DyAnsys

MEASURE

Brought to you by DyAnsys India Pvt. Ltd., For private circulation only
When you can measure what you are
speaking about, and express it in
numbers, you know something about it;
but when you cannot measure it, when
you cannot express it in numbers, your
knowledge is of a meager and
unsatisfactory kind.
- Lord Kelvin (1883)

Director's corner
Greetings!
Narcotics are finally
being recognized for
what they are. They
cause
addiction,
damage to the brain
and a host of other complications. A
reliable, non-narcotic treatment for chronic
pain is the need of the hour.
DyAnsys got involved in neurostimulation
about 4 years ago via our ANSiscope. We
found that chronic pain, almost always
causes an imbalance in the Autonomic
Nervous System, which of course we
measure. It made sense to ally the
ANSiscope with treatments to provide a
monitoring/treatment solution.
Subsequently, we became involved with a
device for auricular neurostimulation called
the P-Stim. The results achieved were
excellent. It provided pain relief in a
majority of the patients that it was put on.
We made a significant commitment to this
business and designed our version of this
device called the ANSiStim.
We are now involved in developing this
business, initially in the USA and then in
other parts of the world. We expect to
publicize successes via this newsletter,
clinical studies, patient testimonials and
other marketing activities.
This is the first of our Measure issues that is
devoted to one of the diseases associated
with Chronic Pain Migraine. We have
known Dr. Meenakshisunderam for many
years through his diabetology practice. The
main application for the ANSiscope was
diabetic autonomic neuropathy.
In this issue he talks about treating his wife
for Migraine that had been dogging her for
over 15 years. It was completely resistant to
any treatment.
Enter the ANSiStim. She is now finally
able to have a majority of pain free days.
More importantly she is able to live a
normal life. She expresses her feelings on
her own words.
The default treatment for migraines in the
US seems to be Botox. We would hope that
US physicians would treat their patients first

April 16

Alleviation of Migraine in a patient

suffering for 15 years
Pro Profile
Many
qualifications
and
long
years
in
practice have established
Dr. L. Meenakshi Sundaram
as one of the leading
medical professionals in
Chennai, India. He graduated with an M.D.
in General Medicine from Madras Medical

College (one of the premier medical

institutions in India). He now has his own
center for diabetes and internal medicine in
Royapettah, Chennai, India. He has been
practicing since 1992.
This case has been particularly close to his
heart since it was his wife that was suffering.

Doc Talk
The patient

His wife (Mrs. M.Meyyammai and 45 years

old) has been suffering from severe migraine
for over 15 years.
History

She consulted various top neurologists in

Chennai without any relief. MRIs of both the
brain and the heart were done 4 times in the
last 15 years.

stimulation by passing minute electrical

currents via the auricular cranial nerves to the
brain.
Three points are chosen for stimulation
depending upon the condition to be treated
The ANSiStim was mounted behind the
patients ear. The three points chosen to treat
chronic migraine, stimulate

Initially she also had maxillary sinusitis with

fungal balls. The fungal balls were removed
through endoscopic sinus surgery. This
relieved her frontal headache to some extent
but the migraines continued.
Various neurologists prescribed rescue
therapy to no avail. Migraine prophylaxis
treatment using topiramate, flunarizine,
propranolol and others were tried but the
patient did not tolerate these medicines. She
refused to take these medications since she
could not handle the side effects. In the
meantime she consulted 4 neurologists without
any result.
Management & Outcome

He got to know about the ANSiStim through

representatives of DyAnsys India. He was told
that this Neurostimulation Therapy was
applicable to all kinds of chronic pain
including but not limited to arthritis,
neuropathy and other chronic pain
syndromes.
When asked about migraine, he was told
that it has been used on migraine patients in
the US and found to be effective.
The patient was reluctant to try yet another
form of therapy. He persuaded her to try at
least two to three applications of the
ANSiStim.
The ANSiStim

The ANSiStim performs cranial electro

Lead I : ABVN GAN ATN

Lead II : ATN
Lead III : ABVN ATN

1. The auricular branch of the vagus nerve

2. The auriculotemporal nerve
3. Greater auricular nerve
Note that the auriculotemporal nerve originates
from the mandibular branch of the trigeminal
nerve. It innervates the anterosuperior and
anteromedial aspects of the auricle.
After the second treatment, the patient found
that it relieved her headaches. Remarkably
there were no side effects unlike medications
that she had been taking.
In the meantime she has had 8 treatments.
The severity and intensity of the headaches
has come down from a VAS score of 9 to 4.

with the ANSiStim before resorting to more

aggressive treatments.
We are going systematically about
building this business. You will see more
announcements, articles, and information
as time goes on.
Unfortunately the default treatment for
chronic pain is still narcotics like Oxycontin,
Vicodin, morphine and so on.
Major organizations like the American
Academy of Pain Management are now
strongly advocating the use of less
aggressive treatments before moving on to
narcotics and more aggressive treatments.
Our goal at DyAnsys is to ensure doctors
try the ANSiStim treatments on patients
FIRST before resorting to aggressive
treatments like narcotics.

With Opioid Addiction On

The Rise, FDA Issues New Guidelines
For Labeling Painkillers
BY ALEX ZIELINSKI MAR 22, 2016 3:09 PM

Discussion

Upon researching this therapy, we found that

the ANSiStim is a patented and FDA cleared
miniaturized Neurostimulation device that
operates on the principle of auricular
Neurostimulation.
We are now convinced of the efficacy of this
form of therapy for migraine. More data on
the effectiveness of ANSiStim on this kind of
patient population will attract the attention of
contemporary medical practitioners. They
could recommend as a routine form of therapy
to treat migraine.
Patient experience

Mrs. Meyyammai was

suffering from Migraines
since 2001 and was
finding it hard to lead a
normal life due to the
severity of pain.
I tried all sorts of
allopathic treatment but was not satisfied by
any of them. My husband convinced me to try
the ANSiStim treatment.
I saw an improvement in pain after the very
first treatment. In the meantime I have been
treated 8 times. My pain has reduced
drastically.
My sleep pattern has improved. I am finally
able to sleep continuously for hours without
any breaks.
Before the ANSiStim treatment my pain level
was a 9. After the ANSiStim treatment my
pain level has dropped down to 4.
I am now able to pursue my daily activities,
both at home at the hospital, without any
discomfort. I was able to carry out all my tasks
even with the ANSiStim on me.
References

https://www.botoxchronicmigraine.com/
New nerve drugs may finally prevent
migraine headaches - David Noonan,
Scientific American Health Nov 17, 2015
The nerve supply of the human auricle Elmar
T.Peuker & Timm J. Fuller Clin Anatomy 15,
35-37
DyAnsys application note #44

OxyContin pills at a pharmacy in Montpelier, Vt.

Faced with an all-time national high of opioid-induced overdoses, the Food and Drug
Administration (FDA) rolled out strict new guidelines for labeling addictive painkillers Tuesday
afternoon. These new rules will require fast-acting opioid-based drugs, like OxyContin, Demerol,
Percocet, and Vicodin, to come with a new warning about the serious risks of abuse, addiction,
overdose, and deaths linked to the painkiller.
These quick-release forms of opioid drugs represent about 90 percent of painkiller products on
the market. And while they are meant to diffuse temporary pain, like a broken bone, wisdom tooth
removal, or surgery, these opioids have quickly become the nations top drug of choice for people
struggling with addiction.
Opioid addiction and overdose have reached epidemic levels over the past decade, and the
FDA remains steadfast in our commitment to do our part to help reverse the devastating impact of
the misuse and abuse of prescription opioids, said Robert Califf, FDA commissioner, in a press
release. Califf said the new regulations are just a part of the FDAs comprehensive action plan
to attack the crisis in 2016.
This sweeping update is just one of the new ways federal organizations and Congress are
expressing their interest in reversing drug addiction. The FDAs announcement comes a week after
the Centers for Disease Control and Prevention (CDC) released new voluntary guidelines that
suggest primary care physicians limit the dosage of opioid painkillers for patients or offer
alternative treatments for chronic pain before prescribing. Days before, the U.S. Senate swiftly
passed a bipartisan bill that would fund addiction prevention and recovery programs.
The new FDA labels will also include the dangers of using these types of drugs while pregnant.
Over the past decade, more than 130,000 newborns have entered the world addicted to drugs
and facing a painful withdrawal process. Regardless, many pregnant women have been
prescribed opioid painkillers.
But will updating the warning labels on addictive drugs be enough? Some legislators dont
think so.
Shortly after the FDAs announcement, Senator Ed Markey (D-MA) told the New York Times that
the changes have done little to prevent prescription drug opioid addiction, and that it has taken
the F.D.A. far too long to address the grave risks of these drugs that have claimed the lives of
thousands this year alone.
This action failed to address a petition signed by 41 city and state health department heads in
February, which asked for labeling that warned users of the risk of mixing a painkiller with another
type of drug. In its press release, the FDA said it is currently reviewing this risk.

DyAnsys India Pvt.Ltd. MEERLAN TOWERS 1 st floor, No.33 , Hanumantha Road, Balaji Nagar, Royapettah,Chennai- 600 014.
Toll free No:1800 4254 222/044 4294 3800

APPLICATION NOTE
Date: Fe b 22 nd 2016 No. IN 0044

ANSiStim & Migraine

Current Treatment
BOTOX is currently used as a preventive medicine if patients have chronic
migraine i.e. >15 headache days a month. The FDA has approved BOTOX
treatments once every 90 days.
Interestingly, BOTOX prevents up to 9 headache days a month compared
to up to 7 days a month for a placebo injection!
It is injected into 7 key areas of the head and neck at a recommended
dosage of 155 units per treatment session.
BOTOX has side effects that can be serious
1. Problems swallowing, speaking or breathing
2. Spread of toxin effects causing problems in other areas of the body
i. Loss of strength and overall muscle weakness
ii. Double or blurred vision
iii. Hoarseness or change or loss of voice
iv. Loss of bladder control
Recent Insights
Recent developments have identified the trigeminal nerve as the most likely
source of these migraines. (See review article attached).
Migraine has been treated with various methodologies
1. Forehead and eyelid surgery to decompress branches of the trigeminal
nerve system
2. As well as transcranial magnetic stimulation (TMS - a noninvasive
technique to alter nerve cell activity).
TMS has shown some good results.
TMS actually induces currents in areas of the brain causing cranial
electrostimulation.

APPLICATION NOTE
Date: Fe b 22 nd 2016 No. IN 0044

ANSiStim & Migraine

The ANSiStim
The ANSiStim performs cranial electro stimulation by passing minute
electrical currents via the auricular cranial nerves to the brain.
Three points are chosen for stimulation depending upon the condition to be
treated
The three points chosen to treat chronic migraine, stimulate
1. The auricular branch of the vagus nerve
2. The auriculotemporal nerve
Note that the auriculotemporal nerve originates from the mandibular
branch of the trigeminal nerve. It innervates the anterosuperior and
anteromedial aspects of the auricle.
Recommendation
1. Try a sequence of ANSiStim treatments on migraine patients. There should
be no side effects.
2. The ANSiStim should work for most patients. For those patients who dont
respond to ANSiStim treatment, one can continue with more aggressive
treatment options.

References
1. https://www.botoxchronicmigraine.com/
2. New nerve drugs may finally prevent migraine headaches David
Noonan Scientific American Health Nov 17, 2015
3. The nerve supply of the human auricle Elmar T.Peuker & Timm J. Fuller
Clin Anatomy 15, 35-37

New Nerve Drugs May

Finally Prevent Migraine
Headaches
The cause of migraine headaches has eluded scientists for centuries.
Now a theory blaming one nerve has led to drugs that prevent attacks
By David Noonan | Nov 17, 2015

Julia Yellow

The 63-year-old chief executive couldn't do his job. He had

been crippled by migraine headaches throughout his adult
life and was in the middle of a new string of attacks. I have
but a little moment in the morning in which I can either

read, write or think, he wrote to a friend. After that, he had

to shut himself up in a dark room until night. So President
Thomas Jefferson, in the early spring of 1807, during his
second term in office, was incapacitated every afternoon by
the most common neurological disability in the world.
The co-author of the Declaration of Independence never
vanquished what he called his periodical head-ach,
although his attacks appear to have lessened after 1808. Two
centuries later 36 million American migraine sufferers
grapple with the pain the president felt. Like Jefferson, who
often treated himself with a concoction brewed from tree
bark that contained quinine, they try different therapies,
ranging from heart drugs to yoga to herbal remedies. Their
quest goes on because modern medicine, repeatedly baffled
in attempts to find the cause of migraine, has struggled to
provide reliable relief.
Now a new chapter in the long and often curious history of
migraine is being written. Neurologists believe they have
identified a hypersensitive nerve system that triggers the
pain and are in the final stages of testing medicines that
soothe its overly active cells. These are the first ever drugs
specifically designed to prevent the crippling headaches
before they start, and they could be approved by the U.S.
Food and Drug Administration next year. If they deliver on
the promise they have shown in studies conducted so far,
which have involved around 1,300 patients, millions of
headaches may never happen.
It completely changes the paradigm of how we treat
migraine, says David Dodick, a neurologist at the Mayo
Clinic's campus in Arizona and president of the International
Headache Society. Whereas there are migraine-specific drugs
that do a good job stopping attacks after they start, the holy
grail for both patients and doctors has been prevention.
Migraine attacks, which affect almost 730 million people
worldwide, typically last from four to 72 hours. Most

sufferers have sporadic migraines and are laid low during 14

or fewer days a month. Those with a chronic formalmost 8
percent of the migraine populationsuffer 15 or more
monthly headache days. Attacks are often preceded by
fatigue, mood changes, nausea and other symptoms. About
30 percent of migraine patients experience visual
disturbances, called auras, before headaches hit. The total
economic burden of migraine in the U.S., including direct
medical costs and indirect costs such as lost workdays, is
estimated at $17 billion annually.
In the 5,000 years since migraine symptoms were first
described in Babylonian documents, treatments have
reflected both our evolving grasp and our almost comical
ignorance of the condition. Bloodletting, trepanation and
cauterization of the shaved scalp with a red-hot iron bar were
common treatments during the Greco-Roman period. The
nadir of misguided remedies was probably reached in the
10th century a.d., when the otherwise discerning
ophthalmologist Ali ibn Isa recommended binding a dead
mole to the head. In the 19th century medical electricity had
become all the rage, and migraine patients were routinely
jolted with a variety of inventions, including the
hydroelectric bath, which was basically an electrified tub of
water.
By the early 20th century clinicians turned their attention to
the role of the blood vessels, inspired in part by observations
of strong pulsing of the temporal arteries in migraine
patients, as well as patients' descriptions of throbbing pain
and the relief they got from compression of the carotid
arteries. For decades to come, migraine pain would be
blamed primarily on the dilation of blood vessels
(vasodilation) in the brain.
That idea was reinforced in the late 1930s with the
publication of a paper on the use of ergotamine tartrate, an
alkaloid that was known to constrict blood vessels. Despite

an array of side effects, among them vomiting and drug

dependence, it did stop attacks in a number of patients.
But if vasodilation was part of the puzzle, it was not the only
thing going on in the brains of migraine sufferers, as the next
wave of treatments suggested. In the 1970s cardiac patients
who also had migraines started telling their doctors that the
beta blockers they were taking to slow rapid heartbeats also
reduced the frequency of their attacks. Migraine sufferers
taking medicines for epilepsy and depression, and others
receiving cosmetic Botox injections, also reported relief. So
headache specialists began prescribing these borrowed
drugs for migraines. Five of the medications eventually were
approved by the FDA for the condition. Unfortunately, it is
still not known exactly how the adopted drugs (which are
effective in only about 45 percent of cases and come with an
array of side effects) help migraines. Dodick says they may
act at various levels of the brain and brain stem to reduce
excitability of the cortex and pain-transmission pathways.
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The first migraine-specific drugs, the triptans, were

introduced in the 1990s. Richard Lipton, director of the
Montefiore Headache Center in New York City, says triptans
were developed in response to the older idea that the dilation
of blood vessels is the primary cause of migraine; triptans
were supposed to inhibit it. Ironically, subsequent drug
studies show that they actually disrupt the transmission of
pain signals in the brain and that constricting blood vessels
is not essential. But they work anyway, Lipton says. A
survey of 133 detailed triptan studies found that they relieved
headache within two hours in 42 to 76 percent of patients.

People take them to stop attacks after they start, and they
have become a reliable frontline treatment for millions.
What triptans cannot doand what Peter Goadsby, director
of the Headache Center at the University of California, San
Francisco, has dreamed about doing for more than 30
yearsis prevent migraine attacks from happening in the
first place. In the 1980s, in pursuit of this goal, Goadsby
focused on the trigeminal nerve system, long known to be the
brain's primary pain pathway. It was there, he suspected,
that migraine did its dirty work. Studies in animals indicated
that in branches of the nerve that exit from the back of the
brain and wrap around various parts of the face and head,
overactive cells would respond to typically benign lights,
sounds and smells by releasing chemicals that transmit pain
signals and cause migraine. The heightened sensitivity of
these cells may be inherited; 80 percent of migraine sufferers
have a family history of the disorder.
Goadsby co-authored his first paper on the subject in 1988,
and other researchers, including Dodick, joined the effort.
Their goal was to find a way to block the pain signals. One of
the chemicals found in high levels in the blood of people
experiencing migraine is calcitonin gene-related peptide
(CGRP), a neurotransmitter that is released from one nerve
cell and activates the next one in a nerve tract during an
attack. Zeroing in on CGRP and interfering with it was hard.
It was difficult to find a molecule that worked on that
neurotransmitter and left other essential chemicals alone.
As biotech engineers' ability to control and design proteins
improved, several pharmaceutical companies developed
migraine-fighting monoclonal antibodies. These designer
proteins bind tightly to CGRP molecules or their receptors
on trigeminal nerve cells, preventing cell activation. The new
drugs are like precision-guided missiles, Dodick says.
They go straight to their targets.
It is that specificity, and the fact that scientists actually know

how the drugs work, that has Dodick, Goadsby and others
excited. In two placebo-controlled trials with a total of 380
people who had severe migraines up to 14 days per month, a
single dose of a CGRP drug decreased headache days by
more than 60 percent (63 percent in one study and 66
percent in the other). In addition, in the first study, 16
percent of the patients remained totally migraine-free 12
weeks into the 24-week trial. Larger clinical trials to confirm
those findings are currently under way. So far the CGRP
drugs work better at prevention than any of the borrowed
heart or epilepsy drugs and have far fewer side effects. They
are given to patients in a single monthly injection.
Migraine specialists are also exploring other treatments,
including forehead and eyelid surgery to decompress
branches of the trigeminal nerve, as well as transcranial
magnetic stimulation (TMS), a noninvasive way of altering
nerve cell activity.
Lipton says he has had some good results with TMS. He has
also referred patients for surgical interventions but says the
experience has been disappointing, and he is not
recommending it. For his part, Goadsby views surgeries and
high-tech efforts as a kind of desperation: They strike me as
a cry for help. If we better understood migraine, we'd know
better what to do.
Even though the cause now appears rooted in the trigeminal
nerve system, the origin of its overactive cells is still a
mystery, Goadsby says. What's the nature of what you
inherit when you inherit migraine? he asks. Why you, and
why not me? If researchers untangle the genetics of
migraine, Jefferson's periodical head-ach may loosen its
painful modern grip.
<p><b>SCIENTIFIC AMERICAN ONLINE</b> <br
/>COMMENT ON THIS ARTICLE AT <a
href="http://ScientificAmerican.com/dec2015">ScientificAmerica
n.com/dec2015</a></p>

ABOUT THE AUTHOR(S)

David Noonan is a science and medical writer. He wrote

about treatments for vertigo in the August issue.
This article was originally published with the title "A Pain in the
Brain."

Clinical Anatomy 15:3537 (2002)

The Nerve Supply of the Human Auricle

ELMAR T. PEUKER*

AND

TIMM J. FILLER

Clinical Anatomy Division, Institute of Anatomy, Westfalian Wilhelms-University, Muenster, Germany

Knowledge of the innervation of the outer ear is crucial for surgery in this region. The aim
of this study was to describe the system of the auricular nerve supply. On 14 ears of seven
cadavers the complete course of the nerve supply was exposed and categorized. A heterogeneous distribution of two cranial branchial nerves and two somatic cervical nerves was
found. At the lateral as well as the medial surface the great auricular nerve prevails. No region
with triple innervation was found. Clin. Anat. 15:3537, 2002. 2002 Wiley-Liss, Inc.
Key words: innervation; external ear; cadaveric study; variation

INTRODUCTION
A detailed knowledge on vascularization and innervation of the outer ear is crucial for reconstructive and
plastic surgery in this region. Moreover, the innervation of the auricle is the theoretical basis of different
reflex therapies (e.g., ear acupuncture). However, data
on the innervation as provided by scientific publications are scarce, incomplete, and inconsistent. The
aim of this study is to describe the system of the
auricular nerve supply.

MATERIALS AND METHODS

On 14 ears of seven cadavers the complete course
of nerve supply was exposed under magnifying
glasses. Each branch was defined by identifying its
origin. The bodies (both sexes, age between 68 and 84
years) donated to the Institute of Anatomy had been
embalmed with a mixture of formaldehyde, chloral
hydrate, and sorbitum solution. Ramifications were
coated with a water-soluble dye and photographically
documented. The results were transferred to a
scheme of the external ear and classified.

RESULTS
A heterogeneous distribution of cranial branchial
nerves and somatic cervical nerves was found.
At the lateral surface the GAN (great auricular
nerve) prevails. In 73% of cases the ABVN (auricular
branch of vagus nerve) and in 18% the GAN was
found on the antihelix solely, and 9% showed a double
2002 Wiley-Liss, Inc.
DOI 10.1002/ca.1089

innervation. The lobule and the antitragus were supplied by the GAN in all cases. The tragus was innervated by GAN in 45% solely, in 9% by the ATN
(auriculotemporal nerve), and in all other cases by
both of them. The tail of helix and the scapha were
always supplied by the GAN, the spine of helix in
91% by the ATN (9% GAN). The ATN was found in
80% at the crus helicis; in 20% the ABVN branched on
this part. In 9% the ABVN provided ramification for
the crura antihelices (91% GAN), in 45% of the specimen for the cavity of conchae, and in 100% for the
cymba conchae. In 55% two nerves were found on the
cavity of conchae (GAN and ABVN). No region with
triple innervation was found. For an overview see
Table 1 and Figure 1A.
At the medial surface of the auricle the LON (lesser occipital nerve) participated in 55% of the innervation of the upper third (in 37% solely). The GAN
participated in 63% (in 27% solely); in 36% double
innervation was found. The supply of the middle third
was provided in 64% by the GAN (18% solely), in 73%
by the ABVN (27% solely), and in 18% by the LON
(in no case solely). Double innervation was seen in
55% of the middle third. At the lower third, in 91% of
the cases GAN was found (73% solely), and in 27%
the ABVN (9% solely). No region with triple innervation was found at the medial surface of the auricle as
*Correspondence to: Dr. Elmar T. Peuker, Institute of Anatomy,
Vesaliusweg 2-4, D-48149 Muenster, Germany.
E-mail: peuker@uni-muenster.de
Received 16 August 2000; Revised 19 January 2001

36

Peuker and Filler

TABLE 1. Overview of the Innervation Pattern
of the Lateral Surface of the Auricle
ABVN
Crus of helix
Spine of helix
Tail of helix
Scapha
Crura of anthelix
Antihelix
Antitragus
Tragus
Cymba conchae
Cavity of concha
Lobule of auricle

20%

9%
73%
45%
100%
45%

GAN

ATN

9%
100%
100%
91%
9%
100%
46%

80%
91%

18%
9%

55%
100%

ABVN ! auricle branch of the vagus nerve; GAN !

great auricular nerve; ATN ! auriculotemporal nerve.

Fig. 2. A. Lateral surface of the external ear with corresponding

scheme. ABVN ! auricular branch of vagus nerve; GAN ! great
auricular nerve; ATN ! auriculotemporal nerve; STA ! superficial
temporal artery. B. Medial surface of the external ear with corresponding scheme. ABVN ! auricular branch of vagus nerve; LON ! lesser
occipital nerve; V ! vessels.

well. For details on double innervation see Figures 1B

and 2.

DISCUSSION

Fig. 1. Scheme of left auricle, lateral aspect.

The external ear appears only in mammals. The

density of nerve fibers in the human auricle compared
to other regions of the head seems rather high. In
addition, four different nerves are distributed to the
external ear. They are partly branchiogenic and somatogenic. Concerning the sensory innervation, there
is a gap in the origin between the first and third
branchiogenic nerves on the upper side and on the

Nerve Supply of the Auricle

37

nervation with both origins of the nerves. The overlapping was seen on the lateral site only within the
middle third (tragus, inferior concha, and antihelix),
whereas the medial surface revealed overlapping in all
parts.
Other studies imply that the sensory innervation is
provided by the cranial and cervical nerves (Satomi
and Takahashi, 1991). Labeling of the central projections shows a remarkable ipsilateral distribution (Nomura and Mizuno, 1984). However, the respective
studies have been performed mainly on cat auricles,
and no suggestions were made on the function of this
extensive innervation. Regulation of temperature
might be a possible explanation, control of ear formation could be another. Nonetheless, to our knowledge,
there are no related studies available.
Depending on the technique, complications of otoplasty and auricular reconstruction are quite common.
Cutaneous problems, residual pain, hypesthesia, sensitivity to cold or touch, and delayed wound healing
are mentioned in scientific publications (Calder and
Naasan, 1994; Caouette-Laberge et al., 2000; Weerda
and Siegert, 1994). Most of the surgical techniques do
not consider the innervation pattern (Heppt and
Trautmann, 1999). However, disturbances of the
nerve supply of the vessels and therefore of the tissue
nutrition may be responsible for the considerable
postoperative problems.

REFERENCES

Fig. 3. Scheme of the distribution patterns of the medial surface

of the auricle. ABVN ! auricular branch of vagus nerve; GAN !
great auricular nerve; LON ! lesser occipital nerve.

third to fourth spinal nerves from the lower side. No

overlapping of the branchial branches was noted,
whereas the somatogenic nerves showed double in-

Calder JC, Naasan A. 1994. Morbidity of otoplasty: a review of

562 consecutive cases. Br J Plast Surg 47:170 174.
Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville C. 2000.
Otoplasty: anterior scoring technique and results in 500
cases. Plast Reconstr Surg 105:504 515.
Heppt W, Trautmann Y. 1999. Otoplastic techniques for the
correction of protruding ears. HNO 47:688 694.
Nomura S, Mizuno N. 1984. Central distribution of primary
afferent fibers in the Arnolds nerve (the auricular branch of
the vagus nerve): a transganglionic HRP study in the cat.
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