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| Journal of the New Zealand Medical Association,
12-September-2003, Vol 116 No 1181
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Correction of deformational auricular anomalies by moulding
– results of a fast-track service
Swee Tan, Anna Wright, Anna Hemphill, Kari Ashton and Joan
Evans
The ear or the auricle consists of a complex, convoluted,
yellow elastic cartilage framework that is covered with hairless skin. The
convoluted prominences and concavities of the underlying cartilage give rise to
the characteristic topographic anatomy of the human ear (Figure
1).1
The helix is the most external portion of the auricle. It
consists of the root, anterior, superior and posterior portions. The lobule
consists of fibro-fatty tissue and does not contain cartilage. The antihelix,
which separates the concha from the helix, is a Y-shaped structure consisting of
a body inferiorly and two crura superiorly. The body of the antihelix blends
into the antitragus, which is sited superior to the lobule. The antitragus is
separated from the tragus by the intertragic notch. The tragus is located
anterior and lateral to the external auditory canal, thus partly obscuring it.
The scaphoid fossa lies between the superior crus and the body of the antihelix
anteriorly and the helix posteriorly. The crura of the antihelix and anterior
part of the helix form the boundaries of the triangular
fossa.1
Figure 1. The topographic anatomy of the human
ear (RH = root of the helix; CF =
conchal fossa; AH = anterior portion of the helix; IC = inferior crus of the
antihelix; SC = superior crus of the antihelix; SH = superior portion of the
helix; PH = posterior portion of the helix; L = lobule; B = body of the
antihelix; AT = antitragus; T = tragus; ITN = intertragic notch; SF = scaphoid
fossa; TF = triangular fossa)
 There are at least 40 descriptive and eponymous terms used
to categorise congenital auricular anomalies.1
This heterogeneous group of anomalies should be classified as either
malformational (eg, auricular tags and sinuses, anotia, microtia and cleft ear)
or deformational (eg, lop, cup, Stahl’s, kinked and prominent
ear).1,2 Malformations are structural
abnormalities that result from abnormal embryological development. Deformation
is caused by abnormal physical forces applied to a normal structure, which may
occur in utero or following birth. Similarly, a malformed ear may be subjected
to deformational forces.1 The majority of
congenital auricular anomalies are deformational in
nature.1
A deformational auricular anomaly can be simply defined as
an ear having normal chondrocutaneous components but with an abnormal
architecture; therefore, it can be manipulated digitally to a normal
shape.1,2 These auricular anomalies usually
affect the helix and antihelix, although occasionally the deformation is
confined to the conchal fossa.2
Conventionally, both malformational and deformational
auricular anomalies are corrected surgically when the ear has adequately
grown,2 although with variable
results3,4 and significant complication
rates.2 Moulding therapy is effective for
deformational2,5–8 and certain
malformational9 auricular
anomalies. Although this simple, effective and
inexpensive technique has been available for over 20 years, its wider acceptance
in Western countries has occurred only relatively
recently.7,8
For a satisfactory outcome, moulding therapy should be
initiated within the first three months of
life.2,7 However, children with congenital
auricular anomalies are normally referred ‘routinely’ to the plastic
surgery service and the narrow ‘window of golden opportunity’ for
moulding is often missed. Having demonstrated the value of auricular moulding
therapy to our neonatal paediatricians, family doctors, and midwives, we have
established a fast-track referral and treatment protocol for infants with
deformational auricular anomalies. This report presents, prospectively, the
results of our approach.
MethodsProtocol
The protocol aimed at identifying newborn infants with deformational
auricular anomalies with a view to early correction with moulding therapy. These
patients were referred by our neonatal paediatricians, general practitioners,
and community midwives through a fast-track referral service established at the
Department of Plastic & Reconstructive Surgery, Radcliffe Infirmary, Oxford,
England and the Wellington Regional Plastic, Maxillofacial & Burns Unit,
Wellington, New Zealand. During the study period, several children with
malformational auricular anomalies were referred for treatment. These children
were excluded from this study.
The obstetric, perinatal and family history and
associated anomalies, if present, were recorded and managed appropriately. The
type and severity of the auricular anomaly were documented both clinically and
photographically. Moulding therapy was offered to these children and was
initiated promptly by one of four nurses who were familiar with the indications
and technique of this treatment.
Technique
Various materials have been used for auricular
moulding.2,5,7–10 We utilised a simple
splint fabricated by inserting a piece of lead-free solder (Multicore Solders
Ltd, UK) within an 8 French polyethylene
suction catheter (Figure 2).2,7 The splint was
customised for each ear with its length determined by the extent of the
deformity. It was applied to the eave of the helical rim and secured to the ear
with Steri-Strips (3M, St Paul, MN) to maintain the ear in the corrected
position (Figure 3). In addition, the ear was taped to the mastoid scalp if it
was protruding (Figure 4). The parents of the infants under treatment were
taught the moulding technique and were given an information sheet outlining the
treatment protocol. They were instructed to inspect and reshape the splint and
replace the adhesive tapes if necessary after each feed. The splint was replaced
weekly and the parents were asked to observe for skin irritation or ulceration.
Treatment was maintained until satisfactory correction was achieved and
continued for a further week, or discontinued if no improvement was observed
after four weeks of continuous moulding.
The infant was reviewed by a
nurse weekly for two weeks, at one
month and then monthly for up to three months. The nurses provided the point of
contact for the parents and arranged for a routine plastic surgical review
whenever necessary.
Figure 2. A simple splint consisting of a lead-free
soldering wire and an 8 French suction catheter. The length of this device is
dependent on the extent of the auricular deformity being corrected, a short
splint being used to correct a localised deformity, and a longer splint required
for a more extensive anomaly.
 Figure 3. Bilateral cup ear anomaly in a one-week-old
boy. (A) The more severely affected right ear was corrected (B) with a long
splint. (C) Improvement after three months of moulding (result = ‘marked
improvement’).
 Figure 4. (A) Right-sided prominent ear with absent
antihelical fold in a two-week-old child born five weeks prematurely (B) treated
with a splint and taping of the ear to the mastoid scalp. (C) Excellent result
(with creation of antihelical fold and reduction of distance between the helical
rim and scalp from 3.0 to 1.2 cm) after 16 weeks of treatment (result =
‘marked improvement’).
 Assessment
Clinical and photographic documentation of the auricular anomaly was
obtained prior to the commencement of treatment and three months following
completion of moulding therapy. The result of treatment was assessed by
comparing pre- and post-treatment photographs and graded as: 1 = complete
correction; 2 = marked improvement; 3 = slight or no improvement. A postal
questionnaire was also dispatched to the parents of the patients three months
following cessation of therapy. The parents were asked to score the results
using the grading described above. They were also asked to indicate whether the
moulding technique was ‘easy’, ‘difficult’, or
‘very difficult’. To help us evaluate parents’ satisfaction
with the therapy, they were asked if the treatment was worthwhile and whether
they would recommend it to other children with a similar auricular
anomaly.
ResultsThirty consecutive children (16 boys
and 14 girls) with 44 deformational auricular anomalies were the subject of this
report. The auricular anomalies affected the right side, left side and both
sides in 9, 7 and 14 children respectively. There were 17 lop ears (11
patients), 14 prominent ears (10 patients), 8 cup ears (6 patients), and 5
kinked ears (3 patients).
Nineteen children were full term, 2 were one week overdue
and 9 children were born prematurely (11, 5, 3 and 1 weeks premature in 1, 3, 2
and 3 infants respectively). Ten children had associated obstetric problems
(mild gestational hypertension in 4, oligohydramnios in 1, gestational diabetes
in 1, breech delivery in 2, and birth by Caesarean section in 2). Associated
anomalies included distal hypospadias in one child and respiratory distress
syndrome in another. Five of the 10 children with prominent ear(s) had a
positive family history of the anomaly.
Moulding therapy was initiated between one day and 15 weeks
(mean 24 days) after birth and treatment was maintained for one to 14 (mean 7)
weeks. The children were followed up for 5 to 11 (mean 8) months. An excellent
result was achieved in 13 children (19 ears) and marked improvement occurred in
13 children (19 ears) (Figures 3–6). Slight or no improvement occurred in
4 patients (6 ears). In the last group, treatment was interrupted by systemic
illness in one child and was associated with poor compliance in the remainder.
In two of these patients, treatment was initiated at 15 and 10 weeks
respectively and these children removed the splints repeatedly.
Figure 5. (A) Left-sided lop ear in a three-day-old
child moulded for three weeks (B) with improvement (result = ‘marked
improvement’).
 Figure 6. (A) The more severely affected left side of a
three-day-old child with bilateral kinked ear deformity splinted for three weeks
(B) with improvement (result = ‘marked improvement’).
 Complications included skin irritation in 4 children (4
ears) requiring temporary cessation of moulding therapy. No skin ulceration
occurred and no relapse of the anomaly was observed during the follow-up
period.
Twenty four of the 30 questionnaires (80%) were returned by
the parents of the children treated. According to the parents’ assessment,
‘excellent result’ was achieved in 10 patients (14 ears),
‘marked improvement’ occurred in 10 patients (15 ears) and
‘slight or no improvement’ in 4 patients (6 ears). The parents of 19
children felt that the moulding technique was ‘easy’; 4 found it
‘difficult’ while one indicated that the technique was ‘very
difficult’. All the parents of these 24 children felt that moulding
therapy was worthwhile and would recommended the treatment for other children
with similar auricular anomalies.
DiscussionSplinting has been successfully used
for correction of congenital dislocation of the
hip,7 club foot,11
and cleft lip nasal deformity.12 The
neonatal auricular cartilage is very pliable and lacks elasticity immediately
after birth. However, within a few days the ears become more elastic and
firm,10 a fact that has been attributed to a
decreasing circulating (maternal) oestrogen level in the
neonate.13 The levels of circulating free
oestradiol are highest during the first 72 hours after birth and decrease
rapidly thereafter, reaching the levels similar to those of older children by
six weeks of age.14 Cartilage elasticity is
dependent upon its proteoglycan
concentration.15 Hyaluronic acid, an important
constituent, is increased by oestrogen and is responsible for the malleable
nature of the neonatal ear.16 It is during this
earlier neonatal period that deformational and certain malformational auricular
anomalies can be moulded, so early treatment is critical for
success.2,7,10,12,16 We have noted that
children who are breast-fed require an extended period of treatment, due to the
ear cartilage remaining pliable for longer,2
presumably because of persistent elevated levels of oestrogen.
Although pleasing results can be obtained with surgical
correction of congenital auricular anomalies, significant complications and
morbidity may occur including pain and emotional trauma associated with the
anomaly and its surgical correction.7 Many
auricular deformities (such as lop ear, Stahl’s ear, cryptotia, and kinked
ear) are difficult to correct surgically, and results are often
disappointing.7 Auricular moulding is the
treatment of choice for deformational auricular
anomalies.1 However, the narrow window of
opportunity for treatment is often missed because of late referral and hence
this technique has not become widely accepted in Western
countries.7
One of the reasons for late referral may be the impression
that auricular anomalies in neonates correct spontaneously with age. Although
there has been a Japanese longitudinal study showing that the incidence of some
auricular anomalies decreases whilst that of some others
increases with age, it
was not possible to predict which of the anomalies would resolve
spontaneously.6
It is also not clear if very minor anomalies were included in the study. The
authors of the present study have not observed complete spontaneous correction
of auricular anomalies amongst the cohort of patients referred to the service.
With our current knowledge, it seems reasonably to carry out non-surgical
correction on all deformities that are significant and
treatable.7
Parental persistence with the treatment is essential for a
satisfactory outcome as shown in our series. Good results can be obtained, often
within a short period if moulding is initiated soon after
birth.2,6–8,10 However, a longer duration
of treatment is required for more complex anomalies or if the treatment is
delayed.2,6–8,10
Although auricular moulding has been shown to be effective
until up to six months of age in the one Japanese
study,6 our experience generally shows that it
is largely ineffective if initiated after three months of
age.7 This is partly related to the less
pliable nature of the auricular cartilage in older children and also partly
because it is more difficult to apply and maintain the splint adequately in
these children because of poor cooperation, as seen in two of our
patients.
Moulding therapy can also be useful in certain
malformational auricular anomalies that have been subjected to deformational
forces,1 although the treatment is unlikely to
completely correct the anomaly. Nevertheless, it forms a useful adjunct that may
minimise the extent of future surgery.
Different materials have been used to achieve auricular
moulding.2,5,7–10 The simple device used
in this study is malleable and its large calibre reduces the risk of pressure
necrosis. Skin irritation occurred in four children requiring temporary
cessation of moulding. Once taught, the parents were happy to replace the splint
and the majority of the parents managed the technique satisfactorily.
Congenital auricular anomalies may be associated with other
abnormalities.7 The auricular anomaly should
not be treated in isolation and any associated anomalies should be evaluated and
managed appropriately.
Auricular moulding is simple, non-invasive, effective, and
it can be done without anaesthetic and at low cost. Deformational auricular
anomaly should be treated non-surgically during the early neonatal period, long
before the child becomes aware of the anomaly. It is hoped that the emotional
disturbance17 that may occur in these children
and the need for surgical correction can be largely avoided in the
future.
Deformational auricular anomalies are not a surgical problem
but rather a paediatric public health issue.1
Our neonatal paediatricians, obstetricians, family doctors and midwives should
be encouraged to manage these anomalies so that the use of this technique will
become widespread.1
Author information:
Swee T Tan, Director, Wellington Regional Plastic, Maxillofacial & Burns
Unit, Wellington, New Zealand; Anna Wright, Staff Nurse; Anna Hemphill, Nurse
Practitioner; Kari Ashton, Staff Nurse, Department of Plastic &
Reconstructive Surgery, Radcliffe Infirmary, Oxford, England; Joan H Evans,
Staff Nurse, Wellington Regional Plastic, Maxillofacial & Burns Unit,
Wellington, New Zealand
Acknowledgements: We
thank Dr P Hope and his colleagues in the Paediatric Department at the John
Radcliffe Hospital, Oxford, England, for their support.
Correspondence: Dr
Swee T Tan, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt
Hospital, Private Bag 31907, Lower Hutt. Fax: (04) 570 9510; email:
sweetan@plastsurg.co.nz
References:
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