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23]
Correspondence to:
Dr. Sujata Sarabahi,
B-18, First Floor, Kailash Colony, New Delhi - 110 048, India. E-mail: ssarabahi@yahoo.co.in
Abstract
Ear is a very prominent part of the face after nose and eyes especially in Indian subcontinent where
in both the males and females it adorns a variety of ornaments to beautify the face. However, because
of limited functional importance of external ear the burns of the ear are often neglected. More often,
isolated burns of the ear are very rare. They are usually involved with facial burns and therefore
inhalational injuries. Overall management of burns to improve survival takes precedence over the
management of just the burned ear. Therefore, neglected ear burns can lead to cosmetic deformity
which can vary from minor to very severe. Giving due importance to this small structure can prevent a
lot of morbidity during the acute phase and deformities later on as a sequel of burns. Correction of those
deformities and giving a normal shape to the ear can be a very daunting task because of the intricacies
involved in framing the cartilage and inadequate soft tissue availability in the surrounding area. This
article emphasizes on the steps which can be taken from the first postburn day to avoid complications
like chondritis, chondral abscess, and various other deformities because in a patient surviving burn
injury, the quality of his or her life will be determined by the degree of these deformities.
Key words:
Ear burn, chondritis, deformity, cover
Figure 1: Superficial dermal burns of the ear showing the peeled off Figure 2: Mixed superficial and deep dermal burns of the ear
epidermis exposing glistening pink superficial dermis
b
Figure 4: (a) Deep burns of the ear, (b) When deep burns of the ear
Figure 3: Full thickness burns of ear seen by the dry eschar and are not debrided and cartilage not covered primarily leads to severe
thrombosed veins deformity as shown
superior sulcus which can accommodate glasses and to thus preventing partial thickness burn from becoming
minimize complications from infection and fibrosis. a full thickness injury. There is no doubt that pressure
on the burnt ear and further trauma of any kind has
ACUTE BURNS to be avoided to prevent further damage to an already
compromised cartilage.
Most of the burns heal without any operative intervention. The application of topical antibiotics like 1% silver
The main goal or aim of treatment of acute ear burns sulphadiazene, sulfamylon, and 0.3% silver nitrate reduces
is to prevent suppurative chondritis. “Chondritis of ear contamination of the wound and allows partial thickness
is better prevented than treated” – is a famous saying. burns to heal.[5,6] However, the most effective topical agent
The main consideration is to avoid pressure on burned for the ear which can prevent and even treat chondritis is
pinna which cannot be overemphasized.[5] Therefore the mafenide (Sulfamylon) cream because of its excellent ability
patient should not lie on either side and neither use a to penetrate the eschar and the cartilage and has a broad
pillow under the head. Instead a ‘donut’ is used to keep antibacterial spectrum with good bacteriostatic action. It has
the head elevated without the ears touching any surface. to be applied twice daily because of its active penetration.
This prevents pressure necrosis of the ears and skin loss,
Like any superficial second degree burn anywhere else on
the body, in the case of ear also biological dressings can
be used as they promote epithelialization and reduce the
chances of infection, chondritis and further ear damage.
A contour dressing with minimal pressure during
bandaging is also helpful [Figure 7]. Use of certain
ingenuous splints instead of a contoured dressing has
been reported in the literature[7-9] but there is no added
advantage of a splint over a contoured dressing. In
fact, it can be difficult to apply a splint for protection
of ear in case the entire face is burned. Instead when a
contoured dressing is given, it helps in reducing edema
and thereby reducing the chances of chondritis. An
occlusive dressing also reduces the chances of nosocomial
infection. With this local care the swelling subsides and
partial thickness burns heal with time. In case skin is lost
Figure 5: Established chondral abscess which has developed even after but perichondrium is preserved, it will ‘take’ a thin skin
all burns have practically healed graft or else granulation and epithelialization can occur.
If cartilage is exposed in a small area, it can be debrided
and skin graft applied over its cut end.
In full thickness burns if the cartilage is not exposed
some authors suggest leaving the eschar to separate
spontaneously as it acts as a biological cover for underlying
cartilage preventing it from desiccation and applying
split skin graft over the underlying granulation tissue
a b later.[10,11] However if the eschar is suppurative it should
be debrided. Others suggest early excision of skin and if
Figure 6: (a) Patient with signs and symptoms of chondritis, i.e.,
complains of severe pain in the pinna with erythema, swelling, and a large area of cartilage gets exposed, the ear cartilage
tenderness, (b) Same patient with increased cephaloconchal angle can be salvaged soon after burns using a vascularized flap.
a b c
Figure 7: (a) Patient with deep burns of the ear after debridement of dead skin, (b) Thick layer of antimicrobial cream applied over paraffin gauze,
(c) Contoured dressing being done with flavine wool to allow proper contact between skin and cartilage
Since local skin is commonly injured, regional or distant ear which splits ear into anterior and posterior surfaces
flaps have been described to cover the cartilage.[12,13] These has been recommended by most authors.[1,6] This prevents
include platysma myocutaneous flap, temporoparietal recurrence. The involved cartilage is soft and yellow and
fascial flap, the latter being the best choice because of its lacks resilience of normal hyaline cartilage. All the soft
thinness and pliability. Though one must remember that cartilage must be removed, leaving behind only cartilage of
temporoparietal fascia is the best option for secondary ear normal consistency. Gauze soaked in antibacterial solution
reconstruction so it should be used judiciously if at all in is packed between the skin flaps which reduces further
the acute stage. Postauricular fascia can also be used as a progression of infection and a light dressings is given
turn over flap to provide cover. over the ear. Dressing is to be changed after 24 hours
and any residual necrotic cartilage should also be excised
Rosenthal[10] described 12 zones of partially burned [Figures 8, 9]. Dressing is continued till secondary closure
ear which were divided into three major regions which is achieved. Topical chemotherapy has a better influence on
include 6 zones which are used as donor sites for outcome of chondritis as systemic antibiotics are ineffective
advancement flap, three zones which can be excised since cartilage survives by diffusion from perichondrium.
and closed primarily and two zones which should be
preserved as far as possible. ESTABLISHED EAR DEFORMITIES
Chondritis
For established suppurative chondritis a number of Ear reconstruction should be undertaken once all the burns
approaches have been advocated. Antibiotic irrigation with have healed and deformity has established. Functional
polymyxin B 0.2% solution or culture specific antibiotics reconstruction of important areas like eyelids, hand, axilla
every 2-3 hours for 4-5 days with help of catheter both and elbow takes priority over the ear however since ear
anteriorly and posteriorly was reported by some authors.[14,15] reconstruction is a staged procedure; it can be started
Iontophoresis using polar charged antibiotic compounds simultaneously when other areas are operated upon.
such as penicillin and gentamycin which are pulsed across Kung et al.[20] classified burned ear deformities into 3 main
avascular membranes was advocated by Greminger[16] and types:
has been recommended by many authors later on.[12,17] • Mild - loss of helix and upper part of pinna without
extensive scarring
Simple drainage of pus is insufficient as chances of
• Moderate - concha is normal, upper half of ear has
recurrence is high.[18,19] Cultures of pus drained may often
sloughed out with loss of antihelix with its anterior
be sterile. Therefore excision of all underlying necrotic
and posterior crura.
cartilage leaving skin intact after a bivalving incision in the
• Severe - only a remnant of concha, marked scarring of
local soft tissue, external meatus normal or stenosed.
Because of limited skin availability in the auricular
region, total reconstruction of ear in these cases is a
challenging task. Bhandari has stated in 1998[2] that
postburn deformed ear can be classified into 5 groups
for management depending upon availability of local skin.
These are given as:
a b • Group I: In this group the postauricular skin is normal
Figure 8: (a) Established suppurative chondritis which was treated and is used to provide cover to the cartilage
timely by excision of all dead cartilage, (b) 1 Month postoperative framework.
picture of same patient
a b c
Figure 9: (a) Patient presented with typical signs and symptoms of chondritis, (b) Bivalving incision given and dead cartilage being excised,
(c) 1 Week postoperative picture of the same
• Group II: In these patients the postauricular skin is region and postauricular mastoid skin flap (inferiorly
either scarred or grafted but is soft and based) can be used to recreate anterior and posterior
supple and can be therefore used for cover. surface of the ear lobe.[28]
• Group III: In these patients local skin is not available
Total or near total loss of ear: Total reconstruction of burned
for draping the cartilage so temporoparietal
fascia is used for covering cartilage as an ear is more difficult than other deformities because of
axial or random flap. poor quality of the skin. Therefore in such cases use of a
• Group IV: In these patients local and regional skin good prosthesis is a good alternative if it is psychologically
as well as fascia is not available for cover. acceptable to the patient. However the best option is to
A free temporoparietal fascial flap from attempt reconstruction of ear with either autogenous
contralateral side or free radial forearm cartilage or implant (medpore/silicone). In 1968,[29] Cronin
fascial flap is indicated for them. et al. used commercially available silastic framework for
• Group V: These are the patients in whom ear reconstruction as an alternative for costal cartilage
reconstruction is not possible because of framework but because of the high incidence of infection
non availability of local and regional skin and and extrusion its use was discontinued. In the case of
anaesthesia problems. They are therefore partial defects involving more than helical rim loss, the
advised to use an external prosthesis. missing cartilage framework is replaced with autogenous
cartilage preferably costal cartilage because of its stiffness
Many methods have been designed for reconstruction of
which resists distortion from contraction of overlying
deformed ear including those by Brent[21] and Feldman.[22]
cover. Cover is given by local skin flap if adequate or
Postburn scar contracture in ear is released and defect temporoparietal fascia flap with skin grafting in case
resurfaced by either split skin graft, full thickness graft, the surrounding tissue is scarred [Figure 11]. In 1974,
transposition flaps, rotation flaps and posterior auricular Tanzer used full thickness graft from supraclavicular area
‘revolving door’ island flap.
Closed book contracture of ear has been reported by
Saraiya wherein the ear gets folded vertically like a book
which was corrected by release and grafting anteriorly
and giving a conchomastoid suture to maintain the ear.[23]
Partial ear loss: It can involve different parts of the ear. In
burns of the ear usually only the helix and lobule are lost
but the central part of the ear is spared though it may
be deformed by contracting scars. The spared conchal
structures have therefore been used as transposition flap a b
for reconstruction of deformed ear[24] [Figure 10].
Figure 10: (a) Postburn ear deformity leading to contraction in helical
In the case of localized defects of helix and scapha, superior rim, (b) Contraction released and corrected with two postauricular
flaps to restore the shape of the pinna
and inferior chondrocutaneous helical rim flaps based on
postauricular skin described by Antia and Buch[25] are used
though it makes the ear smaller. In case only helical rim
is lost, a thin tube can be raised from postauricular area
if undamaged and transferred to form helix in stages. In
case postauricular area is scarred, the tube formation from
preauricular area or from cervical skin expanded flap or
lower supraclavicular area is a good therapeutic option.[26]
Goldstein and Stevenson[27] suggested leaving these flaps a b
open, allowing them to tube themselves thus reducing
vascular compromise from light suturing.
Lobule reconstruction – Usually anteroinferior aspect
of ear lobule is pulled inferiorly by the scarred adjacent
cheek. This is corrected by using the scar band as a
superiorly based flap of scar and subcutaneous fat which
can be lifted up to recreate anterior border of lobule. If c d
lobule is totally lost the local scar tissue can be incised
Figure 11: (a) Near total loss of pinna following burns, (b) Temporoparietal
and raised as earlobe and under surface lined by split skin flap marked and dissected, (c) Temporoparietal flap raised, (d) Flap
graft or turnover inferiorly based skin flap from the same transposed to cover costal cartilage framework
in secondary ear reconstruction and waited for graft to transferred by micro vascular technique to provide cover
mature before inserting cartilage framework but the as reported by Brent and Byrd.[33] In patients with bilateral
grafted skin lacked elasticity and did not give satisfactory devascularized temporoparietal region or in whom
result. In 1974, Edgerton and Bacchetta[30] first used a fan contralateral fascial flap cannot be used, there are very
flap composed of temporal muscle, fascia and epicranium limited options. In those cases use of expanded forearm
to cover a silicone ear implant and in 1976 Fox and skin flaps or forearm fascial flap has been reported.
Edgerton used the same flap for salvaging auricular Akin[44] described the use of a prefabricated free radial
cartilage in acute burns.[31] forearm fasciocutaneous flap with an autogenous costal
cartilage framework for total auricular reconstruction
Flap for cartilage cover should be thin and pliable so
in burn patients. Drawback of using forearm flap is the
as not to mask the convolutions of underlying cartilage
donor site deformities, hair growth, and skin color
framework. For this reason temporoparietal fascial
mismatch and sacrifice of a major artery. Using radial
flap offers the best option. The advantage of using
forearm fascial free flap for ear reconstruction has the
temporoparietal fascial flap is that the scar is hidden in
advantages of providing thin flap with long pedicle and
hair bearing area of scalp and if required hairy scalp can
preserving forearm skin.
also be raised along with it.
Distant-free flaps provide poor quality of skin cover which
Covering carved cartilage with temporoparietal fascial flap
masks the convolutions.
was originally described by Tegmeier and Gooding in 1977
and popularized by Brent in 1980[32] and Brent and Byrd in Park et al. have described the use of Omental free flap in
1983.[33] Fascial flap may be used as an axial pattern flap such cases to provide cover over cartilage framework.[45]
which is based on posterior branch of superficial temporal In selected cases, in which the patient is unwilling to
artery and vein. In case it is unavailable, a random undergo multiple surgical procedures and for patients
pattern fascial flap can be used. In 1978, Ohmori[34] used with anesthetic problems prosthesis can be fixed to cranial
temporoparietal muscle flap to cover the conchal region bone by osseointegrated titanium screws.[46] But the cost
of silicone ear implant whereas Cronin[35] used a fascial and potential long-term complications are deterrents to
flap for the coverage of the same. their regular use.
In 1985, Brent et al.[33] used temporoparietal fascial flap
as free flap with scalp island flap for ear reconstruction CONCLUSION
and recreation of hairline and sideburns. If the
temporo-auriculomastoid region is unfavorable, Mutaf For both the patient and the surgeon, realistic expectations
et al.[36] have successfully used a bilobed cervical flap for are important to the success of any reconstruction. This is
cover, if neck skin is unburned. It offers a simple, well more important in the case of ear burns as many a times
vascularized, hairless skin with good color match, texture it may not be possible to fulfill the patients expectations
and thickness. and also because the entire process of ear reconstruction
is a long process. Therefore, it is more important to
Even medpore ear scaffold covered with superficial
take even the burns of the ears seriously and give it
temporoparietal fascia flap gives a satisfactory one-stage
proper care, thus preventing complications and further
reconstruction of total ear loss as medpore provides better
deformities.
biological compatibility compared to silastic implant.[37]
Wellisz[38] and Jones and Wellisz[39] used temporoparietal
fascial flap with MEDPOR framework for reconstruction REFERENCES
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