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TEIE CANADI&N 3ftDicAL AssociATioN JouRNAL

[July

[July 1940
1940

CONGENITAL ABNORMALITIES OF THE EXTERNAL EAR BY H. 0. FoucAR, B.A., M.D. Chief of Surgery, St. Joseph's Hospital, London, Ont. EARS, by virtue of their position, are hard terior border becomes folded. The tip now apto camouflage. In this respect women have pears as a tubercle on the turned-in posterior an advantage for they may hide a defect which margin. This becomes evident in the sixth would be obvious in a man. Because of this month and is known as Darwin's tubercle. prominence, defects in the ears are noticeable Atavism may explain the so-called faun's ear.
and may cause mental distress to the patient. To obtain a proper perspective, a classification of congenital abnormalities of the ear is given. 1. Complete absence of the external auricle and

The ear consists of a single thin plate of

incomplete. 3. Ectopic ear. It is usually small, tilted and displaced downwards and forwards. 4. Supernumerary tags, usually in front of or below the ear or on a line from the tragus to the angle of the mouth. 5. Preauricular sinus.
6. Prominent ears. 7. Faun ear or incomplete folding of the helix or outer rim of the ear. 8. Abnormally small ears. 9. Abnormally large ears. 10. Asymmetry, one ear being normal and the other either larger or smaller. 12. Adherent lobule.

meatus with or without development of the inner and middle ear. 2. Absence of the external auricle-complete or

11. Large lobule.

For a better understanding of these abnormalities we must turn to embryology. The ear develops around the first pharyngeal cleft. During the sixth week of fetal life three tubercles grow from the mandibular arch, forming (1) the tragus; (2) the crus of the helix; (3) the helix; and three from the hyoid arch to form (4) the lobule; (5) the antitragus and (6) the antihelix. During the latter part of the second month and the first part of the third, they fuse and the pinna assumes its form. Preauricular sinuses result from faulty fusion of these tubercles, usually between the first and second. They pass downwards and forwards, usually for a short distance only, but may extend to the parotid fascia or even to the neck. Generally they are inconspicuous but they may become blocked and infected. Supernumerary nodules can easily be explained as well as absence or variation in the size of the auricle. In the lower mammalian forms ears are pointed at the superior posterior angle. With regression of the posterior border or helix and increased development of the antihelix the pos-

yellow fibro-cartilage, covered by skin and connected to the surrounding parts by extrinsic muscles and ligaments and by fibrous tissue. This thin plate is normally thrown into folds which give form to the external auricle, producing the helix or curved edge of the ear and the antihelix, a ridge running anterior to and roughly parallel with the helix. When this main ridge or antihelix is absent the ear is more concave and smooth and stands away from the side of the head, producing prominent ears which may be at right angles instead of lying parallel with the head. It is not my intention to discuss the more serious conditions such as total absence, because this is extremely rare and involves complicated plastic surgery. Supernumerary tags, consisting of skin, fibrous tissue and possibly of cartilage are readily removed. Asymmetry is not the serious defect that some would think because both ears are not seen at the same time for comparison, except in a direct antero-posterior view when they are seen only on edge. If anything is necessary, the larger one may be cut down to fit the smaller. Large lobules may be diminished by excision. Adherent lobules may be liberated, but, after all, this is a minor defect which can scarcely be considered a real deformity. Prominent ears, however, are probably the commonest abnormality. In many instances, they cause great embarrassment which is often endured in silence because neither the patient nor his attending physician realizes that this is one of the easiest defects to correct. Since business competition is keen, personal appearance is often a deciding factor between success and failure. As indicated above, the underlying pathological lesion is failure of the cartilage to bend backwards. It retains a smooth contour and holds the ear out from the head at varying

July 1940]
July 1940]

Fouc,&i&: Tm EXTMNALEAP.
FoucAR:
THE EXTERNAL
EAR

27

angles. The tip often droops downwards and forwards. The remedy consists of bending the cartilage to form an antihelix and thus allowing the ear to lie parallel with the head. Because of the normal resiliency of the cartilage mere bending is rarely sufficient. It must be cut so that it will retain its new position. Retentive apparatus such as adhesive, bandaging or a night cap has been used. It is possible that this is of some value because in certain cases, with the growth from infancy to adult life, the cartilage may change its form, lessening the defect even without any conscious effort at correction. In more marked cases, an operation will be required. OPERATIVE PROCEDURE In older co-operative children and in adults, local infiltration with a solution of 2 per cent procaine with adrenalin is sufficient. The injection is made posteriorly in the field of operation. This abolishes all except the minimal discomfort noticed as the knife cuts through to the anterior surface of the cartilage. The solution may be injected anteriorly also if desired but this may obscure the fold in the cartilage. Field block can be used but is not necessary. In younger children a general anesthetic will be required. Several surgical procedures have been described. 1. Elliptical excision of the skin only on the back of the ear and closure with interrupted skin sutures may be used, but the resiliency of the cartilage is likely to stretch the overlying skin, resulting in a recurrence. 2. Elliptical excision of the skin and of the cartilage which is then folded back does not reconstruct the antihelix well. 3. After elliptical excision of the skin, a curved V-shaped groove is cut on the posterior surface of the cartilage and the cartilage is then folded back and held in place by interrupted stitches

in the perichondrium and the skin incision

closed.
4. After carefully determining where the antihelix should be, an incision is made through the cartilage from behind in a curved direction, being careful not to perforate the in anteriorly. The cartilage can now be buckled back and held in a slightly over-corrected position by interrupted catgut sutures, all being placed in position before any are tied. This incision must extend high enough, otherwise the top of the ear will still be prominent. It must be carefully placed and long enough so that the bend will

rig. 1 Fig. 2 Fig. 1.-Prominent ears. Before correction Fig. 2.-Ditto. After correction.

reconstruct the antihelix but not so long that it interferes with support. The actual removal of the excess skin may be left to this stage when the incision is closed and the ears bandaged close to the head. The last procedure is simplest and has been satisfactory. The results are seen in Figs. 1 and 2. This patient, a professional man, had become morbidly self-conscious to such an extent that he could not comfortably engage in conversation because he was certain that the other person was scrutinizing his ears. After correction there was a complete change in his personality.

The ideal of medicine is the prevention rather than the cure of disease, and for this end the detection of the earliest stages, and better of the disposing causes of diseases, is essential. Timely warning about diet, exercise and manner of life may do much to prevent disease from getting a firm seat on a man's back . . . -Aspects of Age, Life and Disease, Sir H. Rolleston, 1928, p. 14.

It must always seem strange that so long a time should have elapsed before the circulation of the blood and general physiology of the heart were understood. Even after Harvey's discovery but little knowledge of actual disease of the heart was acquired for nearly a century. In fact, one might say that knowledge of diseases of the heart hardly became a practical matter till auscultation and percussion came into general use in the early part of the nineteenth century.-Growth of our Knowledge of Heart Disease, R. 0. Moon, 1927, p. vii.