. IM/SC administration has rapid onset and short duration of action, deteriorates rapidly on exposure to air or light, turning pink from oxidation to adrenochrome and brown from the formation of melanin. Replace solutions that show evidence of discoloration.
    Pictures Congenital Deformities pictures Atlas attachment.php?s=5c75f7c6754228d55b1644c64215def5&attachmentid=1875&d=1441393166

    Triamcinolone (Aristopan Intra-Articular, Aristopan Intralesional, Aristocort Intralesional) is an intermediate-acting glucocorticoid with essentially no mineralocorticoid activity. It causes decreased inflammation through enzyme induction and decreased immune response by reducing activity and volume of lymphatic system. Use to decrease inflammation and increase immunosuppression. Diacetate and acetonide salts for injection have variable onset and duration of action, depending on whether they are injected into an intra-articular space, a muscle, or on the blood supply to that muscle. It may be administered IM, intra-articularly, intrasynovially, intralesionally, sublesionally, or by soft-tissue injection.

    Diacetate suspension is slightly soluble, providing a prompt onset of action and a longer duration of action of 1-2 wk. Triamcinolone acetonide is relatively insoluble and slowly absorbed. Extended duration of action lasts for several weeks. Triamcinolone hexacetonide is relatively insoluble, absorbed slowly, and has prolonged action of 3-4 wk. Adult dosing of triamcinolone acetonide is 2.5-15 mg intra-articularly, not to exceed 1 mg intralesionally prn. Adult dosing of triamcinolone diacetate is 2-40 mg intra-articularly, intrasynovially, or intralesionally q1-8wk. Adult dosing of triamcinolone hexacetonide is 2-20 mg intra-articularly q3-4wk prn, not to exceed 0.5 mg intralesionally per square inch of skin.

    Bupivacaine hydrochloride (Marcaine) is a long-acting local anesthetic that can be used with or without epinephrine (as bitartrate) 1:200,000 to induce local or regional anesthesia or analgesia for surgery, oral surgery procedures, diagnostic and therapeutic procedures, and obstetric procedures. It has a pKA of 8.1, similar to lidocaine at 7.86. It possesses a greater degree of lipid solubility and is protein bound to greater extent than lidocaine. Local anesthetics block generation and conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in nerve, by slowing propagation of nerve impulse, and reducing rate of rise of action potential. In general, progression of anesthesia is related to diameter, myelination, and conduction velocity of affected nerve fibers.

    Clinically, the order of loss of nerve function is as follows: pain,temperature, touch, proprioception, andskeletal muscle tone. Bupivacaine hydrochloride’s onset of action is rapid and it anesthetic effects long–lasting. Its anesthetic effects are significantly longer than other commonly used local agents. In adults, the usual dose for local infiltration is 0.25% bupivacaine; it may be repeated once q3h, although its long-acting nature usually makes a single dose sufficient. Doses up to 225 mg with epinephrine 1:200,000 and up to 175 mg without epinephrine are most used. In clinical studies to date, total daily doses up to 400 mg have been reported, but, until further experience is gained, this dose is not to be exceeded in 24 h. Pediatric dosing is not established.

    References:
    http://emedicine.medscape.com/article/1288708-treatment











    Last edited by Medical Photos; 09-04-2015 at 06:59 PM.

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