Long-term Outcomes of Surgical Intervention for Symptomatic Aural Atresia and Stenosis

Long-term Outcomes of Surgical Intervention for Symptomatic Aural Atresia and Stenosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term Outcomes of Surgical Intervention for Symptomatic Aural Atresia and Stenosis Runqin Yang, Yu Zhao, Miaomiao Du, Rui Li, Chen Dong, Dingjun Zha, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3810213/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aims to analyze the clinic features of symptomatic aural atresia and stenosis, and to explore the surgical techniques and postoperative care for aural atresia and stenosis. Methods A retrospective analysis on 24 patients with aural atresia (nine patients) or stenosis (15 patients) was conducted. They had done surgery and followed over one years. The basic information, etiologies, symptoms, with or without cholesteatoma were collected. For preventing postoperative restenosis, a plastic sheet with expansive sponge was commonly used as support material. And triamcinolone acetonide was locally injected when a stenotic tendency occurred. Additionally, three representative cases are presented. Results The main symptoms were hearing loss, otorrhea and otalgia. Cholesteatoma appeared in 10 patients (66.7%, 10/15) with aural stenosis and six patients (66.7%, 6/9) with aural atresia. After surgery intervention, the air-bone gaps (ABG) in both stenosis and atresia group significantly improved. Restenosis was observed in two patients (8.3%, 2/24) with aural stenosis. The etiologies of them were congenital and acquired, respectively. Tympanic membrane (TM) lateralization occurred in one patient (4.2%, 1/24) with aural atresia. Intralesional injection of triamcinolone acetonide was performed in two patients. One received injection three times and obtained a satisfying outcome. However, the other one failed to continue this treatment and restenosis occurred. Conclusion Surgical intervention is a gold standard for symptomatic aural stenosis and aural atresia. To achieve a promising outcome, a plastic sheet with expansive sponge was helpful to support the new EAC and a regular follow-up was mandatory. When a restenosis tendency occurred, intralesional injection of triamcinolone acetonide might benefit to improve it. aural atresia aural stenosis restenosis expansive sponge intralesional injection of triamcinolone acetonide Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Aural atresia and stenosis are uncommon diseases, and the etiologies mainly include congenital and acquired. Congenital abnormalities occur independently or coexist with microtia, first branchial cleft abnormalities and other syndromes ( 1 , 2 ). The congenital aural stenosis (CAS) is defined as an external auditory canal (EAC) diameter is or less than 4 mm by Cole and Jahrsdoerfer ( 3 ). The incidence of CAS and congenital aural atresia (CAA) is one in 10,000 to 20,000 ( 4 ). Acquired conditions are frequently caused by recurrent infections, trauma, surgery and tumor of the EAC. Both aural atresia and stenosis may trap epithelial cells and potentially carriers a great risk of developing cholesteatoma ( 5 ). Chan’s systematic review reported that the incidence of cholesteatoma is 43.0% in CAS and 1.7% in CAA ( 5 ). Close follow-up is commonly recommended to asymptomatic patients, such as the CAS patients with EAC diameter ≥ 2mm ( 3 ) However, for symptomatic aural atresia and stenosis, especially for patients with cholesteatoma, most studies agreed with prompt surgery ( 6 , 7 ). Surgical procedure is the only curative standard for symptomatic aural atresia and stenosis. Surgical purposes are to prevent complications and restore function. Not a few otologic pioneers had modified strategies since Paparella and Kurkjian first introduced surgical technique ( 8 – 11 ). The surgical techniques usually refer to how to prevent restenosis and manage middle ear abnormalities ( 2 , 12 – 14 ). The meatoplasty and canalplasty are the main surgical methods to obtain a widen EAC ( 15 ). Additionally, postoperative care also serves to prevent early-stage restenosis. After these intraoperative and postoperative interventions, a high rate of postoperative recurrence is still reported ranging from 9–36% ( 5 , 6 , 8 ). A potential pathology for restenosis is fibroproliferative inflammatory response ( 16 ). Given it, the intralesional injection of triamcinolone acetonide is clinically available to treat this response and pathological scars ( 17 , 18 ). Hence, this study aims to analyze the clinic features of symptomatic aural atresia and stenosis, twenty-four patients who followed over one year were included. Secondly, a plastic sheet with expansive sponge using as support material is introduced. Thirdly, injection of triamcinolone acetonide was applied to treat a tendency of restenosis. Additionally, three representative cases of them are presented. Based on these above, we hope our experiences contribute to the treatment for aural atresia and stenosis. Materials and methods Patients Twenty-four patients who received surgery due to aural atresia or stenosis between May 2015 and May 2022 in the Department of Otorhinolaryngology were included in this retrospective study. Congenital or acquired etiologies were analyzed. High-resolution computed tomography (HRCT) of temporal bone and pure tone audiometry (PTA) were preoperatively performed. Patients’ information was collected, including age, gender, etiologies, symptoms, illness course and surgical ear, with or without cholesteatoma and surgical methods. This research was approved by the Medical Ethics Committee (No. KY20232313-C-1). For three cases present in this study, verbal informed consents were obtained from these three patients’ or their parents. Surgical technique All operations were performed under general anesthesia using endaural or retroauricular incision. The option of surgical approach was based on HRCT examination, hearing evaluation and endoscopic otoscopy. The main surgical techniques included canaloplasty of EAC and wide meatoplasty. Fibrous tissue and cholesteatoma were carefully removed, the EAC skin was preserved as much as possible. Zhang’s modified meatoplasty was adopted in this study [9, 19]. The EAC diameter was widened to 12-15mm and conchal flap was used for EAC reconstruction. A split-thickness scalp flap was transported to cover the rest skin defect. When necessary, tympanoplasty, epitympanoplasty and canal wall-down tympanoplasty were performed. Then, the new EAC with grafts was inserted with a plastic sheet and a trimmed expansive sponge (Medtronic, USA) soaked with dexamethasone. Then, petrolatum gauze was covered to the donor region and fixed on local scalp with suture. Finally, pressure bandage was conducted for retroauricular incision. Postoperative care After 48 hours, pressure bandage was dismantled and ototopical drops was applied once a day. Regular follow-up was mandatory. After two weeks, petrolatum gauze in the donor skin region was relieved. After three weeks, the expansive sponge and plastic sheet were removed and EAC was cleaned. Then, a new expansive sponge was trimmed to place into the EAC. It was soaked with dexamethasone and exchanged every 1–2 weeks. The ototopical drops proceed regularly. This outpatient follow-up was maintained for the first three months. If there was a tendency to restenosis, triamcinolone acetonide was injected into the local skin. Then, the EAC was filled with expansive sponge again. Cleaning and injection of triamcinolone acetonide were performed depending on the debris accumulation and restenosis tendency. Water contact was avoided, and follow-up frequency was lowered until EAC was well-epithelized and stable. All of patients were followed at least one year. Outcome assessment and statistical analysis The otoscopy and PTA tests were performed preoperatively and postoperatively. The PTA was tested three months after surgery, then it repeated every six months regularly. The last postoperative PTA was recorded as the hearing outcomes. The preoperative and postoperative audiometric levels were evaluated by PTA at 0.5, 1, 2, and 4 kHz. The air-bone gaps (ABG) value was calculated as the average difference between the air and bone conduction thresholds at these four frequencies. The ABG gain was calculated as the preoperative ABG minus the postoperative ABG. Statistical analyses were performed using SPSS 20.0 software (SPSS Inc., Chicago, IL). Paired t-test was used to test the difference between preoperative and postoperative audiometric levels. And a p-value of<0.05 was considered statistically significant. Results Clinical Characteristics Six (25%, 6/24) of 24 patients with aural atresia or stenosis were female, the mean age and disease course were 26.0 ± 20.0 years and 31.0 ± 43.7 months, respectively. The main reason for aural stenosis was congenital abnormalities (53.3%, 8/15) and the major cause for aural atresia was trauma (33.3%, 3/9). The common symptoms of aural atresia or stenosis were hearing loss, otorrhea and otalgia. Nine patients (37.5%, 9/24) had a history of auricular surgery. Cholesteatoma appeared in 10 patients (66.7%, 10/15) with aural stenosis and six patients (66.7%, 6/9) with aural atresia. Wide meatoplasty or canaloplasty of EAC can resolve issues of eight patients (33.3%, 8/24). However, other surgical procedures, including epitympanoplasty, canal wall-down tympanoplasty, and tympanoplasty were required for most patients. The mean time to follow-up was 37.8 ± 10.0 months (Table 1 ). Table 1 Characteristics of 24 patients of aural atresia or stenosis Case Sex/age (year) /side Stenosis/ atresia Etiologies Complaints Course (month) Cholesteatoma Auricular surgery history Surgical methods Follow-up (month) Complications 1 M/58/R Stenosis Congenital + FBCAs Otorrhea, otalgia 4 No No C 12 No 2 F/5.9/R Stenosis Congenital HL, otorrhea 24 Yes No C + T + SG 36 No 3 M/16/R Stenosis Congenital HL, otorrhea 2 No No WM 57 No 4 M/7/L Stenosis Congenital HL, otorrhea 48 Yes No WM + E 33 No 5 M/14/R Stenosis Congenital microtia Otorrhea 2 Yes Yes WM + E + OCR 33 No 6 F/5.4/R Stenosis Congenital microtia HL, otorrhea 2 No Yes WM + T + SG 60 Restenosis 7 M/19/L Stenosis Congenital microtia HL, otorrhea 1 Yes Yes WM + SG 35 No 8 M/12/L Stenosis Congenital microtia Otorrhea 1 Yes No WM + E + SG 60 No 9 M/26/R Stenosis Osteoma Otorrhea 3 No No C 12 No 10 F/24/L Stenosis Osteoma HL 6 Yes No C 57 No 11 M/9/R Stenosis Osteoma Otorrhea 1 Yes No C 72 No 12 M/20/L Stenosis FD HL, otalgia 72 Yes Yes C + SG 12 No 13 M/50/L Stenosis Trauma HL 24 No Yes WM + SG 40 No 14 M/53/L Stenosis Trauma HL 120 Yes Yes WM 23 Restenosis 15 M/11/R Stenosis Surgery HL 5 Yes Yes CWDT + OCR 52 No 16 M/18/R Atresia Congenital HL, otorrhea 120 Yes No WM + T + SG 21 No 17 M/9/L Atresia Congenital microtia Otorrhea 36 Yes No WM + SG 41 No 18 M/23/R Atresia FD HL, otorrhea 48 Yes Yes C + E + OCR 34 No 19 M/11/L Atresia Trauma HL 1 No No C + OCR 23 TM lateralization 20 F/73/L Atresia Trauma HL 2 No No C 34 No 21 M/49/L Atresia Trauma HL 3 No No WM + SG 26 No 22 F/20/L Atresia Inflammation HL, otorrhea 144 Yes No C + T + SG 59 No 23 F/63/R Atresia Inflammation HL, otorrhea 72 Yes No C 30 No 24 M/19/R Atresia Surgery HL, otorrhea 5 Yes Yes WM + T + SG 45 No M, male; F, female; FBCAs, first branchial cleft anomalies; HL, hearing loss; FD, fibrous dysplasia; C, canalplasty of the EAC; T, tympanoplasty; SG, skin graft; WM, wide meatoplasty; E, epitympanoplasty; OCR, ossicular chain reconstruction; CWDT, canal wall-down tympanoplasty; TM, tympanic membrane. Postoperative outcomes Restenosis occurred in two (8.3%, 2/24) patients, No.6 and No.14. The No.14 patient underwent surgery again in our hospital and recovered well. The ABG of No.6 patient did not close significantly but otorrhea was disappeared. Tympanic membrane (TM) lateralization was observed in one (4.2%, 1/24) patient. Intralesional injection of triamcinolone acetonide was performed in two patients (No.14 and No.15). No.14 received twice injection and then failed to continue this treatment due to the coronavirus disease 2019 (COVID-19). No.15 patient repeated it three times and there was no restenosis for a long term. The hearing levels of two patients (No.1 and No. 9) did not decrease preoperatively and postoperatively. Hence, hearing outcomes of 22 patients were analyzed. As shown in Fig. 1 , the average of preoperative ABG in stenosis and atresia group were 45.91 ± 14.50 dB and 47.50 ± 6.07 dB, respectively. After surgery intervention, the average ABG in stenosis and atresia group were 21.14 ± 23.18 dB and 18.89 ± 15.89 dB. The hearing improvement in these two groups were significantly different ( p < 0.05). There was no postoperative cholesteatoma reoccurred or occurred. None of these patients showed facial nerve facial paralysis or hearing deterioration. Case Series Case 1 (No. 5). A 14-year-old boy who complained otorrhea for two months was referred from orthopedic surgery. He was born with right microtia and had done auricle reconstruction three years ago. After preoperative examinations (Fig. 2 A-C), a diagnosis of aural stenosis was made and surgery was suggested. An endaural incision was designed, the EAC was drilled to 12–15 mm and the epitympanoplasty was commenced. A fused malleus-incus and residual stapes-foot were observed (Fig. 2 D). A shaped conchal cartilage was placed on the stapes footplate. Myringoplasty was built by conchal flap combing temporalis muscle fascia. A split-thickness scalp flap was transported to cover the new EAC in a tube. It was supported by a plastic sheet and expansive sponge. Postoperative care and follow-up completed as previous introduced. A widen and well epithelialized EAC was achieved and hearing significantly increased (Fig. 2 E-H, 33 months after surgery). Case 2 (No. 12). A 20-year-old man visited outpatient for hearing loss and otalgia. He had a surgical history of fibrous dysplasia (FD). The relevant tests (Fig. 3 A-C) were carried out and he was diagnosed with aural stenosis caused by FD. The wide meatoplasty and skin graft were performed. The new EAC treatment and follow-up proceeded as scheduled. The expansive sponge was renewed postoperatively every two weeks until six months. Then, he visited outpatient every three months. The hearing was notably increased, and no restenosis occurred (Fig. 3 D-E). Secretory otitis media (Fig. 3 E) developed one year after surgery due to the fibrosis of nasal bone blocked the eustachian tube. The hearing loss recovered after effusion was extracted (Fig. 3 F). Case 3 (No. 15). A 11-year-old boy had done surgery for middle ear cholesteatoma two years ago in local hospital. One year later, he was diagnosed with aural atresia. Surgery was recommended and he was referred to our department. Otoscope, hearing test and HRCT were conducted preoperatively (Fig. 4 A-C). During surgery, the whole fibrotic plug was removed and the EAC was widened. Mastoid air cells and ossicular chain were partly invaded by cholesteatoma. After cholesteatoma was eradicated, partial ossicular replacement prosthesis (PORP) was implanted. The conchal flap combing temporalis muscle fascia was used for myringoplasty. Routine postoperative care and follow-up was conducted. However, this patient featured with scar diathesis. Cicatrix tissue postopreatively formed in cartilaginous part of EAC and retroauricular incision. Triamcinolone acetonide was injected into the local skin and it was performed once every 2–3 weeks. This injection was operated three times and then the EAC was stable at six months after surgery. The follow-up was over 52 months and there was no restenosis and the hearing level remarkably improved (Fig. 4 D-E). Discussion The congenital aural stenosis or aural atresia is usually unilateral, with a prone to affect males and right ear ( 20 ). Some studies also reported that right ear and males was also likely involved in acquired aural stenosis or aural atresia ( 21 , 22 ). Similarly, in this study, major subjects (75%, 18/24) were male. But there was no predilection for the right ear (50%, 12/24). The issues relate to aural stenosis or aural atresia are hearing loss and EAC cholesteatoma. For bilateral CAA, rehabilitation of audiologic function is pressing to prevent delays in speech and learning development. But for unilateral patients scoring higher than 6 of Jahrsdoerfer’s classification, surgery should be commenced at the age of 6–7 years ( 3 , 23 ). Cole and Jahrsdoerfer considered CAS with a diameter of 2 mm or less should perform surgery for a high risk of developing cholesteatoma ( 3 ). They also advocated surgery could be delayed to patients aged 6–12 years for the slow-growing of pediatric cholesteatoma ( 3 ). In this study, two patients under six years had done surgery and restenosis occurred in one of them. It may attribute this child was not old enough to comply with postoperative care ( 3 , 5 ). Thereby, for those younger patients, the lesion extent should be considered, and adequate communication is necessary before surgery. We also recommended a close surveillance to congenital case without cholesteatoma or clinic symptoms and proposed surgical intervention for symptomatic patient. In this study, trauma made a large proportion of acquired aural stenosis and aural atresia while inflammation was the main cause for some studies ( 24 , 25 ). Hence, the EAC should treated at the meanwhile when managing related trauma. Chronic inflammation should get timely adequate treatment. A study analyzing 68 patients (70 ears) with acquired aural stenosis or aural atresia, which found the interval from trauma to cholesteatoma formation varied one month to 30 years. Thereby, it recommended early surgery for aural atresia and aural stenosis of 1mm once general and auricula condition was stable ( 21 ). Surgery may also lead to aural stenosis and aural atresia. It is very critical to protect local skin of EAC during surgery and to manage postoperative infection. Two CAS patients (No.5 and No.7) had a history of reconstructive surgery for congenital microtia. Acute inflammation and scar formation may aggravate stenosis or trap epithelial cells, which would increase the cholesteatoma incidence. Hence, for a positive outcome of reconstructive surgery, fully preoperative assessment and cohesive corporation between auricular reconstructive surgeon and otologist are imperative. Additionally, benign tumors of the EAC also account for acquired aural stenosis and aural atresia. FD is a rare and progressive skeletal disorder ( 7 , 26 ). It may present at any age, but patients aged less than 30 years are mostly affected. Aural atresia or aural stenosis may arise from the FD of the temporal bone, though it is uncommon. For patients without complications, such as cholesteatoma, peripheral facial paralysis and malignancy, most studies advocated conservative treatment and disapproved radiotherapy ( 7 , 27 ). The FD growth is relative active for adolescence, surgical intervention is preferred for patients when they are adulthood. In this study, two adulthoods with FD achieved promising outcomes. Not a few studies focused on surgical techniques to optimize outcomes ( 1 , 9 , 25 ). Zhang introduced an endaural-conchal incision, which fully utilize local rotation flaps and a transposition split-thick-ness scalp flap to widen and reconstruct EAC ( 9 ). A retroauricular incision is necessary for managing extensive cholesteatoma. Most studies advocated that complete removal of the fibrotic plug and diseased skin with a widen EAC to reduce restenosis ( 24 , 25 , 28 ). In this study, all fibrotic plugs were resected meticulously, the EAC was drilled to 12–15 mm as well as the tympanum was totally visible as Zhang described ( 19 ). All otologists agree with that the bare areas of new EAC should be covered with grafting skin. Although this procedure performs routinely, postoperative stenosis develops frequently. It may attribute to the grafting skin lacks of ceruminous and sebaceous glands, leading to the new EAC is short of the self-purification and anti-infection function. And Zhang also reported that restenosis rate in aural atresia was higher in aural stenosis due to the latter retained some EAC skin ( 6 ). Even more, he proposed using the EAC skin graft of the healthy side to treat unilateral CAA to prevent restenosis rate ( 29 ). In our daily work, the EAC skin was preserved as possible because the inflammatory skin commonly recovered after removing local lesions. A plastic sheet was used to cover the reconstructed EAC skin in this study. It was easy to harvest and shape comparing with silicone sheet. It also prevents probable adhesion between support materials and the new EAC. Many stenting materials have been used for stretching EAC, including ribbon gauge and some devices ( 6 , 30 ). In our practice, expansive sponge is used to support the new EAC. The strengths list as, 1) it could be trimmed into different shapes and sizes, which will support the whole EAC, 2) it is water expansion and will produce pressure to the EAC, which also could anti-restenosis, 3) ototopical antibiotic/steroid drops could arrive at EAC through it, which will inhibit inflammatory response and scar formation, 4) the cost is moderate and available. The expansive sponge replacement and ear cleaning commenced every 1–2 weeks. Stenting time varied from one week to six months in different studies ( 9 , 25 ). A regular stenting time for three months was required in our practice. However, it may extend according to individuals and even have to sustain about two years occasionally to achieve a stable EAC. These above managements usually attained a favorable outcome for preventing early-stage restenosis, such as case 1 (No.5) and case 2 (No.12). However, stenotic tendency postoperatively occurred in two patients (No.15 and No.14) 3–4 months. The possible reasons for restenosis may attribute to the fibroproliferative inflammatory response and hyperplasia scar. Hence, intralesional injection of triamcinolone acetonide was adopted to address this concern. Given its low recrudescence rate and non-invasive feature, injection of triamcinolone acetonide is the most universal and effective treatment for pathological scars ( 18 ). It was also used to prevent postoperative stenosis of EAC and a 73.3% satisfaction rate was obtained. 31 In this present study, case 3 (No.15) closely adhered to follow-up and repeated injection for three times. Although he was featured with scar diathesis, intralesional injection of triamcinolone acetonide for him was still effective. The No.14 patient did not completely conduct. There may raise a doubt about whether triamcinolone acetonide or long-term support play the crucial role to prevent restenosis. In our opinion, intralesional injection of triamcinolone acetonide was responsible for the success of case 3 (No.15), which needs large number cases to verify it. Lambert believed that a stable result achieved more than one year follow-up ( 32 ). In this study, all patients were followed more than one year. The restenosis rate was 8.3% and TM lateralization occurred in one patient (4.2%). The audiological outcome of these 22 patients significantly elevated after surgical intervention. These outcomes were comparable to most studies ( 7 , 24 , 33 ). Conclusion Surgical intervention is a gold standard for symptomatic aural stenosis and aural atresia. However, a high recurrence rate is still challenging otologists. It may relate to fibroproliferative inflammatory response and hyperplasia scar. To achieve a promising outcome, a plastic sheet with expansive sponge was described to support the new EAC and a regular follow-up was mandatory. When a tendency of restenosis occurred, intralesional injection of triamcinolone acetonide was proposed to improve it. Given the small scale of this study, we expect to collect more patients’ information and analyze the prognostic factors influencing postoperative outcomes. Abbreviations CAS congenital aural stenosis EAC external auditory canal CAA congenital aural atresia HRCT High-resolution computed tomography PTA pure tone audiometry ABG air-bone gaps TM tympanic membrane FD fibrous dysplasia PORP partial ossicular replacement prosthesis. Declarations Ethics approval and consent to participate This retrospective research was approved by the Medical Ethics Committee of the First Affiliated Hospital of the Air Force Medical University (KY20232313-C-1). The informed consent was obtained from three representative patients. Consent for publication Not applicable. Availability of data and materials The datasets are available from the corresponding author upon reasonable request. Competing interests The authors have no financial or nonfinancial interests to disclose. Funding This work was supported by grants from the National Natural Science Foundation of China (81870719), the Foundation of Shaanxi Province (2023-YBSF-209), Teaching Reform Research Project of Air Force Medical University (KJJYDXYB025), Xijing Hospital Promotion Project (XJZT21CM10). The funder was supported by Yu Han. Authors' contributions The study was designed by YH, and all of the operations were conducted by him. RY and YZ collected data and wrote this manuscript. MD, RL and CD performed the statistical analysis and participated in the patient follow-up. Some suggestions were provided by DZ and the revision work was conducted by him. All authors performed data interpretation and approved the manuscript. Acknowledgments Not applicable References Farhood Z, Muus JS, Chang DK, Edmonds JL. Case series: A novel technique for the treatment of external auditory canal stenosis. 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Li Z, Raynald, Wang Z, Qian H. Malignant transformation of craniofacial fibrous dysplasia: a systematic review of overall survival. Neurosurg Rev Jun. 2020;43(3):911–21. 10.1007/s10143-019-01089-1 . Paparella MM. Surgical treatment of intractable external otitis. Laryngoscope Jun. 1966;76(6):1136–47. 10.1288/00005537-196606000-00013 . Li CL, Xie YZ, Zhu YY, Fu YY, Zhang TY. Using the external auditory canal skin graft of the healthy side to treat unilateral congenital aural atresia: preliminary results of clinical research. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi Mar. 2022;7(3):338–44. 10.3760/cma.j.cn115330-20211117-00744 . Tirelli G, Nicastro L, Gatto A, Boscolo Nata F. Stretching stenoses of the external auditory canal: a report of four cases and brief review of the literature. Acta Otorhinolaryngol Ital Feb. 2015;35(1):34–8. Chen Ying XIEYZ. Therapeutic effect of local triamcinolone acetonide injection on external auditory canal stenosis induced by scar hyperplasia. Chin J Ophthalmol and Otorhinolaryngol. 2022;22(4):363–5. 10.14166/j.issn.1671-2420.2022.04.009 . Lambert PR. Congenital aural atresia: stability of surgical results. Laryngoscope Dec. 1998;108(12):1801–5. 10.1097/00005537-199812000-00007 . Droessaert V, Vanspauwen R, Offeciers E, Zarowski A, Dinther JV, Somers T. Surgical Treatment of Acquired Atresia of the External Auditory Ear Canal. Int Arch Otorhinolaryngol Oct. 2017;21(4):343–6. 10.1055/s-0037-1598604 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3810213","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264566919,"identity":"c42d5768-f611-4f95-aa4b-6d9a6f3914c5","order_by":0,"name":"Runqin Yang","email":"","orcid":"","institution":"Xijing Hospital, Air Force Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Runqin","middleName":"","lastName":"Yang","suffix":""},{"id":264566920,"identity":"751293a5-60b0-4509-9b88-ca9e48c93134","order_by":1,"name":"Yu Zhao","email":"","orcid":"","institution":"Xi'an Children's Hospital, Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhao","suffix":""},{"id":264566921,"identity":"64ba386c-10e5-498e-9351-5c0e41aebcab","order_by":2,"name":"Miaomiao Du","email":"","orcid":"","institution":"Ansai District People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miaomiao","middleName":"","lastName":"Du","suffix":""},{"id":264566922,"identity":"7b8c9cdf-3e40-4a41-9dea-00f298051a3d","order_by":3,"name":"Rui Li","email":"","orcid":"","institution":"Xijing Hospital, Air Force Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Li","suffix":""},{"id":264566923,"identity":"90e26dd7-ae42-495f-9e62-acbab96ed144","order_by":4,"name":"Chen Dong","email":"","orcid":"","institution":"Xijing Hospital, Air Force Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Dong","suffix":""},{"id":264566924,"identity":"c0495812-c764-47c8-a9fb-7f0ae4c44d53","order_by":5,"name":"Dingjun Zha","email":"","orcid":"","institution":"Xijing Hospital, Air Force Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dingjun","middleName":"","lastName":"Zha","suffix":""},{"id":264566925,"identity":"7e0dce93-806e-49fb-b959-5ecbff5678b6","order_by":6,"name":"Yu Han","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYBACAwYexsMMPDY8/OwNxGthAGpJk5HsOUCSFobDNgY3HIjUYi6Re+Bwgcx5HoYbDIwfPuYQocVyRl7C4Rk8t3kYZzcwS87cRozDbuQYHOYBamGWOcDGzEuClnM8bBIJpGk5wMNDvJYzb0BaknkkeA42E+mX4zmGj3l77Oztjzcf/PCRGC0MAgkMDIw9IBZjAzHqgYD/AJD4QaTiUTAKRsEoGJkAADU2NZdzy4HUAAAAAElFTkSuQmCC","orcid":"","institution":"Xijing Hospital, Air Force Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yu","middleName":"","lastName":"Han","suffix":""}],"badges":[],"createdAt":"2023-12-27 02:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3810213/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3810213/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49125675,"identity":"86a20b8d-23d0-468a-bc25-9c8e588b5629","added_by":"auto","created_at":"2024-01-03 14:50:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22329,"visible":true,"origin":"","legend":"\u003cp\u003eComparison in preoperative and postoperative air-bone gaps (ABG). After surgical intervention, ABG value significantly gained in aural stenosis and aural atresia group (*\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-3810213/v1/ae5a9ab50482b411756578b4.png"},{"id":49125674,"identity":"c711a5df-59d6-42fe-bf1a-ba723f9c7f39","added_by":"auto","created_at":"2024-01-03 14:50:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":859274,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative, intraoperative postoperative situation of case 1 (No.15), right ear. A-C, Preoperative situation; D, Intraoperative tympanum observation (white arrow, stapes footplate; dark arrow, chorda tympani nerve); E-H, Postoperative situation.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-3810213/v1/b4b39566d4ea72b72b6cf5e3.png"},{"id":49125673,"identity":"52dabaf4-b642-4fdb-a092-85de02645957","added_by":"auto","created_at":"2024-01-03 14:50:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":549289,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and postoperative examinations of case 2 (No.12), left ear. A-C, Preoperative examinations; D-F, Postoperative examinations.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-3810213/v1/b3abb6211d554d671bfeee16.png"},{"id":49125676,"identity":"ef151004-399d-4d10-a6eb-907953a183df","added_by":"auto","created_at":"2024-01-03 14:50:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":621329,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperativeand postoperative examinations of case 3 (No.5), right ear. A-C, Preoperative presentations; D-F, Postoperative presentation.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-3810213/v1/ccc7431691cc67386d7c3ced.png"},{"id":53681138,"identity":"4455a7e4-548f-4b7f-897f-36c75264044e","added_by":"auto","created_at":"2024-03-28 20:29:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3248073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3810213/v1/39f60198-c2c6-4070-bc06-6cb2a1b499ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term Outcomes of Surgical Intervention for Symptomatic Aural Atresia and Stenosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAural atresia and stenosis are uncommon diseases, and the etiologies mainly include congenital and acquired. Congenital abnormalities occur independently or coexist with microtia, first branchial cleft abnormalities and other syndromes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The congenital aural stenosis (CAS) is defined as an external auditory canal (EAC) diameter is or less than 4 mm by Cole and Jahrsdoerfer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The incidence of CAS and congenital aural atresia (CAA) is one in 10,000 to 20,000 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Acquired conditions are frequently caused by recurrent infections, trauma, surgery and tumor of the EAC. Both aural atresia and stenosis may trap epithelial cells and potentially carriers a great risk of developing cholesteatoma (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Chan\u0026rsquo;s systematic review reported that the incidence of cholesteatoma is 43.0% in CAS and 1.7% in CAA (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Close follow-up is commonly recommended to asymptomatic patients, such as the CAS patients with EAC diameter\u0026thinsp;\u0026ge;\u0026thinsp;2mm (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) However, for symptomatic aural atresia and stenosis, especially for patients with cholesteatoma, most studies agreed with prompt surgery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical procedure is the only curative standard for symptomatic aural atresia and stenosis. Surgical purposes are to prevent complications and restore function. Not a few otologic pioneers had modified strategies since Paparella and Kurkjian first introduced surgical technique (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The surgical techniques usually refer to how to prevent restenosis and manage middle ear abnormalities (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The meatoplasty and canalplasty are the main surgical methods to obtain a widen EAC (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Additionally, postoperative care also serves to prevent early-stage restenosis. After these intraoperative and postoperative interventions, a high rate of postoperative recurrence is still reported ranging from 9\u0026ndash;36% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A potential pathology for restenosis is fibroproliferative inflammatory response (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Given it, the intralesional injection of triamcinolone acetonide is clinically available to treat this response and pathological scars (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHence, this study aims to analyze the clinic features of symptomatic aural atresia and stenosis, twenty-four patients who followed over one year were included. Secondly, a plastic sheet with expansive sponge using as support material is introduced. Thirdly, injection of triamcinolone acetonide was applied to treat a tendency of restenosis. Additionally, three representative cases of them are presented. Based on these above, we hope our experiences contribute to the treatment for aural atresia and stenosis.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eTwenty-four patients who received surgery due to aural atresia or stenosis between May 2015 and May 2022 in the Department of Otorhinolaryngology were included in this retrospective study. Congenital or acquired etiologies were analyzed. High-resolution computed tomography (HRCT) of temporal bone and pure tone audiometry (PTA) were preoperatively performed. Patients\u0026rsquo; information was collected, including age, gender, etiologies, symptoms, illness course and surgical ear, with or without cholesteatoma and surgical methods. This research was approved by the Medical Ethics Committee (No. KY20232313-C-1). For three cases present in this study, verbal informed consents were obtained from these three patients\u0026rsquo; or their parents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eAll operations were performed under general anesthesia using endaural or retroauricular incision. The option of surgical approach was based on HRCT examination, hearing evaluation and endoscopic otoscopy. The main surgical techniques included canaloplasty of EAC and wide meatoplasty. Fibrous tissue and cholesteatoma were carefully removed, the EAC skin was preserved as much as possible. Zhang\u0026rsquo;s modified meatoplasty was adopted in this study [9, 19]. The EAC diameter was widened to 12-15mm and conchal flap was used for EAC reconstruction. A split-thickness scalp flap was transported to cover the rest skin defect. When necessary, tympanoplasty, epitympanoplasty and canal wall-down tympanoplasty were performed. Then, the new EAC with grafts was inserted with a plastic sheet and a trimmed expansive sponge (Medtronic, USA) soaked with dexamethasone. Then, petrolatum gauze was covered to the donor region and fixed on local scalp with suture. Finally, pressure bandage was conducted for retroauricular incision.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative care\u003c/h2\u003e \u003cp\u003eAfter 48 hours, pressure bandage was dismantled and ototopical drops was applied once a day. Regular follow-up was mandatory. After two weeks, petrolatum gauze in the donor skin region was relieved. After three weeks, the expansive sponge and plastic sheet were removed and EAC was cleaned. Then, a new expansive sponge was trimmed to place into the EAC. It was soaked with dexamethasone and exchanged every 1\u0026ndash;2 weeks. The ototopical drops proceed regularly. This outpatient follow-up was maintained for the first three months. If there was a tendency to restenosis, triamcinolone acetonide was injected into the local skin. Then, the EAC was filled with expansive sponge again. Cleaning and injection of triamcinolone acetonide were performed depending on the debris accumulation and restenosis tendency. Water contact was avoided, and follow-up frequency was lowered until EAC was well-epithelized and stable. All of patients were followed at least one year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome assessment and statistical analysis\u003c/h2\u003e \u003cp\u003eThe otoscopy and PTA tests were performed preoperatively and postoperatively. The PTA was tested three months after surgery, then it repeated every six months regularly. The last postoperative PTA was recorded as the hearing outcomes. The preoperative and postoperative audiometric levels were evaluated by PTA at 0.5, 1, 2, and 4 kHz. The air-bone gaps (ABG) value was calculated as the average difference between the air and bone conduction thresholds at these four frequencies. The ABG gain was calculated as the preoperative ABG minus the postoperative ABG. Statistical analyses were performed using SPSS 20.0 software (SPSS Inc., Chicago, IL). Paired t-test was used to test the difference between preoperative and postoperative audiometric levels. And a p-value of\u003c0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical Characteristics\u003c/h2\u003e \u003cp\u003eSix (25%, 6/24) of 24 patients with aural atresia or stenosis were female, the mean age and disease course were 26.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.0 years and 31.0\u0026thinsp;\u0026plusmn;\u0026thinsp;43.7 months, respectively. The main reason for aural stenosis was congenital abnormalities (53.3%, 8/15) and the major cause for aural atresia was trauma (33.3%, 3/9). The common symptoms of aural atresia or stenosis were hearing loss, otorrhea and otalgia. Nine patients (37.5%, 9/24) had a history of auricular surgery. Cholesteatoma appeared in 10 patients (66.7%, 10/15) with aural stenosis and six patients (66.7%, 6/9) with aural atresia. Wide meatoplasty or canaloplasty of EAC can resolve issues of eight patients (33.3%, 8/24). However, other surgical procedures, including epitympanoplasty, canal wall-down tympanoplasty, and tympanoplasty were required for most patients. The mean time to follow-up was 37.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 months (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of 24 patients of aural atresia or stenosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex/age (year) /side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis/\u003c/p\u003e \u003cp\u003eatresia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEtiologies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComplaints\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCourse\u003c/p\u003e \u003cp\u003e(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCholesteatoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAuricular surgery history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSurgical methods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003e(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/58/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital\u0026thinsp;+\u0026thinsp;FBCAs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea, otalgia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/5.9/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u0026thinsp;+\u0026thinsp;T\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/16/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/7/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/14/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital microtia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;E\u0026thinsp;+\u0026thinsp;OCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/5.4/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital microtia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;T\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRestenosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/19/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital microtia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/12/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital microtia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;E\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/26/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/24/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/9/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/20/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otalgia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/50/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/53/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRestenosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/11/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCWDT\u0026thinsp;+\u0026thinsp;OCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/18/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;T\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/9/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital microtia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOtorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/23/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u0026thinsp;+\u0026thinsp;E\u0026thinsp;+\u0026thinsp;OCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/11/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u0026thinsp;+\u0026thinsp;OCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eTM lateralization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/73/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/49/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/20/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u0026thinsp;+\u0026thinsp;T\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/63/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/19/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAtresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHL, otorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWM\u0026thinsp;+\u0026thinsp;T\u0026thinsp;+\u0026thinsp;SG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eM, male; F, female; FBCAs, first branchial cleft anomalies; HL, hearing loss; FD, fibrous dysplasia; C, canalplasty of the EAC; T, tympanoplasty; SG, skin graft;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eWM, wide meatoplasty; E, epitympanoplasty; OCR, ossicular chain reconstruction; CWDT, canal wall-down tympanoplasty; TM, tympanic membrane.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes\u003c/h2\u003e \u003cp\u003eRestenosis occurred in two (8.3%, 2/24) patients, No.6 and No.14. The No.14 patient underwent surgery again in our hospital and recovered well. The ABG of No.6 patient did not close significantly but otorrhea was disappeared. Tympanic membrane (TM) lateralization was observed in one (4.2%, 1/24) patient. Intralesional injection of triamcinolone acetonide was performed in two patients (No.14 and No.15). No.14 received twice injection and then failed to continue this treatment due to the coronavirus disease 2019 (COVID-19). No.15 patient repeated it three times and there was no restenosis for a long term.\u003c/p\u003e \u003cp\u003eThe hearing levels of two patients (No.1 and No. 9) did not decrease preoperatively and postoperatively. Hence, hearing outcomes of 22 patients were analyzed. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the average of preoperative ABG in stenosis and atresia group were 45.91\u0026thinsp;\u0026plusmn;\u0026thinsp;14.50 dB and 47.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.07 dB, respectively. After surgery intervention, the average ABG in stenosis and atresia group were 21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;23.18 dB and 18.89\u0026thinsp;\u0026plusmn;\u0026thinsp;15.89 dB. The hearing improvement in these two groups were significantly different (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no postoperative cholesteatoma reoccurred or occurred. None of these patients showed facial nerve facial paralysis or hearing deterioration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCase Series\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003cp\u003e \u003cb\u003e(No. 5).\u003c/b\u003e A 14-year-old boy who complained otorrhea for two months was referred from orthopedic surgery. He was born with right microtia and had done auricle reconstruction three years ago. After preoperative examinations (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-C), a diagnosis of aural stenosis was made and surgery was suggested. An endaural incision was designed, the EAC was drilled to 12\u0026ndash;15 mm and the epitympanoplasty was commenced. A fused malleus-incus and residual stapes-foot were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). A shaped conchal cartilage was placed on the stapes footplate. Myringoplasty was built by conchal flap combing temporalis muscle fascia. A split-thickness scalp flap was transported to cover the new EAC in a tube. It was supported by a plastic sheet and expansive sponge. Postoperative care and follow-up completed as previous introduced. A widen and well epithelialized EAC was achieved and hearing significantly increased (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE-H, 33 months after surgery).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003e \u003cb\u003e(No. 12).\u003c/b\u003e A 20-year-old man visited outpatient for hearing loss and otalgia. He had a surgical history of fibrous dysplasia (FD). The relevant tests (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-C) were carried out and he was diagnosed with aural stenosis caused by FD. The wide meatoplasty and skin graft were performed. The new EAC treatment and follow-up proceeded as scheduled. The expansive sponge was renewed postoperatively every two weeks until six months. Then, he visited outpatient every three months. The hearing was notably increased, and no restenosis occurred (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD-E). Secretory otitis media (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE) developed one year after surgery due to the fibrosis of nasal bone blocked the eustachian tube. The hearing loss recovered after effusion was extracted (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 3\u003c/strong\u003e \u003cp\u003e \u003cb\u003e(No. 15).\u003c/b\u003e A 11-year-old boy had done surgery for middle ear cholesteatoma two years ago in local hospital. One year later, he was diagnosed with aural atresia. Surgery was recommended and he was referred to our department. Otoscope, hearing test and HRCT were conducted preoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA-C). During surgery, the whole fibrotic plug was removed and the EAC was widened. Mastoid air cells and ossicular chain were partly invaded by cholesteatoma. After cholesteatoma was eradicated, partial ossicular replacement prosthesis (PORP) was implanted. The conchal flap combing temporalis muscle fascia was used for myringoplasty. Routine postoperative care and follow-up was conducted. However, this patient featured with scar diathesis. Cicatrix tissue postopreatively formed in cartilaginous part of EAC and retroauricular incision. Triamcinolone acetonide was injected into the local skin and it was performed once every 2\u0026ndash;3 weeks. This injection was operated three times and then the EAC was stable at six months after surgery. The follow-up was over 52 months and there was no restenosis and the hearing level remarkably improved (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD-E).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe congenital aural stenosis or aural atresia is usually unilateral, with a prone to affect males and right ear (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Some studies also reported that right ear and males was also likely involved in acquired aural stenosis or aural atresia (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similarly, in this study, major subjects (75%, 18/24) were male. But there was no predilection for the right ear (50%, 12/24). The issues relate to aural stenosis or aural atresia are hearing loss and EAC cholesteatoma. For bilateral CAA, rehabilitation of audiologic function is pressing to prevent delays in speech and learning development. But for unilateral patients scoring higher than 6 of Jahrsdoerfer\u0026rsquo;s classification, surgery should be commenced at the age of 6\u0026ndash;7 years (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Cole and Jahrsdoerfer considered CAS with a diameter of 2 mm or less should perform surgery for a high risk of developing cholesteatoma (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). They also advocated surgery could be delayed to patients aged 6\u0026ndash;12 years for the slow-growing of pediatric cholesteatoma (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In this study, two patients under six years had done surgery and restenosis occurred in one of them. It may attribute this child was not old enough to comply with postoperative care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Thereby, for those younger patients, the lesion extent should be considered, and adequate communication is necessary before surgery. We also recommended a close surveillance to congenital case without cholesteatoma or clinic symptoms and proposed surgical intervention for symptomatic patient.\u003c/p\u003e \u003cp\u003eIn this study, trauma made a large proportion of acquired aural stenosis and aural atresia while inflammation was the main cause for some studies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Hence, the EAC should treated at the meanwhile when managing related trauma. Chronic inflammation should get timely adequate treatment. A study analyzing 68 patients (70 ears) with acquired aural stenosis or aural atresia, which found the interval from trauma to cholesteatoma formation varied one month to 30 years. Thereby, it recommended early surgery for aural atresia and aural stenosis of 1mm once general and auricula condition was stable (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Surgery may also lead to aural stenosis and aural atresia. It is very critical to protect local skin of EAC during surgery and to manage postoperative infection. Two CAS patients (No.5 and No.7) had a history of reconstructive surgery for congenital microtia. Acute inflammation and scar formation may aggravate stenosis or trap epithelial cells, which would increase the cholesteatoma incidence. Hence, for a positive outcome of reconstructive surgery, fully preoperative assessment and cohesive corporation between auricular reconstructive surgeon and otologist are imperative.\u003c/p\u003e \u003cp\u003eAdditionally, benign tumors of the EAC also account for acquired aural stenosis and aural atresia. FD is a rare and progressive skeletal disorder (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). It may present at any age, but patients aged less than 30 years are mostly affected. Aural atresia or aural stenosis may arise from the FD of the temporal bone, though it is uncommon. For patients without complications, such as cholesteatoma, peripheral facial paralysis and malignancy, most studies advocated conservative treatment and disapproved radiotherapy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The FD growth is relative active for adolescence, surgical intervention is preferred for patients when they are adulthood. In this study, two adulthoods with FD achieved promising outcomes.\u003c/p\u003e \u003cp\u003eNot a few studies focused on surgical techniques to optimize outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Zhang introduced an endaural-conchal incision, which fully utilize local rotation flaps and a transposition split-thick-ness scalp flap to widen and reconstruct EAC (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A retroauricular incision is necessary for managing extensive cholesteatoma. Most studies advocated that complete removal of the fibrotic plug and diseased skin with a widen EAC to reduce restenosis (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In this study, all fibrotic plugs were resected meticulously, the EAC was drilled to 12\u0026ndash;15 mm as well as the tympanum was totally visible as Zhang described (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). All otologists agree with that the bare areas of new EAC should be covered with grafting skin. Although this procedure performs routinely, postoperative stenosis develops frequently. It may attribute to the grafting skin lacks of ceruminous and sebaceous glands, leading to the new EAC is short of the self-purification and anti-infection function. And Zhang also reported that restenosis rate in aural atresia was higher in aural stenosis due to the latter retained some EAC skin (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Even more, he proposed using the EAC skin graft of the healthy side to treat unilateral CAA to prevent restenosis rate (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In our daily work, the EAC skin was preserved as possible because the inflammatory skin commonly recovered after removing local lesions.\u003c/p\u003e \u003cp\u003eA plastic sheet was used to cover the reconstructed EAC skin in this study. It was easy to harvest and shape comparing with silicone sheet. It also prevents probable adhesion between support materials and the new EAC. Many stenting materials have been used for stretching EAC, including ribbon gauge and some devices (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In our practice, expansive sponge is used to support the new EAC. The strengths list as, 1) it could be trimmed into different shapes and sizes, which will support the whole EAC, 2) it is water expansion and will produce pressure to the EAC, which also could anti-restenosis, 3) ototopical antibiotic/steroid drops could arrive at EAC through it, which will inhibit inflammatory response and scar formation, 4) the cost is moderate and available. The expansive sponge replacement and ear cleaning commenced every 1\u0026ndash;2 weeks. Stenting time varied from one week to six months in different studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A regular stenting time for three months was required in our practice. However, it may extend according to individuals and even have to sustain about two years occasionally to achieve a stable EAC.\u003c/p\u003e \u003cp\u003eThese above managements usually attained a favorable outcome for preventing early-stage restenosis, such as case \u003cspan refid=\"FPar1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (No.5) and case \u003cspan refid=\"FPar2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (No.12). However, stenotic tendency postoperatively occurred in two patients (No.15 and No.14) 3\u0026ndash;4 months. The possible reasons for restenosis may attribute to the fibroproliferative inflammatory response and hyperplasia scar. Hence, intralesional injection of triamcinolone acetonide was adopted to address this concern. Given its low recrudescence rate and non-invasive feature, injection of triamcinolone acetonide is the most universal and effective treatment for pathological scars (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). It was also used to prevent postoperative stenosis of EAC and a 73.3% satisfaction rate was obtained.\u003csup\u003e31\u003c/sup\u003e In this present study, case \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (No.15) closely adhered to follow-up and repeated injection for three times. Although he was featured with scar diathesis, intralesional injection of triamcinolone acetonide for him was still effective. The No.14 patient did not completely conduct. There may raise a doubt about whether triamcinolone acetonide or long-term support play the crucial role to prevent restenosis. In our opinion, intralesional injection of triamcinolone acetonide was responsible for the success of case \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (No.15), which needs large number cases to verify it.\u003c/p\u003e \u003cp\u003eLambert believed that a stable result achieved more than one year follow-up (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In this study, all patients were followed more than one year. The restenosis rate was 8.3% and TM lateralization occurred in one patient (4.2%). The audiological outcome of these 22 patients significantly elevated after surgical intervention. These outcomes were comparable to most studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgical intervention is a gold standard for symptomatic aural stenosis and aural atresia. However, a high recurrence rate is still challenging otologists. It may relate to fibroproliferative inflammatory response and hyperplasia scar. To achieve a promising outcome, a plastic sheet with expansive sponge was described to support the new EAC and a regular follow-up was mandatory. When a tendency of restenosis occurred, intralesional injection of triamcinolone acetonide was proposed to improve it. Given the small scale of this study, we expect to collect more patients\u0026rsquo; information and analyze the prognostic factors influencing postoperative outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econgenital aural stenosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eexternal auditory canal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econgenital aural atresia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHigh-resolution computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epure tone audiometry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eABG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eair-bone gaps\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etympanic membrane\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efibrous dysplasia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePORP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epartial ossicular replacement prosthesis.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective research was approved by the Medical Ethics Committee of the First Affiliated Hospital of the Air Force Medical University (KY20232313-C-1). The informed consent was obtained from three representative patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no financial or nonfinancial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the National Natural Science Foundation of China (81870719), the Foundation of Shaanxi Province (2023-YBSF-209), Teaching Reform Research Project of Air Force Medical University (KJJYDXYB025), Xijing Hospital Promotion Project (XJZT21CM10). The funder was supported by Yu Han.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was designed by YH, and all of the operations were conducted by him. RY and YZ collected data and\u0026nbsp;wrote this manuscript. MD, RL and CD\u0026nbsp;performed the statistical analysis\u0026nbsp;and participated in the patient follow-up. Some suggestions were provided by DZ and the revision work was conducted by him.\u0026nbsp;All authors performed data interpretation and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFarhood Z, Muus JS, Chang DK, Edmonds JL. Case series: A novel technique for the treatment of external auditory canal stenosis. 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Int Arch Otorhinolaryngol Oct. 2017;21(4):343\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0037-1598604\u003c/span\u003e\u003cspan address=\"10.1055/s-0037-1598604\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aural atresia, aural stenosis, restenosis, expansive sponge, intralesional injection of triamcinolone acetonide","lastPublishedDoi":"10.21203/rs.3.rs-3810213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3810213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aims to analyze the clinic features of symptomatic aural atresia and stenosis, and to explore the surgical techniques and postoperative care for aural atresia and stenosis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis on 24 patients with aural atresia (nine patients) or stenosis (15 patients) was conducted. They had done surgery and followed over one years. The basic information, etiologies, symptoms, with or without cholesteatoma were collected. For preventing postoperative restenosis, a plastic sheet with expansive sponge was commonly used as support material. And triamcinolone acetonide was locally injected when a stenotic tendency occurred. Additionally, three representative cases are presented.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe main symptoms were hearing loss, otorrhea and otalgia. Cholesteatoma appeared in 10 patients (66.7%, 10/15) with aural stenosis and six patients (66.7%, 6/9) with aural atresia. After surgery intervention, the air-bone gaps (ABG) in both stenosis and atresia group significantly improved. Restenosis was observed in two patients (8.3%, 2/24) with aural stenosis. The etiologies of them were congenital and acquired, respectively. Tympanic membrane (TM) lateralization occurred in one patient (4.2%, 1/24) with aural atresia. Intralesional injection of triamcinolone acetonide was performed in two patients. One received injection three times and obtained a satisfying outcome. However, the other one failed to continue this treatment and restenosis occurred.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSurgical intervention is a gold standard for symptomatic aural stenosis and aural atresia. To achieve a promising outcome, a plastic sheet with expansive sponge was helpful to support the new EAC and a regular follow-up was mandatory. When a restenosis tendency occurred, intralesional injection of triamcinolone acetonide might benefit to improve it.\u003c/p\u003e","manuscriptTitle":"Long-term Outcomes of Surgical Intervention for Symptomatic Aural Atresia and Stenosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 14:50:44","doi":"10.21203/rs.3.rs-3810213/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5c16b3a-9390-4eb7-afeb-a13a5329f753","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-28T20:29:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 14:50:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3810213","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3810213","identity":"rs-3810213","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}