Pediatric Annals

THE EAR AND HEARING 

Nonsurgical Treatment of Auricular Deformities in Neonates and Infants

David W Furnas, MD

Abstract

Many deformities of the external ear can be corrected by nonsurgical molding and taping techniques if treatment is begun in the early neonatal period. In years past, nonsurgical efforts at influencing the shape of infants' ears by well-meaning family members or friends were considered futile, even humorous, by physicians. In 1891, Monks reported failure in his efforts to treat prominent ears with a brass compression device. As a result, he developed one of the earliest reported surgical otoplasties.1

In 1980, Smith and Takashima2 noted that activity or inactivity of extrinsic muscles of the ear influenced the form of the ear after the time of birth. They observed that prominent ears were more common in children with Möbius's syndrome. Smith and Takashima ascribed this to inactivity of the auricularis posterior muscle associated with failure of facial nerve function. Thus, they felt that certain ear deformities in the postpartum period were acquired rather than congenital.

In 1984, Matsuo et al.3 reported successful nonsurgical correction of certain ear deformities by molding and taping the ears. Their successes included correction of prominent ears, lop ears, Stahl's ears (third crus), prolonged crus helicis, and shell ear. Matsuo et al. employed a dental compound that they shaped by hand as it polymerized and solidified. This custom-made mold was then taped to the ear and the ear was taped to the head, overcorrecting the deformity. Splinting continued until a normal auricular shape was achieved that was stable. The ears were held in their new position for approximately 3 weeks, during which progress was monitored and care was taken not to create an iatrogenic deformity. Successful correction of the deformities during approximately 3 weeks was the rule.

Auricular cartilage consists of chondrocytes and intercellular materials that are bound by collagen, elastin, and a proteoglycan aggregate. Matsuo et al.4 postulated that, in the auricular cartilage of the newborn, these materials were more loosely bound because of increased hyaluronic acid. Maternal estrogens cause a great increase in the level of hyaluronic acid in the neonatal period, and hyaluronic acid is at its maximum in auricular cartilage immediately after birth. Thus, auricular cartilage of the newborn is soft and pliable and lacks intrinsic resilience and elasticity. This soft cartilage yields readily to external forces.

Matsuo et al. studied the ears of 1,000 infants over time and observed that more than half of this group had external ear malformations of various types. They noted that a majority of these deformities were self-correcting during the ensuing months. Matsuo et al. felt that action of the extrinsic and intrinsic auricular muscles played a role in shaping the ears, as had been suggested by Smith and Takashima. As the cartilage gained elasticity, the effect of external muscle forces was overcome and the incidence of deformities diminished. In Matsuo et al.' s group of 1,000 infants, lop ear and Stahl's ear were noted in 47% just after the time of birth. But at the age of 1 year, the incidence of these deformities was only 7% of these 1,000 infants.

The total period of time needed for correction has varied widely. In one neonate, a cupped, prominent ear "snapped" into an aesthetic position with minimal pressure of the splint. When the splint was changed on the fourth day, the new position was retained. No relapse was seen on daily reexaminations. However, this was indeed the exception. The physician should be prepared to splint the ear for 6 weeks, employing the steps described. The understanding and compliance of the parents in performing these treatments cannot be overemphasized. In the only case the author attempted later than the…

Many deformities of the external ear can be corrected by nonsurgical molding and taping techniques if treatment is begun in the early neonatal period. In years past, nonsurgical efforts at influencing the shape of infants' ears by well-meaning family members or friends were considered futile, even humorous, by physicians. In 1891, Monks reported failure in his efforts to treat prominent ears with a brass compression device. As a result, he developed one of the earliest reported surgical otoplasties.1

In 1980, Smith and Takashima2 noted that activity or inactivity of extrinsic muscles of the ear influenced the form of the ear after the time of birth. They observed that prominent ears were more common in children with Möbius's syndrome. Smith and Takashima ascribed this to inactivity of the auricularis posterior muscle associated with failure of facial nerve function. Thus, they felt that certain ear deformities in the postpartum period were acquired rather than congenital.

In 1984, Matsuo et al.3 reported successful nonsurgical correction of certain ear deformities by molding and taping the ears. Their successes included correction of prominent ears, lop ears, Stahl's ears (third crus), prolonged crus helicis, and shell ear. Matsuo et al. employed a dental compound that they shaped by hand as it polymerized and solidified. This custom-made mold was then taped to the ear and the ear was taped to the head, overcorrecting the deformity. Splinting continued until a normal auricular shape was achieved that was stable. The ears were held in their new position for approximately 3 weeks, during which progress was monitored and care was taken not to create an iatrogenic deformity. Successful correction of the deformities during approximately 3 weeks was the rule.

Auricular cartilage consists of chondrocytes and intercellular materials that are bound by collagen, elastin, and a proteoglycan aggregate. Matsuo et al.4 postulated that, in the auricular cartilage of the newborn, these materials were more loosely bound because of increased hyaluronic acid. Maternal estrogens cause a great increase in the level of hyaluronic acid in the neonatal period, and hyaluronic acid is at its maximum in auricular cartilage immediately after birth. Thus, auricular cartilage of the newborn is soft and pliable and lacks intrinsic resilience and elasticity. This soft cartilage yields readily to external forces.

Matsuo et al. studied the ears of 1,000 infants over time and observed that more than half of this group had external ear malformations of various types. They noted that a majority of these deformities were self-correcting during the ensuing months. Matsuo et al. felt that action of the extrinsic and intrinsic auricular muscles played a role in shaping the ears, as had been suggested by Smith and Takashima. As the cartilage gained elasticity, the effect of external muscle forces was overcome and the incidence of deformities diminished. In Matsuo et al.' s group of 1,000 infants, lop ear and Stahl's ear were noted in 47% just after the time of birth. But at the age of 1 year, the incidence of these deformities was only 7% of these 1,000 infants.

Figure 1. Neonatal ear deformity. Lopped helix and small "third crus" (arrow) in a 2-week-old infant. The hair around the ear is clipped and the ear and the scalp are coated with adhesive solution in preparation for application of the armature and the tape.

Figure 1. Neonatal ear deformity. Lopped helix and small "third crus" (arrow) in a 2-week-old infant. The hair around the ear is clipped and the ear and the scalp are coated with adhesive solution in preparation for application of the armature and the tape.

This trend was true in all types of ear deformities that were studied except for protruding ears. Protruding ears were present in 0.4% of the 1,000 infants immediately after birth. At 1 year of age, the incidence of protruding ears had increased to 5.5%. Matsuo et al. attributed this increase to the fact that Japanese infants are kept in a supine position in their cribs. When the infants turn their heads from side to side, the ears are pressed into a position of protrusion. Matsuo et al.4 and Hirose et al.5 also noted that, if constriction of the ear accompanied a lop ear deformity, the lop ear was unlikely to spontaneously improve with time.

Matsuo et al. found that essentially all of the auricular deformities that they treated were successfully corrected if the molding and taping were undertaken in the first 3 months of life. In their experience, auricular deformities were difficult to correct after 6 months of age.

Figure 2. Materials for splints. Upper row: Roll of foam-type tape; strip of tape ready to be rolled and curved as splint; and completed "soft enchilada" splint (solid arrow). Lower row: Roll of soft copper wire; curved wire armature; and silicone tubing with armature partially inserted (open arrow).

Figure 2. Materials for splints. Upper row: Roll of foam-type tape; strip of tape ready to be rolled and curved as splint; and completed "soft enchilada" splint (solid arrow). Lower row: Roll of soft copper wire; curved wire armature; and silicone tubing with armature partially inserted (open arrow).

Recently, Yotsuyanagi et al.6 reported experience with nonsurgical treatment in 45 older children (50 ears in total). The age range was from 1 to 14 years with an average age of 3.6 years. The ears were molded with thermoplastic splints of a proprietary material that is hard hut elastic at room temperature. The material softens at 6000C, and is easily shaped by manual kneading. The average time of splint application was 2.1 months. Twenty-seven of the 50 ears that were treated showed improvement graded as excellent. Tan et al. used a flexible solder wire splint encased in plastic tubing as a substitute for plastic molding materials.7,8

The author's department has employed polymer dental compound, wire and plastic tubing armatures, and also dental wax to form the initial mold for nonsurgical treatment of ear deformities. These harder materials are discontinued as early as possible and a "soft enchilada" splint of rolled and shaped foam-type tape is substituted.

TECHNIQUE

The hair around the ear is clipped in a circumference of approximately 2 inches (Fig. 1). The scalp and the ear are coated with adhesive solution. Tincture of benzoin or other adhesive solutions are a satisfactory substitute. A molding armature formed with a core of thin, soft copper wire and padded with silicone tubing (Fig. 2) is shaped to fit the ear (Fig. 3) and is taped in place (Figs. 4 and 5).

Figure 3. Armature of curved copper wire with protective cover of silicone tubing. The armature gently supports the lopped helix and flattens the elevation of the third crus.

Figure 3. Armature of curved copper wire with protective cover of silicone tubing. The armature gently supports the lopped helix and flattens the elevation of the third crus.

Figure 4. The armature is held in position with a hemostat while the first strip of tape is applied. Adhesive solution applied to the ear aids in positioning the armature and in securing the tape.

Figure 4. The armature is held in position with a hemostat while the first strip of tape is applied. Adhesive solution applied to the ear aids in positioning the armature and in securing the tape.

Figure 5. The armature taped in place. The armature is replaced daily and the ear is inspected for any signs of pressure.

Figure 5. The armature taped in place. The armature is replaced daily and the ear is inspected for any signs of pressure.

Figure 6. "Soft enchilada" splint of rolled and curved foamtype tape taped in place. This soft splint replaces the armature after the first few days.

Figure 6. "Soft enchilada" splint of rolled and curved foamtype tape taped in place. This soft splint replaces the armature after the first few days.

The ear of a newborn is an exquisitely soft and vulnerable structure; therefore, extreme care must be taken to avoid pressure points. The armature is reapplied daily and the ear is carefully inspected. After a few days, as the ear responds to molding, the armature is replaced by a "soft enchilada" splint (Fig. 6) fashioned by rolling and curving a rectangle of foam-type tape to fit the ear. When the new shape appears stable without splinting, the ear is supported with tape alone for a few days (Figs. 7 and 8).

Figure 7. Support by tape strips alone is employed to maintain the shape of the ear in the final week (sixth week in this case).

Figure 7. Support by tape strips alone is employed to maintain the shape of the ear in the final week (sixth week in this case).

Figure 8. Appearance of the ear 8 weeks after commencement of splinting and taping, and 2 weeks after removal of the final tape supports.

Figure 8. Appearance of the ear 8 weeks after commencement of splinting and taping, and 2 weeks after removal of the final tape supports.

The total period of time needed for correction has varied widely. In one neonate, a cupped, prominent ear "snapped" into an aesthetic position with minimal pressure of the splint. When the splint was changed on the fourth day, the new position was retained. No relapse was seen on daily reexaminations. However, this was indeed the exception. The physician should be prepared to splint the ear for 6 weeks, employing the steps described. The understanding and compliance of the parents in performing these treatments cannot be overemphasized. In the only case the author attempted later than the first 3 or 4 months, parental compliance was inadequate. The author has had no experience with nonsurgical treatment for children in the 1- to 14-year age range described by Yotsuyanagi et al.6

This is a procedure that can be performed by any observant, dexterous, and patient physician who has carefully studied the features of the normal infant's external ear and who is conscious of the vulnerability of the soft tissues of the ear to damage from excess pressure.

REFERENCES

1. Monks GH. Operations for correcting the deformity due to prominent ears. Boston Medical & Surgical Journal. 1891;124:84-86. In: Goldwyn RM. George H. Monks, MD: neglected innovators. Plast Reconstr Surg. 1971;48:478-484.

2. Smith DW, Takashima H. Ear muscles and ear form. BiVrA Defects: Original Article Series. 1980;16:299-302.

3. Matsuo K, Takeshi H, Tomono T, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 1984;73:38-50.

4. Matsuo K, Hayashi R, Kiyono M, Hirose T, Netsu Y. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17:383-395.

5. Hirose T, Satoh R, Matsuo K, Iwasawa M, Netsu Y. Studies on the shape of the auricle: changes of die shape of the auricle after birth. In: Maneksha RJ, ed. Transactions of the 9th International Congress of Plastic and Reconstructive Surgery. New Delhi, India: Tata McGraw Hill; 1987.

6. Yotsuyanagi T, Yokoi K, Urushidate S, Sawada Y. Nonsurgical correction of congenital auricular deformities in children older than early neonates. Plast Reconstr Surg. 1998;101:907-914.

7. Tan SX Shibu M, Gault DT. A splint for correction of congenital ear deformities. Br J Plast Surg. 1994;47:575-578.

8. Tan SX Abramson DL, MacDonald DM, Mulliken JB. Molding therapy for infants with defonnational auricular anomalies. Ann Plast Surg. 1997;38:263-268.

10.3928/0090-4481-19990601-10

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