What Sets Us Apart?
What Sets Us Apart?
Why would people travel from around the world to the California Ear Institute (CEI) for Atresia Microtia surgery - an excellent question for anyone who is looking into receiving care for this condition. We are incredibly humbled and honored to have been asked to care for and help change the lives of thousands of patients born with Atresia Microtia. To date, we have served patients from nearly every continent (Antarctica being the only outstanding continent) and from most states across the USA. As the only medical centers focused on Atresia Microtia in the world, we have been privileged to provide specialized care for this challenging condition in over 4,000 surgical cases performed to date. We offer no-charge consultations to determine what treatment options are available to each patient in order to provide the needed information to make this large decision.
In many areas of the world, canal surgery has been discouraged due to poor outcomes among local surgeons. Not everyone is a candidate for ear canal creation (called atresia repair or canalplasty). It is our experience, however, that with extreme attention to detail, state-of-the-art equipment and facilities, a dedicated team, and careful selection of patients, atresia repair can and does produce excellent, long-lasting results.
When atresia repair cannot be performed, other options to provide hearing are almost always available. Through a rich and long history of practice in the treatment of Atresia Microtia, Dr. Roberson has pioneered several techniques and strategies that translate to improved results for patients. It is our experience that nearly every ear can hear – the question is “how” to achieve that goal for each child.
Canalplasty & CAM for Ear Hearing Restoration
Traditionally, microtia repair was performed first and included 3-4 separate surgeries. After microtia repair was complete, ear canal surgery could then be performed. It is well known in human development that stimulation of a sense during a critical period of development is crucial to the development of that sense. In a challenge to the current traditional medical practice at the time, Dr. Roberson was the first to perform ear canal surgery before microtia repair. He pioneered this early intervention to provide hearing to the developing brain and language centers of children with Atresia Microtia at a time when maximal stimulation and development may occur. Prior to this change, the average age of atresia repair was over 11 years of age – a time where the majority of the brain development associated with language has already passed.
The first publication of this work occurred in 2009 in several peer-reviewed medical journals and can be seen here. This change was directly facilitated by the Medpor technique for microtia repair and also reduced the total number of surgeries needed from 4 to 2.
Our patients were very happy with this reduction in the number of surgeries, travel, time away from home, psychological impact, etc. Several patients asked if both surgeries could be performed at one time. After several years of experience with canal surgery, first followed by Medpor as a second surgery, Dr. Roberson performed the first Combined Atresia Microtia (CAM) surgery in the world in January 2008. We have now completed over 475 CAM surgeries with several different surgeons. Currently, CAM repair is the most commonly selected option for patients who are candidates for an ear canal and outer ear reconstruction. We are the only ones performing this surgery in the world at this time. The CAM procedure offers several advantages over traditional techniques, including lower anesthesia risk (due to a single procedure), reduced psychological trauma to the child (avoiding multiple surgeries), reduced financial and logistical burden by reducing total travel and care time, and often superior aesthetic outcomes and reduced Medpor complication rates.
Complication Rates: Worldwide vs. CEI
The list of possible complications that can occur with atresia surgery has led many doctors across the world to abandon surgery for Atresia Microtia altogether. It has been our practice to address areas of previously common complications with a goal of improved, permanent surgical outcomes.
One such area is the skin transplanted from another site on the body used to line the new ear canal or outer ear reconstruction. Historically, skin for atresia surgery has been taken from the leg, buttocks, arm, or abdomen. The skin quality of these areas is vastly different than that of the normal ear canal skin. This, in turn, increases the risk of suboptimal outcomes, including a higher incidence of narrowing or closure of the ear canal over time (called “stenosis”). This occurs worldwide in approximately 20-30% of canalplasty cases.
At our center, we have pioneered the use of skin grafting from the scalp to reduce the likelihood of canal stenosis, with excellent results. As detailed in the publication below, we see that the best-proven graft site for atresia surgery is from the scalp. Skin from the scalp is an excellent match for the ear canal skin, it hurts very little and heals incredibly quickly. The skin taken is so thin the hair follicles are not disturbed, allowing hair to grow back completely and leaves the site essentially invisible after healing. This practice has effectively reduced the incidence of postoperative stenosis in our patient population to less than 2% (1.9%).
Split Thickness Skin Graft Donor Site for Congenital Atresia Repair PDF
Another common challenge to atresia surgery has been the joint between the 2nd and 3rd middle ear bones, where the connection should be bone on bone. Frequently, this is not the case with atresia, as scar tissue replaces the normal bone-to-bone connection between the two bones. As you might imagine, vibration coming through the bones from the eardrum can be lost, causing a hearing loss. In some cases, the middle ear bones can be replaced with a middle ear bone prosthesis developed by Dr. Roberson. The CEI team has been the first to report this finding and the solution. In 13% of patients, reconstruction of the middle ear bones is needed because of the malunion that exists. In some cases, the malformation can be seen prior to surgery on the CT, but in most cases, this finding is not known until we are in the operating room since the malformation is extremely small and may only be seen under the operating room microscope in some patients.
We continue to improve and refine both our techniques and protocols and desire to share those with others to improve the care of atresia children worldwide. As with any surgery, case volume and surgical experience profoundly impact surgical outcomes and complication rates. As the leading center of excellence worldwide, our team completes over 100 atresia-related cases each year and are the only team completing CAM surgery in the world at this time. We continue to improve and refine both our techniques and protocols and desire to share those with others to improve the care of atresia children worldwide.
Cholesteatoma
Cholesteatoma is a collection of skin trapped in the area the ear canal should occupy. In 4% of patients we evaluate, a cholesteatoma is present and must be addressed before it causes destruction or damage to surrounding structures. Left untreated, disability and even death may result from injury or the spread of infection. This is a rare condition best treated in a center with a large volume of cases. As cholesteatoma associated with atresia is different from standard congenital cholesteatomas, identification on imaging and surgical removal, both require a surgeon with extensive experience in diagnosis and surgical excision. If unidentified or not successfully removed, cholesteatomas continue to grow over time and can become life-threatening to the patient, making correct diagnosis and treatment of ultimate importance.
Frequently, physicians with limited experience with Atresia Microtia may not know how to evaluate or treat a cholesteatoma. For this reason, it is critical to understand EVERY patient who undergoes treatment for congenital atresia microtia must have a CT scan to rule out cholesteatoma. Frequently, plastic surgeons who do not consider hearing forego this evaluation tool and we have multiple examples of patients who had an outer ear placed over a cholesteatoma. Months or years later, the tumor makes itself known, sometimes with disastrous consequences.
HEARMAPS Classification System & Implantable Hearing Aids
Several medical specialties must cooperate and coordinate care for Atresia Microtia patients. Audiologists, Plastic Surgeons, Craniofacial Surgeons, Otologists, Anaplastologists, and others routinely must be in communication with each other in order to define the best course of treatment and its timing. We developed a classification outline using the acronym HEAR MAPS to facilitate communication among professionals. This classification is used worldwide and allows us to compare treatment types among similar patients, enhancing our ability to improve treatment protocols over time.
Dr. Roberson has been involved with most implantable hearing solutions for Atresia Microtia from their development stage forward. Our center offers implantable hearing devices for Atresia Microtia and is experienced in their use. This is a continually developing area of treatment and is important to understand and know as you choose the best treatment for you or your child. Please see the Treatment section of this site for those devices currently available.