The application of computer-enhanced imaging to improve preoperative counselling and informed consent in children considering bone anchored auricular prosthesis surgery

Abstract

Objectives: Bone anchored auricular prostheses have become a valuable option in the treatment of congenital and acquired deformities of the pinna. However, preoperative counselling and informed consent remains a challenging issue. Until recently it has been difficult to provide the child with a realistic prediction of their own postoperative appearance. This is particularly relevant when a remnant pinna needs to be excised prior to the second stage. The potential for psychological repercussions and the possibility that remnant excision might compromise future autologous tissue reconstruction make it imperative that the decision to proceed with surgery is founded on the best possible information. Methods: The authors describe the use of computer enhanced images using the Adobe Photoshop (Apple Mac. Inc.) software package to provide such a preview. This technique is used in the outpatient clinic as an adjunct to counselling provided by clinic staff and is reinforced by meeting children who have already enrolled on to the implant programme. Children are encouraged to follow the stages of their planned operation on the computer screen, providing an accurate insight into the physical consequences of surgery. Results: Our experiences suggest that this approach has encouraged a better qualitative understanding of implant surgery which has helped to foster the on-going commitment that is required to maintain a long-lasting, trouble-free implant site. Conclusions: This application of the Adobe Photoshop package has strengthened our basis for a personal informed consent and has provided an opportunity to lessen the adverse psychological consequences of such irreversible surgery. It is commended for its simplicity as it employs established software to enhance photographic prints or slides taken from the child's clinical records.

Introduction

At the Royal Manchester Children's Hospital a paediatric implant programme has been operational for 11 years for bone anchored hearing aids and implant retained artificial ears. The hospital trust serves a population of three and a half million people and, over the past 11 years, 97 children have been referred with microtia. Although we provide a parallel adult programme it has become clear that the issue of microtia in childhood presents fundamental differences requiring a unique and sensitive approach.

Osseointegrated implant retained prostheses in the treatment of children with congenital ear deformities is one of three possible treatment options. These are, to do ‘nothing’, to consider an implant retained artificial ear or to explore the option of reconstructive surgery. All have their advantages and disadvantages.

The congenital ear team consists of a paediatric otolaryngologist, a reconstructive surgeon, an expert in medical prosthetics and a team of audiologists. Our main aim is to be an ‘information centre’ so that parents and children can be fully informed about all aspects of microtia. Our first role is to give an explanation to the parents, reducing their anxiety and any feelings of guilt that they may be responsible for their child's condition. Reassurance that something can be done helps to develop the self-confidence of their child, an essential ingredient to a successful outcome whatever the choice of treatment option.

Until recently the results of plastic surgical reconstruction were unpredictable in the UK. Initial work in the 1970s [1] has been developed and expanded [2], [3], [4] and these recent advances have made this a realistic option in certain cases. It would be interesting to think that osseointegrated implants have acted as a stimulus in this area but, in turn, now that plastic surgery is seen as a viable option, the criteria for recommending implantation need to be carefully defined and issues such as the excision of the remnant pinna, long term commitment to the care of a percutaneous implant and advances in silastic technology need to be addressed.

The decision by a child to opt for an implant retained prosthesis is complex The child is on a ‘psychological roller-coaster’, with doubts about their own self-image, compounded by parental and peer pressure. The surgery may be ‘simple’ but may involve the irreversible removal of a remnant pinna and tissue reduction may preclude the option of plastic surgical reconstruction, including any future developments in this field. The child is also wedded to a lifetime of implant care and periodic prosthetic replacement.

In an attempt to ensure the child fully understands the concept of implantation we use a verbal explanation carefully chosen to avoid technical jargon. A leaflet with photographs and illustrations is given to each family and at a subsequent visit they are shown photographs of children who have already completed implantation. Arrangements are made for the child to meet a patient who has completed both implant and ‘autologous’ surgery without a doctor being present.

It is important that the team has a conservative approach to case management. Many of our children have been under our care for more than 5 years before a treatment decision is made. Nineteen children have received prosthetic ears and all, except one, have been pleased with the results. Five have opted for plastic surgery and the remainder have either decided to do nothing or are too young to have made a decision.

For four years we have also used computerised images of the patient, generated with the Adobe photoshop software. This produces preoperative images of how the individual child might look after implantation. Photographs and, more recently, slides are scanned into an Apple Mackintosh computer. The tool box of the Adobe photoshop allows the remnant pinna to be ‘removed’ and the abutments and gold bars ‘implanted’ by importing the images and merging them with the scanned photographs. A photograph of an artificial ear rather than a reversed copy of the opposite ear can also be superimposed to simulate the final result of surgery.