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microtia, microtia external ear
Microtia is a congenital deformity where the pinna external ear is underdeveloped A completely undeveloped pinna is referred to as anotia Because microtia and anotia have the same origin, it can be referred to as microtia-anotia1 Microtia can be unilateral one side only or bilateral affecting both sides Microtia occurs in 1 out of about 8,000–10,000 births In unilateral microtia, the right ear is most commonly affected It may occur as a complication of taking Accutane isotretinoin during pregnancy2


  • 1 Classification
  • 2 Medical treatment
    • 21 Hearing
    • 22 External ear
      • 221 Related conditions
  • 3 Notable cases
  • 4 References
  • 5 External links


There are four grades of microtia:

  • Grade I: A less than complete development of the external ear with identifiable structures and a small but present external ear canal
  • Grade II: A partially developed ear usually the top portion is underdeveloped with a closed stenotic external ear canal producing a conductive hearing loss
  • Grade III: Absence of the external ear with a small peanut-like vestige structure and an absence of the external ear canal and ear drum Grade III microtia is the most common form of microtia
  • Grade IV: Absence of the total ear or anotia

Medical treatmentedit

The goal of medical intervention is to provide the best form and function to the underdeveloped ear


Typically, testing is first done to determine the quality of hearing This can be done as early as in the first two weeks with a BAER test Brain Stem Auditory Response Test34 At age 5–6, CT or CAT scans of the middle ear can be done to elucidate its development and clarify which patients are appropriate candidates for surgery to improve hearing For younger individuals, this is done under sedation

The hearing loss associated with congenital aural atresia is a conductive hearing loss—hearing loss caused by inefficient conduction of sound to the inner ear Essentially, children with aural atresia have hearing loss because the sound cannot travel into the usually healthy inner ear—there is no ear canal, no eardrum, and the small ear bones malleus/hammer, incus/anvil, and stapes/stirrup are underdeveloped "Usually" is in parentheses because rarely, a child with atresia also has a malformation of the inner ear leading to a sensorineural hearing loss as many as 19% in one study5 Sensorineural hearing loss is caused by a problem in the inner ear, the cochlea Sensorineural hearing loss is not correctable by surgery, but properly fitted and adjusted hearing amplification hearing aids generally provide excellent rehabilitation for this hearing loss If the hearing loss is severe to profound in both ears, the child may be a candidate for a cochlear implant beyond the scope of this discussion

Unilateral sensorineural hearing loss was not generally considered a serious disability by the medical establishment before the nineties; it was thought that the afflicted person was able to adjust to it from birth In general, there are exceptional advantages to gain from an intervention to enable hearing in the microtic ear, especially in bilateral microtia Children with untreated unilateral sensorineural hearing loss are more likely to have to repeat a grade in school and/or need supplemental services eg, FM system – see below than their peers67

Children with unilateral sensorineural hearing loss often require years of speech therapy in order to learn how to enunciate and understand spoken language What is truly unclear, and the subject of an ongoing research study, is the effect of unilateral conductive hearing loss in children with unilateral aural atresia on scholastic performance If atresia surgery or some form of amplification is not used, special steps should be taken to ensure that the child is accessing and understanding all of the verbal information presented in school settings Recommendations for improving a child's hearing in the academic setting include preferential seating in class, an FM system the teacher wears a microphone, and the sound is transmitted to a speaker at the child's desk or to an ear bud or hearing aid the child wears, a bone conducting hearing aid, or conventional hearing aids Age for BAHA implantation depends on whether the child is in Europe 18 months or the US age 5 Until then it is possible to fit a Baha on a softband89

It is important to note that not all children with aural atresia are candidates for atresia repair Candidacy for atresia surgery is based on the hearing test audiogram and CT scan imaging If a canal is built where one does not exist, minor complications can arise from the body's natural tendency to heal an open wound closed Repairing aural atresia is a very detailed and complicated surgical procedure which requires an expert in atresia repair10 While complications from this surgery can arise, the risk of complications is greatly reduced when using a highly experienced otologist Atresia patients who opt for surgery will temporarily have the canal packed with gelatin sponge and silicone sheeting to prevent closure The timing of ear canal reconstruction canalplasty depends on the type of external ear Microtia repair desired by the patient and family Two surgical teams in the USA are currently able to reconstruct the canal at the same time as the external ear in a single surgical stage one stage ear reconstruction

In cases where a later surgical reconstruction of the external ear of the child might be possible, positioning of the Baha implant is critical It may be necessary to position the implant further back than usual to enable successful reconstructive surgery – but not so far as to compromise hearing performance If the reconstruction is ultimately successful, it is easy to remove the percutaneous BAHA abutment If the surgery is unsuccessful, the abutment can be replaced and the implant re-activated to restore hearing

External earedit

The age when outer ear surgery can be attempted depends upon the technique chosen The earliest is 7 for Rib Cartilage Grafts However, some surgeons recommend waiting until a later age, such as 8–10 when the ear is closer to adult size External ear prostheses have been made for children as young as 5

For auricular reconstruction, there are several different options:

  1. Rib Cartilage Graft Reconstruction: This surgery may be performed by specialists in the technique1112131415 It involves sculpting the patient's own rib cartilage into the form of an ear Because the cartilage is the patient's own living tissue, the reconstructed ear continues to grow as the child does In order to be sure that the rib cage is large enough to provide the necessary donor tissue, some surgeons wait until the patient is 8 years of age;1415 however, some surgeons with more experience with this technique may begin the surgery on a child aged six121316 The major advantage of this surgery is that the patient's own tissue is used for the reconstruction This surgery varies from two to four stages depending on the surgeon's preferred method A novel one stage ear reconstruction technique is performed by a few select surgeons One team is able to reconstruct the entire external ear and ear canal in one operation
  2. Reconstruct the ear using a polyethylene plastic implant also called Medpor: This is a 1–2 stage surgery that can start at age 3 and can be done as an outpatient without hospitalization Using the porous framework, which allows the patient's tissue to grow into the material and the patient's own tissue flap, a new ear is constructed in a single surgery A small second surgery is performed in 3–6 months if needed for minor adjustments This surgery should only be performed by experts in the techniques involved17 The use of porous polyethylene implants for ear reconstruction was initiated in the 1980s by Alexander Berghaus18
  3. Ear Prosthesis: An auricular ear prosthesis is custom made by an anaplastologist to mirror the other ear19 Prosthetic ears can appear very realistic They require a few minutes of daily care They are typically made of silicone, which is colored to match the surrounding skin and can be attached using either adhesive or with titanium screws inserted into the skull to which the prosthetic is attached with a magnetic or bar/clip type system These screws are the same as the BAHA bone anchored hearing aid screws and can be placed simultaneously The biggest advantage over any surgery is having a prosthetic ear that allows the affected ear to appear as normal as possible to the natural ear The biggest disadvantage is the daily care involved and knowing that the prosthesis is not real

Related conditionsedit

Aural atresia is the underdevelopment of the middle ear and canal and usually occurs in conjunction with microtia Atresia occurs because patients with microtia may not have an external opening to the ear canal, though However, the cochlea and other inner ear structures are usually present The grade of microtia usually correlates to the degree of development of the middle ear4 10 Microtia is usually isolated, but may occur in conjunction with hemifacial microsomia, Goldenhar Syndrome or Treacher-Collins Syndrome20 It is also occasionally associated with kidney abnormalities rarely life-threatening, and jaw problems, and more rarely, heart defects and vertebral deformities13

Notable casesedit

  • Paul Stanley, vocalist and rhythm guitarist of Kiss, was born with grade III microtia of his right ear


  1. ^ Online Mendelian Inheritance in Man OMIM Microtia-Anotia -600674
  2. ^ Pretest self assessment and review for the USMLE, pediatrics, 12th edition, question 84, general pediatrics
  3. ^ De la Cruz A, Kesser BW 1999 "Management of the Unilateral Atretic Ear" In Pensak M Controversies in Otolaryngology—Head and Neck Surgery New York: Thieme Medical Publishers pp 381–385 
  4. ^ a b Kountakis SE, Helidonis E, Jahrsdoerfer RA 1995 "Microtia grade as an indicator of middle ear development in aural atresia" Arch Otolaryngol Head Neck Surg 121 8: 885–6 PMID 7619415 doi:101001/archotol199501890080053010 
  5. ^ Vrabec JT, Lin JW 2010 "Inner Ear Anomalies in Congenital Aural Atresia" Otology & Neurotology 31: 1421 doi:101097/mao0b013e3181f7ab62 
  6. ^ Bess FH, Tharpe AM 1986 "Case History Data on Unilaterally Hearing-Impaired Children" Ear and Hearing 7: 14–19 doi:101097/00003446-198602000-00004 
  7. ^ Bess FH, Tharpe AM 1988 "Performance and Management of Children with Unilateral Sensorineural Hearing Loss" Cand Audiol Supple 30: 75–9 PMID 3067327 
  8. ^ Nicholson N, Christensen L, Dornhoffer J, Martin P, Smith-Olinde L 2011 "Verification of speech spectrum audibility for pediatric baha softband users with craniofacial anomalies" The Cleft Palate-Craniofacial Journal 48 1: 56–65 PMID 20180710 doi:101597/08-178 
  9. ^ Verhagen CV, Hol MK, Coppens-Schellekens W, Snik AF, Cremers CW 2008 "The Baha Softband A new treatment for young children with bilateral congenital aural atresia" International journal of pediatric otorhinolaryngology 72 10: 1455–9 PMID 18667244 doi:101016/jijporl200806009 
  10. ^ a b Jahrsdoerfer RA, Kesser BW 1995 "Issues on Aural Atresia for the facial Plastic Surgeon" Facial Plastic Surgery 11 4: 274–277 doi:101055/s-2008-1064543 
  11. ^ Tanzer RC 1959 "Total Reconstruction of the External Ear" Plastic & Reconstructive Surgery 23: 1–15 doi:101097/00006534-195901000-00001 
  12. ^ a b Brent B 1999 "Technical Advances with Autogenous Rib Cartilage Grafts—A Personal Review of 1,200 Cases" Plastic & Reconstructive Surgery 104 2: 319–334 doi:101097/00006534-199908000-00001 
  13. ^ a b c Brent B 1992 "Auricular Repair with Autogenous Rib Cartilage Grafts: Two Decades of Experience with 600 Cases" Plastic & Reconstructive Surgery 90 3: 355–374 doi:101097/00006534-199209000-00001 
  14. ^ a b Firmin F 1992 "Microtie Reconstruction par la Technique de Brent" Annals Chirurgie Plastica Esthetica 1: 119 
  15. ^ a b Nagata S 1994 "Modification of the Stages in Total Reconstruction of the Auricle: Part I Grafting the Three-Dimensional Costal Cartilage Framework for Lobule-Type Microtia" Plastic & Reconstructive Surgery 93 2: 221–30 PMID 8310014 doi:101097/00006534-199402000-00001 
  16. ^ Brent B 2000 "The Team Approach to Treating the Microtia-Atresia Patient" Otolaryngologic Clinics of North America 33 6: 1353–65, viii PMID 11449792 doi:101016/s0030-66650570286-3 
  17. ^ Reinisch JF, Lewin S 2009 "Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap" Facial Plast Surg 25 3: 181–9 PMID 19809950 doi:101055/s-0029-1239448 
  18. ^ Alexander Berghaus Implantate für die rekonstruktive Chirurgie der Nase und des Ohres Sammelwerk=Laryngo-Rhino-Otologie Vol86 2007 Page 67–76 DOI=101055/s-2007-966301
  19. ^ Tanner PB; Mobley SR 2006 "External Auricular and Facial Prosthetics: A Collaborative Effort of the Reconstructive Surgeon and Anaplastologist Auricular Surgery: Aesthetic and Reconstructive" Facial Plast Surg Clin North Am 14 2: 137–45, vi–vii doi:101016/jfsc200601003 
  20. ^ Huston Katsanis S, Cutting GR July 2004 "Treacher Collins Syndrome" GeneReviews PMID 20301704 

External linksedit

  • Microtia Treatment Comparison: Rib Graft and Medpor options for Microtia reconstruction
  • Microtia Overview - Stanford Children's Health
  • Bennun RD, Mulliken JB, Kaban LB, Murray JE December 1985 "Microtia: a microform of hemifacial microsomia" Plast Reconstr Surg 76 6: 859–65 PMID 4070453 doi:101097/00006534-198512000-00010 
  • Asociación Microtia España AME : The Association arises from the concerns of a group of families with the intention, among others, grouping and linking children, adolescents and adults with microtia Born in 2013 Currently based in Barcelona, Spain Makes biannual meetings with medical professionals, patients and families http://wwwinfoameorg

microtia, microtia atresia, microtia awareness day, microtia children, microtia ear reconstruction, microtia external ear, microtia grade 3, microtia pictures, microtia reconstruction, microtia surgery

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