April issue.indd

J.L. Lancaster* T.M. Jones* A.R. Kay** D.D. McGeorge***
Royal Liverpool and Broadgreen University Hospitals, Prescot Road, Liverpool, U.K. *University Hospital Aintree, Lower Lane, Liverpool, U.K. **Frenchay Hospital, Bristol, U.K. ***Countess of Chester NHS Trust, Liverpool Road, Chester, U.K.

Correspondence to: J.L. Lancaster, 6 Harford Close, (Off Heath Rd.), Penketh, Warrington, Cheshire, WA5 2JD, U.K. Email: jeffreylancaster@hotmail.com

Introduction

Keywords: Otoplasty, pinnaplasty, local anaesthesia, day-case surgery, paediatric
Surg J R Coll Surg Edinb Irel., 1 April 2003, 96-98

Background: Correction of prominent ears (otoplasty) is routinely done as an elective cosmetic procedure. The operation is typically performed under general anaesthesia, which is favoured in the paediatric population, being considered more `humane` than local anaesthesia. Aim: Our aims were to demonstrate the feasibility of paediatric otoplasty as a day case procedure and to examine the relative efficacy of general versus local anaesthesia, paying particular attention to post-operative morbidity. Methods: Data were gathered retrospectively from case notes, day case surgery pro-formas and dressing clinic notes to compare post-operative morbidity in the two groups. Specific parameters assessed included vomiting, post-operative bleeding, wound dehiscence, necessity of overnight stay and need for revision surgery. Results: Eighty-five children, underwent a day case otoplasty procedure (age range 4 -17 years; mean 7.3). Forty-four received a general anaesthetic, whilst fortyone received percutaneous infiltration of local anaesthetic. Local anaesthetic was well tolerated by the children. No procedure was abandoned due to pain. No disadvantage was demonstrable in either group by performing the operation as a day case procedure. Post-operative vomiting was shown to be a significantly greater problem in the children receiving general anaesthesia (p<0.0001). Conclusion: Otoplasty as a day case procedure appears acceptable whether general or local anaesthesia is used. In addition, percutaneous infiltration of local anaesthetic, results in a marked reduction in postoperative vomiting without compromising surgical outcome

INTRODUCTION
Correction of prominent ears (otoplasty) is routinely done as an elective cosmetic procedure. It is frequently performed on young children in an attempt to prevent any further psychological trauma resulting from school-yard teasing.

The operation is typically performed under general anaesthesia, with the patient remaining in hospital for one post-operative night. General anaesthesia is favoured in the paediatric population, being considered more `humane` than local anaesthesia. The reason for the mandatory overnight stay is less clear, but relates to long-term practice and a belief that the child needs `professional observation` after an operation, presumably to enable detection of early post-operative complications. This practice is largely based on dogma.

In recent times, increasing numbers of paediatric surgical procedures are routinely undertaken as day-case surgery.¹ This results in a greater throughput of patients, earlier discharge to a more comfortable home environment and decreased cost.

In 1985, Attwood and Evans proposed local anaesthesia as an acceptable alternative to general anaesthesia, for the correction of prominent ears in selected cases in both adult and paediatric populations.²

Otoplasties performed in our department, under the care of D.D.M. have, for some time, been considered a day-case procedure and subject to patient selection are performed using local anaesthesia. This approach does require a small increase in outpatient time and effort by the surgeon to adequately counsel both child and parent, thereby, providing reassurance and decreasing anxiety.

We present a retrospective analysis of eighty-five cases of paediatric otoplasty, performed routinely as a day case procedure.

Our aims were to demonstrate the feasibility of paediatric otoplasty as a day case procedure, and to examine the relative efficacy of general versus local anaesthesia, paying particular attention to post-operative morbidity.

PATIENTS AND METHODS
Over a 19-month period, 85 children, underwent a day case otoplasty procedure. Forty-four received a general anaesthetic (GA), (age range, 4-14 years; mean 7.3 years), whilst forty-one received percutaneous infiltration of local anaesthesic (LA), (age range, 7-16 years; mean 11.9 years).

For both types of anaesthetic an identical surgical procedure, employing a cartilage scoring technique, was used.³

In selecting children for otoplasty two main considerations were undertaken. Firstly, whether the social circumstances of the child lent itself to a day case procedure at all and secondly, whether the child received local or general anaesthesia. Acceptability for day case surgery depended on 1) parental agreement, 2) whether the child could be conveyed home in a private car, 3) whether there was a responsible adult willing to undertake the immediate post-operative care of the child and 4) whether the child was able to return to the hospital with relative ease should a complication arise.

The decision regarding general or local anaesthesia depended on two factors; Firstly, the perceived maturity of the child to tolerate the administration of local anaesthesia based on the surgeon’s assessment of the child during the consultation and secondly and ultimately, on parental consent after receiving a full explanation of the relative advantages and disadvantages of each technique. Although written consent was not taken directly from the child, verbal consent was and all children turned up for the local anesthetic procedure fully understanding that it involved some initial discomfort during infiltration of the anaesthetic. Over the time period of this retrospective study although the waiting times for both local and general anaesthetic procedures did not extend past three months the wait for local procedures was shorter, as is the case in most hospitals. Otoplasty is an unusual paediatric operation in as much as it is frequently sought after as much by the child, if not more, than by the parents. One has to consider that the willingness of children encountered, to withstand a measured discomfort for what they believed would result in genuine personal gain may have been influenced by an earlier operative date on offer for LA procedures. Ideally, this allocation should have been randomised, however, for the basis of this retrospective study it was not. Although age per se was not used as a criterion for inclusion or exclusion from the LA group, inevitably, children judged mature enough to undergo the local anaesthetic procedure were older, (GA mean age: 7.3 years, LA mean: 11.9 years).

A variety of `standard` general anaesthetic techniques were used, variations being dependent on the individual preference of either of the two consultant anaesthetists administering the anaesthesia.

Percutaneous infiltration of LA, using a solution of 2% lignocaine and 1: 80 000 adrenaline, comprised a circumauricular block, followed by infiltration to both surfaces of the pinna.

Post-operatively a full head bandage dressing was applied. It was intended that the bandage remained in place for 5-7 days, prior to review in a specialist nurse-led clinic. At this follow-up, if no complications had occurred, the patient was formally reviewed in outpatient clinic, 2-3 months later.

RESULTS
A retrospective analysis of the 85 cases was undertaken. Data were gathered from patient case notes, day case surgery pro-formas and dressing clinic notes. Four parameters of postoperative morbidity were identified.

These were vomiting, necessity of overnight admission, post-operative bleeding and wound dehiscence. The need for revision surgery at three months was also included in an attempt to compare surgical outcome.

In view of the categorical nature of the data and the relatively small numbers of post-operative complications in either group, Fisher`s exact test was employed to statistically compare the group data.

• Twenty children in the GA group suffered post-operative vomiting, compared with no children in the LA group. (p<0.0001)

• Two of these children were sufficiently unwell to warrant an overnight admission. No children in the LA group needed to stay overnight. (p=0.495)

• Two children in the LA group, compared with no children in the GA group, re-attended within 24 hours, as blood was visible on the dressing. Neither of these required further surgical intervention to stem the bleeding. (p=0.230)

• Two children in the LA group and two children in the GA group were noted to have minor wound dehiscence at one week. An additional child in the LA group had significant full thickness skin loss over the antihelix at one week. (p=0.669)

• Three children in the LA group and two children in the GA group were considered to require minor revision surgery when assessed at three-month follow-up. (p=0.669)

In summary, a statistically significant difference was demonstrable between the groups, only with respect to postoperative vomiting.

DISCUSSION
Our study, we believe, confirms the acceptability of day-case otoplasty irrespective of the anaesthesia used. In both groups the incidence of postoperative surgical complications was extremely low. Moreover, in no case would the detection of any complication during the first post-operative night have changed the patient’s management.

The study does, however, challenge the perceived superiority of general anaesthesia over local anaesthesia in this setting. As we have seen, there is no demonstrable difference in surgical outcome whether a GA or LA is used. There is, however, a highly significant difference in post-operative vomiting. A high incidence of post-operative vomiting is not specific for our unit, or for otoplastic surgery, rather a consequence of the GA itself.⁴

The argument against percutaneous infiltration of local anaesthetic in children hinges on the discomfort of infiltration and the consequent negative psychological effects especially related to subsequent hospital attendance.

It is our experience, however, that infiltration of local anaesthetic is well tolerated, especially when an adequately relaxed atmosphere is created. This was achieved by ensuring that a parent is in attendance, that there was distracting background music and that the child was dealt with in a compassionate, reassuring manner by all the members of the team. Moreover, if a circumauricular block is performed initially, we observed that the discomfort of subsequent infiltration of the dorsal and ventral surfaces of the pinna - the most painful step of the procedure - is largely negated. On no occasion was the local anaesthetic procedure abandoned due to intolerance of either the procedure or the LA infiltration. It was our experience that only the younger children became a little upset at the initial infiltration of LA resulting in a few tears. This was only short-lived and in all cases the actual operative procedure was pain free with the child appearing to be in a relaxed state. The technique of using LA with adrenaline solution gave a near bloodless operative field because of local vasoconstriction, as well as providing excellent post-operative analgesia.⁵

Cost is greatly reduced if LA is performed. Otoplasty under LA is undertaken in a designated room requiring only the surgeon and one attendant paediatric nurse. This contrasts with the cost of providing an anaesthetist and fully staffing an operating theatre, in order to undertake a GA procedure. In addition, LA was subjectively a much quicker procedure since our day case unit runs with almost no inter-case delays and the post-operative/anaesthetic recovery period was negligible. This allows a greater throughput of paediatric otoplasties, thus significantly reducing the waiting times for this procedure. Although the children in our series did not receive topical LA cream preoperatively, we do accept that this could further reduce the discomfort of the procedure.⁶ Other options of reducing the pain of local infiltration would be to reduce the solution’s acidity by combining it with a small quantity of bicarbonate.

We accept that our retrospective study based on relatively small numbers has its limitations, but we suggest that our results reinforce the argument in favour of daycase otoplasty. Additionally, it suggests local anaesthesia as a reasonable option for otoplasty in the paediatric population, assuming careful selection of the child and adequate counseling of the parents.

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