Does Inspection Have The Same Value In All Sectors Of The Outer

For all the following observations and analyses I have restricted the number of patients to the 357 that I had examined over the preceding 3 years.

If we consider the mean number of skin alterations on the right and left ear we obtain respectively 7.5 and 6.7. We would therefore expect a uniform distribution among the different sectors but this is not always the case. If we make a spatial cluster analysis8,9 of the total number of skin alterations on the right and left ears, regardless of sex, we may observe that there are some specific sectors with a significantly higher concentration. Figure 4.7 shows a distribution of skin alterations on the right ear which is quite uniform throughout from sector 3 to sector 19; on the left ear, there are two main groups of sectors on the upper and lower part of the auricle with a significantly greater cluster of skin alterations compared to the mean of the remaining sectors (Table 4.5A). It is possible that the reduced concentration of skin alterations on the remaining parts of the upper and lower conchae may be related to the more difficult visual access to these areas. Another possibility is that uneven or asymmetrical distribution of skin alterations in some sectors may be due to chance. This phenomenon in my opinion is worth particular consideration

Fig. 4.7 Distribution of the total amount of skin alterations (SAs) on the right and left ear of 711 patients. The sectors with a significantly higher concentration of SAs at cluster analysis are colored.
Table 4.5A Sectors in which the number of skin alterations in 357 patients was significantly higher than the average of points per sector according to the Getis-Ord local statistic Gi8,9

Sectors

Z

P

Right ear

3-19

4.35

<0.001

Left ear

5-12

3.42

<0.001

16-19

3.01

<0.005

because it seemingly happens also if we apply the pain pressure test (PPT) (see Fig. 5.5) and electrical skin resistance test (ESRT) (see Fig. 7.1) in diagnostic procedures.

The application of Nogier's alignment principle to the inspection of the ear may furthermore add some elements to the issue of asymmetrical distribution of skin alterations. I have always been intrigued by aligned skin alterations because my clinical impression is that they can have a particular value for diagnosis and therapy to the pertaining sector, no matter to which category they belong. It should be pointed out here that the number of skin alterations which are aligned in two or more units is not negligible as it represents 38.5% of the total.

If we go back to the issue of asymmetrical distribution of skin alterations, we can see that the concentration of alignments on both auricles is not random but favors certain sectors above others. Cluster analysis indicates that sectors 9 and 16-19 on the right ear and 8-10 and 15-19 on the left ear have a significantly higher number of alignments than the average in the other sectors (Fig. 4.8; Table 4.5B).

The majority of alignments consisted of two skin alterations (82.9%) and the minority of three (16.6%). Moreover the categories often seen in the alignment phenomenon are in decreasing order: two vascular skin alterations (see Plate IIA); one vascular and one pigmented (see Plate IXD); one vascular and one related to cartilaginous structure.

16 15 14

13 12

15

14

13

12

Fig. 4.8 Distribution of skin alterations (SAs) which are aligned in two or more units on the right and left ear of 357 patients. The sectors with a significantly higher concentration of aligned SAs at cluster analysis are colored.

Table 4.5B Sectors in which the number of alignments of two or more skin alterations was significantly higher in 357 patients than the average of alignments per sector, according to the Getis-Ord local statistic Gi8,9

Sectors

Z

P

Right ear

9

2.25

<0.05

16-19

3.63

<0.001

Left ear

8-10

3.56

<0.001

15-19

2.74

<0.005

If we consider the auricular parts on which the skin alterations are more often aligned we find the same part in 23.6%, anthelix with helix or with medial surface in 21.3%, followed by lower concha with ear lobe or antitragus in 14.5%. The second group of combinations appears to be related to the frequent occurrence of musculoskeletal problems in the aging population; the latter, however, seems to be associated with the presence of psychosomatic and metabolic disorders so common in contemporary patients.

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