Congenital Ear Deformities Treatment & Management
- Author: Carl H Manstein, MD, MBA, CPE; Chief Editor: Deepak Narayan, MD, FRCS more...
Historically, prominent or protruding ears have been treated surgically. More recently, nonsurgical techniques have emerged to treat neonates immediately after delivery. The posterior helical rim is taped to the posterior retroauricular region with surgical tape. Tubular elastic net bandage or some type of ear wrap is used for reinforcement. To achieve the desired result, such techniques must begin in the first few weeks of life and take several weeks or months of constant and vigilant therapy.
A protruding ear tends to become more apparent as the child ages, particularly in the neonatal period. Matsuo believes most prominent ear deformities are acquired and recommends careful positioning of babies in their cribs to keep the auricles from folding anteriorly. One preventive method is to lay babies in a prone position.
Medications are listed below.
Epinephrine (Adrenalin, Bronitin, EpiPen) is a sympathomimetic catecholamine that acts as vasoconstrictor on alpha-adrenergic receptors in capillaries and decreases permeability of dilated capillaries to plasma. This vasoconstrictive action reduces absorption of local anesthetic, prolonging duration of action and decreasing risk of anesthetic's toxicity. Vasoconstrictive action also causes hemostasis in small vessels, relaxes smooth muscle of bronchioles, stomach, intestine, pregnant uterus, and urinary bladder wall. Use to prolong anesthetic effect and provide hemostasis. IM/SC administration has rapid onset and short duration of action, deteriorates rapidly on exposure to air or light, turning pink from oxidation to adrenochrome and brown from the formation of melanin. Replace solutions that show evidence of discoloration.
Adult dosing of epinephrine is 1:500,000-1:50,000 mixed with local anesthetic. Pediatric dosing has not been established.
Triamcinolone (Aristopan Intra-Articular, Aristopan Intralesional, Aristocort Intralesional) is an intermediate-acting glucocorticoid with essentially no mineralocorticoid activity. It causes decreased inflammation through enzyme induction and decreased immune response by reducing activity and volume of lymphatic system. Use to decrease inflammation and increase immunosuppression. Diacetate and acetonide salts for injection have variable onset and duration of action, depending on whether they are injected into an intra-articular space, a muscle, or on the blood supply to that muscle. It may be administered IM, intra-articularly, intrasynovially, intralesionally, sublesionally, or by soft-tissue injection.
Diacetate suspension is slightly soluble, providing a prompt onset of action and a longer duration of action of 1-2 wk. Triamcinolone acetonide is relatively insoluble and slowly absorbed. Extended duration of action lasts for several weeks. Triamcinolone hexacetonide is relatively insoluble, absorbed slowly, and has prolonged action of 3-4 wk. Adult dosing of triamcinolone acetonide is 2.5-15 mg intra-articularly, not to exceed 1 mg intralesionally prn. Adult dosing of triamcinolone diacetate is 2-40 mg intra-articularly, intrasynovially, or intralesionally q1-8wk. Adult dosing of triamcinolone hexacetonide is 2-20 mg intra-articularly q3-4wk prn, not to exceed 0.5 mg intralesionally per square inch of skin.
Bupivacaine hydrochloride (Marcaine) is a long-acting local anesthetic that can be used with or without epinephrine (as bitartrate) 1:200,000 to induce local or regional anesthesia or analgesia for surgery, oral surgery procedures, diagnostic and therapeutic procedures, and obstetric procedures. It has a pKA of 8.1, similar to lidocaine at 7.86. It possesses a greater degree of lipid solubility and is protein bound to greater extent than lidocaine. Local anesthetics block generation and conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in nerve, by slowing propagation of nerve impulse, and reducing rate of rise of action potential. In general, progression of anesthesia is related to diameter, myelination, and conduction velocity of affected nerve fibers.
Clinically, the order of loss of nerve function is as follows: (1) pain, (2) temperature, (3) touch, (4) proprioception, and (5) skeletal muscle tone. Bupivacaine hydrochloride’s onset of action is rapid and it anesthetic effects long–lasting. Its anesthetic effects are significantly longer than other commonly used local agents. In adults, the usual dose for local infiltration is 0.25% bupivacaine; it may be repeated once q3h, although its long-acting nature usually makes a single dose sufficient. Doses up to 225 mg with epinephrine 1:200,000 and up to 175 mg without epinephrine are most used. In clinical studies to date, total daily doses up to 400 mg have been reported, but, until further experience is gained, this dose is not to be exceeded in 24 h. Pediatric dosing is not established.
Many techniques exist to treat prominent or protruding ears, but no standard technique exists. Most surgeons use at least one, but certainly not all, of the techniques listed below.
Excision is perhaps the original treatment for protruding ears and is now included in most operations that involve a posterior auricular approach. Commonly, a crescent of 3-5 mm of skin is excised in the posterior auricular incision. The incision should not be made in the posterior sulcus but slightly higher onto the surface of the external auricle, with the incision extending almost pole to pole.
Scoring the cartilage
Stenstrom and Davis have widened the popularity of this technique. Anterior perichondral scoring in the area of the absent antihelical fold allows the cartilage to bend away from the incised or abraded side to create the fold. Many different techniques and tools are available to score the anterior cartilage. Most surgeons do not use this technique alone to achieve the desired result. A study by Erol (from Turkey) advocates use of exclusively the anterior approach for both scoring of the cartilage and placement of horizontal buried mattress sutures.
This technique of cutting cartilage has fallen out of favor because of the sharp antihelical fold it creates but is mentioned for historical significance. The Luckett procedure consists of excising a crescent of medial skin and cartilage to restore the antihelical fold. Plastic surgeons have modified this technique to create a smoother antihelical fold.
Radial placed mattress sutures
Sutures, placed posteriorly, are probably the most common method used by most surgeons. They result in a more accurate and natural fold at the scaphoconchal angle. All 5 sutures are placed before tying and tightening, providing the operator with a great deal of control to achieve the desired degree of angulation and setback. Sutures should go through the full thickness of cartilage to include the anterior perichondrium.
These were popularized by Furnas.[9, 10] He espoused mattress sutures from conchal cartilage to mastoid fascia, from scaphoid fossa to temporal fascia, from scapha to concha, and from the earlobe to the sternocleidomastoid muscle insertion to obtain a satisfactory result for setback otoplasty.
Excision of conchal cartilage
Bauer and associates from Chicago comment that many surgeons fail to recognize conchal hypertrophy as one of the leading causes of the prominent ear deformity. The excision of conchal cartilage is a common part of this author's surgical plan and treatment.
Incisionless and sutureless methods
A literature review by Leclère et al found a promising success rate for laser-assisted cartilage reshaping of protruding ears. The seven clinical studies used in the report addressed results from three different wavelengths: 1064 nm (Nd:YAG); 10,600 nm (CO2); and 1540 nm (Er:Glass).
Patients are operated on under local anesthesia with or without IV or IM sedation; therefore, preoperative testing is not required. If the patient cannot tolerate the slight discomfort of local infiltration, he or she is unlikely to be cooperative with postoperative care (eg, bandages, night guards).
No scientific evidence indicates a need for preoperative audiologic evaluation unless a history of hearing deficits exists. Setback otoplasty does not improve or decrease auditory acuity.
With the exception of congenital atresia reconstruction or other procedures in which rib cartilage is harvested, almost all congenital ear reconstruction can be performed under local anesthesia with or without IV or IM sedation. This technique is successful for treatment of protruding ears, even with young patients. Though many adult and pediatric patients operated upon without an anesthetist have excellent compliance, a general anesthetic is a part of many surgeons’ practices.
Ask patients to shower thoroughly and shampoo their hair the morning of surgery. Although draping hair out of the surgical field is not necessary, men should get a short haircut just before surgery, and women should braid or secure their hair so that it is not a distraction in the operative field. Prophylactic antibiotics are not routinely given. A cerebellar ring headrest, most commonly employed by neurosurgical services, allows easy access to both ears and inspection of the completed result for symmetry. A small cotton plug placed into the patient's ear canal prevents blood from becoming an unpleasant irritant of the tympanic membrane.
For anesthesia, use 0.25% Marcaine with 1:200,000 epinephrine as a direct infiltration. This has the advantage of a 6-8 hour postoperative analgesic effect. Epinephrine can be diluted to 1:400,000, if desired, with similar hemostatic effects. Using a long-acting drug such as Marcaine, infiltrate both ears (usually 5-10 mL per ear), wash hands, prepare and drape the patient, and begin surgery. This allows the epinephrine to gain its optimal hemostatic effect (after about 7 min) without wasting operating room time.
Many operative techniques are available to correct protruding ears. This means no single preferred way exists to perform the operation. Most surgeons combine several procedures. The key is to achieve symmetry and a natural-looking ear on each side. How to achieve that goal is a matter of scientific debate and discussion.
The entire operation can be performed using only a posterior incision, although some use a strictly anterior approach and others use both. The surgeon's preference and comfort level determine this. No matter which incisions and approaches are used, meticulous hemostasis and gentle handling of tissues must remain paramount. Even small hematomas can be disastrous. That stated, the author never uses drains. Close all skin incisions using a single layer of running 5-0 fast-absorbing plain gut suture.
Dissecting the skin off the cartilage up to and over the edge of the helical rim is an important element when using the posterior incision approach. Release of the skin envelope allows complete visualization of deformed cartilage without restraint from attachments to the skin. It allows a precise examination of the location of excessive conch resection as well as placement of sutures. Suture material is usually a 4-0 or 5-0 Mersilene on a small cutting needle, placed in a vertical mattress fashion.
To improve upon the natural folding of the scaphoconchal angle, score the anterior perichondral. This can be achieved even with a posterior incision by dissecting anteriorly at the root of the helix. Scoring can be performed using Georgiade otoraspers. This may be unnecessary if the physician is resecting hypertrophic conch cartilage.
Many patients are candidates for conchal resections. In the naturally aesthetic ear, the antihelical fold should lie closer to the head than the helical rim and should not obstruct the rim from a frontal view. This cannot be achieved without resecting some of the conchal cartilage. To determine the amount of excess cartilage to remove, place four 25-gauge hypodermic needles along the scaphoconchal angle with the points exposed posteriorly. Apply methylene blue to each tip and pull out the needles; the exact location of the angle can be seen on the posterior surface. Estimate a small wedge of resection, complete the excision, and remove additional cartilage as needed. This allows for a break in the cartilage and does not result in a sharp angle at the fold.
Surgery is performed on an outpatient basis; thus, patients go home the same afternoon. Patients usually are wrapped with a large turban-type dressing. Highlights of postoperative care in the author’s practice include the following:
Use fast-absorbing external skin sutures to eliminate the chance of disruption to the ear upon removal.
Drains are not used.
Use mineral oil-impregnated cotton as the direct dressing over the ear.
Place a minimal amount of the oil-cotton dressing in the posterior auricular sulcus.
After the turban is removed (4-5 d postoperatively), the patient wears a protective ear wrap (eg, loose-fitting ski headband) continuously except for showering. Use warm compresses 3 times per day for 2 weeks following turban removal.
Patient should wear the headband continuously for about a month and then at night for an additional 2 months as a safety precaution. No contact sports are allowed during these first 3 months.
Little postoperative follow-up care is required for patients who have undergone corrective surgery for protruding ears. The wrap-around turban bandage is removed at 4-5 days, and a protective headband is worn at all times for the next 2-3 weeks. Recommend that patients wear headbands at night for 2-3 months. See patients once or twice during the immediate postoperative period. Discourage aggressive contact sports for the first 3 months following surgery.
Take follow-up photographs at 4-6 months, at which point any relapse would begin to appear. At this time, patients occasionally complain about suture abscess (because of Mersilene) in the posterior auricular sulcus. Treatment usually can take place in the office by removing the offending suture. Warm compresses are also valuable. Patients with hypertrophic or keloid scar formation (a rare phenomenon) can be treated with Kenalog-40 injections.
See the list below:
Perhaps the most frequent complication of setback otoplasty is an unhappy patient with unrealistic expectations. As in all elective procedures, minimize this by lengthy discussions with the patient, parents, and significant other to ensure that all parties clearly understand what to expect.
Relapse of the protrusion is another complication unique to this operation. Relapse is not commonly observed in suture-style otoplasty but can occur if sutures break. It usually is observed within the first 6 months postoperatively. Other causes of recurrence include insufficient anterior scoring of cartilage, improper suture placement, poor postoperative compliance, and normal ear growth.
Overcorrection, resulting in an appearance of pinned-back, flat ears, can occur with either anterior scoring or posterior suturing techniques.
Distortion of the meatus may occur following conchomastoid suturing.
Patient may experience "telephone ear," a persistent prominence of the upper and lower poles away from the skull. This can be caused by overresection of the central portion of conchal cartilage, overresection of skin from the posterior surface of the concha, or overcorrection of the central portion of the antihelical fold.
"Reverse telephone ear," a prominence of the middle pole, is caused by inadequate correction of conchal excess or overcorrection of upper and lower poles of the helix and antihelix.
Another complication is obliteration of the postauricular sulcus because of excessive skin resection.
Sharp antihelical fold deformity is observed more often with anterior scoring in an effort to weaken cartilage without using sutures.
Hematoma, infection, and abnormal scarring also are complications.  A hematoma can have disastrous implications on ear reconstruction. Use meticulous care in drying the surgical field to avoid this complication, if possible. Once present, the wound must often be re-opened to allow for proper drainage and relief of the tension and pressure created by the hematoma. Theoretically, one can also use a compression dressing to prevent a re-occurrence of the hematoma. For instructions on the creation of a compression dressing, see Clinical Procedures article Drainage, Auricular Hematoma.
Infection often first manifests through local erythema, edema, and subtle fluctuance or drainage. The ear should be frequently scrutinized for signs of infection or vascular compromise. When an infection is suspected, the ear should first be cultured and empiric antibiotic therapy started. Systemic antibiotic therapy is necessary, often in addition to the use of an irrigation drain with continuous antibiotic drip irrigation.
The ear can also form scar tissue in an abnormal manner, creating a less-than-ideal appearance. The author recommends waiting at least 6 months before considering a revision of the ear to allow for the formation of scar tissue and a decrease in inflammation. The healing process can take some time; often, time can be a surgeon's best friend.
The use of Mersilene or other permanent sutures may result in extrusion (also known as “spitting of sutures”), which can be bothersome to the patient.
Outcome and Prognosis
As the ear withstands trauma well, patients typically do well after surgery. For setback otoplasty, outcome depends upon expectation. If the patient is well informed, he or she has a better outcome because it matches expectations.
Examples of preoperative and postoperative otoplasty are shown in the images below.
Future and Controversies
Future treatment of congenital ear deformities probably lies in 2 arenas. Diagnosis and surgery in utero have already been investigated with cleft lip and palate and neural tube abnormalities. Soon, other abnormalities of the head and neck, such as ear atresia, will probably at least be recognized before birth. With early diagnosis comes the hope of in utero correction.
As discussed, nonsurgical techniques emerging from Japan have been used to treat auricular deformities with nothing more than tape and head bands. Whether this will become the standard of care for the protruding ear in the 21st century is difficult to predict. As physicians advance toward minimally invasive surgery, the assumption is that parents who become aware of this nonsurgical option will choose this procedure. Patient and parent compliance is an entirely different issue.
The second area, and one that is currently occurring, is the advent of osseous integrated implants for reconstruction. As these devices become the criterion standard for dental reconstruction, their use in craniofacial reconstruction has grown. Devices and prostheses are available for surgically resected ears in the treatment of cancers. Similar implantation devices are likely to replace the vastly complex and multistaged operations currently considered state-of-the-art for the congenitally absent ear.
Lastly, advances are being made in gene therapy and tissue generation. In these fields, the reconstructive surgeon is limited only by his or her imagination. Cartilage frameworks someday may be grown in a laboratory and then implanted into an undermined skin pocket to recreate an atretic ear.
Medicolegal pitfalls associated with congenital ear deformities are similar to those found in other areas of surgery. Of particular concern to the plastic surgeon is patient satisfaction. A well-informed patient with realistic expectations of the end result is less likely to be dissatisfied with the outcome. Always address the issue of scarring with the patient, as well as the possible success or failure of cartilage grafts that may be used during surgery.
Litschel R, Majoor J, Tasman AJ. Effect of protruding ears on visual fixation time and perception of personality. JAMA Facial Plast Surg. 2015 May-Jun. 17 (3):183-9. [Medline].
Elliott RA Jr. Otoplasty: a combined approach. Clin Plast Surg. 1990 Apr. 17(2):373-81. [Medline].
Gosain AK, Kumar A, Huang G. Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty?. Plast Reconstr Surg. 2004 Oct. 114(5):1042-54. [Medline].
Gosain AK, Recinos RF. Otoplasty in children less than four years of age: surgical technique. J Craniofac Surg. 2002 Jul. 13(4):505-9. [Medline].
Janz BA, Cole P, Hollier LH Jr, Stal S. Treatment of prominent and constricted ear anomalies. Plast Reconstr Surg. 2009 Jul. 124(1 Suppl):27e-37e. [Medline].
Furnas DW. Complications of surgery of the external ear. Clin Plast Surg. 1990 Apr. 17(2):305-18. [Medline].
Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990 Apr. 17(2):383-95. [Medline].
Erol OO. New modification in otoplasty: anterior approach. Plast Reconstr Surg. 2001 Jan. 107(1):193-202; discussion 203-5. [Medline].
Furnas DW. Correction of prominent ears with multiple sutures. Clin Plast Surg. 1978 Jul. 5(3):491-5. [Medline].
Taboada-Suarez A, Brea-Garcia B, Couto-Gonzalez I, Vila-Moriente JL. Correction of protruding ears (Weerda grade I deformity) using knotless bidirectional barbed absorbable sutures. Otolaryngol Head Neck Surg. 2014 Dec. 151 (6):939-44. [Medline].
Bauer BS, Song DH, Aitken ME. Combined otoplasty technique: chondrocutaneous conchal resection as the cornerstone to correction of the prominent ear. Plast Reconstr Surg. 2002 Sep 15. 110(4):1033-40; discussion 1041. [Medline].
Obadia D, Quilichini J, Hunsinger V, Leyder P. Cartilage splitting without stitches: technique and outcomes. JAMA Facial Plast Surg. 2013 Dec 1. 15(6):428-33. [Medline].
Strychowsky JE, Moitri M, Gupta MK, Sommer DD. Incisionless otoplasty: a retrospective review and outcomes analysis. Int J Pediatr Otorhinolaryngol. 2013 Jul. 77(7):1123-7. [Medline].
Leclere FM, Vogt PM, Casoli V, Vlachos S, Mordon S. Laser-assisted cartilage reshaping for protruding ears: A review of the clinical applications. Laryngoscope. 2015 Sep. 125 (9):2067-71. [Medline].
Rubino C, Farace F, Figus A, et al. Anterior scoring of the upper helical cartilage as a refinement in aesthetic otoplasty. Aesthetic Plast Surg. 2005 Mar-Apr. 29(2):88-93; discussion 94. [Medline].
Blessing JD. Physician Assistant's Drug Handbook. Springhouse, Pa: Springhouse Pub Co; 1999.
Davis J. Part II: Aesthetic surgery. Aesthetic and Reconstructive Surgery. 1987. 129-87.
Medical Economics Staff. Physician's Desk Reference. 53rd ed. Medical Economics Co; 2000.
Wilkes GH, Wolfaardt JF. Craniofacial osseointegrated prosthetic reconstruction. Habal MB, ed. Advances in Plastic and Reconstructive Surgery. 1999. Vol 15.: 51-82.