Stick-out Ears

Prominent (sticking out or bat) ears

The average adult ear protrudes 19mm from the side of the head. A third of ears which stick out in adulthood do not do so until the age of three months or more. Bat ears or prominent ears can be corrected at birth or soon after by moulding with Ear Buddies™ splints. After the age of 5, otoplasty or pinnaplasty can be performed under local or general anaesthetic. A suture technique is safest, minimising the risk of haematoma and infection associated with cartilage scoring techniques.

Introduction

The overall frequency of prominent ears in North America (defined as those which stick out from the side of the head at an angle greater than 40 degrees) is 4.5% but many more people are concerned about smaller degrees of prominence. About two thirds (61%) of prominent ears are noticeable soon after birth. The remaining third become obvious around three months of age, as baby’s head shape changes and as the cartilage framework of the ear hardens during early life.

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Parents are often falsely reassured by Health Professionals that their child’s ears will look more normal with age, but this is rarely the case. An ear which is easily pushed forward when baby sleeps, feeds or turns its head is likely to become more prominent until, at least, the age of six months. The condition is not viewed as a deformity in all cultures; in some Eastern cultures, ears which stick out are thought to catch good luck.

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Splintage with Ear Buddies™ splints

The cartilage of the newborn ear is extremely soft and pliable, possibly due to the influence of mother’s oestrogen. If there is a normal amount of skin and cartilage, most abnormally shaped or prominent ears can be corrected by splintage with Ear Buddies™ splints if performed soon after birth. The technique will treat prominent ears, Stahl’s bars, lop ears, cryptotia and kinks of the rim. Some cup ears can be improved, but splintage will not help microtia.

It is several weeks before the ear cartilage begins to harden and ideally splintage should be started in the first few days of life. At this stage the cartilage is easily remoulded, the sweat and sebaceous glands are poorly developed so that the tapes which hold the splint in place stick well, and the child moves its head little, and does not reach up to the ears to dislodge or pick at the splints.

For prominent (stick-out) ears, rim kinks, Stahl’s bar, lop and cup ear, Ear Buddies™ splints are taped close to the rim of the ear and then the ear is taped back to the side of the head. The splint exerts pressure on the scaphal hollow of the ear, reforming, then emphasising the antihelical fold and the helical rim. Simply taping the ear back without the splint in situ does not effect a permanent improvement and distortion of the rim of the ear can develop later in life. To correct cryptotia, the ear should be pulled out from the side of the head, and the splint taped into position in the groove above and around the ear.

In the newborn, splintage for one to two weeks is all that is necessary.  Perseverance is required once the “golden” period shortly after birth is missed. It was previously thought that splintage was only effective in babies of up to six months but nevertheless, some persistent parents achieve a worthwhile correction in toddlers as old as two years.

Early splintage may improve ear shape without the need for later surgery or anaesthetic. Splintage has the additional advantage of preventing pre-surgery teasing. It is not yet a widespread practice, despite a number of reports which show neonatal splintage of misshapen ears to be of benefit, cheap and safe. Nevertheless, it is clear that the future of treatment of such deformities lies in this direction.

Ear Buddies

To avoid teasing and otoplasty in later years, splintage using Ear Buddies™ is now recognised as the treatment of choice for stick-out or deformed ears. Babies move their heads very little in the first few weeks of life, the skin hardly sweats and once the birth coating has been cleaned off, the tapes used to fix the splints in place usually stick for long enough - about two weeks - to ensure a good correction. Sticking back the ears with tape alone can cause flattening or notching of the rim or antihelix which may not become apparent until much later.

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Ear Buddies™ are best used at birth, or as soon as the ears start to stick out. A third of prominent ears don’t begin to stick out until about three months of age but by then, splintage takes longer. Unsplinted, about one in twenty people will have prominent ears by the age of 5. With persistence, splintage with Ear Buddies’ can still be effective up to the age of two years, but the process is much more difficult as the infant is by then able to reach up to the ears and potentially interfere with the splints.

Surgery to correct stick-out or bat ears is currently the most common paediatric plastic surgery undertaken in the UK. Splinting the stick-out or deformed ears of a baby at birth can save the need for surgery at a later date.  The greater the delay, the more difficult it is likely to be and the more persistence is needed if it is to be effective. As the use of splintage becomes widespread, it is anticipated that pinnaplasty (otoplasty) surgery in the UK, North America and Australia would become unusual by 2030.

“It is vital that neonatal paediatricians, obstetricians, general practitioners, and midwives are
educated about early detection [of ear deformity] and how to initiate treatment themselves.”

“If successful, an effective splinting programme could consign the surgical correction of all but the
most severe ear deformities to the past.”

Post-partum splinting of ear deformities Lindford AJ, Hettiaratchy S, Schonauer  F. British Medical
Journal 17 Feb 2007, Volume 334

Surgery (also called otoplasty or pinnaplasty)

If the opportunity to splint the ears is missed, surgery to set back ears is best delayed until after the age of 5 years. Prior to this, the cartilage is especially soft and efforts to reshape it may instead cause irregularity. There is no upper age limit for surgery. It is quite common for women to request set back of ears so that they can wear their hair up to marry, for example, or in the case of men, as they start to lose their hair.

Sometimes parents [quite understandably] request that their child’s prominent ears are corrected when the child [equally understandably] is reluctant to have the operation. It is safest in such a situation to put the wishes of the child first. Children who are teased are usually willing to have otoplasty. Sometimes the need to wear hair up in a ballet class, for example, will prompt a request for pinnaplasty surgery. It is essential before surgery to discuss the desired position of the ears. Some patients want only a gentle change whilst, for others, only ears which are flat to the side of the head are acceptable.

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No two prominent ears are the same. The commonest problem is an inadequate antihelical fold. This can cause the ear to protrude at right angles to the mastoid skin. In other ears the bowl of the ear (the conchal bowl) is excessively deep but the antihelical fold is normal. A grading scale for prominent ears has been put forward by Graham and Gault, which also includes factors such as elasticity and memory of the cartilage. Some ears will need additional attention to a protruding lobe or an isolated protrusion of the upper pole alone. Some ears are pinned back specifically so that a hearing aid can be worn, and in these, space must be left for the device - too tight a set-back should be avoided.

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Historically, a variety of otoplasty techniques have been used to attempt to remould the cartilage. Excision techniques to set back the ear are rarely used now, and so the main alternatives are cartilage scoring (in which the framework of the ear is scored to weaken it) and cartilage sparing (in which the curves and folds are reshaped using sutures (stitches) without damaging the cartilage). It is unwise to rely on skin excision alone to hold back the ear, since this may increase the risk of hypertrophic scarring.

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The safest technique for correction of prominent ears uses sutures (cartilage sparing). Although cartilage scoring surgery can be successful in most cases, complications are unpredictable. The cartilage can continue to bleed post-operatively, encouraging infection, and in a small but significant number of cases, the ear becomes severely deformed. Other complications of scoring surgery include tethering of the ear (telephone ear) and buckling of the rim. Total ear reconstruction is sometimes necessary because of extensive loss of ear tissue.

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Gault Technique (cartilage sparing with posterior fascial flap)

A suture technique alone can allow the ears to become prominent again if the stitches “cheesewire” through the cartilage, but a modification using a posterior fascial flap (known as the Gault technique) solves this problem.

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A 2005 independent review of the three techniques concludes “cartilage sparing otoplasty refined with the posterior fascial flap results in significantly improved aesthetic and functional outcomes” (From Comparison of Cartilage Scoring and Cartilage Sparing Otoplasty - a Study of 203 Cases. Abstract , British Journal of Plastic Surgery (2005) 58, 127-144 Mandal, Bahia and Stewart).

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Options

Pinnaplasty can be performed under general, twilight or local anaesthesia. Local anaesthetic is especially good if you are very particular about how much the ears are pinned back, since you can sit up before the stitches are finally tied and look at the results. It avoids the very small but real risk of general anaesthesia and the recovery time is much shorter - you can decide to stay in hospital just for the day, or to have Out-Patient surgery, also called walk-in, walk-out surgery. The local anaesthetic option is also the cheapest; the hospital fee is less and there is no anaesthetist’s fee.

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Quick Facts

Length of surgery: 45 mins to 1 hour per ear

Anaesthetic: Local, twilight or general

Hospital stay: Out-Patient, Day Case or 1 night

Recovery: A head bandage recommended for seven days (to prevent the ears being pushed forwards by the pillow) A head band can be worn in its place for those unable to wear a head bandage (available from Mr Gault’s office)

Risks of otoplasty:
Haematoma (bleeding and bruising)
Keloid and hypertrophic scars
Infection
Necrosis (loss of tissue)
Prolonged redness of scars
Recurrence

All these complications can be minimised by sticking to pre and post-operative guidelines

Relevant Publications

Books:

Gault DT and Rothera M
Management of Congenital Deformities of the External and Middle Ear - a chapter for Scott Brown's Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold

Academic Papers:

Ridings P, Gault DT and Khan L. (l994)
Reduction in post operative vomiting after surgical correction of prominent ears
British Journal of Anaesthesia - 72 : 592 - 593.

Tan ST and Gault DT. (1994)
When Do Ears Become Prominent?
British Journal of Plastic Surgery 47: 573 - 574.

Tan ST, Shibu MM and Gault DT. (1994)
A Splint for Correction of Congenital Ear Deformities
British Journal of Plastic Surgery 47 : 575 - 578.

Gault DT. (1995)
Invited commentary on: Congenital anomalies of the auricle: correction through external splints
European Journal of Plastic Surgery 18: 291 - 292.

Gault DT. (1995)
Can I Bend Your Ear?
You and Your Baby Magazine page 72.

Laing H and Gault DT. (1995)
Bat Ears - A European Perspective
Christmas Edition of the British Medical Journal 311: 1715.

Graham KE and Gault DT. (1997)
Endoscopic Assisted Otoplasty: a preliminary report
British Journal of Plastic Surgery 50: 47-55.

Graham KE and Gault DT. (1998)
Clinical Experience of Endoscopic Otoplasty (Letter)
Plastic and Reconstructive Surgery 102:2275.

Gault DT. (1998)
Ear Splintage Face 5: 211-212.

Sylaidis P and Gault D.
Antihelical folding for pinnaplasty using one posterior cartilage score and horizontal mattress sutures.
Annals of Plastic Surgery Vol 45 (no 3) Sept 2000 341-342.

Horlock N, Misra A, Gault D.
The postauricular fascial flap as an adjunct to Mustarde and Furnas type otoplasty.
Plastic and Reconstructive Surgery 108: 6 1487 - 1490, 2001.

Beckett KS and Gault D
Operating in an eczematous surgical field; Don’t be rash, delay surgery to avoid infective complications
Accepted by the British Journal of Plastic Surgery 2006

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Ear Reconstruction