Psychosocial adjustment in children with port-wine stains and prominent ears

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.

Quality of Life and Psychological Effects of Port-Wine Stain: A Review of Literature

Introduction

Port-wine stain (PWS) is a congenital malformation that does not resolve spontaneously and can cause a physiological or psychological burden to the patients. At present, most of the studies done on PWS are focused on the treatment rather than the quality of life and psychological effects of the disease.

Material and Methods

A comprehensive literature search was done in MEDLINE using PubMed database, Embase^®, and Cochrane. All observational studies were included in this review.

Results

A total of 17 relevant articles with 2,135 PWS patients were included in this review. There were 36 measurement tools used to assess the quality of life and the psychological effects among PWS patients. The results showed that patients with facial PWS had a significant negative effect on their quality of life and had also suffered from psychological disabilities. The PWS lesion tends to worsen with age and may cause further adaptation problems towards the social environment, especially in children.

Conclusion

Early treatment, psychological assistance, and patient support are the key management in improving the quality of life of patients with PWS. Quality of life must be regularly assessed together with the improvement of treatment.

Correction of Congenital Auricular Deformities Using the Ear-Molding Technique

Background

Studies of the ear-molding technique have emphasized the importance of initiating molding early to achieve the best results. In the present study, we describe the immediate effects and long-term outcomes of this technique, focusing on children who were older than the ideal age of treatment initiation.

Methods

Patients who visited our institution from July 2014 to November 2015 were included. Medical charts were reviewed to collect data on demographics, the duration of treatment, the types of deformities, and the manner of recognition of the deformity and referral to our institution. Parents were surveyed to assess the degree of improvement, the level of procedural discomfort at the end of treatment, any changes in the shape of the molded auricle, and overall satisfaction 12 months after their last follow-up visits.

Results

A review of 28 ears in 18 patients was conducted, including the following types of deformities: constricted ear (64.2%), Stahl ear (21.4%), prominent ear (7.1%), and cryptotia (7.1%). The average score for the degree of improvement, rated on a 5-point scale (1, very poor; 5, excellent), was 3.5 at the end of treatment, with a score of 2.6 for procedural discomfort (1, very mild; 5, very severe). After 12 months, the shapes of all ears were well maintained. The average overall satisfaction score was 3.6 (1, very dissatisfied; 5, very satisfied).

Conclusions

We had reasonable outcomes in older patients. After 1 year of follow-up, these outcomes were well maintained. Patients past the ideal age at presentation can still be candidates for the molding technique.

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

Objectives:

To investigate the psychosocial impact of prominent ears on children, and evaluate the outcomes of otoplasty two years after surgery, using the Child Behavior Checklist to comparatively evaluate patients' psychosocial profiles.

Method and results:

A total of 198 otoplasty procedures were performed in 107 patients (85 per cent bilateral procedures). Otoplasty was performed solely in 86 patients and concurrently with other procedures in 21 patients. All children who underwent surgery obtained good post-operative results, with satisfactory correction of the deformity reported by the patients and their parents or guardians. There were statistically significant decreases in Child Behavior Checklist scores in the domains of: anxiety and depression (p = 0.028), social problems (p = 0.018), difficulties in thinking (p = 0.012), total behavioural problems (p = 0.012), internalising problems (p = 0.020) and externalising problems (p = 0.044), and near-significant decreases in scores for attention problems (p = 0.055) and aggressive behaviour (p = 0.078). There was a statistically significant increase in the score for total social competence (p = 0.031).

Conclusion:

Psychological problems associated with anatomical deformities such as prominent ears can be reduced by means of appropriate corrective surgery. Psychological support is necessary for the patient.

Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version

BACKGROUND

Appearance concerns in individuals with adolescent idiopathic scoliosis can result in impairment in daily functioning, or body image disturbance. The Body Image Disturbance Questionnaire (BIDQ) is a self-reported, seven-question instrument that measures body image disturbance in general populations; no studies have specifically examined body image disturbance in those with adolescent idiopathic scoliosis. This study aimed to validate a modified version of the BIDQ in a population with adolescent idiopathic scoliosis and to establish discriminant validity by comparing responses of operatively and nonoperatively treated patients with those of normal controls.

METHODS

In the first phase, a multicenter study of forty-nine patients (mean age, fourteen years; thirty-seven female) with adolescent idiopathic scoliosis was performed to validate the BIDQ-Scoliosis version (BIDQ-S). Participants completed the BIDQ-S, Scoliosis Research Society (SRS)-22, Children's Depression Index (CDI), and Body Esteem Scale for Adolescents and Adults (BESAA) questionnaires. Descriptive statistics and Pearson correlation coefficients were calculated. In the second phase, ninety-eight patients with adolescent idiopathic scoliosis (mean age, 15.7 years; seventy-five female) matched by age and sex with ninety-eight healthy adolescents were enrolled into a single-center study to evaluate the discriminant validity of the BIDQ-S. Subjects completed the BIDQ-S and a demographic form before treatment. Independent-sample t tests and Pearson correlation coefficients were calculated.

RESULTS

The BIDQ-S was internally consistent (Cronbach alpha = 0.82), and corrected item total correlations ranged from 0.47 to 0.67. The BIDQ-S was significantly correlated with each domain of the SRS-22 and the total score (r = -0.50 to -0.72, p ≤ 0.001), with the CDI (r = 0.31, p = 0.03), and with the BESAA (r = 0.60, p < 0.001). BIDQ-S scores differed significantly between patients (1.50) and controls (1.06, p < 0.005), establishing discriminant validity.

CONCLUSIONS

The BIDQ-S is an internally consistent outcomes instrument that correlated with the SRS-22, CDI, and BESAA outcomes instruments in a scoliosis population. The scores of the patients with scoliosis indicated greater back-related body image disturbance compared with healthy controls. To our knowledge, this user-friendly instrument is the first to examine body image disturbance in adolescent idiopathic scoliosis, and it provides a comprehensive evaluation of how scoliosis-related appearance concerns impact psychosocial and daily functioning.

Developmental disorders of the ear in children and adolescents: conservative and surgical treatment options

BACKGROUND

Developmental disorders of the ear can impair hearing and cause cosmetic deformities. In recent years, new surgical treatments have become established, above all in audiological rehabilitation.

METHOD

We selectively searched the PubMed database up to May 2013 for publications in English and Germanabout the therapeutic options.

RESULTS

No randomized trials have been performed, for both ethical and practical reasons (inadmissibility of placebo surgery, specialization of surgeons for individual techniques). To correct prominent ears, cartilage-sparing suture techniques are preferred, as they lead less often than scoring and incisional techniques to the formation of persistent, incompletely correctable ridges and scaffolding defects. The successful esthetic rehabilitation of severe deformities of the external ear is achievable through pinna reconstruction with costal cartilage (main risks: tissue defect at donor site, scaffolding resorption) or porous polyethylene (main risk: implant extrusion). The functional rehabilitation of conductive or mixed hearing impairment due to ear-canal atresia and major middle-ear deformities is preferably achieved with active middle-ear implants or bone-conduction hearing aids. Functional rehabilitation should be provided even when the hearing impairment is unilateral, in order to improve directional hearing and hearing with ambient noise. In cases of purely cochlear, unilateral, severe hearing impairment or deafness, a boneconduction hearing aid can be tried, and the individual indication for a cochlear implant can be considered.

CONCLUSION

The treatment options described here enable the affected children to benefit from complete functional and esthetic rehabilitation before they start school.

Body image of children and adolescents with chronic illness: a meta-analytic comparison with healthy peers

This meta-analysis integrates results from 330 studies on differences between body image of children and adolescents with and without chronic physical illness. Young people with a chronic illness had a less positive body image than their healthy peers although the average size of differences was small (g=-.30 standard deviation units). A comparison of diseases showed that young people with obesity (g=-.79), cystic fibrosis (g=-.50), scoliosis (g=-.41), asthma (g=-.37), growth hormone deficits (g=-.35), spina bifida (g=-.23), cancer (g=-.20), and diabetes (g=-.17) evaluated their body less positively than their healthy peers. Furthermore, levels of body dissatisfaction varied by age at onset of the disease, method for assessing body image, ethnicity, year of publication, and comparison group. Recommendations are stated for reducing effects of chronic illness on the body image of people with chronic illness.

Self-concept in youth with congenital facial differences: development and recommendations for medical providers

Congenital facial differences may impact a child's self-perception, activities and valuation, and what has been termed their "self-concept." This article reviews what constitutes self-concept, and its development during childhood and adolescence. The literature examining the role of physical appearance, specifically congenital facial differences on individuals' perceptions of self are reviewed in the context of psychosocial development. Positive self-concept can impact healthy behaviors, positive interactions with peers, and academic achievement. The role of mental health professionals in evaluating self-concept and objective measures of self-concept are discussed, and recommendations are made to assist medical practitioners regarding monitoring and encouragement of positive self-concept in children with congenital facial differences.

Otoplasty in children younger than 5 years of age

OBJECTIVE

The prominent ear is the most common congenital deformity of the auricle. It is often recommended that prominent ears be surgically repaired before children start school and most surgeons seem to perform the surgery after 5 years of age. The aim of our study is to summarize the rationale of performing otoplasty procedure in children under the age of 5, to discuss the advantages and disadvantages, and to review the patient (parent) satisfaction.

METHODS

A retrospective study was performed on 10 children under the age of 5 who underwent otoplasty procedure and was followed for over a year.

RESULTS

Ten patients (3 boys and 7 girls) between the ages of 48 months and 59 months, with a median age of 51.5 months were evaluated. Otoplasty was bilateral in 8 patients and unilateral in 2 patients. Global Aesthetic Improvement Scales of the patients were rated as "improved" or "better" at 52 weeks. The patient (parent) satisfaction was measured by a telephone survey. Parents revealed that 9 out of 10 were "very" or "completely" satisfied with the appearance and symmetry of their children's ears. We did not observe any visible disturbance or growth restriction in our patients, even in the unilateral operated group.

CONCLUSION

Timing of surgery is an issue of concern with regard to otoplasty in children. There may be significant psychosocial benefit to early intervention, particularly in light of changing norms for interaction with peers at ages considerably earlier than what had previously been thought of as the "school age." Our preference is to plan the otoplasty as young as four years of age, after the child has expressed some concern about the deformity.

Prominent ears: the effect of reconstructive surgery on self-esteem and social interaction in children with a minor defect compared to children with a major orthopedic defect

BACKGROUND

In a prospective study of patients with prominent ears, the effect of reconstructive surgery on self-esteem and social interaction was examined 1 year after surgery.

METHODS

Of 42 patients with prominent ears aged 7 to 15 years, 21 were matched with a comparison group of orthopedic patients (leg lengthening) and a control group of schoolchildren. Psychological measures evaluated self-esteem, depression, anxiety, cognition, parents' ratings of child behavior and symptoms, and parent anxiety. Semistructured interviews with the child and parents were also conducted.

RESULTS

The motivation to be operated on was pain, teasing, and feelings of being different. The satisfaction rate with the result of reconstructive surgery was high. The psychological measures of the prominent ears group had results close to those of the control group, although the leg lengthening group had lower self-esteem and higher depression and anxiety scores. With few exceptions, all patients had scores within the normal range on self-rating scales. Parents reported less activity at leisure time in both patient groups than in the control group. After surgery, parents reported improved behavior on the Child Behavior Checklist total problem score.

CONCLUSIONS

Patients with minor defects had fewer self-reported psychological and behavior problems than the major defect group. Interestingly, prominent ears patients also had low activity levels. Reconstructive surgery had no adverse effect on the prominent ears patients in this interim study but rather resulted in improved well-being. It is important to investigate further the effect of reconstructive surgery on children's self-esteem and social interaction.

Nuances of otoplasty: a comprehensive review of the past 20 years

Otoplasty for the correction of the prominent ear is a heavily debated topic in Facial Plastic Surgery. This article presents the past 20 years of literature on the topic in a concise and organized manner. The greatest area of focus is on the finer nuances between cartilage-sparing and cartilage-incising techniques. In addition, some of the latest research on anesthesia techniques, nonoperative approaches, and social issues are discussed.

Quality of Life in Vascular Anomalies

Hemangiomas and vascular malformations that cause disfigurement or functional limitations may affect the quality life of the affected individual and their families. Negative reaction from strangers, social stigmatization, sadness, stress and low self-esteem are some of the commonly reported effects of having such lesions. Extensive and accurate education about the disease process and advice from support groups may improve quality of life. Psychological intervention may be indicated for some individuals and families.

Introduction of the flash-lamp pulsed-dye laser treatment of facial port-wine stains in childhood: A case of health care technology assessment

BACKGROUND AND OBJECTIVE

Lasers have been used in the treatment of port-wine stains (PWS) for more than 30 years. With the introduction of the flash-lamp pulsed-dye laser (FPDL) it was assumed that infants could be treated safely, effectively, and probably more efficiently. Nowadays, FPDL treatment is an established form of treatment of PWS in childhood.

STUDY DESIGN/MATERIALS AND METHODS

On the basis of the iterative Health Care Technology Assessment (HCTA) loop, we examined whether sufficient evidence from evaluations has been present to support the introduction of FPDL treatment for facial PWS at an early age. Such an assessment requires an interdisciplinary approach focusing on aspects of safety, efficacy, effectiveness, quality of life, costs, and the ethical issues of treatment.

RESULTS

Assessment of the FPDL in PWS treatment of children did not follow the model of medical innovation and evaluation. Most assessments have been focused on laser applications that were already in clinical use. Efficacy and effectiveness of laser treatment have been the major concern in most assessments. Only a few studies have looked at costs and ethical aspects of treating children.

CONCLUSIONS

The introduction and diffusion of the use of the FPDL in the treatment of PWS in childhood were uncontrolled, and the field was not prepared to use this technique properly. We believe that this nonadherence to the iterative HCTA model reflects the gradual way by which innovations find their way into clinical practice.

Management of large birthmarks

Birthmarks are commonly seen in neonates. Most are insignificant incidental findings and straightforward in their diagnosis and management. Others are of more serious concern and may require intervention for medical or cosmetic reasons. They may also be an indication of abnormalities in other organ systems. This chapter will focus on the diagnosis and management of large vascular and pigmented birthmarks. A multidisciplinary team approach involving paediatricians, dermatologists, plastic surgeons and other specialists is often required in the management of these children.

Assessing adolescents and young girls for plastic surgical intervention: pre-surgical appearance ratings and appearance-related burdens as reported by adolescents and young adults, parents and surgeons

Currently available research on psychological aspects of plastic surgery offers little basis for clinical decision making in the plastic surgeon's assessment of adolescents and young adults applying for surgery. Therefore, the research aims were to study: first, how these adolescents and young adults estimate their appearance as compared to their parents and plastic surgeons to determine the reality of their own appearance perception; second, what appearance-related burdens they experience to determine the urgency of their request for surgery; and third, the surgeons' considerations for the operation. Data were obtained from 184 plastic surgical patients aged 12-22 years (71.2% girls), 172 of their parents and 37 surgeons from 16 hospitals in The Netherlands, using appearance rating scales and to surgeons and parents, and reported substantial appearance-related suffering. There was a moderate to large overlap between the adolescent- and parent-reported burdens. In their assessment, surgeons took psychological and social impediments into consideration. In conclusion, plastic surgeons may rightfully assume that adolescents and young adults have a realistic view of their appearance and that they suffer from significant appearance-related burdens. Parents prove to be an important additional source of information.

Stress and family satisfaction in parents of children with facial port-wine stains

A cross-sectional survey was employed to assess parenting stress, family satisfaction, and parental concerns and to determine predictors of stress in parents of children with port-wine stains (PWSs). The participants were 46 parents of 24 children receiving treatment with pulsed dye laser photocoagulation for facial PWS at an outpatient dermatology clinic based at a university medical center. Outcome measures used were self-report instruments assessing psychosocial adjustment (Parenting Stress Index, Family Satisfaction Scale, and Parental Concerns Questionnaire). As a group, parents scored in the average range on the stress and family satisfaction measures when compared with a normative sample; five parents (11%) scored in the clinical range for stress. Forty-nine percent of the variance in parenting stress was accounted for by four variables: the child's age (beta = 0.34; p = 0.031), the parents' degree of family satisfaction (beta = -0.27; p = 0.077), the level of parental concern regarding the child's facial PWS (beta = 0.45; p = 0.005), and the parents' satisfaction with staff communication (beta = -0. 51; p = 0.002). The data suggest that while, as a group, parents of children with a facial PWS report to be in the average range for psychological stress, some do not fare as well as others. Factors associated with lower stress include younger children, more family cohesion and adaptation, fewer parental concerns, and greater satisfaction with parent-staff communication. The potential for the development of medical complications and psychological problems over time suggests the need for treatment of the PWS at an early age. Health care providers should be prepared to screen for clinical levels of distress and to refer parents for psychological intervention when needed.

Psychosocial adjustment of children and adults with port wine stains

OBJECTIVES

To assess the impact of a facial port wine stain (PWS) on behavioural problems in children and on health related quality of life in adults applying for laser treatment.

DESIGN

A survey by questionnaire of patients with PWS not previously treated.

OUTCOME MEASURES

Two standard general instruments and a more specific PWS questionnaire were used. Adolescents and adults (13-31 years) received a short version of the RAND Health Insurance Questionnaire from the Medical Outcome Study (MOS-24). Children's (4-12 years) parents received the Child Behaviour Checklist (CBCL). A specific PWS questionnaire was sent to both age groups.

ANALYSIS

The results of the MOS-24 were compared with those of a reference population without chronic illness. Observed behaviour in children was compared with data from a Dutch reference group, from children with constipation and from another group of children with a PWS.

RESULTS

41 MOS-24 and 41 CBCL were returned (91% and 95% response rates, respectively). Adolescents and adults reported little effect on role and social functioning, but showed low scores for mental health, self-perceived health and vitality/health. Children's parents reported no clinically significant problem behaviour (T-score > 70). Adults experienced more negative psychosocial consequences of having a PWS than children (specific PWS questionnaire).

CONCLUSIONS

Children with PWS do not show significant problem behaviour. Adolescents and adults reported less vitality/energy than was expected in this age group. Adolescents and adults showed statistically significant negative consequences of their PWS in social contacts compared to children (P < or = 0.01, Mann-Whitney).