Case Report: Unusual Complication Post Otoplasty

Otoplasty is very commonly used for the surgical correction of prominent ears. This procedure generally does not involve major complications. Pain and itching, hematoma and bleeding and infection are the most common complications generally observed in post otoplasty patients. We present a case of a 13 years old boy who showed abnormal swelling from the preto the post-auricular area throughout the temporal region one day after the surgery. This case is distinct as the swelling was without the involvement of active bleeding but hematoma like complication at the site of surgery. The investigations were undertaken and the probable cause for these unusual observations were most likely related to lymphatic malformation.


Introduction
The prominent ear is a congenital deformity that can affect the psychology of a child. It affects around 5% of the population [1]. Otoplasty, the procedure commonly performed to correct protruding ears, usually shows a good outcome with a positive influence on the psychology of the children. The shape, position and proportion of the ear can be improved through the use of this technique. The procedure is safe but associated with complications. In a recent review on the outcomes of otoplasty, Sadhra et al. [2], observed that pain and itching were the most commonly observed complications after otoplasty, followed by revision surgery/recurrence (5%), skin wound healing problems (3%), hematoma and/or bleeding (2.5%), suture-related problems (1.8%), scarring (1.6%) and infection (0.8%). On the other hand, complications such as temporal nerve paresis [3], Modern Plastic Surgery meatal obstruction [4], and Ramsay Hunt syndrome [5], have also been reported following otoplasty. We present a case of unusual swelling at the pre-to the post-auricular area throughout the temporal region one day after otoplasty without any hematoma or active bleeding at the site of surgery in a healthy child after ear deformity surgical correction.

Case Report
A 13 years old healthy boy presented with a bilateral congenital ear deformity. In the very early childhood of the patient, a congenital posterior auricular mass with unknown diagnosis was excised from the right ear. Clinically the child presented was unhappy with the shape of his right ear deformity. The clinical features showed a low set ear, lidding, prominence of the concha and bilateral protrusion that was more significant on the right side ( Figure 1 and    Figure 5). There was no redness, inflammation or continuous bleeding from the site of the wound. The dressing was dry with old blood    with cystic configuration (Figure 9). There were no bleeding vessels so cauterization was not required. Since a clear diagnosis could not be reached the wound was closed.
The swelling subsided over the next few days, the patient recovered very well.
Histopathology examination showed fibro-adipose tissue with extensive focal dilated lymphatics and mild dispersion of acute inflammatory cells. These findings

Discussion
Generally, the complications following otoplasty include hematoma recorded in around 2.2% of the patients [6]. The hematoma usually develops in early post-surgery hours mostly due to the rebound vasodilatation effect of the local anesthesia [7]. The hallmark sign of the postoperative hematoma is intense pain, bluish discoloration of the skin, and bleeding with soaked dressing within 24 hours postoperatively [8], which is not consistent with the observation made in this case. The swelling observed in this case appeared on the following day and observed by the physician. In addition to that, the main leading sign of hematoma or any bleeding is normally distributed in an asymmetrical fashion or unilaterally, which was also not observed in this case.
A bluish discoloration of the skin started to appear later and mandate the exploration only in the second day from the surgical day. The swelling appeared awkwardly in the non-operated pre auricular, and the temporal region as well and was not accompanied by any bleeding or oozing, thus ruling out hematoma as the cause of the swelling.

Conclusion
This is an unusual case of extensive swelling extending from the pre-to the post-auricular area throughout the temporal region of post otoplasty without any indication of a hematoma or bleeding. The investigations suggest the involvement of dilated lymphatic channels. The outcome of this case suggests that children with an earlier surgery and removal of the auricular mass may be susceptible to an abnormal swelling in the pre-to post-auricular areas post otoplasty.