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Review Article Indian Journal of Burns

Management of ear burns

Sujata Sarabahi
Department of Burns and Plastic Surgery, VMMC and Safdarjung Hospital, New Delhi, India

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

INTRODUCTION 52.7% of all admitted patients sustained burns in one or

External ear is particularly vulnerable to thermal burns
because of their prominent projecting location on the sides
of the face. It is very uncommon to find isolated burns of
the ear. They are most commonly associated with facial
burns either due to thermal burns or chemical or electrical
contact injury. Facial burns represent one fourth to one
third of all burns. There are very few studies quoting
incidence of ear burns. Mills et al. in 1998 reported that
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both ears.[1] Bhandari stated that 90% of patients with
cervicofacial burns will have ear burns and 30% of ear
burns develop chondritis.[2] The incidence of complete loss
of ear in a series of 100 ear burns was 13%.[3]
Ear can get involved by direct burns or due to chondritis.
Aggressive treatment is required to prevent deformities
and complications which can range from minor scarring
to near total loss of pinna.
A burned ear may be characterized by the following
features: (1) Scarring at the site of and surrounding the
ear, (2) Loss of different components of ear framework
helix/antihelix/lobule, (3) Total loss of ear leading to
different deformities.

DOI: In the face of these deformities and limitations, the

10.4103/0971-653X.111774 surgical goals of reconstruction vary and can be very
challenging.
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Sarabahi: Management of ear burns
Anatomical consideration
The peculiarity of the ear cartilage is that it is very thin
and is covered on its anterolateral aspect by an equally
thin layer of subcutaneous tissue and skin which is tightly
adherent to the perichondrium. This cartilage has no
intrinsic blood supply and depends on diffusion from
perichondrium which in turn depends on overlying skin
for vascularity.
Involvement of ear in burns
[Figures 1, 2, 3]: In the case of partial thickness burns the
covering skin gets burned and edematous thus getting
separated from underlying cartilage. This interferes with
the blood supply of the cartilage which then undergoes
avascular necrosis. In full thickness burns of the ear, if
the skin is completely charred it may expose the cartilage
which eventually sloughs out due to exposure and
infection. The loss of the supporting structure ultimately
results in deformity of pinna[4] [Figure 4].
Chondritis or secondary infection of ear cartilage
Figure 1: Superficial dermal burns of the ear showing the peeled off
epidermis exposing glistening pink superficial dermis
Figure 3: Full thickness burns of ear seen by the dry eschar and
thrombosed veins
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develops in the former, i.e., superficial and deep
dermal burns and is seen 3-5 weeks postburn. In fact
at times suppurative chondritis may occur even after
reepithelialization has occurred [Figure 5]. It is not
possible to predict which burned ear will develop
chondritis. It is characterized by dull ear pain which
rapidly increases in intensity, not relieved by analgesics.
Ear becomes warm, erythematous, swollen and very
tender and cepahaloconchal angle is increased [Figure 6].
This usually starts along the helix or antihelix and
gradually involves entire ear and may eventually form an
abscess. In 95% cases cultures yield Pseudomonas and
Staphylococcus.
Proper head positioning and timely intervention can
prevent destructive chondritis of the ears.
MANAGEMENT
Goals of treatment: The goal for ear reconstruction is
to restore aesthetic appearance of ear and maintain a
Figure 2: Mixed superficial and deep dermal burns of the ear
b
Figure 4: (a) Deep burns of the ear, (b) When deep burns of the ear
are not debrided and cartilage not covered primarily leads to severe
deformity as shown
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Sarabahi: Management of ear burns
superior sulcus which can accommodate glasses and to
minimize complications from infection and fibrosis.
ACUTE BURNS
Most of the burns heal without any operative intervention.
The main goal or aim of treatment of acute ear burns
is to prevent suppurative chondritis. “Chondritis of ear
is better prevented than treated” – is a famous saying.
The main consideration is to avoid pressure on burned
pinna which cannot be overemphasized.[5] Therefore the
patient should not lie on either side and neither use a
pillow under the head. Instead a ‘donut’ is used to keep
the head elevated without the ears touching any surface.
This prevents pressure necrosis of the ears and skin loss,
Figure 5: Established chondral abscess which has developed even after
all burns have practically healed
a b
Figure 6: (a) Patient with signs and symptoms of chondritis, i.e.,
complains of severe pain in the pinna with erythema, swelling, and
tenderness, (b) Same patient with increased cephaloconchal angle
a b
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
Indian Journal of Burns || December 2012 || Vol 20 || Issue 1
thus preventing partial thickness burn from becoming
a full thickness injury. There is no doubt that pressure
on the burnt ear and further trauma of any kind has
to be avoided to prevent further damage to an already
compromised cartilage.
The application of topical antibiotics like 1% silver
sulphadiazene, sulfamylon, and 0.3% silver nitrate reduces
contamination of the wound and allows partial thickness
burns to heal.[5,6] However, the most effective topical agent
for the ear which can prevent and even treat chondritis is
mafenide (Sulfamylon) cream because of its excellent ability
to penetrate the eschar and the cartilage and has a broad
antibacterial spectrum with good bacteriostatic action. It has
to be applied twice daily because of its active penetration.
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
but perichondrium is preserved, it will ‘take’ a thin skin
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
later.[10,11] However if the eschar is suppurative it should
be debrided. Others suggest early excision of skin and if
a large area of cartilage gets exposed, the ear cartilage
can be salvaged soon after burns using a vascularized flap.
c
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Sarabahi: Management of ear burns
Since local skin is commonly injured, regional or distant
flaps have been described to cover the cartilage.[12,13] These
include platysma myocutaneous flap, temporoparietal
fascial flap, the latter being the best choice because of its
thinness and pliability. Though one must remember that
temporoparietal fascia is the best option for secondary ear
reconstruction so it should be used judiciously if at all in
the acute stage. Postauricular fascia can also be used as a
turn over flap to provide cover.
Rosenthal[10] described 12 zones of partially burned
ear which were divided into three major regions which
include 6 zones which are used as donor sites for
advancement flap, three zones which can be excised
and closed primarily and two zones which should be
preserved as far as possible.
Chondritis
For established suppurative chondritis a number of
approaches have been advocated. Antibiotic irrigation with
polymyxin B 0.2% solution or culture specific antibiotics
every 2-3 hours for 4-5 days with help of catheter both
anteriorly and posteriorly was reported by some authors.[14,15]
Iontophoresis using polar charged antibiotic compounds
such as penicillin and gentamycin which are pulsed across
avascular membranes was advocated by Greminger[16] and
has been recommended by many authors later on.[12,17]
Simple drainage of pus is insufficient as chances of
recurrence is high.[18,19] Cultures of pus drained may often
be sterile. Therefore excision of all underlying necrotic
cartilage leaving skin intact after a bivalving incision in the
a b
Figure 8: (a) Established suppurative chondritis which was treated
timely by excision of all dead cartilage, (b) 1 Month postoperative
picture of same patient
a b
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
14
ear which splits ear into anterior and posterior surfaces
has been recommended by most authors.[1,6] This prevents
recurrence. The involved cartilage is soft and yellow and
lacks resilience of normal hyaline cartilage. All the soft
cartilage must be removed, leaving behind only cartilage of
normal consistency. Gauze soaked in antibacterial solution
is packed between the skin flaps which reduces further
progression of infection and a light dressings is given
over the ear. Dressing is to be changed after 24 hours
and any residual necrotic cartilage should also be excised
[Figures 8, 9]. Dressing is continued till secondary closure
is achieved. Topical chemotherapy has a better influence on
outcome of chondritis as systemic antibiotics are ineffective
since cartilage survives by diffusion from perichondrium.
ESTABLISHED EAR DEFORMITIES
Ear reconstruction should be undertaken once all the burns
have healed and deformity has established. Functional
reconstruction of important areas like eyelids, hand, axilla
and elbow takes priority over the ear however since ear
reconstruction is a staged procedure; it can be started
simultaneously when other areas are operated upon.
Kung et al.[20] classified burned ear deformities into 3 main
types:
• Mild - loss of helix and upper part of pinna without
extensive scarring
• Moderate - concha is normal, upper half of ear has
sloughed out with loss of antihelix with its anterior
and posterior crura.
• 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:
• Group I: In this group the postauricular skin is normal
and is used to provide cover to the cartilage
framework.
c
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Sarabahi: Management of ear burns

• 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

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Sarabahi: Management of ear burns
in secondary ear reconstruction and waited for graft to
mature before inserting cartilage framework but the
grafted skin lacked elasticity and did not give satisfactory
result. In 1974, Edgerton and Bacchetta[30] first used a fan
flap composed of temporal muscle, fascia and epicranium
to cover a silicone ear implant and in 1976 Fox and
Edgerton used the same flap for salvaging auricular
cartilage in acute burns.[31]
Flap for cartilage cover should be thin and pliable so
as not to mask the convolutions of underlying cartilage
framework. For this reason temporoparietal fascial
flap offers the best option. The advantage of using
temporoparietal fascial flap is that the scar is hidden in
hair bearing area of scalp and if required hairy scalp can
also be raised along with it.
Covering carved cartilage with temporoparietal fascial flap
was originally described by Tegmeier and Gooding in 1977
and popularized by Brent in 1980[32] and Brent and Byrd in
1983.[33] Fascial flap may be used as an axial pattern flap
which is based on posterior branch of superficial temporal
artery and vein. In case it is unavailable, a random
pattern fascial flap can be used. In 1978, Ohmori[34] used
temporoparietal muscle flap to cover the conchal region
of silicone ear implant whereas Cronin[35] used a fascial
flap for the coverage of the same.
In 1985, Brent et al.[33] used temporoparietal fascial flap
as free flap with scalp island flap for ear reconstruction
and recreation of hairline and sideburns. If the
temporo-auriculomastoid region is unfavorable, Mutaf
et al.[36] have successfully used a bilobed cervical flap for
cover, if neck skin is unburned. It offers a simple, well
vascularized, hairless skin with good color match, texture
and thickness.
Even medpore ear scaffold covered with superficial
temporoparietal fascia flap gives a satisfactory one-stage
reconstruction of total ear loss as medpore provides better
biological compatibility compared to silastic implant.[37]
Wellisz[38] and Jones and Wellisz[39] used temporoparietal
fascial flap with MEDPOR framework for reconstruction
in burned ear with excellent results. Shanbagh et al.[40]
compared MEDPOR polyethylene implant with silicone
implant in external ear reconstruction showing higher
extrusion of silicone implants.
Many authors have used tissue expanders for creating
excess skin in the postauricular region for ear
reconstruction even in the presence of scarred skin.[41-43]
Tissue expander can also be inserted in the pre- or
postauricular skin if unscarred[32,42] and the expanded
normal skin can be advanced to the auricular region to
provide cover over a cartilage framework or implant.
In case all of the above options are not available
then contralateral temporoparietal fascial flap can be
16
transferred by micro vascular technique to provide cover
as reported by Brent and Byrd.[33] In patients with bilateral
devascularized temporoparietal region or in whom
contralateral fascial flap cannot be used, there are very
limited options. In those cases use of expanded forearm
skin flaps or forearm fascial flap has been reported.
Akin[44] described the use of a prefabricated free radial
forearm fasciocutaneous flap with an autogenous costal
cartilage framework for total auricular reconstruction
in burn patients. Drawback of using forearm flap is the
donor site deformities, hair growth, and skin color
mismatch and sacrifice of a major artery. Using radial
forearm fascial free flap for ear reconstruction has the
advantages of providing thin flap with long pedicle and
preserving forearm skin.
Distant-free flaps provide poor quality of skin cover which
masks the convolutions.
Park et al. have described the use of Omental free flap in
such cases to provide cover over cartilage framework.[45]
In selected cases, in which the patient is unwilling to
undergo multiple surgical procedures and for patients
with anesthetic problems prosthesis can be fixed to cranial
bone by osseointegrated titanium screws.[46] But the cost
and potential long-term complications are deterrents to
their regular use.
CONCLUSION
For both the patient and the surgeon, realistic expectations
are important to the success of any reconstruction. This is
more important in the case of ear burns as many a times
it may not be possible to fulfill the patients expectations
and also because the entire process of ear reconstruction
is a long process. Therefore, it is more important to
take even the burns of the ears seriously and give it
proper care, thus preventing complications and further
deformities.
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How to cite this article: Sarabahi S. Management of ear burns. Indian
J Burns 2012;20:11-7.
Source of Support: Nil, Conflict of Interest: None declared.
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