The Pinna

Accessory Lobule

Fig. 2.2 Hillocks (or accessory lobules).

These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks.

Fig. 2.1 Minor deformities. These are of little importance. This shows duplication of the lobule.

Fig. 2.2 Hillocks (or accessory lobules).

These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks.

Fig. 2.1 Minor deformities. These are of little importance. This shows duplication of the lobule.

Darwin Tubercle

Fig. 2.3 Darwin's tubercle (arrow). A

deformity of the pinna of phylogenetic interest. It is homologous to the tip of the mammalian ear and may be sufficiently prominent to justify surgical excision. Although Darwin's name is used for this tubercle, Woolmer gave the first description.

Darwins Tubercle

Fig. 2.5 Surgical reconstruction for microtia. Multiple surgical procedures are usually necessary, and a near-normal pinna is difficult to achieve. Rib cartilage grafts (1) are taken and fashioned (2) to act as a scaffold for local skin rotation flaps and free skin grafts. The reconstruction is a challenge for the innovative surgeon and results vary with the severity of pinna deformity.

Fig. 2.4 Microtia. Absence of the pinna or gross deformity is often associated with meatal atresia and ossicular abnormalities. Faulty development of the 1st and 2nd branchial arches results in aural deformities which may be associated with hypoplasia of the maxilla and mandible, and eyelid deformities (Treacher-Collins syndrome, Fig. 2.6b). This type of pinna deformity is difficult to reconstruct.

Treacher Collins Syndrome

Fig. 2.5 Surgical reconstruction for microtia. Multiple surgical procedures are usually necessary, and a near-normal pinna is difficult to achieve. Rib cartilage grafts (1) are taken and fashioned (2) to act as a scaffold for local skin rotation flaps and free skin grafts. The reconstruction is a challenge for the innovative surgeon and results vary with the severity of pinna deformity.

Helix Hearing Aids Bone Anchored Hearing Aid

Fig. 2.6a, b Gross microtia with a bone-anchored prosthesis and hearing aid.

If microtia is gross, a prosthesis rather than reconstruction is to be considered. Prosthetic ears (b) have improved greatly in recent years. It is possible for these to be attached to the cranium using screws and plates (osseo-integrated implants, see Fig. 1.23) with a bone-anchored hearing aid.

Fig. 2.7 Preauricular sinuses, which are closely related to the anterior crus of the helix, cause many problems. Discharge with recurrent swelling and inflammation may occur. The small opening of the sinus (arrow) is easily missed on examination, particularly when it is concealed, as may rarely be the case, behind the fold of the helix, rather than in the more obvious anterior site.

Endaural Incision

Fig. 2.8 An infected preauricular sinus. A furuncle or skin ulceration in this site is diagnostic of an underlying infected preauricular sinus. Quite extensive skin loss can occur in this site with recurrent infection of a preauricular sinus. The variation in the appearance of an infected preauricular sinus is striking—but the site in the preauricular region is constant.

Fig. 2.8 An infected preauricular sinus. A furuncle or skin ulceration in this site is diagnostic of an underlying infected preauricular sinus. Quite extensive skin loss can occur in this site with recurrent infection of a preauricular sinus. The variation in the appearance of an infected preauricular sinus is striking—but the site in the preauricular region is constant.

Sinus Pre Auricular

Fig. 2.9 Preauricular sinus excision. A furuncle or skin inflammation, which may be quite extensive in this preauricular site, is invariably related to a preauricular sinus. Careful examination for the sinus must be made. Excision when the infection is quiescent is necessary and this, although minor surgery, is not easy.

A long-branched and lobular structure must be excised. Incomplete excision of the tract leads to further infection and the need for revision surgery. To ensure complete excision of the preauricular sinus, the extension of an endaural incision as shown is needed, with reflection of the skin anteriorly down to the temporal facia. If the sac is injected with a dye it is better defined, and it is possible to be certain of complete excision. The sac is dissected from its deep aspect towards the sinus puncture, which is excised with an elipse of skin.

Fig. 2.9 Preauricular sinus excision. A furuncle or skin inflammation, which may be quite extensive in this preauricular site, is invariably related to a preauricular sinus. Careful examination for the sinus must be made. Excision when the infection is quiescent is necessary and this, although minor surgery, is not easy.

A long-branched and lobular structure must be excised. Incomplete excision of the tract leads to further infection and the need for revision surgery. To ensure complete excision of the preauricular sinus, the extension of an endaural incision as shown is needed, with reflection of the skin anteriorly down to the temporal facia. If the sac is injected with a dye it is better defined, and it is possible to be certain of complete excision. The sac is dissected from its deep aspect towards the sinus puncture, which is excised with an elipse of skin.

Fig. 2.10 Prominent ears. The fold of the antihelix is either absent or poorly formed in a prominent ear; it is not simply that the angle between the posterior surface of the conchal cartilage and the cranium is more "open." Parents and child may be offended by the diagnosis of "bat or lop" ears, although these terms are commonly used.

Fig. 2.10 Prominent ears. The fold of the antihelix is either absent or poorly formed in a prominent ear; it is not simply that the angle between the posterior surface of the conchal cartilage and the cranium is more "open." Parents and child may be offended by the diagnosis of "bat or lop" ears, although these terms are commonly used.

Piercing Cartilage

Prominent ears are best corrected between the ages of four and six years at the beginning of school. There is, however, no additional surgical problem in correcting adult ears. Youngsters may be the subject of considerable ridicule in early years because of bat ears and, therefore, surgical correction is not to be deferred.

Fig. 2.12 Bat ears are often familial (a).

The son (b) has the firm ear dressing required for five to ten days after operation for prominent ears.

Fig. 2.12 Bat ears are often familial (a).

The son (b) has the firm ear dressing required for five to ten days after operation for prominent ears.

Baby Prominent Ear

Fig. 2.13 Prominent ears are often apparent either at or soon after birth. In the first six months of life the elastic cartilage of the ear is "moldable." a-d demonstrate how a baby's ear can be molded to give a normal shape and produce an anti-helix. After the age of one year, however, the cartilage spring is usually resistant to "molding" techniques.

Fig. 2.13 Prominent ears are often apparent either at or soon after birth. In the first six months of life the elastic cartilage of the ear is "moldable." a-d demonstrate how a baby's ear can be molded to give a normal shape and produce an anti-helix. After the age of one year, however, the cartilage spring is usually resistant to "molding" techniques.

Piercing Cartilage Keloid Ear Clip Earring

Fig. 2.14a-c Keloid formation is common in black patients, and is difficult to treat.

Recurrence follows excision, and repeated excision may lead to huge keloid formation (c).

Radiotherapy or local triamcinolone injections following excision reduce the incidence of recurrence of the keloid. Pressure at the site of keloid excision has also been shown to reduce recurrence. Special pressure clip-on earrings are available to apply to the ear lobe after operation. Keloid formation is common near the ear and on the neck, but is almost unheard of in the middle third of the face.

Ear Correction Keloids
Fig. 2.15 Keloid formation may be unpredictable: a normal ear punctum from an earring puncture is adjacent to a large earring keloid.

Fig. 2.16 An infected granuloma at the site of earring insertion.

Traumatic Granuloma Earlobe
Fig. 2.17 Nickel sensitivity limits the use of certain earrings and has caused eczema on the lobule (arrow).
Pinna Earring

Fig. 2.19 Trauma. Traumatic "cutting-out" when the earring is pulled by a baby or adult in ill-humor. Infection at the time the sleepers are inserted is another hazard (see Fig. 2.16).

Fig. 2.18 "High" ear piercing (Fig. 2.17, arrow) complicated by infection (frequently pseudomonas) may lead to abscess formulation. The puncture with high ear piercing (unlike the lobule) punctures cartilage and may lead to the additional problem of cartilage infec-tion—perichondritis. Abscess incision with drainage, splinting, and antibiotic therapy (e.g., ciprofloxacin) is needed. Permanent deformity of the pinna may result, requiring a difficult plastic surgical repair (a). This involves taking a rib graft and modeling this to reconstruct the absent helix, antihelix, and scaphoid fossa of the pinna (b; c, post-op.).

Fig. 2.19 Trauma. Traumatic "cutting-out" when the earring is pulled by a baby or adult in ill-humor. Infection at the time the sleepers are inserted is another hazard (see Fig. 2.16).

Avulsed Humerous

Fig. 2.20a-d Trauma to the pinna. The projecting and obvious pinna is a frequent site for trauma. Partial or complete avulsion is common. This loss of tissue is from a bite. Although small loss of the periphery of the helix can be closed with a wedge excision, larger loss (c) requires more complex surgical repair involving cartilage graft reconstruction of the helix (d).

Fig. 2.20a-d Trauma to the pinna. The projecting and obvious pinna is a frequent site for trauma. Partial or complete avulsion is common. This loss of tissue is from a bite. Although small loss of the periphery of the helix can be closed with a wedge excision, larger loss (c) requires more complex surgical repair involving cartilage graft reconstruction of the helix (d).

Auricular Hematoma Child

Fig. 2.22 Hematomas of the pinna following trauma. Bruising with minimal swelling settles (a). A hematoma or collection of serous fluid, however, is common, and these, particularly if recurrent from frequent injury and left untreated, will result in a "cauliflower ear." The fluid, if aspirated with a syringe (b, c), usually recurs, and incision and drainage may be necessary. Some thickening, however, of the underlying cartilage invariably takes place, and a return to a completely normal-shaped pinna is not usual.

Fig. 2.21 A sebaceous cyst near the site of an earring puncture. The punctum is just apparent and is diagnostic. Sebaceous cysts are common behind the ear, particularly in the postaural sulcus.

Fig. 2.21 A sebaceous cyst near the site of an earring puncture. The punctum is just apparent and is diagnostic. Sebaceous cysts are common behind the ear, particularly in the postaural sulcus.

Sebaceous Cyst Pinna

Fig. 2.22 Hematomas of the pinna following trauma. Bruising with minimal swelling settles (a). A hematoma or collection of serous fluid, however, is common, and these, particularly if recurrent from frequent injury and left untreated, will result in a "cauliflower ear." The fluid, if aspirated with a syringe (b, c), usually recurs, and incision and drainage may be necessary. Some thickening, however, of the underlying cartilage invariably takes place, and a return to a completely normal-shaped pinna is not usual.

Auricle Collapse

Fig. 2.24 Collapse of the pinna cartilage following perichondritis. This happened prior to the availability of effective antibiotics. However, perichondritis is still a worrying complication which requires intensive antibiotic treatment. Collapsing or alteration of the shape of the pinna cartilage may also occur in relapsing polychondritis.

Fig. 2.23 Perichondritis. A painful red, tender, and swollen pinna accompanied by fever, following trauma or surgery, suggests an infection of the cartilage. The organism is frequently Pseudomonas pyocyanea.

Fig. 2.23 Perichondritis. A painful red, tender, and swollen pinna accompanied by fever, following trauma or surgery, suggests an infection of the cartilage. The organism is frequently Pseudomonas pyocyanea.

Perichondritis

Fig. 2.24 Collapse of the pinna cartilage following perichondritis. This happened prior to the availability of effective antibiotics. However, perichondritis is still a worrying complication which requires intensive antibiotic treatment. Collapsing or alteration of the shape of the pinna cartilage may also occur in relapsing polychondritis.

Fig. 2.25 Relapsing polychondritis.

This is a rare inflammatory condition involving destruction and replacement with fibrous tissue of body cartilage. The elastic aural cartilage is replaced by fibrous tissue so that the ear has an unusual "felty" feel and does not have any "spring" on palpation.

The larynx cartilage also may be affected, causing hoarseness which may proceed to stridor. The nasal septum may collapse with a nasal saddle deformity (Figs. 3.23a-d). One or more of the lower limb joints are usually swollen and painful.

Perichondritis Pinna

Fig. 2.27 Burn scars in the ear region are evidence of the past use of cautery to relieve ear symptoms in childhood. In the Arab world, these burns are still common, and are known as chowes.

Fig. 2.26 Iodoform sensitivity. An antiseptic ear dressing commonly used contains bismuth, iodoform, and paraffin (B.I.P.). Sensitivity to iodoform may occur, and a red ear with marked irritation suggests this complication (rather than perichondritis, which is characterized by pain). Neomycin is one of the more commonly used topical antibiotics that may give rise to a skin sensitivity.

Fig. 2.27 Burn scars in the ear region are evidence of the past use of cautery to relieve ear symptoms in childhood. In the Arab world, these burns are still common, and are known as chowes.

Fig. 2.26 Iodoform sensitivity. An antiseptic ear dressing commonly used contains bismuth, iodoform, and paraffin (B.I.P.). Sensitivity to iodoform may occur, and a red ear with marked irritation suggests this complication (rather than perichondritis, which is characterized by pain). Neomycin is one of the more commonly used topical antibiotics that may give rise to a skin sensitivity.

Erysipelas Head

Fig. 2.28 Erysipelas is caused by hemolytic streptococci entering fissures in the skin near the orifice of the ear meatus (fissures such as those in otitis externa). A well-defined, raised erythema spreads to involve the face. This condition, which is often accompanied by malaise and fever, was serious in the preantibiotic era, but settles rapidly with penicillin.

Face Shingles Maxilary Zoster Nasal Septum

Fig. 2.29 The herpes zoster virus in the head and neck may affect the gasserian ganglion of cranial nerve V. Here the mandibular (a) and the maxillary (b) divisions are involved. The vesicular type of skin eruption is confined to the distribution of the nerve. The ophthalmic division of V is most frequently involved, but all three divisions of V are rarely affected at the same time. The herpes zoster virus also involves the geniculate ganglion of cranial nerve VII (Ramsay-Hunt syndrome or geniculate herpes). Herpes affects the pinna and preauricular region (c), and is associated with a facial palsy. In most cases, there is also vertigo and sensorineural deafness. There is less likelihood of a full recovery of the facial palsy than in Bell's palsy (Fig. 2.100). Treatment is with antiviral agents, e.g., acyclovir, and oral steroids if not contraindicated.

Basal Cell Carcinoma Pinna
Fig. 2.30 Basal cell carcinoma. Ulcers on the helix are common. A long history suggests a basal cell carcinoma. This is treated with wedge resection. An ulcer of short duration suggests a squamous cell carcinoma or more rarely a melanoma, both of which require more extensive surgical resection.

Fig. 2.31 Solar keratoses (arrows).

These warty growths affect the skin of the fair-headed when exposed to strong sunlight. They may become malignant. The skin of the helix may be affected with several of these keratoses.

Ear Helix Piercing
Fig. 2.32 Gouty tophi (arrow) from a characteristic lesion on the helix.
Lesions The Helix

Fig. 2.34 Ulcers of the antihelix are usually traumatic (on a particularly prominent antihelix fold). A basal or squamous cell carcinoma, however, may present on the antihelix.

Fig. 2.33 Inflammatory ulcers (arrows) affect the helix and occasionally the antihelix. The lesions on the helix are blessed with a lengthy diagnosis— chondrodermatitis nodularis helicis chronicis—which presents as a longstanding intermittent ulceration.

It is primarily a chronic chondritis with secondary skin infection. A wedge resection of the ulcer and cartilage may be necessary, as the ulcer only heals temporarily with ointments.

Pressure on the ulcer, e.g., from a hard pillow, is a perpetuating factor. Relief of pressure with a soft "padding" dressing may lead to healing.

Fig. 2.34 Ulcers of the antihelix are usually traumatic (on a particularly prominent antihelix fold). A basal or squamous cell carcinoma, however, may present on the antihelix.

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