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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: protruding ears, bat ears.
The physical problem
Prominent ears are an inherited problem affecting 1-2% of the population (although the diagnosis is somewhat subjective and this figure depends on what is considered to be a prominent ear). It may be unilateral or bilateral and arises as a result of lack (or malformation) of cartilage during primitive ear development in intrauterine life. The external ear anatomy is intricate, with thin skin and resilient cartilage. The ear subsequently has abnormal helical folds or grows laterally. Occasionally, folds seen at birth resolve spontaneously.
Prominent ears do not tend to improve and about 30% of babies who have prominent ears are born with normal-looking ears with the problem only arising in the first three months of life. This may be exacerbated when the soft cartilage is repeatedly bent over, particularly during breastfeeding. There are no functional problems associated with prominent ears.
The psychological problem
The psychological distress caused by prominent ears can be considerable. The main clinical significance of prominent ears is the aesthetic problems, which can lead to a reduced quality of life, reduced self-esteem, social avoidance behaviour and poor performance in school. Teasing at school causes both short-term unhappiness and a potential long-term impact on perception of self-image and self-worth. Children and adults alike with ears that stick out may experience a damaged psyche secondary to outside ridicule and self-criticism.
Prior to 6 months of age, the ear cartilage is very soft and may be amenable to moulding and splinting. Bandaging and taping have been used in the past but now sophisticated splints have been designed to correct problems more specifically.
Ear splintage can be a very effective technique for treatment of neonates with deformational auricular anomalies. After 6 months, surgical correction is the only option.
There is still uncertainty about the spontaneous course of prominent ears as well as at what age to start using ear splints, how long to continue them and how effective they are in the long term. As the risks are so minimal, ear splints are often recommended for a trial in infants.
The management of protruding ears has evolved over time to include a number of different surgical techniques (eg, Mustardé, Furnas, and Stenstrom techniques). These methods have been continuously modified in order to both improve aesthetic results and to minimise the need for surgical revision.
Referring for surgery
Pinnaplasty or otoplasty can be carried out in the child from about 5 years of age - there is a balance to strike between doing it before the child goes to school (with possible teasing or bullying) and allowing enough time to see if the child perceives it as a problem - the latter is more likely to be co-operative with surgery and to be happier with results. The operation can also be carried out on adult patients.
Once the decision is made, referral can be made either to the local ear, nose and throat (ENT) team or to a plastic surgeon. The procedure is usually available on the NHS to children; most adults have to go privately unless the person can be shown to be in extreme psychological distress, in which case decisions are made on an individual basis.
- Anaesthetic - usually done under general anaesthesia in children and local anaesthesia in adults. However, otoplasty can be performed safely and effectively under local anaesthesia in children as young as 5 years of age.
- There are different techniques available. Cartilage-sparing techniques or percutaneous adjustable closed otoplasty (PACO) may be considered; the choice of operation may depend on the amount and type of cartilage involved for the operation.
- In prominent ear deformities with soft cartilage, PACO should be the preferred surgical choice because of its advantages of shorter time in surgery, lack of need for prolonged postoperative compressive dressing, and also of allowing patients to view the results immediately after surgery.
- Incisionless otoplasty has been shown to be a well-tolerated and effective operation which can be performed both on paediatric and on adult patients. This procedure is less invasive than the open operation and is associated with minimal complications.
- A modification of an incisionless otoplasty can be performed in adults with local anaesthesia with excellent results. After the operation, patients can return to their daily activities immediately. It is associated with a low complication rate and high patient satisfaction.
- Postoperative care varies according to local practice:
- Some patients may be advised to wear a protective headband for several weeks afterwards (particularly at night).
- Hair can be washed after 14 days; patients should be advised to take particular care in cleaning that area and drying it well afterwards.
- Swimming should be avoided for at least two weeks (ideally wait 4-6 weeks). Contact sports should be avoided for eight weeks.
- Patients can travel by plane at any time after the procedure.
- Generally rare (no more than 5% in total).
- Those associated with a general anaesthetic.
- Development of keloid scars.
- Numbness of the ear(s), which may take several weeks to resolve.
- Asymmetry between the ears.
- Haematoma - seek advice from the operating team (patients sometimes need to return to theatre for clot removal).
- Dehiscence - if not secondary to infection, a small gap can usually heal with appropriate dressing (done by the operating team).
- Infection - if severe, this can lead to complete wound breakdown and the cartilage may get involved, so giving rise to long-term deformities which may need a further procedure to correct them.
This condition does not resolve spontaneously. After the age of 6 months, surgical correction is currently the only available method of addressing it.
There is generally an excellent rate of satisfaction after successful surgery, with reports of improved self-esteem, social life and leisure activities. Psychological problems associated with prominent ears can be reduced by means of appropriate corrective surgery.
Following otoplasty, parents have reported a significant improvement in their children's health-related quality of life.
Further reading and references
Jones ES, Gibson JAG, Dobbs TD, et al; The psychological, social and educational impact of prominent ears: A systematic review. J Plast Reconstr Aesthet Surg. 2020 Dec73(12):2111-2120. doi: 10.1016/j.bjps.2020.05.075. Epub 2020 May 26.
Handler EB, Song T, Shih C; Complications of otoplasty. Facial Plast Surg Clin North Am. 2013 Nov21(4):653-62. doi: 10.1016/j.fsc.2013.08.001.
Schonauer F, La Rusca I, Molea G; Non-surgical correction of deformational auricular anomalies. J Plast Reconstr Aesthet Surg. 2009 Jul62(7):876-83. Epub 2008 May 19.
Braun T, Hempel JM, Berghaus A; Developmental disorders of the ear in children and adolescents: conservative and surgical treatment options. Dtsch Arztebl Int. 2014 Feb 7111(6):92-8. doi: 10.3238/arztebl.2014.0092.
Ali K, Meaike JD, Maricevich RS, et al; The Protruding Ear: Cosmetic and Reconstruction. Semin Plast Surg. 2017 Aug31(3):152-160. doi: 10.1055/s-0037-1604241. Epub 2017 Aug 9.
Setting back prominent ears; British Association of Aesthetic Plastic Surgeons
Laberge LC; Local anesthesia for otoplasty in children. Clin Plast Surg. 2013 Oct40(4):671-86. doi: 10.1016/j.cps.2013.07.007. Epub 2013 Aug 22.
Ozturan O, Dogan R, Eren SB, et al; Cartilage-sparing techniques versus percutaneous adjustable closed otoplasty for prominent ear deformity. J Craniofac Surg. 2014 May25(3):752-7. doi: 10.1097/SCS.0000000000000828.
Ozturan O, Dogan R, Eren SB, et al; Percutaneous adjustable closed otoplasty for prominent ear deformity. J Craniofac Surg. 2013 Mar24(2):398-404. doi: 10.1097/SCS.0b013e31827ff103.
Mehta S, Gantous A; Incisionless Otoplasty: A Reliable and Replicable Technique for the Correction of Prominauris. JAMA Facial Plast Surg. 2014 Sep 11. doi: 10.1001/jamafacial.2014.552.
Haytoglu S, Haytoglu TG, Yildirim I, et al; A modification of incisionless otoplasty for correcting the prominent ear deformity. Eur Arch Otorhinolaryngol. 2014 Oct 14.
Songu M, Kutlu A; Long-term psychosocial impact of otoplasty performed on children with prominent ears. J Laryngol Otol. 2014 Sep128(9):768-71. doi: 10.1017/S0022215114001662. Epub 2014 Aug 13.
Hao W, Chorney JM, Bezuhly M, et al; Analysis of health-related quality-of-life outcomes and their predictive factors in pediatric patients who undergo otoplasty. Plast Reconstr Surg. 2013 Nov132(5):811e-817e. doi: 10.1097/PRS.0b013e3182a3c133.