Kamal A., Kamel A.H., El Oteify M.

Burns Unit, Plastic and Reconstructive Surgery Department, Assiut University Hospital, Assiut, Egypt

SUMMARY. The auricle is frequently injured during thermal injury. Because it is covered by skin without any underlying subcutaneous tissue, it does not have significant insulation to protect the cartilaginous framework from subsequent deformity. This study was carried out on 30 patients with 40 burned auricles (age range, 7 months to 55 yr; mean age, 26 yr ± 12; 12 females and 8 males). The burn size ranged from 6 to 60% TBSA (mean, 23 ± 13%). All were admitted to the burns unit in Assiut University Hospital, Assiut, Egypt, during the period September 2000-September 2001. Statistical analysis and correlation of the patients’ data were performed in order to understand the nature of burns involving the auricle, evaluate the results of various lines of treatment, determine the complications of the burned auricle, study changes that lead to chondritis, and consider its fate.

Introduction

The auricle is frequently injured during thermal injury of the head and neck. Because it is covered by skin without any underlying subcutaneous tissue, it does not have significant insulation to protect the cartilaginous framework.

Three theories published in the literature have described the pathophysiology of post-burn chondritis. The first maintained that as the cartilage has no intrinsic blood supply, a full-thickness injury of the skin and perichondrium exposes the cartilage with the subsequent risk of chondronecrosis and secondary infection.2 The second theory was that following partial-thickness burn injury, burn oedema results in thrombosis of central vessels.1 The third possibility was that chondritis develops from bacterial invasion through damaged skin. Bacteria embedded in the burn prior to epithelialization can proliferate and eventually cause chondritis.

Chondritis is the commonest early complication following burn of the auricle, and it may be severe enough to destroy the cartilage completely. If it is not recognized and treated early, there will be an unacceptable cosmetic result.4 Clinically, there will be oedema, an increase in the auriculocephalic angle, pain, erythema, warmth, the “ear springing” sign (a positive sign present when the patient feels pain on springing an auricle which at rest is not painful), and tenderness. Late complications of the burned auricle include hyperpigmentation, hypertrophic scarring, mild deformity, moderate deformity, and total loss of the ear.

Treatment

Non-surgical treatment. This includes preventing the conversion of a deep second-degree burn to third degree, keeping the eschar dry while epithelialization is proceeding, and preventing infection.

Surgical treatment. Once chondritis is evident, treatment must be aggressive to preserve ear architecture. Simple incision and drainage are usually inadequate treatment for suppurative chondritis. This is due to the rigid cartilage, which should be excised. Loculation of exudates occurs under the skin flaps, causing spreading of the infection to adjacent cartilage. The ideal surgical lines of treatment are the bivalve technique10 or the window technique.

Patients and methods

This study was carried out on 30 patients with 40 burned auricles. Their ages ranged from 7 months to 55 yr (mean, 26 ± 15 yr). Twelve patients were females and 18 males. The burn size ranged from 6 to 60% TBSA (mean, 23 ± 13%). The patients were admitted to the burns unit in Assiut University Hospital during the period September 2000-September 2001. All the patients were subjected to the following procedures: 1. classical examination of the burn area; 2. diagnosis of burn depth in the affected auricle; 3. assessment of distribution of burn in the affected auricle; 4. first-aid measures (including shaving of hair around the burned auricle, gentle washing of the auricle with saline and application of topical ointment after each washing twice daily, and avoidance of pressure on the auricle). This treatment continued until complete healing, which occurred within 7-52 days (mean, 13 days ± 10).

The patients were classified into three groups: group 1 (10 patients), in which nitrofurazone ointment was used as a topical treatment; group 2 (10 patients), where we used povidone iodine ointment topically; and group 3 (10 patients), where we used 0.25% B-sistosterol applied topically.

Monitoring of complications. The ear springing sign indicated early perichondritis, which required early drainage.

Drainage

1. Bivalve technique. An incision is made along the helical margin and the ear is split in bivalve fashion with all necrotic cartilage being removed. A single layer of fine mesh gauze soaked in an antibacterial solution is placed between the skin flaps of the ear to reduce the risk of progressive infection. A light dressing is applied over the ear without pressure, and the fine mesh gauze is changed daily until healing by secondary intention.
2. Window technique. This is the excision of the anterior wall of the abscess plus all necrotic cartilage and a thin rim of normal cartilage, leaving only the posterior skin in the base of the defect. Saline dressing is applied with topical antimicrobial ointment until healing by secondary intention or grafting.

Results

Analysis of our data showed that the commonest cause of the burned auricle was flame burn (Table I), the anterior surface being more affected than the posterior (Table II). Most of the auricular burns were diagnosed as deep second degree (Table III). The incidence of chondritis in our series was 10% (4 auricles), as shown in Table IV. Although 75% of cases developed chondritis after flame, the difference between this percentage and that of other agents was statistically insignificant (Table V). All patients developing chondritis had burns in both surfaces and on admission were diagnosed as having deep burns. There was a statistically insignificant difference between the types of ointments used and chondritis. Four out of the 40 burned auricles (10%) presented deformity: two a mild deformity, one a moderate deformity, while in one case there was complete loss of the auricle.

Discussion

The exposed position of the auricle makes it very vulnerable to burns,10 which is why in our study the anterior aspect of the auricle was affected more commonly than the posterior. The thin skin of the outer surface of the auricle explains the high third-degree burn affection of the auricle, while the incidence of superficial second-degree burns was 30%; no first-degree burns were recorded. The healing time was more or less the same as that reported by Nigm,5 ranging from 4 to 52 days (mean, 13 days ± 10).

The reported incidence of chondritis ranges from 5 to 25%.3,11 In our study the incidence was 10% (4 out of 40 burned auricles). All the patients in our series who developed chondritis presented deep burns on both surfaces. This most probably led to affection of the blood supply on both sides, while only outer surface affection was not associated with chondritis - this is may be due to the preservation of the blood supply on the posterior surface, together with our lines of management of the burned auricle to prevent the development of chondritis.

Many types of topical agent have been described in the literature for the control of auricular infection and its sequelae. The incidence of chondritis after the use of sulfamylon was reported as ranging from 3.3 to 19%,2 while it was up to 43% after gentamicin iontophoresis.8,12 In our study we used three different types of topical agents in ointment form. There was a statistically insignificant difference in the incidence of chondritis after use of each type. The incidences of chondritis were respectively 9, 12, and 8% after use of nitrofurazone, povidone iodine, and 0.25% B-sistosterol.

The key to the management of the burned auricle lies in the prevention of infection. In the past, surgical treatment was instituted only when the full picture of chondritis was evident. The patient with established chondritis has a painful swollen auricle with an obtuse auriculocephalic angle. The pain is severe and throbbing, and the patient is irritable and unable to sleep. It is important to diagnose chondritis before this stage because the cartilage involvement will invariably be necrosed and result in partial or total loss of the auricle.5 In our series early detection of chondritis was of the utmost importance. One of the earliest features of chondritis is slight pain at rest, which is worsened by springing the auricle. This auricle springing sign is an early and reliable clinical indication. Once the condition is diagnosed, the auricle should be surgically treated and the chondritic cartilage radically excised. In the absence of infection there is no or only mild auricular deformity.

This is concomitant with our finding that there was no deformity in cases that were free of perichondritis.

The incidence of deformity after perichondritis in our series was mild (i.e. involvement of less than half the auricle) in 50% of cases (two auricles), moderate (i.e. involvement of more than half the auricle) in 25% (one auricle), and severe (i.e. total loss of the auricle) in 25% (one auricle). These results are consistent with those reported in the literature.

Conclusion

The favourable results achieved in this series were mainly attributable to the following ten recommendations: 1. shaving of hair around the burned auricle; 2. early and accurate assessment of burn depth; 3. daily cleaning and use of topical antibiotic ointment; 4. avoidance of pressure on the ear; 5. early clinical detection of chondritis by the ear springing sign; 6. early surgical intervention; 7. radical removal of chondritic cartilage; 8. meticulous post-operative care to prevent cross-infection; 9. observation of these measures irrespective of the type of topical agent; 10. the consideration that prevention is more important than treatment, as once chondritis occurs the auricle never returns to normal.

RESUME. Le pavillon de l’oreille est très exposé au risque de lésion en occasion des brûlures. Puisqu’il est couvert par la peau sans tissu sous-cutané sous-jacent, il ne possède aucun isolement significatif pour protéger la structure cartilagineuse d’une difformité successive. Les Auteurs ont étudié 40 pavillons de l’oreille dans 30 patients (variation d’âge, 7 mois à 55 ans; âge moyen, 26 ans ± 12). L’extension des brûlures variait de 6 à 60% de la surface totale corporelle (moyen, 23 ± 13%). Tous les patients ont été hospitalisés dans l’unité des brûlures de l’Hôpital de l’Université d’Assiut, Assiut, Egypte, pendant la période septembre 2000-septembre 2001. Les Auteurs ont effectué une analyse statistique et une corrélation des données des patients pour comprendre la nature des brûlures qui touchent le pavillon de l’oreille, évaluer les résultats des diverses modalités de traitement, déterminer les complications du pavillon, étudier les modifications qui portent à la chondrite et considérer son destin.

Bibliography

1. Mills D.C., Roberts L.W., Mason A.D. et al.: Suppurative chondritis: Its incidence, prevention and treatment in burn patients. Plast. Reconstr. Surg., 82: 267, 1988.
2. Dowling J.A., Foly F.D., Moncrief J.A.: Chondritis in the burned ear. Plast. Reconstr. Surg., 42: 115-22, 1968. Quoted from Clinics in Plastic Surgery, 19 (3): 1992.
3. Skedros D.G., Goldfarb I.W., Slater H., Rocco J.: Chondritis of the burned ear. Ear Nose Throat J., 71: 359-62, 1992.
4. Bentrem D.J., Bill T.J., Himel H.N.: Chondritis of the ear: A late sequela of deep partial-thickness burns of the face. J. Emerg. Med., 14: 469-71, 1996.
5. Nigm R.C.: The burned ear II: A prospective clinical study of 100 patients with 150 ear burns. Ann. Acad. Med. Singapore, 21: 605-11, 1992.
6. Barrow R.E., Ramirez R.J., Zhang X.J.: Ibuprofen modulates tissue perfusion in partial-thickness burns. Burns, 26: 341-6, 2000.
7. Jordan M.H., Gallagher J.M., Allely R.R., Leman C.J.: A pressure prevention device for burned ears. J. Burn Care Rehabil., 13: 673-7, 1992.
8. Kaweski S., Baldwin R.C., Wong R.K., Manders E.K.: Diffusion versus iontophoresis in the transport of gentamicin in the burned rabbit ear model. Plast. Reconstr. Surg., 92: 1342-51, 1993.
9. Pickus E.J., Lionelli G.T., Charles E.W. 3rd, Korentager R.A.: Mafenide acetate allergy presenting as recurrent chondritis. Ann. Plast. Surg., 48: 202-4, 2002.
10. Neale H.W, Billmire D.A., Carey J.: Reconstruction following head and neck burns. Clin. Plast. Surg., 13: 119-36, 1986.
11. Goel T.K., Law E.J., MacMillan B.G.: Management of the burned ear. Burns, 9: 218, 1982.
12. Desai M.H., Rutan R.L., Heggers J.P., Alvardo M.I., McElroy K., Herndon D.N.: The role of gentamicin iontophoresis in the treatment of burned ears. J. Burn Care Rehabil., 12: 521-4, 1991.
13. David C.: Ear reconstruction. In: “Georgiade Textbook of Plastic, Maxillofacial and Reconstructive Surgery”, Georgiade G., Georgiade N., Riefkohl R., Barwick W. (eds), 2nd edition, William and Wikins, Philadelphia, 1996.