Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-016-4299-4

OTOLOGY

Mechanisms of ear trauma and reconstructive techniques in 105

consecutive patients
Michail N. Kolodzynski1 • Moshe Kon1 • Silvan Egger1 • Corstiaan C. Breugem1

Received: 7 March 2016 / Accepted: 6 September 2016

Ó The Author(s) 2016. This article is published with open access at Springerlink.com

Abstract Acquired auricular deformities may diminish Keywords Ear reconstruction
Auricular defect
Costal
facial esthetics and cause psychological distress. The aim of cartilage
Traumatic ear amputation
this article is to provide an overview of the type of injuries
and applied reconstructive techniques in a large academic
hospital in The Netherlands. A retrospective chart review Introduction
was conducted for the last 105 patients who underwent
auricular reconstruction for an acquired deformity. Data Acquired auricular defects, especially partial defects, are
concerning gender, affected side, cause of injury, anatomical relatively frequent, because of the prominent position of
region, the previous and further surgeries, type of cartilage, the ear on the side of the head and the delicate skin cover of
and skin cover used were collected and analyzed. 105 the complex cartilaginous framework [1, 2]. The auricle
patients were included. Acquired auricular deformities were with its convex and concave surfaces is designed to collect
mainly caused by bite injuries (22 %), traffic accidents and amplify sound and direct it to the auditory canal [1]. It
(17 %), burns (9.5 %), and post-otoplasty complications is, however, also a ‘decorative’ structure, and although not
(9.5 %). The upper third of the auricle was most often injured the most defining part of the face, it can detract from
(41 %), followed by the entire auricle (19 %). 70 % of cases overall esthetics of the face if deformed [3–5]. A deformity
required reconstruction with costal cartilage. The most or (partial) absence of the auricle can cause psychological
common form of cutaneous cover was a postauricular skin problems for the patient [3, 5–7]. The psychological benefit
flap (40 % of cases). This study gives a complete overview of of reconstruction of auricular defects, regardless whether
causes and treatment of acquired auricular deformities. The congenital or acquired, has been well documented in the
results are comparable with the results of similar studies literature [8, 9].
found in literature. Bite wounds are the leading cause of Reconstruction of an acquired auricular deformity is a
acquired auricular injuries. The upper third is most com- challenging procedure. It differs in every case and requires
monly affected. In the largest percentage of reconstructions, tailor-made reconstructions. The aim of any reconstruction
costal cartilage and a postauricular flap were used to correct is to restore the normal architecture of the auricle. To
the deformity. achieve this, the reconstructed part must have a support
structure, usually made out of conchal or costal cartilage,
and soft-tissue cover [10–12]. Postauricular skin flaps or
& Michail N. Kolodzynski advancements are often used, because of easy access and
[email protected] great mobility of the skin. In certain cases, when the skin
& Corstiaan C. Breugem surrounding the auricle is scarred, tissue expanders or
[email protected] temporoparietal fascia may be used [12, 13].
1
The aim of this article is to provide an overview of the
Department of Plastic and Reconstructive Surgery, Dutch
type of injuries and applied reconstructive techniques using
Center for Ear Reconstruction, University Medical Center
Utrecht, Heidelberglaan 100, PO Box 85500, autologous cartilage grafts in a Dutch University Medical
3508 GA Utrecht, The Netherlands Center. Patient characteristics, mechanisms of injury, as

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well as details about the reconstructions are presented to cases, the bite resulted in the loss of the entire ear, and in
provide baseline information on the reconstruction of three cases, two-thirds of the ear were lost. The lower third
acquired auricular defects. was injured in a single case. Out of these 23 cases of bite
injury, 15 were severe enough to require reconstruction
with costal cartilage.
Methods In 18 cases (eight women and ten men), the injury to the
auricle was caused by a traffic accident, resulting in the
A retrospective chart review was performed for the last 105 total amputation of seven auricles, four upper thirds, and
patients who underwent a reconstruction of the auricle with four upper two-thirds. The middle and lower third were
a cartilage graft at the Dutch Center for Ear Reconstruction affected in one and two cases, respectively. Two of the
of the University Medical Center Utrecht (UMCU). upper third defects were reconstructed with costal cartilage
Patients who were treated for congenital auricular defor- and one with conchal cartilage. The fourth upper third
mities and those reconstructed after tumor excision were defect could be reconstructed without the use of a cartilage
excluded. The following characteristics were recorded: graft by advancing the helix. Both lower third cases
name, gender, date of birth, laterality, the etiology of the required conchal cartilage only. All twelve remaining
injury, and the previous surgery of the ear. Each injury was injuries (seven total reconstructions, four upper two-thirds,
also classified by anatomical region, which was defined as and one middle third) caused by traffic accidents were
upper third, middle third, and lower third or any combi- repaired with costal cartilage.
nation. This division of the auricle into three zones made it Burn injuries were the cause in ten cases (three women,
possible to compare our results with those in the literature. seven men). Burns damaged the upper two-thirds in four
Furthermore, the age at reconstruction, the technic of cases; the upper third in two cases, and the lower third in
reconstruction, and type of cartilage used and the need for one case, and led to complete loss of three ears. Two
additional cover for the cartilage framework were recorded. defects, one of the upper third and one of the lower third,
Only the largest groups of each analysis will be discussed could be reconstructed with a conchal graft. The remaining
at length. Smaller groups will be summarized in the text eight cases required costal cartilage grafts.
and are visible in the tables. The findings were compared Ten reconstructions were mandatory following oto-
with previously published literature. plasty; three because of post-operative infection and one
The Medical Ethical Committee UMC Utrecht approved because of post-operative hematoma and subsequent
this study. infection and cartilage resorption. In the remaining six
IBM SPSS Statistics 21 (Armonk, NY: IBM Corp.) was patients with post-otoplasty deformities, the exact cause
used to compile statistics and figures. could not be found in the records. In at least four cases, the
employed otoplasty technique involved scoring of the
auricular cartilage; in five cases, the technique used was
Results not mentioned in the records. The upper and middle third
were the most common sites for auricular defects following
A total of 105 patients, 44 females (42 %) and 61 males otoplasty, with these areas being affected in four and three
(58 %), were included and their records analyzed in this cases, respectively. In the other three cases, post-otoplasty
study. The mean age in the female group was 29.7 years complications resulted in one lower third defect, one upper
(SD 16.12) and 33.2 years (SD 11.65) in the male group. two-thirds defect, and one total auricular loss.
The left ear was affected in 56 cases (54 %), one case did Six auricles (all in female patients) were deformed fol-
not mention left or right. lowing a piercing of the upper pole. Reconstruction
involved three upper thirds, two upper two-thirds, and one
Etiology total auricle, all of which were reconstructed with costal
cartilage.
The majority of injuries were due to bite injuries (n = 24, In 12 cases, the exact cause of injury could not be
23 %). Nine were inflicted by dogs, ten by humans, and identified. In this group of cases, injuries involved the
five by horses. All victims of horse bites were female, upper third in eight cases, the upper two-thirds in one case,
whereas the majority of human bite victims were male and the lower two-thirds in one case. In two cases, no
(n = 9). Dog bites were relatively evenly distributed information was available. Seven out of these twelve cases
between both sexes (four women versus five men). were reconstructed with costal cartilage; four with conchal
The upper third was most often affected in bite injuries cartilage, and in one case, the type of cartilage was not
(n = 13), followed by middle third injury (n = 4). In two specified.

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Table 1 Causes of injury Anatomical region

Etiology Total (%) Female (%) Male (%)
The upper third of the auricle was most often affected by
Bite (total) 23 (22) 9 (8.6) 14 (13) traumatic injury (n = 43; 41 %). In another 16 cases, the
Dog bite 9 (8.6) 4 (3.8) 5 (4.8) uppermost two-thirds of the auricle were affected. Twenty
Horse bite 4 (3.8) 4 (3.8) – ears were lost completely and required total auricular
Human bite 10 (9.5) 1 (0.9) 9 (8.6) reconstruction. Injuries of the middle third (n = 12), the
Traffic accident 18 (17) 8 (7.6) 10 (9.5) lower third (n = 6), and lower two-thirds (n = 5) were
Burn 10 (9.5) 3 (2.9) 7 (6.6) seen less frequently. Unfortunately, in three of these cases,
Post-otoplasty complication 10 (9.5) 7 (6.6) 3 (2.9) no information on the anatomical region could be found.
Hematoma 1 (0.9) 1 (0.9) – An overview of various anatomical regions affected is
Infections 3 (2.9) – 3 (2.9) shown in Fig. 1.
Deformity 6 (5.7) 6 (5.7) –
Cause unclear 12 (11) 3 (2.9) 9 (8.6) Type of reconstruction
Post-piercing deformity 6 (5.7) 6 (5.7) –
Fall 5 (4.8) 2 (1.9) 3 (2.9) The majority of ears were reconstructed using costal car-
Infection 5 (4.8) 2 (1.9) 3 (2.9) tilage (n = 73; 70 %). In most cases, the cartilage was
Occupational accident 4 (3.8) – 4 (3.8) harvested from the eighth rib (47 out of 73 cases), often in
Iatrogenic 4 (3.8) 2 (1.9) 2 (1.9) combination with cartilage from adjacent ribs. Conchal
Glass laceration 3 (2.9) – 3 (2.9) cartilage was used in 28 ears (27 %). This type of cartilage
Blunt force trauma 2 (1.9) 1 (0.9) 1 (0.9) was mainly used in the reconstruction of upper third
Gunshot 1 (0.9) – 1 (0.9) defects (n = 20). Any defect spanning more than a third of
Chronic inflammation 1 (0.9) 1 (0.9) – the auricle required the use of costal cartilage. Helical
Fight 1 (0.9) – 1 (0.9)
advancement techniques, requiring no additional cartilage,
Total 105 (100) 44 (42) 61 (58)
were employed in two patients. In another two cases, the
type of cartilage could not be found in the records.
Usually, local skin pockets were created to cover the
The remainder of cases had a variety of causes and framework (n = 53, 51 %). Additional cutaneous cover for
reconstructions. All information pertaining to these cases the cartilage framework was used in 52 cases (50 %). The
can be found in Table 1. (pedicled) postauricular flap was most often used to pro-
vide cover (n = 21), followed by tissue expansion
Previous surgery (n = 12) and temporoparietal fascia flap (n = 11). The

Thirty-four patients (32 %) had some form of auricular

surgery prior to reconstruction. Thirteen (12 %) underwent
the previous reconstruction with the unsatisfactory results.
Three patients (2.9 %) had amputated segments of the
auricle replanted unsuccessfully. A further three patients
(2.9 %) had the denuded cartilage of the lost segment
implanted under the skin. None of this cartilage was sub-
sequently used in reconstruction, due to extensive resorp-
tion rendering the cartilage useless. In ten cases (9.5 %),
the previous surgery, otoplasty, was the cause of a signif-
icant deformity, which required reconstruction. A bone-
anchored episthesis was placed in two individuals (1.9 %)
prior to reconstruction with autologous cartilage. Two
cases (1.9 %) had undergone unsuccessful surgeries to
improve the shape and definition of the auricle either by
deepening the concha or by lipofilling. In a single case, the
deformed cartilage was removed in a separate operation Fig. 1 Overview of the affected areas of the ear. Percentages are
prior to reconstruction. rounded to one decimal

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anatomical regions requiring any form of additional cuta- bite injury with accidents and shootings, so separate anal-
neous cover in descending order are upper two-thirds (10/ ysis of bite injuries was not possible. However, his number
16; 63 %), middle third (7/12; 58 %), upper third (23/43; of 146 out of 249 cases does suggest that bites were among
53 %), and total auricle (10/20; 50 %). Lower ear injuries the leading causes. A literature review of trauma cases
required additional cover in 17 % (1 out of 6 cases) and from 1980 to 2004 performed by Steffen et al. [16] con-
20 % (1 out of 5 cases), respectively, for lower third and cerning 74 cases in 56 publications shows that 35 %
lower two-thirds defects. (n = 26) of auricular injuries resulted from bites, mainly
The types of injury that required additional cutaneous caused by dogs (12 %) and humans (23 %).
cover most frequently were burns (7 out of 10; 70 %) and A study performed by Henry et al. showed that bite
bite injuries (15 out of 23; 65 %). In the group of patients injuries are not only the most common cause of acquired
suffering a bite injury to the ear, horse bite victims (n = 4) auricular defects, but also demonstrated that the ear is the
had the highest rate of any form of additional cover used predominant site for facial bite injuries, even more so than
(75 %), followed by human bite victims (7 out of 10; the other facial ‘extremity’, the nose [17]. The bite injuries
70 %) and dog bite victims (5 out of 9; 55 %). were similarly distributed over the three regions of the ear
74 patients (71 %) underwent mobilization of the ear as in Henry et al., as in our study, with the upper third being
a second-stage procedure to achieve normal projection. In affected in most cases (49 % compared with 57 % in this
21 cases, a skin graft and additional cartilage were used. article).
The second most leading cause in this study, traffic
accident, is also found to be a common cause in the liter-
Discussion ature. Harris found traffic accidents to be the cause of
auricular injury in 18 % (n = 5) of cases, compared with
Ear reconstruction remains one of the most challenging 12 % (n = 6) found by Pearl and 17 % (n = 18) found in
procedures encountered by reconstructive surgeons. This is this study [10, 13]. Hyckel found a very high incidence of
due to the intricate detail and anatomic complexity of the traffic accidents with 13 out of 15 cases (87 %) of trauma
cartilaginous auricular framework and its relationship with to the ear being caused by traffic accidents over a period of
its thin soft-tissue envelope. The golden standard is a 25 years [6]. The incidence for burn injury to the ear found
reconstruction with autologous costal cartilage introduced in this article (9.5 %) is lower than those found by Harris
by Tanzer [14]. This is later expounded by Brent [11] and (15 %), Gault (12 %), and Pearl (10 %) [3, 10, 13].
refined by the work of Nagata and Firmin [15]. This study Complications of otoplasty are not that common, but can
focused on autologous ear reconstruction after trauma. cause a significant damage to the auricle, and are among
Bite injuries were the leading cause of acquired auric- the leading causes of acquired auricular deformities. In this
ular deformities. Subsequent injuries were due to traffic study, 10 out of 105 (9.5 %) reconstructions were follow-
accidents, burns, and complications of otoplasty. Surpris- ing otoplasty. The numbers and percentages found by
ingly, in a country known for its high percentage of bikers, Gault, 32 out of 249 cases (13 %), and Harris, 3 out of 27
only few cases of auricular trauma were seen due to biking cases (11 %), confirm the significance of post-otoplasty
injuries. As shown in Table 2, these results are in line with complications in causing acquired auricular deformities
other publications. Pearl [13] found that 36 out of 50 cases [3, 10]. Literature suggests that deformities are more likely
(72 %) over a 4-year period were due to bite injury, which to occur in cutting or scoring the cartilage sculpting tech-
is three times as many than seen in this study. Harris [10] niques and that the result of cartilage sculpting is more
found that bites were the causes of injury in 14 out of 28 difficult to control [18]. Based on these findings, suturing
cases (50 %). Gault [3] pooled the number of cases due to techniques are recommended over sculpting techniques.

Table 2 Causes of injury compared with other literature

Etiology Harris [10] (n = 28) Steffen [16] (n = 74) Pearl [13] (n = 50) This study (n = 105)

Bite (total) 50 % 35 % 72 % 21.9 %

Dog bite 15 % 12 % 4% 8.6 %
Horse bite – – 2% 3.8 %
Human bite 35 % 23 % 66 % 9.5 %
Traffic accident 18 % 34 % 12 % 17.1 %
Burn 15 % – 10 % 9.5 %
Post-otoplasty (total) 11 % – – 9.5 %

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Upper third injuries of the auricle were, by far, the most Open Access This article is distributed under the terms of the
common, followed by total auricle injury, upper two-thirds Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
injury, and middle third injury. In almost 70 %, a costal distribution, and reproduction in any medium, provided you give
cartilage graft was mandatory to correct the deformity. appropriate credit to the original author(s) and the source, provide a
Subsequently a mastoid flap also often encountered. link to the Creative Commons license, and indicate if changes were
Although not the scope of this study, autologous rib car- made.
tilage reconstruction can be associated with complications,
such as infections, pneumothorax, and chest wall defor-
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