Prominent ears

Synonyms: protruding ears, bat ears.

Background

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 considerable¹ . 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-criticism² .

Conservative management

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 specifically³ .

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 term⁴ . As the risks are so minimal, ear splints are often recommended for a trial in infants.

Surgical management

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 revision⁵ .

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 results⁶ . 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 not usually available on the NHS and most people will have to go privately.

The procedure

• 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 age⁷ .

• 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 operation⁸ .

• 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 surgery⁹ .

• Incisionless otoplasty has been shown to be a well-tolerated and effective operation which can be performed both on paediatric and on adult patients¹⁰ . 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 results¹¹ . 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.

Complications

• 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 resolve⁶ .

• 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.

• Recurrence.

Prognosis

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 surgery¹² .

Following otoplasty, parents have reported a significant improvement in their children's health-related quality of life¹³ .