Subtotal ear amputation can be approached in a variety of ways in the acute setting. Much of this depends on the situation surrounding the injury, the extent of the injury, and the extent of the surgeon’s experience with such an injury. Park et al,1,2,3 the first to successfully perform microvascular anastomoses of the ear in 1980, suggested that the ear can survive via a single vessel, either a posterior pedicle or a superior pedicle. Here, we present a case where a narrow skin pedicle bridge remains after traumatic injury due to dog bite. In the literature, reports of subtotal ear amputations supplied by narrow pedicles are scarce. We found 4 cases that describe subtotal amputation provided by superior pedicles4–6 and 5 cases with the ear attached by inferior pedicles, similar to our case.7–9 Of these 5 cases, 4 were repaired primarily and 1 was repaired with postauricular artery anastomoses.
In the cases of anterior pedicles, 2 of the 4 resulted in the lobule becoming congested and necrosed. We also found 1 case with ear attached by small superior and inferior skin bridges10 and 1 case where the attachment was not described, but from the image in the article it appeared that the ear was attached by a superior pedicle attached at the helix.11
Park et al2,3 demonstrated the detailed anatomy of the arterial supply of the posterior and anterior aspects of the auricle in fresh cadavers. Two arterial networks originating mainly from the superficial temporal artery and posterior auricular artery were shown to share enormous communicating branches between them. More recently, Erdmann et al12 at Duke demonstrated a helical arcade in cadaver studies, a vascular arcade found along the helical rim proceeding through watershed areas of communication with branches of the postauricular artery. The postauricular artery has the greatest impact on auricular blood flow, and consequently a better chance of survival is expected, provided that the postauricular arteriovenous system is preserved at the posterior aspect of the auricle. The study by Park et al3 noted that the earlobe consistently contained a perforator from the posterior auricular artery measuring on average 0.7 mm in diameter. This is the system that we believe may have remained intact in our case.
Many adjunct postoperative therapies have been applied after ear reattachment to augment tissue perfusion and survival of the tissue; however, there is no consensus on use of one therapy over another. Methods that have been applied include administration of heparin, aspirin, dextran, prostaglandin, leeches, and HBOT. Of the cases reviewed above, 2 applied the use of HBOT to their postoperative treatment.10, 11 The first one described a case of primary repair of traumatically sheered ear supplied by a 4- and 7-mm skin pedicle at the helical root and lobule, respectively. Postoperative care of this patient consisted of a combined therapy with leeches, dextran-40, vitamin E, and HBOT at 2 atm for 90 minutes twice a day for 6 days while in the hospital and 5 additional days as an outpatient. The result was a completely viable ear on POD 18 with a small 10-mm area of necrosis at the helical root.10 The second case described a significant avulsion injury to the left ear in a motor vehicle accident. After surgical replacement of the ear without microvascular anastomosis, ischemic changes were seen near the inferior pole. After 24 hours, no capillary refill was detectable, and HBOT was initiated twice daily for a total of 10 treatments given over a 5-day period. The result was improved perfusion at the end of the treatments. In this case, this article shows only an image of the ear at 1 year postoperatively without comments, in which the ear appears to have healed completely without tissue loss.11 Although details of this article are lacking, it seems that a hyperbaric protocol similar to the one used in our case has been used.
Hyperbaric oxygen is demonstrated to increase neovascularization, enhance oxygen delivery, and stimulate granulation tissue formation and collagen deposition.13 A study14 on HBOT in 2010 reviewed the mechanisms of wound healing associated with hyperbaric oxygen. The increase in atmospheric pressure increases the concentration of reactive oxygen and nitrogen species. This increase promotes neovascularization by increasing growth factors such as vascular endothelial growth factor among others and mobilization and differentiation of bone marrow stem/progenitor cells to form vessels de novo.14
Hyperbaric oxygen can also reduce tissue edema; it causes constriction of blood vessels in normal tissues without creating hypoxia. It does not, however, cause vasoconstriction in previously oxygen-deprived tissues because of the reflex vasodilatation that occurs after an ischemic insult.15 This peripheral arteriolar vasoconstriction caused by hyperbaric oxygen can reduce tissue edema and may be useful in the treatment of acute traumatic ischemia. The blood flow that contributes to increased edema seems to be reduced while maintaining oxygen delivery to the compromised tissues through the tremendous amounts dissolved in plasma.11
Complications of HBOT are rare, especially if sessions are limited to 90 minutes at no greater than 2.5 atm.11
The decision regarding the management of a near-total ear avulsion should be made at the time of presentation based on the viability and condition of the ear, surgeon’s experience and expertise, hospital resources, and associated injury or morbidity. Primary closure without microsurgery of the nearly avulsed ear is possible with good results as long as there is a small skin pedicle intact. Anatomic studies have shown that there is an extensive helical arcade that can supply perfusion to the majority of the ear through an inferior or superior pedicle.
Even after successful reattachment, the postoperative course can be hindered by poor circulation and edema. Although there is no absolute consensus for the postoperative care of reattachment of the auricle after traumatic injury, here we demonstrate a case with successful use of HBOT in the immediate postoperative period. Though this is an anecdotal case report, it shows that hyperbaric oxygen may play a role as an overlooked clinical tool that can help improve outcomes. In this case, hyperbaric oxygen proved effective with minimal risk of side effects associated with medicinal therapy and ease of use in a pediatric patient.
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12. Erdmann D, Bruno AD, Follmar KE, et al. The helical arcade: anatomic basis for survival in near-total ear avulsion. J Craniofac Surg. 2009;20:245–248
13. Hunt T, Pai M. The effect of varying ambient oxygen tensions in wound metabolism and collagen synthesis. Surg Gynecol Obstet. 1972;135:561–567
14. Thom SR. Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg. 2011;127(Suppl 1):131S–141S
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15. Strauss MB, Hargens AR, Gershuni DH, et al. Reduction of skeletal muscle necrosis using intermittent hyperbaric oxygen in a model compartment syndrome. J Bone Joint Surg Am. 1983;65:656–662