Management of Congenital Auricular Anomalies.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe normal ear anatomy and development, and evaluate the patient's ears for differences in shape, size, prominence, and symmetry. 2. Identify common congenital ear deformities, including prominent ear, macrotia, Stahl ear, cryptotia, constricted ear, and lobule anomalies. 3. Describe both early nonoperative management and operative techniques for correction of these ear deformities. 4. Be aware of advantages and disadvantages of common and emerging techniques for correction of pediatric ear deformities. SUMMARY: Whereas severe ear malformations such as microtia/anotia are rare, other ear deformities, such as prominent ear, Stahl ear, and cryptotia, are common. Although these ear deformities result in minimal physiologic morbidity, their psychological and cosmetic impact can be significant. Identifying these common deformities and understanding how they differ from normal ear anatomy is critical to their management. In cases where a deformity is identified in neonatal life, ear molding may obviate the need for surgery. Although various surgical techniques have been described for correction of common ear deformities, the surgeon should follow a careful stepwise approach to address the auricular deformity or deformities present. By using such an approach, complications may be minimized and predictable aesthetic outcomes achieved.

Effects of microcurrent therapy on excisional elastic cartilage defects in young rats.

The effects of microcurrent application on the elastic cartilage defects in the outer ear of young animals were analyzed. Sixty male Wistar rats were divided into a control (CG) and a treated group (TG). An excisional lesion was created in the right outer ear of each animal. Daily treatment was started after 24h and consisted of the application of a low-intensity (20µA) continuous electrical current to the site of injury for 5min. The animals were euthanized after 7, 14 and 28 days of injury and the samples were submitted to analyses. In CG, areas of newly formed cartilage and intense basophilia were seen at 28 days, while in TG the same observations were made already at 14 days. The percentage of birefringent collagen fibers was higher in CG at 28 days. The number of connective tissue cells and granulocytes was significantly higher in TG. Ultrastructural analysis revealed the presence of chondrocytes in TG at 14 days, while these cells were observed in CG only at 28 days. Cuprolinic blue staining and the amount of glycosaminoglycans were significantly higher in TG at 14 days and 28 days. The amount of hydroxyproline was significantly higher in TG at all time points studied. The active isoform of MMP-2 was higher activity in TG at 14 days. Immunoblotting for type II collagen and decorin was positive in both groups and at all time points. The treatment stimulated the proliferation and differentiation of connective tissue cells, the deposition of glycosaminoglycans and collagen, and the structural reorganization of these elements during elastic cartilage repair.

Rib Cartilage Assessment Relative to the Healthy Ear in Young Children with Microtia Guiding Operative Timing.

BACKGROUND: The optimal age at which to initiate for auricular reconstruction is controversial. Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction. We developed a method to guide the timing of auricular reconstruction in children with microtia ranging in age from 5 to 10 years. METHODS: Rib cartilage and the healthy ear were assessed using low-dose multi-slice computed tomography. The lengths of the eighth rib cartilage and the helix of the healthy ear (from the helical crus to the joint of the helix and the earlobe) were measured. Surgery was performed when the two lengths were approximately equal. RESULTS: The preoperative eighth rib measurements significantly correlated with the intraoperative measurements (P < 0.05). From 5 to 10 years of age, eighth rib growth was not linear. In 76 (62.8%) of 121 patients, the eighth rib length was approximately equal to the helix length in the healthy ear; satisfactory outcomes were achieved in these patients. In 18 (14.9%) patients, the eighth rib was slightly shorter than the helix, helix fabrication was accomplished by adjusting the length of the helical crus of stent, and satisfactory outcomes were also achieved. Acceptable outcomes were achieved in 17 (14.0%) patients in whom helix fabrication was accomplished by cartilage splicing. In 9 (7.4%) patients with insufficient rib cartilage length, the operation was delayed. In one (0.8%) patient with insufficient rib cartilage length, which left no cartilage for helix splicing, the result was unsatisfactory. CONCLUSIONS: Eighth rib cartilage growth is variable. Rib cartilage assessment relative to the healthy ear can guide auricular reconstruction and personalize treatment in young patients with microtia.

External ear microRNA expression profiles during mouse development.

MicroRNAs (miRNAs) comprise a class of approximately 22 nucleotide regulatory non-coding RNAs that play several roles in diverse biological processes. Recent reports suggest that embryonic development in mammals is accompanied by dynamic changes in miRNA expression; however, there is no information regarding the role of miRNAs in the development of the external ear. The aim of this study was to determine the stage-specific expression of miRNAs during mouse external ear development in order to identify potentially implicated miRNAs along with their possible targets. miRNA expression profiles from fetal mice pinnae and back skin tissues at 13.5 dpc and 14.5 dpc were obtained using an Affymetrix GeneChip miRNA 3.0 array. Biological triplicates for both tissues, each collected from a litter averaging 16 fetuses, were analyzed. The results were analyzed with Affymetrix's Transcriptome Analysis Console software to identify differentially expressed miRNAs. We observed differential expression of 40 miRNAs including some predicted to target genes implicated in external ear development, such as mmu-miR-10a, an miRNA known to modulate Hoxa1 mRNA levels, and mmu-miR-200c and mmu-miR-205. To our knowledge, this is the first miRNA expression profiling study of external ear development in mammals. These data could set the basis to understand the implications of miRNAs in normal external ear development.

Wideband acoustic immittance measures: developmental characteristics (0 to 12 months).

Rapid developmental changes of the peripheral auditory system in normal infants occur in the first year of life. Specifically, the postnatal development of the external and middle ear affects all measures of external and middle ear function including wideband acoustic immittance(WAI). This article provides an overview of WAI studies in newborns and infants from a developmental perspective. Normative WAI data in newborns are fairly consistent across studies. However, there are discrepancies in some WAI measures between studies, possibly due to differences in sampling, methodology, and instrumentation. Accuracy of WAI measurements is compromised when a good probe seal cannot be maintained during testing or an inaccurate estimate of the cross-sectional area of the ear canal of newborns occurs. Comparison of WAI data between age groups from 0 to 12 months reveals maturation effects. Additional age-specific longitudinal and cross-sectional normative WAI data for infants from birth to 12 months are required to validate and consolidate existing data.

Evaluation of some facial anthropometric parameters in an Iranian population: infancy through adolescence.

OBJECTIVES: By finding the mean value of anthropometric parameters in normal samples of a population, it is possible to create a template for facial analysis. The aim of our study was to measure the anthropometric parameters in 0- to 12-year-old girls of Fars ethnic origin in the Northeast of Iran. STUDY DESIGN: Six hundred sixty-two newborn to 12-year-old girls of Fars ethnic origin participated in the study. A digital camera was used to take frontal full-face photographs of each child. Thirteen measurements were taken with the Smile Analyzer software: al-al, ch-ch, en-en, ex-ex, ft'-ft', go'-go', t-t, zy'-zy', n'-gn', n'-sn, t-g', t-gn', t-sn. Data were analyzed using the SPSS software at the significance level of 0.05. RESULTS: In almost all parameters, we found significant growth acceleration between 2 and 4 years as well as 5 and 6 years of age. Another growth spurt was seen between 9 and 11 years, although it was less noticeable. Comparing the linear regression equations suggests that different craniofacial dimensions do not grow similarly. CONCLUSIONS: By age, craniofacial dimensions change at different rates. Different craniofacial dimensions do not grow at consistent rates. Some parts grow slower compared with others. The intercanthal width has the slowest growth. Facial height shows the fastest growth.

A comparison of digital morphometry and clinical measurements of ears.

Clinical measurements are necessary in many routine follow-ups and scientific evaluations, but the accuracy of these measurements is seldom challenged. The size of the reconstructed ear is one important parameter in the follow-up regarding patients operated on due to microtia. With the introduction of digital morphometry one was obliged to evaluate its accuracy in comparison to its analogue equivalents. In a first series of measurements the ears of 30 persons were assessed using digital morphometry, compass and ruler, and calliper to test the accuracy of these methods. In a second series of measurements, 10 patients with reconstructed unilateral microtia were assessed with digital morphometry to test the inter-individual variation of this method. The accuracy of digital morphometry was of the same magnitude as the manual methods. When the inter-individual variation of accuracy was assessed in digital morphometry it was found that random error differed from person to person. In scientific settings, for instance when evaluating possible growth of the cartilage framework, the specific individual accuracy must therefore be taken into account in order to draw safe conclusions.

Progression of growth in the external ear from birth to maturity: a 2-year follow-up study in India.

BACKGROUND: This study aimed to follow the growth dynamics of auricular dimensions from birth to the age of 18 years. The norms of dimensions at different ages, the peak growth period and the maturity age of the dimensions are essential information to Physicians for early clinical diagnosis or for deciding the optimal time for surgery to correct abnormalities. METHODS: For this study, 2,147 children belonging to central Indian population were measured in at least three sequential sessions. Eight dimensions including the physiognomic length and width of the ear and its morphologic width; conchal length, width, and depth; and lobular length and width were measured using anthropometric technique. Three new dimensions (tragal length and height and maximum width of the antihelix) were introduced in the study. Three indices (auricular, conchal, and lobular) also were derived. RESULTS: Most dimensions exhibited very rapid growth during the first 3-6 months of infancy and thereafter proceeded at a slow pace until adulthood. The smaller dimensions (conchal depth, tragal height, and maximum width of the antihelix) increased continuously throughout the growth period. At birth, most of the dimensions were 52-76 % of their adult size, while tragal length and height were less than half their adult size. Unlike the other dimensions, the lobule length was smaller in males, probably due to the higher frequency of hypoplastic and bow-shaped lobules among them. The width dimensions matured earlier, at 5.6-11 years, whereas the maturity age of lengths varied from 12 to 16 years. CONCLUSIONS: The data generated in the current study will be useful to Physicians as a guideline in correcting auricular deformity and in constructing age progression charts of the external ear. Knowledge concerning the maturation age of the ear will help law enforcement authorities in deciding when to use it for establishing personal identification. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

High-fidelity tissue engineering of patient-specific auricles for reconstruction of pediatric microtia and other auricular deformities.

INTRODUCTION: Autologous techniques for the reconstruction of pediatric microtia often result in suboptimal aesthetic outcomes and morbidity at the costal cartilage donor site. We therefore sought to combine digital photogrammetry with CAD/CAM techniques to develop collagen type I hydrogel scaffolds and their respective molds that would precisely mimic the normal anatomy of the patient-specific external ear as well as recapitulate the complex biomechanical properties of native auricular elastic cartilage while avoiding the morbidity of traditional autologous reconstructions. METHODS: Three-dimensional structures of normal pediatric ears were digitized and converted to virtual solids for mold design. Image-based synthetic reconstructions of these ears were fabricated from collagen type I hydrogels. Half were seeded with bovine auricular chondrocytes. Cellular and acellular constructs were implanted subcutaneously in the dorsa of nude rats and harvested after 1 and 3 months. RESULTS: Gross inspection revealed that acellular implants had significantly decreased in size by 1 month. Cellular constructs retained their contour/projection from the animals' dorsa, even after 3 months. Post-harvest weight of cellular constructs was significantly greater than that of acellular constructs after 1 and 3 months. Safranin O-staining revealed that cellular constructs demonstrated evidence of a self-assembled perichondrial layer and copious neocartilage deposition. Verhoeff staining of 1 month cellular constructs revealed de novo elastic cartilage deposition, which was even more extensive and robust after 3 months. The equilibrium modulus and hydraulic permeability of cellular constructs were not significantly different from native bovine auricular cartilage after 3 months. CONCLUSIONS: We have developed high-fidelity, biocompatible, patient-specific tissue-engineered constructs for auricular reconstruction which largely mimic the native auricle both biomechanically and histologically, even after an extended period of implantation. This strategy holds immense potential for durable patient-specific tissue-engineered anatomically proper auricular reconstructions in the future.

Movement of the external ear in human embryo.

INTRODUCTION: External ears, one of the major face components, show an interesting movement during craniofacial morphogenesis in human embryo. The present study was performed to see if movement of the external ears in a human embryo could be explained by differential growth. METHODS: In all, 171 samples between Carnegie stage (CS) 17 and CS 23 were selected from MR image datasets of human embryos obtained from the Kyoto Collection of Human Embryos. The three-dimensional absolute position of 13 representative anatomical landmarks, including external and internal ears, from MRI data was traced to evaluate the movement between the different stages with identical magnification. Two different sets of reference axes were selected for evaluation and comparison of the movements. RESULTS: When the pituitary gland and the first cervical vertebra were selected as a reference axis, the 13 anatomical landmarks of the face spread out within the same region as the embryo enlarged and changed shape. The external ear did move mainly laterally, but not cranially. The distance between the external and internal ear stayed approximately constant. Three-dimensionally, the external ear located in the caudal ventral parts of the internal ear in CS 17, moved mainly laterally until CS 23. When surface landmarks eyes and mouth were selected as a reference axis, external ears moved from the caudal lateral ventral region to the position between eyes and mouth during development. CONCLUSION: The results indicate that movement of all anatomical landmarks, including external and internal ears, can be explained by differential growth. Also, when the external ear is recognized as one of the facial landmarks and having a relative position to other landmarks such as the eyes and mouth, the external ears seem to move cranially.

A novel anthropometric chart for craniofacial surgery.

Various indices and measurements of the growing cranial vault exist, but there is no single head-shape chart specific to craniofacial surgery. The authors have produced a reliable head-shape chart that will enable accurate charting of patients with craniosynostosis both in the preoperative and postoperative period.One thousand eighty-two participants were used to obtain normal anthropometric measurements, specifically the ear-to-ear measurement and the glabella-to-external occipital protuberance measurement. Both male and female participants aged 6 months to 25 years were used to obtain these measurements. These measurements were correlated with the cephalic index as described by Farkas according to the different age groups.A head-shape chart has been created for males and females using the normal ear-to-ear measurements and the cephalic index that define both qualitative and quantitative elements of the growing skull. Craniofacial surgeons may find this chart useful for managing patients with craniosynostosis. This chart is also useful in the assessment of how the skull grows after surgery.

Age- and sex-related changes in the normal human ear.

The objective of this study was to supply information about: (1) normal sex-related dimensions of ears (linear distances and ratios, area); (2) left-right symmetry; and (3) growth changes between childhood and old age. The three-dimensional coordinates of several soft-tissue landmarks on the ears and face were obtained by a non-invasive, computerized electromagnetic digitizer in 497 male and 346 female healthy subjects aged 4-73 years. From the landmarks, paired ear width and length, the relevant ratios, ear areas and angles relative to the facial midline, as well as indices of left-right symmetry, were calculated, and averaged for age and sex. Comparisons were performed by factorial analysis of variance. All ear dimensions were significantly larger in men than in women (p<0.001). A significant effect of age was found (p<0.001), with larger values in older individuals. The ear width-to-length ratio and the sagittal angle of the auricle significantly decreased as a function of age (p<0.001) but without sex-related differences. On average, the three-dimensional position of ears was symmetric, with symmetry coefficients ranging between 92% and 96%. Asymmetry was found in the sagittal angle of the auricle (both sexes), in the ear width-to-length ratio and ear width (men only). Data collected in the present investigation could serve as a data base for the quantitative description of human ear morphology and position during normal growth, development and aging. Forensic applications (evaluations of traumas, craniofacial alterations, teratogenic-induced conditions, facial reconstruction, aging of living and dead persons, personal identification) may also benefit from age- and sex-based data banks.

Cross-sectional anthropometric study of the external ear.

This cross-sectional anthropometric study was aimed at estimating expansion of the external ear during adult life, in order to evaluate the extent to which anatomical features appearing in earprints may vary with time. A review of the literature was provided. Data extracted from photographed ears of 1353 subjects were analyzed. The effect of age on auricle length, earlobe length, and auricle width was explored using univariate analyses of variance. The regression coefficients of age on these dimensions were, respectively, 0.178, 0.115, and 0.073 mm/yr for males, and 0.162, 0.100, and 0.073 mm/year for females (p=0.000). Regression coefficients of age corrected for stature were assumed to be less accurate. Anthelix prominence and helix width were analyzed using data of 175 subjects, and appeared unaffected by age. As lobe expansion appeared to exceed the estimated cartilage expansion, it was assumed that particularly the imprint of the lobe would be less stable with time.

Effects of oral exposure of synthetic pyrethroid, cypermethrin on the behavior of F1-progeny in mice.

Cyermethrin, a type II synthetic pyrethroid insecticide, was evaluated through assessment of the behavioral development of F1-progeny of mice. Groups each of 30 male and 30 female ICR (CD-l) mice, as F0-generation, were given 0, 2.5, 5, and 10mg/kg/day cypermethrin in corn oil orally for 4 weeks/5 days in a week before mating. Behavioral endpoints of motor reflexes, motor coordination, and activity were evaluated in F1-progeny. Clinical signs of toxicity including salivation, hyperactivity, and tremors which attributed to cypermethrin were observed in the F0-mice treated with 10mg/kg/day. A significant delay in the development of pinna detachment, down appearance, and eye opening of 48, 59, and 27 pups (47, 64, and 39%, respectively) was observed in the high dose group. Reduction of body weight became significantly evident only for F0-females either during treatment or gestation and lactation periods for the high dose group. Significant differences in the development of reflexes, swimming ability, and open-field activity were evident in the offspring for the 10mg/kg/day dose group compared to the control group. These results show that cypermethrin at dose level of 10mg/kg/day can induce a significant risk to the offspring following treatment of F0-mice before mating. The NOAEL obtained in this study for the effects of cypermethrin on the development of the F1-progeny is 5mg/kg/day.

Anthropometric growth study of auricle of healthy preterm and term newborns.

OBJECTIVE: Auricular abnormalities are important for early diagnosis of the birth defects in the prematures and newborns. Auricular antropometric studies in healthy premature and mature population depend on their gestational age are limited and insufficient. The aims of this study were to reveal antropometric growth and dynamics of the auricle in the healthy newborns from the 28th to the 42nd gestation weeks. MATERIALS AND METHODS: A total of 600 newborns were evaluated in 40 groups. Each group comprising 20 preterm or term newborns according to their sexes and gestational weeks. Six surface dimensions were performed directly from the right ears of the subjects: the length from the superaurale to subaurale, the width from the tragus to helix, the width from the tragus to antihelix, the conchal depth, the distance from the helix to mastoid at superaural level and the distance from the helix to mastoid at tragal level. The frequency of the prominent ear deformity and lobule attachment were also noted. RESULTS: The results of auricular antropometric measurements of healthy preterm and term newborns in different gestational weeks were to determined. No statistical differences of auricular length were found between male and female infants. The incidence of the prominent ear deformity and attached lobule was 8.16 and 27.4%, respectively. CONCLUSIONS: Normal anthropometric features for healthy newborns on the basis of gestational age are very important for the diagnosis of a variety of congenital malformations or syndromes. In this study, antropometric measurements of the auricle in the healthy preterm and term newborns on the basis of gestational age in our region were noted. Similar anthropometric studies in the preterm and term newborns at different geographic and various socioeconomic areas should be performed to constitute normative data in the literature.

Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty?

The present study was conducted to determine whether otoplasty performed in children younger than 4 years of age has an acceptable long-term outcome. This two-part study consisted of (1) a questionnaire mailed to 481 members of the American Association of Plastic Surgeons to ask their opinion on the timing of otoplasty, and (2) a consecutive series of 12 patients who had otoplasty performed before the age of 4 years. The survey demonstrated that the majority (57 percent) of the respondents perform otoplasty on patients who are aged 5 years or older. The prospective series consisted of 12 patients ranging in age from 9 months to 3 years at the time of the procedure. Otoplasty was bilateral in nine patients and unilateral in three patients. Length of follow-up ranged from 21 months to 7(1/2) years, with a median follow-up of 41 months. Growth following otoplasty was evaluated in three patients who underwent unilateral otoplasty by measuring the length of both ears at the time of final follow-up. No difference in ear length was noted between the sides that were and were not operated on during a follow-up period of 46 to 63 months. Noticeable recurrence was noted in only one (8 percent) of 12 patients. In response to a follow-up questionnaire to the patients' families, all respondents (n = 10) stated that if again asked to choose the timing of otoplasty in their children, they would opt to have it performed at the same age of younger than 4 years. Otoplasty can be safely performed at ages younger than previously thought without interfering with growth of the operated ear.