An active role of reconstructive surgeon in otologic tumor surgery

Due to sun exposure, skin cancer in the head and neck is the most common malignant tumor. Auricular tumors account for 5% to 8% of malignant cutaneous tumors in this region. Auricles as prominent facial organs not only affect an individual’s appearance, but are also necessary for wearing glasses or masks. Moreover, corresponding or surrounding structures, such as the temporal bone or facial nerves, play important roles in auditory sensation and facial expression. In the clinical setting, multi-disciplinary collaboration is conducive to acquiring the best outcome in malignant tumor treatment. Otologic surgeons are responsible for resecting tumors to the greatest extent possible, while reconstructive surgeons should be obligated to wound defect coverage, facial appearance, and relative function restoration. In our institution, reconstructive surgeons participate in designing the surgical procedures in detail, prior to the surgery, to obtain the most satisfactory result concerning the patient’s survival and life quality. The reconstructive algorithm is displayed in Figure 1 and discussed in the following parts.

Figure 1.

Reconstructive algorithm for auricular tumor resection.

On the one hand, the three-dimensional cartilage complex covered with thin skin forms sophisticated subunits. Partial reconstructions focusing on auricular subunits contain a diversity of options described in the literature. The ipsilateral laterocervical twisted flap has been reported to reconstruct the external auditory canal (EAC) in elderly patients without excessive subcutaneous fat. ¹ Similarly, a preauricular square screw flap, with the advantages of anterograde perfusion and shorter incision, was applied to reconstruct EAC in T1 or T2 cases by the Pittsburgh classification. ² A retrograde preauricular flap using natural skin excess was used to cover the antihelix defects involving the superior, inferior crus and the triangular fossa in a pull-through maneuver. ³ The postauricular rotation flap was an optimal option for the reconstruction of anterior auricular defects due to abundant blood supply from the superior auricular artery and the posterior auricular artery. A postauricular island flap with adipodermal pedicle was transferred to the defects in antihelix or scapha through the transauricular tunnel with a 180-degree turnover. ⁴ In summary, the postauricular or preauricular flap may be a good alternative for repairing small auricular tissue defects (< 2 cm in diameter) because of color similarity, the appropriate thickness, good vascularization, inconspicuous scar, and one-stage procedure.

On the other hand, it is feasible to perform tumor en bloc resection with the assistance of various tissue transplantations involving the coverage of soft tissue and bone defects and replacement of absent nerves during one surgical procedure. Local pedicled flaps or free vascularized myocutaneous flaps are the available methods for covering tremendous tissue defects, which facilate opstoperative radiotherapy without delay. Free anterolateral thigh (ALT) flaps are popular in head and neck reconstruction as they may be harvested together with tensor fascia lata or nearby nerves at the same time as tumor resection, without altering the patient’s position. Fascia might be used for dura repair or static facial suspension, and nerve graft can improve facial nerve paralysis. Since natural auricles have evident advantages in wearing glasses or masks, resistance to trauma, and esthetic appearance, auricle-conserving surgery should be encouraged for exploration, especially in the case of the EAC and/or middle ear carcinoma. Tanaka et al ⁵ reported a study regarding lateral skull reconstruction by the ALT flap while preserving most of the auricle. The operation began with a long transcranial incision, subgaleal dissection, and a large flap with the remaining auricle. The anterolateral thigh flap with de-epithelized skin paddle was then transferred to cover the large cavity after subtotal temporal bone removal and invasive facial nerve resection. Finally, the exfoliated scalp with the remaining auricle was replaced and closed, taking into consideration the correct position of the external ear. Additionally, distinguished from congenital microtia, the patients with tumor resection are not suitable for autologous auricular reconstruction because of brittle costal cartilage and overall health in elderly persons. Therefore, the auricular prosthesis should be considered when the reconstruction is a strong desire in those individuals.