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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 23  |  Issue : 2  |  Page : 71-73

Effect of postauricular sulcus incision for myringoplasty on auricle protrusion: 5 years' experience


Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Web Publication14-Jun-2017

Correspondence Address:
Mohammad Waheed El-Anwar
Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_41_17

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  Abstract 

Objective: The objective of this study was to investigate the effect of postauricular incision (sulcus incision) during myringoplasty using conchal perichondrial graft with or without conchal cartilage on the ear protrusion. Patients and Methods: A prospective study was conducted on 243 patients who underwent myringoplasty using small postauricular sulcus incision. The distances from postauricular area to the lateral aspects of helical rim and ear lobule at three different levels and the maximum ear protrusion were measured pre- and post-operatively. Results: There were no statistically significant differences between the measures of the auricle position preoperatively and 2 weeks, 1 month, and 3 months postoperatively. Conclusion: There was no effect of the short postauricular sulcus incisions for myringoplasty on the ear position. It does not affect or annoy the glasses wearers with highly satisfactory cosmetic results without reported persistent complications.

Keywords: Auricle, concha, myringoplasty


How to cite this article:
El-Anwar MW, ElAassar AS. Effect of postauricular sulcus incision for myringoplasty on auricle protrusion: 5 years' experience. Indian J Otol 2017;23:71-3

How to cite this URL:
El-Anwar MW, ElAassar AS. Effect of postauricular sulcus incision for myringoplasty on auricle protrusion: 5 years' experience. Indian J Otol [serial online] 2017 [cited 2017 Aug 24];23:71-3. Available from: http://www.indianjotol.org/text.asp?2017/23/2/71/208030


  Introduction Top


Myringoplasty was first described by Berthold in 1879 as a method of reconstruction of a tympanic membrane (TM) perforation.[1]

Tympanoplasty is a safe, easy, straightforward procedure with a high success rate.[2],[3],[4] Approaches for tympanoplasty include transcanal, endaural, and postauricular approaches. The transcanal and endaural approaches could not do any changes in ear pinna.[5]

Postauricular incision is the most popular approach in middle ear surgery. In addition, it is used as a combined approach of tympanoplasty, cortical mastoidectomy, and cochlear implant surgery due to the cosmetic advantage from their concealed position and direct access to the mastoid air cells.[6],[7] It is helpful in other head and neck surgeries such as resection of benign parotid gland tumors.[8]

Ear protrusion, either over- or under-protrusion, is one of the reported side effects of the postauricular incision. To avoid this effect, some surgeons use to do skin incision which is carried out along the hairline and is made only through skin.[5] Another group of surgeons make curved incision in the postauricular sulcus (sulcus incision or in the groove incision).[9] Others prefer to do postauricular incision about 1 cm behind the postauricular crease, a location that simplifies closure.[10] Others do it about 5 mm posterior to the postauricular sulcus.[11]

Sulcus incision and hairline incision are the most common surgical approaches for postaural incisions in the context of middle ear surgery. Specific local factors such as skin lesions or previous scarring may affect the precise site of surgery, but largely the incision location is based on surgeon's preference and can vary considerably.[9]

After cutting through skin and subcutaneous tissue, the auricular muscles, namely, auricularis superior and posterior are generally divided to access and incise the periosteum overlying the mastoid bone to access the external auditory canal.[9]

In our study, we investigated the effect of postauricular incision (sulcus incision) during myringoplasty using conchal perichondrial graft with or without conchal cartilage on the ear protrusion.


  Patients and Methods Top


This retrospective study has been done from December 2009 to May 2016 at otorhinolaryngology department. It includes patients for whom myringoplasty was performed using postauricular sulcus incision and conchal perichondrial grafts with or without conchal cartilage. Any patient who had preoperative auricular protrusion, revision cases, patients who need mastoidectomy work, or patients operated before for pinnaplasty were excluded from the study. All patients signed informed consent to participate in the study, and ethics committee approval was obtained.

All procedures were performed under general anesthesia. Skin incision was curved and made in the postauricular sulcus. It was done by scalpel and did not exceed the temporalis level superiorly, and the level of the inferior wall of the external auditory canal inferiorly ranged from 3 to 4 cm. After cutting through skin and subcutaneous tissue, the postauricular muscles were divided to access and incise the periosteum overlying the mastoid bone. All grafts were obtained from the conchae by dissection to the conchae through the same incision. The postauricular incisions were repaired in 3 layers: periosteal layer using Vicryl 3/0, muscle layer by Vicryl 3/0, and skin layer using silk 3/0. All layers were repaired by interrupted sutures. Pressure dressing was left on the ear till 1 week postoperatively when it was removed with the silk sutures.

We measured the distances from postauricular area to the lateral aspects of helical rim and ear lobule at three different levels (upper, middle, and lower parts), in addition to the measurement of the maximum ear protrusion. The interval of measurements was taken intraoperatively before infiltration of local anesthesia, and then at 2 weeks, 1 month, and 3 months postoperatively. Patients' complaints of protrusion of their auricle were also registered at the same postoperative periods. At 3 months, patients were also asked whether they were satisfied, highly satisfied, or unsatisfied by the postauricular scar [Figure 1].
Figure 1: Measurement of the distances from postauricular area to the lateral aspects of helical rim and ear lobule at three different levels; upper (a), middle (b), and lower part (c)

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Statistical analysis

Pre- and post-operative evaluations were compared statistically using tests from the SPSS program version 17.0 (Chicago, Illinois, USA). P < 0.05 was considered statistically significant.


  Results Top


This study was conducted on 243 patients; 164 females (67.5%) and 79 males (32.5%), with age range from 11 to 56 years with a mean of 29.6 years.

There were no significant differences between the measures of the auricular position preprocedure and 2 weeks, 1 month, and 3 months postoperatively [Table 1]. No patient complained change in the auricle position.
Table 1: Pre- and post-operative measurement of the auricular protrusion

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About 96 patients (39.5%) were wearing glasses and none of them had discomfort or problems on glass wearing associated with their postoperative scar.

Ten patients (4.1%) (6 females and 4 males) suffered from wound dehiscence and postoperative infection. Keloid formation developed in two cases (0.82%) postoperatively. No seroma, hematoma, or ugly scar was reported. Two (0.82%) patients (who developed keloid) were unsatisfied by the postauricular scar, while the rest of the patients (241, 99.18%) were highly satisfied.


  Discussion Top


Myringoplasty aims to close the TM perforation to prevent recurrent otorrhea, restore the sound-conducting mechanism through an aerated tympanic cavity, and maintain these achievements over time.[12]

Ear protrusion has a negative psychological impact on the patients.[13] Other functional problems such as wearing of eye glasses and improperly fitted hearing aids may also occur.[14]

In this study, there is no significant effect of the used postauricular incision on the auricle position. Taking into consideration that the incision was performed in the postauricular sulcus and did not exceed the temporalis level superiorly, the level of the inferior wall of the external auditory canal inferiorly with small incision length ranged from 3 to 4 cm.

Glasses wearers did not complain of any problems or discomfort with their glasses wearing mostly because the performed incisions did not exceed the temporal line, so it did not reach area in contact with glasses' limb. Moreover, there were no significant changes in auricular position.

The present study results are in line with the results of a study by Hong et al.[15] which showed that in 19 children, a postauricular approach did not significantly affect pinna position.

In a study by Al Amry et al.[16] (on 34 patients), pinna protrusion measures showed statistically significant differences from preoperative measurements using postauricular incision 5 mm posterior to the sulcus. However, in case of sulcus incision, the preoperative measurements were not significantly different from their measurements after 1 month. Maximum pinna protrusion was not changed significantly after 3 months in both types of incisions.[16] However, their sample size was small and they did not commented on the length and extent of the incisions.

On the other hand, Shekhar and Bhavana [17] in a study including 19 children and Barrett et al.[18] in their study on 81 patients concluded that retro-sulcus incisions are better in preserving the conchomastoid angle than the sulcus incisions. However, those studies depended only on a questionnaire for patient satisfaction, not on objective measurements. Moreover, those studies did not detail the length and extents of the used incisions in their small samples.

Therefore, results of our study documented that, in myringoplasty, small sulcus postauricular incision that was done by scalpel did not exceed the temporalis level superiorly and the level of the inferior wall of the external auditory canal inferiorly and opened in three layers and closed in three layers (periosteal, muscle, and skin layers) which has no significant effect on ear pinna position.


  Conclusion Top


There is no effect of the short sulcus postauricular incisions on the ear position as an incision for myringoplasty. It does not affect or annoy the glasses wearers or the hearing aid fitting. It has minimal cosmetic side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
El-Ahl MA, Amer HS, El-Anwar MW. Simultaneous bilateral myringoplasty as a single-stage operation. Egypt J Otolaryngol 2013;29:16-9.  Back to cited text no. 1
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2.
Kotecha B, Fowler S, Topham J. Myringoplasty: A prospective audit study. Clin Otolaryngol Allied Sci 1999;24:126-9.  Back to cited text no. 2
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3.
El-Anwar MW, El-Ahl MA, Zidan AA, Yacoup MA. Topical use of autologous platelet rich plasma in myringoplasty. Auris Nasus Larynx 2015;42:365-8.  Back to cited text no. 3
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4.
Yung MW. Myringoplasty for subtotal perforation. Clin Otolaryngol Allied Sci 1995;20:241-5.  Back to cited text no. 4
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5.
Fisch U. Tympanoplasty, mastoidectomy, and stapes surgery. Inc. Stuttgart, New York: Thieme Medical Publishers; 1994. p. 15-35.  Back to cited text no. 5
    
6.
Gibson WP, Harrison HC, Prowse C. A new incision for placement of cochlear implants. J Laryngol Otol 1995;109:821-5.  Back to cited text no. 6
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7.
Braun T, Langhagen T, Berghaus A, Krause E. Evaluation of skin scars following cochlear implant surgery. J Int Adv Otol 2014;10:30-2.  Back to cited text no. 7
    
8.
Kim DY, Park GC, Cho YW, Choi SH. Partial superficial parotidectomy via retroauricular hairline incision. Clin Exp Otorhinolaryngol 2014;7:119-22.  Back to cited text no. 8
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9.
Johnson GM, Valle-Inclán F, Geary DC, Hackley SA. The nursing hypothesis: An evolutionary account of emotional modulation of the postauricular reflex. Psychophysiology 2012;49:178-85.  Back to cited text no. 9
    
10.
Baily BJ. Atlas of Head and Neck Surgery Otolaryngology. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 310-13.  Back to cited text no. 10
    
11.
Saeed BM. Cartilage tympanoplasty: The outcome in 35 patients. J Med J 2012;46:45-51.  Back to cited text no. 11
    
12.
Hosny S, El-Anwar MW, Abd-Elhady M, Khazbak A, El Feky A. Outcomes of myringoplasty in wet and dry ears. Int Adv Otol 2014;10:256-9.  Back to cited text no. 12
    
13.
Ali MS. Unilateral secondary (acquired) postmastoidectomy low-set ear: Postoperative complication with potential functional and cosmetic implications. J Otolaryngol Head Neck Surg 2009;38:240-5.  Back to cited text no. 13
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14.
Gasques JA, Pereira de Godoy JM, Cruz EM. Psychosocial effects of otoplasty in children with prominent ears. Aesthetic Plast Surg 2008;32:910-4.  Back to cited text no. 14
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15.
Hong P, Arseneault T, Makki F. A long-term analysis of auricular position in pediatric patients who underwent post-auricular approaches. Int J Pediatr Otorhinolaryngol 2014;78:471-3.  Back to cited text no. 15
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16.
Al Amry S, Alshehri H, Al Sanosi A. Ear protrusion post tympanoplasty: Sulcus incision immediately through post auricular groove versus 5 mm post auricular. SMU Med J 2015;2:202-10.  Back to cited text no. 16
    
17.
Shekhar C, Bhavana K. Aesthetics in ear surgery: A comparative study of different post auricular incisions and their cosmetic relevance. Indian J Otolaryngol Head Neck Surg 2007;59:187-90.  Back to cited text no. 17
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18.
Barrett G, Koecher S, Ronan N, Whinney D. Patient satisfaction with postaural incision site. Int J Otolaryngol 2014;2014:851980.  Back to cited text no. 18
[PUBMED]    


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Abstract
Introduction
Patients and Methods
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Discussion
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