Long-term psychosocial impact of otoplasty performed on children with prominent ears

Ear Molding Therapy of Congenital Ear Anomalies: Long-Term Aesthetic Outcomes and Caretaker Satisfaction

INTRODUCTION

Ear molding is a safe, non-surgical approach to treat newborns with congenital ear anomalies. In this study, we aimed to investigate long-term aesthetic outcomes and caretaker satisfaction from ear molding therapy.

METHODS

A retrospective chart review from 2018 to 2020 was conducted for infants who underwent ear molding treatment at our institution. Patient demographics and treatment related variables were collected. Caretakers were surveyed regarding their experience, expectations, and aesthetic outcome at 1 year (short-term) and 3 years (long-term) from treatment. Independent physicians evaluated treatment efficacy. Responses were converted to a Likert scale (1-5), with 5 representing most desirable.

RESULTS

Overall, 38 of 42 patients participated in our long-term study (90%) for a total of 62 ears. Average follow-up was 3.31 ± 0.50 years after completion of treatment. Mean age at treatment was 23.2 ± 19.7 days with a mean treatment duration of 21.7 ± 7.7 days. Caretakers' satisfaction regarding auricular appearance remained high (short-term: 4.18 vs. long-term: 4.17, p = 0.54) and anticipated social distress decreased over time. Physician aesthetic evaluations were favorable between "somewhat effective" and "very effective" and remained consistent over time (short term: 3.46 vs. long-term: 3.31, p = 0.31). Furthermore, physician evaluations were higher for deformations than malformations (p = 0.04) and in children who began treatment by 30 days old (p = 0.04).

CONCLUSION

Caretaker satisfaction from ear molding therapy remained high after long-term follow up, and social distress from the perception of their child's ears decreased with time. Physician aesthetic ratings confirmed efficacy, with better outcomes seen in deformations than in malformations.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The psychosocial impact of microtia and ear reconstruction: A national data-linkage study

Introduction

Children with visible facial differences are believed to be at increased risk of negative psychosocial behaviours which may manifest as affective disorders. The aim of this study was to determine whether a diagnosis of microtia, and the associated surgical intervention, is associated with psychosocial implications including impaired educational attainment and a diagnosis of an affective disorder.

Methods

A retrospective case-control study was conducted using data linkage to identify patients in Wales with a diagnosis of microtia. Matched controls were sought on the basis of age, gender and socioeconomic deprivation status to yield a total sample size of 709. incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Educational attainment at 11 years of age, plus a diagnosis of depression or anxiety were used as markers of adverse psychosocial outcomes and the relative risk was attained using logistic regression analyses.

Results

There were no significant associations between a diagnosis of microtia and an increased risk of adverse educational attainment or a risk of an affective disorder diagnosis. Male gender and higher deprivation scores were significantly associated with poorer educational attainment, irrespective of a diagnosis of microtia. Surgical intervention of any nature was also not associated with any increased risk of adverse educational or psychosocial outcomes in microtia patients.

Discussion

Microtia patients in Wales do not appear to be at greater risk of developing affective disorders or impaired academic performance as a result of their diagnosis or associated surgical intervention. Whilst reassuring, the need for appropriate support mechanisms to maintain positive psychosocial wellbeing and academic achievement in this patient cohort is reinforced.

Non-Surgical Correction of Congenital Ear Anomalies: A Critical Assessment of Caretaker Burdens and Aesthetic Outcomes

INTRODUCTION

Congenital ear anomalies result from cartilage and skin compression in utero. They can be corrected in infancy before the cartilage hardens and loses its malleability. Caretaker burden of ear molding and its impact on esthetic outcomes has not been studied.

METHODS

Demographic and procedural variables were retrospectively collected for infants who underwent ear molding. Parents were surveyed regarding their experience, caretaker burden, and esthetic outcome. Outside physicians were provided with pre- and post-treatment photographs and asked to rate outcomes. A Likert scale was developed for responses and converted to a numeric score from 1 to 5 with 5 as the most desirable.

RESULTS

Seventy-four patients comprising 121 ears were included. Mean age at treatment was 20.1 ± 21.4 days with treatment duration of 21.1 ± 7.7 days. Parental participation in the survey was 70.1%. Questions that queried parents' experiences revealed a "very positive" experience with minor burden related to bathing and cleaning (Mean Likert Score 4.1, Range 1-5). Favorable parent-reported outcomes were obtained regarding anticipated social distress (4.28, 1-5), satisfaction with results (4.27, 1-5), and perception of final appearance (4.18, 1-5). Physician assessments of esthetic outcomes were slightly lower, but favorable between "somewhat effective" and "very effective" (3.46, 1-5). Earlier treatment trended favorably, but did not reach significance. Ear malformations had higher parent-reported satisfaction than ear deformations (4.75 ± 0.46 vs 4.21 ± 1.25, p = 0.025).

CONCLUSION

Despite the additional obligation for new parents, infant ear molding is rated low in terms of caretaker burden. Esthetic outcomes are excellent as assessed by parents and physicians. However, caretakers reported higher esthetic outcomes than physician evaluations.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Spontaneous Resolution of Ear Lidding in Newborns: A Prospective Observational Cohort Study

ABSTRACT

Ear lidding is a cosmetic outer ear shape deformity commonly observed in newborns. Although lidding is considered a benign condition, psychological concerns such as bullying and depression have been observed in older children supporting correction of the condition. Nonsurgical correction of lidding using molding and splinting techniques has become increasingly popular, achieving successful outcomes in the majority of cases. Spontaneous resolution of the condition has also been reported in the literature however there is minimal prospective data available on the natural progression of ear lidding. In our case series of 11 closely followed newborns, we aimed to characterize the natural progression and resolution of lidding. Ten consecutive newborns participated in the observation plan and all 10 had complete spontaneous resolution of lidding within an average of 40 days. One other newborn's parents self-selected to have molding and splinting treatment. These results suggest that cosmetic treatment for less severe cases of ear lidding may be unnecessary as they have the potential to resolve on their own. Future research in this area could include controlled study designs and more work is needed to identify, which infants will require treatment. Our study may provide helpful reassurance to families and physicians that many newborns may see complete resolution of lidding without intervention.

A Cross-Sectional Analysis of American Insurance Coverage of Prominauris Otoplasty

BACKGROUND

Prominent ears affect up to 5% of the population and can lead to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. The authors assessed insurance coverage of all indications of otoplasty and their medical necessity criteria.

METHODS

A cross-sectional analysis was conducted of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies.

RESULTS

Of the 58 insurance policies assessed, 25 (43%) provide coverage of otoplasty. There were 2 indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 14, 56%), which would encompass prominent ears. Normal approximation was a covered indication for significantly fewer insurers than hearing loss (56% versus 80%, P = 0.0013). Of all the otoplasty policies which covered normal approximation, 21% (n = 3) addressed protruding ears as an etiology. Prominent ears were not included in any policies which covered hearing loss. All policies inclusive of prominent ears required a protrusion of >20 mm from the temporal surface of the head (n = 3, 100%).

CONCLUSIONS

There is a great discrepancy in insurance coverage of otoplasty. A greater proportion of policies cover hearing loss compared to normal approximation. The authors encourage plastic surgeons to advocate for the necessity and coverage of normal approximation by insurers.

Ear Abnormalities

Congenital ear abnormalities present an aesthetic and psychosocial concern for pediatric patients and their parents. Diagnosis of external ear deformities is based on clinical examination and is facilitated by an understanding of normal ear anatomy. Ear anomalies can be categorized as malformations or deformations. Malformations are characterized by absent anatomical structures of the ear (or absence of the ear itself), as exemplified by microtia and anotia. Ear deformations are characterized by ear anatomical landmarks that are present but are distorted or abnormal, with Stahl ear, constricted ear, and prominent ear being common presentations. Ear malformations will not improve with growth of the patient and uniformly require surgical intervention to recreate an anatomically typical ear. Although a small percentage of ear deformations can self-resolve, most patients with ear deformations will require nonsurgical or surgical reconstruction to achieve a normal or more aesthetic ear. In recent decades the use of nonsurgical ear splinting or molding has been recognized as a highly effective method in correcting a variety of congenital ear deformations when treatment is initiated in the first 8 weeks of life. The urgency in initiating nonsurgical treatment of ear deformations at an early age makes prompt recognition of these ear deformations essential because surgical correction remains the only viable reconstructive option in older infants and children.

Understanding child anxiety before otoplasty: A qualitative study

BACKGROUND

Pre-operative anxiety in pediatric patients is a major concern in surgical care due to the future medical and behavioral consequences that can occur. The objective of this study was to understand the factors that lead to pre-operative anxiety before otoplasty.

METHODS

Participants at a Canadian pediatric hospital were identified to discuss their experience with otoplasty and any anxiety they experienced using a semi-structured interview. Interviews were transcribed and analyzed using a qualitative semantic thematic approach. Major themes were identified and supporting quotes were extracted from the interviews.

RESULTS

Ten participants were enrolled in the study. Three main themes (and seven subthemes) were identified: concern for post-operative well-being (perception by others, physical well-being, and negative experiences), fear of the unknown (surgical uncertainty, vulnerability), and support (family and friends, surgeon).

CONCLUSIONS

Otoplasty was shown to be an emotional experience for participants with multiple sources of anxiety being identified. While most anxiety sources were similar to those for other pediatric surgeries, a number were specific to otoplasty and its post-operative care plan. This understanding of anxiety will allow physicians and care teams to better prepare patients and their families for otoplasty and enhance the patient's overall experience.

Cartilage-Sparing Otoplasty: The Effects of Adipo-Perichondrial Flap-Assisted Posterior Auricular Muscle Complex Flap Technique on the Repair of Prominent Ear Deformities

BACKGROUND

In the repair of prominent ear deformities, the main objectives are to recreate the antihelical fold, reduce projection in patients with a large concha, and normalize the distance between the ear and the cranium. This study evaluated the efficacy of the adipo-perichondrial flap-assisted posterior auricular muscle complex (PAMC) flap technique, which involves a new approach to the repair of prominent ear deformities.

MATERIALS AND METHODS

A medially based PAMC flap and a laterally based adipo-perichondrial flap were elevated in 22 patients with prominent ear deformities. In order to shape the ear, the PAMC flap was sutured to the transition zone between the helix and antihelix, and the adipo-perichondrial flap to the periosteum of the mastoid bone. The ear-cranium distances were measured preoperatively and at postoperative first and sixth months.

RESULTS

Thirteen patients were female and 9 were male. The mean age of the patients was 19.4 years, and the mean follow-up period was 10.6 months. The ear-cranium distance significantly decreased in the postoperative first-month and sixth-month evaluations compared to the preoperative values (P < .05). No relapse, suture exposition, hematoma, keloid scar, or infection was observed.

CONCLUSION

Posterior auricular muscle complex is a strong anatomical structure that includes the trapezius muscle, occipital muscle, extrinsic ear muscles, temporal fascia, and sternocleidomastoid fascia. By elevating this structure as a flap and combining it with an adipo-perichondrial flap, successful results can be achieved in the repair of prominent ear deformities, which prevents relapses and maintains the shape of the ear in the long term.

Prospective Evaluation of Psychological Healing in Adults Who Underwent Otoplasty for Prominent Ear

BACKGROUND

Otoplasty is performed to heal the psychological discomfort caused by the appearance of prominent ear by bringing the ear to its anatomical position. However, there have been few studies with limited numbers of patients that have prospectively evaluated psychosocial recovery following otoplasty in adults. The purpose of this prospective study was to evaluate the versatile psychological recovery that can be achieved in adults following otoplasty.

METHODS

In this prospective cohort study, a single-group, pretest-posttest model was used as the experimental research model. Patient satisfaction status was measured, and the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory I-II (STAI I-II), Rosenberg Self-Esteem (RSES), and Body Cathexis Scale (BCS) tests were performed on patients before and after surgery.

RESULTS

A total of 66 patients with a mean age of 20.7 ± 3.1 years, 66.7% of whom were women, were included in the study. While 97% of the patients were satisfied with the results of the operation, 3% were undecided. The mean values of the BDI, STAI-I, STAI-II, and BCS before and after surgery were 11.4 ± 5.7, 40.9 ± 6.7, 43 ± 9.4, 74.2 ± 20.5, and 8.5 ± 5.5, 38.6 ± 7.4, 39.5 ± 9.2, 63.5 ± 17.6, respectively. While the proportion of patients with a high RSES score before surgery was 42.42%, the proportion after surgery was 96.96%. The differences in the mean scores of all tests before and after surgery were also statistically significant (p < 0.05).

CONCLUSION

Our study demonstrated that otoplasty made positive contributions to body perception, self-esteem, anxiety, and depression in adults. Otoplasty is as beneficial in adults as it is in pediatric patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ear Molding Therapy: Laypersons' Perceptions, Preferences, and Satisfaction with Treatment Outcome

Supplemental Digital Content is available in the text.

This study investigates laypersons’ perceptions of congenital ear deformities and preferences for treatment, particularly with ear molding therapy—an effective, noninvasive, yet time-sensitive treatment.

"Auricular reconstruction: A sociocultural, surgical and scientific perspective"

The functional and sociocultural role of the auricle has been prevalent in art, literature and history for millennia. It is no surprise, therefore, that auricular anomalies can be associated with affective disorders and impaired academic performance in children. The challenge of auricular reconstruction has captured the attention of surgical innovators for millennia with the earliest records of auricular reconstruction documented in the Edwin Smith Surgical Papyrus dating back to 3000 BCE. Since the 19th century, however, the interest in the ambition partial and total auricular reconstruction witnessed a rebirth, with refinements in frame construction, projection and skin coverage improving exponentially over the last two centuries. The gold standard auricular reconstruction practices today have their roots in these historical milestones, and form a solid foundation for the introduction of technological advancements such as 3D bioprinting and composite tissue allotransplantation into future auricular reconstruction practice. The aim of this review is to outline the sociocultural role of the auricle, the history and evolution of auricular reconstruction surgery and to provide an insight into potential future avenues of restoring auricular form and function.

Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life

Background

An early observation after chest wall correction is direct inspection from the PE patient of their “new” thorax. Changes in self-perception may give raise to other psychological adaptations. The aim of this study was to evaluate the early changes in the fields of self-esteem, body image and QoL.

Methods

Prospective observational longitudinal multicenter cohort study. Self-esteem, emotional limitations and general health were assessed using the Child Health Questionnaire (CHQ) in patients under 18 and the World Health Organization Quality of Life Questionnaire-bref (WHOQOL-bref) was used for body image, psychological domain and overall QoL in patients over 16 years of age. Measurements were taken before surgery (T1) and 6 weeks (T2), and 6 months thereafter (T3).

Results

Scores on post-operative self-esteem were significantly higher compared with scores pre-operatively (p < 0.007). Also body image, psychological domain and emotional limitations showed significant improvement, respectively p < 0.001, p < 0.001, and p < 0.016. Significant improvement in the first three components was mainly achieved in the first 6 weeks post-operative. In emotional limitation, however, the largest change was between 6 weeks and 6 months. Overall quality of life in the WHOQOL-bref and general health domain in the CHQ showed no significant improvement in relation to the pre-operative scores.

Conclusion

Post-operative PE patients after Nuss procedure showed an improved body image, increased self-esteem and increased psychological resilience in the first 6 months, with the most marked change in the first 6 weeks. Also emotional limitations changed significantly over time. The changes were not large enough to influence general QoL or general health significantly.

Proposal of a Classification System for the Assessment and Treatment of Prominent Ear Deformity

BACKGROUND

Prominent ear is the most common external ear deformity. To comprehensively treat prominent ear deformity, adequate comprehension of its pathophysiology is crucial. In this article, we analyze cases of prominent ear and suggest a simple classification system and treatment algorithm according to pathophysiology.

METHODS

We retrospectively reviewed a total of 205 Northeast Asian patients' clinical data who underwent an operation for prominent ear deformity. Follow-up assessments were conducted 3, 6, and 12 months after surgery. Prominent ear deformities were classified by diagnostic checkpoints. Class I (simple prominent ear) includes prominent ear that developed with the absence of the antihelix without conchal hypertrophy. Class II (mixed-type prominent ear) is defined as having not only a flat antihelix, but also conchal excess. Class III (conchal-type prominent ear) has an enlarged conchal bowl with a well-developed antihelix.

RESULTS

Among the three types of prominent ear, class I was most frequent (162 patients, 81.6%). Class II was observed in 28 patients (13.6%) and class III in 10 patients (4.8%). We used the scaphomastoid suture method for correction of antihelical effacement, the anterior approach conchal resection for correction of conchal hypertrophy, and Bauer's squid incision for lobule prominence. The complication rate was 9.2% including early hematoma, hypersensitivity, and suture extrusion. Unfavorable results occurred in 4% including partial recurrence, overcorrection, and undercorrection.

CONCLUSIONS

To reduce unfavorable results and avoid recurrence, we propose the use of a classification and treatment algorithm in preoperative evaluation of prominent ear.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Otoplasty for prominent ears - demographics and surgical timing in different populations

INTRODUCTION

Prominent ears are seen in approximately 5% of the population. This benign condition can be treated surgically to reduce or prevent psychological and social problems, most commonly in children before the start of school. Our aim was to examine the demographic characteristics of patients undergoing prominent ear surgery in Finland, and compare findings with international data.

METHODS

A retrospective study of all the patients treated for prominent ears in our academic tertiary care referral center during 2007-2011 was performed to gather demographic details of operated patients. A systematic review of published series of prominent ear surgery after the year 2000 was performed to gather demographic details for international comparison.

RESULTS

A total of 180 patients were operated in our institution for prominent ears, most of the cases (78.9%) were bilateral. Age at operation ranged between 3 and 36 years, with mean of 9.2 y and median of 7 y. The most common reason for seeking operative treatment was aesthetic complaint, followed by bullying. Review process gathered 20 publications, describing a total of 4433 patients who had been operated for prominent ears. There was wide variation the mean age at operation, ranging 7-38 y while the mean overall was 15.0y. Gender distribution of patient samples was also very variable, with percentage of females ranging from 38 to 71% (overall 52%). There was also considerable variation in the tendency to perform unilateral operations: from 0% up to 21% of the reported population. There were no statistically significant correlations linking these demographic variables, though there was a trend that females are more likely to have this operation performed at an older age.

CONCLUSIONS

The treatment culture of prominent ear surgery varies substantially in international comparison. The age at which this operation is performed showed most variation. Omitting some of the basic demographic variables while reporting the results of surgery was common in the reviewed publications.

A novel approach for classifying protruding ears is easy to calculate and implement in daily clinical practice

AIM

Protruding ears are a prevalent deformity, with a reported incidence of 5% in the paediatric population, but it lacks a simple digital classification. The aim of this study was to find a parameter that would objectively allow the photographic classification of protrusion, by comparing frontal facial images of patients with protruding ears with aged-matched controls.

METHODS

This prospective cohort study compared the frontal facial images of 105 patients with protruding ears with 112 aged-matched controls without protruding ears. A rectangle was drawn on the image for each ear, encompassing its full visible anatomy. The width of each rectangle was divided by its height to create an index. The mean value of both ears was defined as the Frontal Aesthetics Translation Index for Measurement of Amplitude of the Ears (FATIMAE).

RESULTS

The calculated values for group with protruding ears were significantly higher than for the controls. No gender differences were found. However, the FATIMAE values decreased with age, establishing different classification criteria for separate age groups.

CONCLUSION

The FATIMAE is easy to calculate and implement in daily clinical practice and establishes a practical approach for classification of protrusion, as well as for referral criteria for a specialised surgical consultation.

Patient-performed pinnaplasty using industrial nail glue

Malformations of the pinna occur in around 2-5% of all newborns. Prominent ears in childhood can be a source of psychological distress and lead to bullying and social exclusion. We present the case of a 14-year-old girl who inflicted chronic, non-healing wounds in the post auricular area bilaterally after attempting to glue back her ears with industrial strength glue. To our knowledge, this is the first case of its kind to be published.