International Journal of Pediatric Otorhinolaryngology 78 (2014) 471–473
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A long-term analysis of auricular position in pediatric patients who underwent post-auricular approaches Paul Hong a,b,*, Todd Arseneault c, Fawaz Makki a a
Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada School of Human Communication Disorders, Dalhousie University, Halifax, Nova Scotia, Canada c School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 October 2013 Received in revised form 17 December 2013 Accepted 17 December 2013 Available online 27 December 2013
Objective: Post-auricular approach is commonly used in otologic surgery. The objective of this study was to ascertain whether post-auricular approach alters the position of the auricle. Methods: All patients who underwent post-auricular approach for mastoidectomy or tympanoplasty from October 2010 to June 2012 were enrolled. Measurements of ear prominence at three distinct sites were taken preoperatively, and postoperatively at day one and at three and 12 months. Data were analyzed with repeated measures ANOVA analysis. Results: Nineteen patients were included in the study. Mean age at surgery was 9.05 years; 11 were male and 8 were female. Overall, there was no statistically significant long-term postoperative change in any of the three measurements, indicating stability of the auricular position. No difference was also noted on the basis of patient variables. Conclusion: Post-auricular approach did not alter the position of the external ear in our patient population. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Retroauricular Postauricular incision Mastoidectomy Tympanoplasty Ear position Auricle
1. Introduction Post-auricular approaches are commonly used in otologic procedures. Mainly, this involves an incision in the retro-auricular region to gain exposure to the mastoid bone and the bony external auditory canal. The auricle itself is usually retracted anteriorly during the operation. Chronic ear disease requiring mastoidectomies and tympanic membrane perforations with poor visualization due to external auditory canal bony prominences, are commonplace indications necessitating post-auricular approaches. Rarely, post-auricular approaches have been utilized for other purposes, such as temporomandibular joint procedures, [1] removal of facial lesions and upper neck masses, [2,3] and rhytidoplasties [4]. Potential risks of common otologic operations, such as mastoidectomies and tympanoplasties, are well documented in the literature [5–7]. For instance, complications of mastoidectomies, albeit rare, include irreversible hearing loss, vertigo, facial nerve injury, cerebrospinal fluid leak, and brain injury [6]. Another
* Corresponding author at: IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada. Tel.: +1 902 470 0841; fax: +1 902 470 8929. E-mail address:
[email protected] (P. Hong). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.12.023
extremely rare complication post-mastoidectomy reported in the literature is auricular positional changes [8]. More specifically, some patients have reported that their ears appear asymmetrical, or that their eyeglasses no longer fit the same after their otologic operation [8]. The objective of this study is to examine the long-term effects of otologic surgery with post-auricular approaches on post-operative auricular position. 2. Materials and methods 2.1. Patients After obtaining local Institutional Review Board approval, all patients who underwent otologic surgery with post-auricular approaches from October 2010 to June 2012 at the Izaak Walton Killam Health Center were prospectively enrolled. These included patients undergoing tympanomastoidectomy for chronic ear disease and tympanoplasty requiring post-auricular approaches. Patients who had previous post-auricular approaches were excluded. Demographic data, indications for surgery, surgical technique employed, and auricular measurements were collected from each participant. The position of the ear was measured from the lateral most aspect of the helical rim and lobule to the mastoid skin at the
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 471–473
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Graft material consisted of either temporalis fascia or tragal cartilage and perichondrium. No cases of pinna cartilage harvest or canal wall down mastoidectomy procedures were included in our series. Closure was done in layers. Periosteal flap was reapproximated with 4–0 vicryl sutures (Ethicon, Inc., Somerville, N.J.) in a simple interrupted fashion. Subcutaneous tissue was closed with the same suture material in a simple interrupted inverted manner. Finally, the skin was closed using a 5–0 fast absorbing gut suture with running technique (Ethicon, Inc., Somerville, N.J.). Mastoid head dressing was placed at the end of the case, which was removed on postoperative day one, prior to discharge home. 2.3. Statistical analysis Repeated measures analysis of variance (ANOVA) was used to compare auricular measurements over time (within-subjects main effect). A P value less than 0.05 were considered significant. Statistical analysis was performed using SAS version 9.1 (SAS Institute, Inc., Cary, N.C.). 3. Results 3.1. Demographics
Fig. 1. The three auricular measurement sites used in the present study: (1) superior most aspect of the helix (A); (2) half way between the superior most aspect and the lobule (B); and (3) lobule (C).
following specific locations: (1) superior most aspect of the helix (A); (2) half way between the superior most aspect of the helix and the lobule (B); and (3) lobule (C) (Fig. 1). All measurements were performed by the senior author using a surgical caliper preoperatively, on postoperative day one, and during follow-up visits at three and 12 months. 2.2. Surgical procedure All patients were placed under general anesthesia and intubated orally. The senior author performed all of the procedures. A standard post-auricular approach was used in all cases. Briefly, a curvilinear incision, approximately 5 mm away from the post-auricular sulcus, was carried out with a No. 15 scalpel blade from the mastoid tip inferiorly to the region of the supra-aural sulcus superiorly. Sharp dissection was performed to the level of the temporalis fascia superiorly and the mastoid periosteum inferiorly. An anteriorly based C-shaped periosteal flap was raised exposing the bony external auditory canal and the mastoid cortical bone. Self-retaining retractor was placed to hold the auricle in an anterior position. A standard underlay tympanoplasty with canaloplasty and/or cortical mastoidectomy was then performed. All mastoidectomies were canal wall up.
A total of 19 patients were enrolled (nine right ears and 10 left ears). The mean age at time of surgery was 9.05 years (range 4–16 years). Eleven patients were male and eight were female. Operative indications were: (1) cholesteatoma (N = 12); (2) chronic suppurative otitis media (N = 2); and (3) chronic tympanic membrane perforation with bony external auditory canal prominence (N = 5). Regarding complications, one patient had residual tympanic membrane perforation and one had postoperative otorrhea, which was managed effectively with ototopical medication. No other complications were observed. 3.2. Auricular measurements Measurements were performed preoperatively and postoperatively on day number one, and at three and 12 months. The mean measurements at each site and their standard deviations are presented in Table 1. Overall, there was no statistically significant difference between the auricular measurements at any of the three measured sites at 12 months follow-up when compared to the preoperative measurements with the repeated measures ANOVA test (Table 1). That is, the ear measurements were not significantly altered on a long-term basis. However, there was a significant difference on postoperative day number one for mean auricular measurements taken at the superior helical rim (measurement A) [10.95 mm preoperative and 14.63 postoperative day one; P = .040 (paired ttest)]. As well, a non-significant trend toward increasing prominence at midpoint (measurement B) was noted between the same time period [14.95 mm preoperative and 16.47 mm postoperative day one; P = .055 (paired t-test)]. When considering perioperative factors, there was no statistically significant change in ear measurements over time when age, gender, and indication(s) for surgery were considered as variables.
Table 1 The mean auricular measurements at each site and time period, in millimeters, with standard deviations. Locationa
Preop
Postop day 1
Postop 3 months
Postop 12 months
P valueb
A B C
10.95 1.31 14.95 1.08 19.21 1.58
14.63 2.79 16.47 1.54 19.68 1.83
11.26 1.45 15.05 1.13 19.21 1.58
11.05 1.37 15.00 1.05 19.21 1.58
0.4985 0.7563 0.6987
a b
A-superior most aspect of the helix; B-midpoint (between A and C); C-lobule. MANOVA analysis.
P. Hong et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 471–473
4. Discussion Anecdotal evidence suggests auricular positional changes being observed in clinical settings after otologic surgeries with postauricular approaches. Similar findings have been reported in patients who undergo otoplasty procedures [9,10]. Specifically, some of these patients had increased protrusion of their auricles after otoplasty and thus one study recommended overcorrecting the prominent ear in the operating room [10]. And although up to 60,000 mastoidectomies are performed every year in the United States, [6] there has been only one study that assessed auricular position post-mastoidectomy [8]. This retrospective case series identified several patients who were noted to have inferiorly displaced auricles. As well, some subjects became aware that their ears appeared asymmetrical after their otologic surgery [8]. However, no objective or quantitative measures were used to assess the positional changes, and the time to follow-up was not clear or consistent. It is important to determine whether relative ear positioning can be permanently altered following post-auricular approach for tympanomastoidectomy or tympanoplasty operations, as repositioning of the ear may affect patient satisfaction. Significant cases of auricular movement may result in the patient being concerned about their self-image, which in turn can lead to psychological issues [11]. Other functional problems, such as eyeglasses not fitting well, may also occur in severe cases [8]. As mentioned above, the sole study relating to this topic suggested that the auricle may be displaced post-mastoidectomy [8]. Our results suggest, however, that the position of the ear does not change significantly overtime. There were some changes noted on post-operative day one but overall, the ear measurements were not significantly changed at 12-months follow-up. Furthermore, when considering the baseline demographic and surgical variables, such as age and indications for surgery, the results remained non-significant. The significant change observed at the superior pole of the helical rim (measurement A) at post-operative day one is most likely due to post-operative edema. Specifically, the local swelling as a result of soft tissue dissection may place pressure on the compliant ear, forcing it into a more prominent position. This conjecture is supported by the transient nature of the positional change. That is, as the local edema resolves, the ear retracts closer to the head to its original position as evidenced by the measurements taken at 12 months follow-up. This indicates that the wound can be closed in the usual manner without the need for ‘overcorrection’ or other alterations to maintain the initial auricular position. It is unclear whether the possible change in auricular position should be discussed during the informed consent process with those patients undergoing otologic procedures with post-auricular approach. Admittedly this may be considered a minor issue and many patients may not have major concerns relating to this matter, as long-term positional changes were found to be non-significant. Yet, the transient short-term change was significant and noticeable in many patients. Subsequently this initial alteration can be a point of discussion with patients. Potential limitation of the study involves the inclusion of only pediatric patients and therefore conclusions may not be generalized to adult patients. However, the external ear growth is completed at a young age and no considerable change occurs afterwards [12]. Therefore, adult ears may show similar results as observed in our study. Regarding auricular measurements, only the lateral protrusion of the ear was considered in the present study. That is, the height and vertical position of the auricle, and the angle of the conchal bowl rotation were not measured. This is another limitation since
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these dimensions of the external ear may have changed during the postoperative period. Yet, no patients (and caregivers) reported noticing any changes in the appearance of their ears. As well, three patients who had eyeglasses did not report any changes, suggesting that the vertical position of the ear was not altered. Another limitation is the small sample size. No statistical calculation was performed to determine the ideal sample size and the number of patients enrolled was based on convenience. Yet due to the novel nature of this study, it was difficult to devise an expected difference to determine the sample size a priori. Surgical technique can also vary between surgeons, which can lead to different outcomes than observed in the current series. That is some surgeons may close the wound in a different manner or remove excessive subcutaneous tissue. Furthermore, generalizability of our results may not be applied to some otologic procedures that involve post-auricular approaches. For instance, radical mastoidectomies where the canal wall and the mastoid tip are removed may lead to inward migration of the auricle. Finally, one assessor performed all measurements and they were not repeated to assess for agreement. Multiple assessors and repeated measurements would have allowed for inter- and intrarater variability assessment; however, one assessor was used for practicality purposes. As well, using one assessor may increase the consistency of measurement technique. 5. Conclusion In the present study, there was no statistically significant change in auricular position from baseline to one year following otologic operations with post-auricular approaches. There was a transient prominence of the outer ear soon after the operation but in the long-term the auricle returned to its native position. Financial disclosure None declared. Conflict of interest None declared. References [1] S. Kowalik, Retroauricular incision for exposure of temporomandibular joint, Czas. Stomatol. 24 (1971) 917–920. [2] J.L. Roh, Retroauricular hairline incision for removal of upper neck masses, Laryngoscope 115 (2005) 2161–2166. [3] B. LeBert, S. Weiss, J. Johnson, R. Walvekar, Retroauricular hairline approach for excision of second branchial cleft cysts: a preliminary experience, Laryngoscope 120 (Suppl.) (2010) S160. [4] A. Barrera, Face lift and hair transplantation as a single procedure, Plast. Reconstr. Surg. 104 (1999) 1831–1838. [5] M. Bennet, F. Warren, D. Haynes, Indications and technique in mastoidectomy, Otolaryngol. Clin. North Am. 39 (2006) 1095–1113. [6] L.C. French, M.S. Dietrich, R.F. Labadie, An estimate of the number of mastoidectomy procedures performed annually in the United States, Ear Nose Throat J. 87 (2008) 267–270. [7] A.L. James, B.C. Papsin, Ten top consideration in pediatric tympanoplasty, Otolaryngol. Head Neck Surg. 147 (2012) 992–998. [8] M.S. Ali, Unilateral secondary (acquired) postmastoidectomy low-set ear: postoperative complication with potential functional and cosmetic implications, J. Otolaryngol. Head Neck Surg. 38 (2009) 240–245. [9] M.E. Graham, M. Bezuhly, P. Hong, A long-term morphometric analysis of auricular position post-otoplasty, J. Plast. Reconstr. Aesthet. Surg. (2013) (Epub ahead of print). [10] P.A. Adamson, B.L. McGraw, G.J. Tropper, Otoplasty: critical review of clinical results, Laryngoscope 101 (1991) 883–888. [11] J.A. Gasques, J.M. Pereira de Godoy, E.M. Cruz, Psychosocial effects of otoplasty in children with prominent ears, Aesthet. Plast. Surg. 32 (2008) 910–914. [12] M.T. Kalcioglu, Y. Toplu, O. Ozturan, C. Yakinci, Anthropometric growth study of auricle of healthy preterm and term newborns, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 121–127.