eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

External Auditory Canal Atresia: Follow-up

Author: Rahul K Shah, MD, FAAP, Assistant Professor of Otolaryngology and Pediatrics, George Washington University, Children's National Medical Center; Attending Physician, Department of Otolaryngologoy, Children's National Medical Center
Coauthor(s): Udayan K Shah, MD, Attending Surgeon, Division of Otolaryngology, Alfred I duPont Hospital for Children
Contributor Information and Disclosures

Updated: Jul 18, 2008

Follow-up

Further Inpatient Care

• Most children require overnight admission to monitor oral intake. Pain control is often accomplished early in healing with oral narcotics; later, nonnarcotics are used.

Further Outpatient Care

• Care immediately following discharge involves oral pain control with a narcotic if needed, an oral antibiotic for 10 days, ear drops after the oral antibiotic is completed to keep the ear canal sterile, and water precautions (ie, no water onto the wound for 3 days, no water into the ear canal until the first postoperative visit).
• Follow-up care is at least yearly to assess social, developmental, and clinical issues. Audiologic follow-up testing may be more frequent, and informational meetings with providers to keep families abreast of new developments are essential.

Complications

Complications after surgery include those related to the surgical site, middle-ear function, inner-ear function, and facial-nerve function. Careful attention to perioperative care and informed discussion with the family of possible complications limit the occurrence and psychologic impact of postoperative problems.

• Wound
  • Infection of the surgical site is limited by sterile technique and perioperative use of intravenous antibiotics and oral antibiotics. Infection of the skin graft donor site is prevented by careful perioperative hygiene.
  • Stenosis of the newly created external auditory canal (EAC) occurs in 8-12% of cases. Narrowing at the meatus or more medially may be caused by infection or by cicatricial wound healing. The House Ear Institute evaluated its outcomes after instituting changes in their surgical approach in these patients and found that the use of the argon laser, thinner split-thickness skin grafts, silastic sheets in the external auditory canal, and Merocel wicks have all combined to decrease rate of external auditory canal stenosis to 3.8%.¹²
• Hearing loss
  • Hearing should improve by 3 months after surgery. Persistent conductive hearing loss can occur because of failed ossicular reconstruction or scar formation (synechiae) in the middle ear. Hearing loss that develops after initial improvement may be due to OM, displacement of reconstructed ossicles or prostheses, synechiae formation, or lateralization of the reconstructed tympanic membrane, which occurs in 12-28% of cases. As expected, the acoustic characteristics of the newly reconstructed external auditory canal differ from those of contralateral healthy ear canals. A study showed that a significant shift existed in reconstructed canals in the resonant frequency toward the higher frequencies and a nonsignificant bandwidth change.¹³
  • New sensorineural hearing loss is a rare occurrence and may happen with any middle ear surgery.
• Vertigo
  • Dizziness for several hours after surgery is not unusual and reflects inner-ear trauma from manipulation of the stapes footplate during middle ear surgery. This vertigo should be transient.
  • Oral or intravenous vestibular suppressants may be used if needed.
• Facial nerve injury
  • Facial nerve function should be assessed preoperatively, with objective measures taken if necessary.
  • Injury during surgery, when visible nerve injury is identified or indicated by nerve monitoring, is treated with high-dose intravenous corticosteroids, along with nerve reanastomosis and/or decompression.
  • Upon emergence from general anesthesia, postoperative facial nerve palsy may be identified by absence of nasal flaring on the operative side, or it may be detected upon crying or grimacing after awakening. High-dose corticosteroids and observation are followed by a decision to re-explore the surgical site and decompress the nerve if injury is felt to be due to edema and is not responding to nonsurgical measures. This is addressed in more detail in the eMedicine article Dynamic Reanimation for Facial Paralysis.

Prognosis

• Hearing is measured in dB; normal hearing is considered to be between 0 and 15-20 dB for children. Higher measurements indicate sounds must be louder for a person to perceive them. A jet plane, for example, has a sound pressure level (SPL) of approximately 110 dB. Children with ear infections usually have a 40-dB hearing level.
• In a series of 16 patients published in 1988, Lambert obtained a speech reception threshold (SRT) or hearing threshold of 30 dB or greater in 67% of the operated ears.⁷ In De la Cruz's larger study of 302 ears, 73% of patients had a residual hearing deficit of 30 dB or less at 6-month follow-up.¹⁴ Jahrsdoerfer reported that 73% of 90 patients who had scores higher than 6 according to his grading system (see Surgical Care) and underwent operation achieved an SRT less than or equal to 25 dB.⁸
• The House Ear Institute published its results in 2004.¹² It compared modifications in its technique with its previous surgical technique. The new modifications included the use of the Argon laser, thinner split-thickness skin grafts, Silastic sheets, and Merocel wicks in the external auditory canal. With these modifications, hearing results were closure of the air-bone gap to 30 dB or less in 63% of patients, with a long-term postoperative air-bone gap of 30 dB or less in 50% of patients. Ossicular chain refixation occurred in only 4% of these patients.
• According to Wetmore et al, Krowiak and Grundfast believe that the standard of care when surgically correcting an atretic EAC includes creation of a patent external auditory canal, resolution to a hearing level of 25 dB or less, and closure of the air-bone gap.¹⁵
• For unilateral conductive hearing loss due to unilateral EACA, Glasscock et al explain to patients that if surgery is successful, they should be able to listen to stereo music, tell the directionality of sound, and hear better in a noisy environment.⁹ In a quiet place or in one-to-one conversation, patients are told not to expect improved hearing after surgery.
• An excellent study that included a cost analysis of the surgery versus hearing aids found that "even with significant investments in EAC reconstruction, most patients still required some form of amplification."¹⁶  Cost analysis suggests that osteointegrated bone-conduction devices may have an economic advantage over surgical intervention.

Miscellaneous

Medicolegal Pitfalls

• Appropriate informed consent must be obtained before photographic documentation. In most cases, photographic consent is required if the person is identifiable from a particular image. Failure to obtain consent may have legal implications and result in significant social and psychologic injury, particularly in children.

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