SPECIAL TOPIC Pediatric/Craniofacial Non-surgical Correction of Congenital Ear Anomalies: A Review of the Literature Michelle M.W. Feijen, MD* Cas van Cruchten, BSc* Summary: Congenital ear anomalies have been known to cause lasting psychoso- Phileemon E. Payne, MD† cial consequences for children. Congenital ear anomalies can generally be divided Rene R. W. J. van der Hulst, PhD, into malformations (chondro-cutaneous defect) and deformations (misshaped pinna). Operative techniques are the standard for correction at a minimal age 12/16/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= by https://journals.lww.com/prsgo from Downloaded MD‡ of 5–7, exposing the children to teasing and heavy complications. Ear molding is a non-operative technique to treat ear anomalies at a younger age. Having been Downloaded popularized since the 1980s, its use has increased over the past decades. However, uncertainties about its properties remain. Therefore, this review was conducted from to look at what is known and what has been newly discovered in the last decade, https://journals.lww.com/prsgo comparing different treatment methods and materials. A literature search was per- formed on PubMed, and 16 articles, published in the last decade, were included. It was found that treatment initiated at an early age showed higher satisfactory out- come rates and a shorter duration of treatment. A shorter duration of treatment also led to higher satisfactory rates, which might be attributable to age at initiation, by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= individual moldability, and treatment compliance. Complications were minor in all articles. Recurrence rate was low and mostly concerned prominent ears, which proved to be the most dif"cult to correct deformity as well. Malformations, how- ever, were even more dif"cult to treat than deformations. Our analysis shows ear molding to be a successful treatment method for ear anomalies with a preference for early diagnosis and treatment. (Plast Reconstr Surg Glob Open 2020;8:e3250; doi: 10.1097/GOX.0000000000003250; Published online 30 November 2020.) INTRODUCTION helical rim deformities, lidding/lop ear, Stahl’s/Spock Not every infant is born with anatomically correct ears ear, and prominent ear (Figs. 2–8).6 The pathogenesis of (Fig. 1). Congenital ear anomalies are a defect that may deformations is unknown, but it is believed that they are occur during the fetal or perinatal period. There are two caused by either external pressure or abnormal ear mus- different kinds of ear anomalies: malformations, chondro- cle development, or genetic predisposition.7–10 A distinct cutaneous defects occurring during fetal development,1–4 kind is the constricted ear. This type of ear anomaly has and deformations, which develop perinatally.1 Examples the appearance of a cup ear but is seen as a malformation of malformations are microtia (small external ear), anotia when severe. Malformations have a lower incidence than (no external ear), or preauricular skin tags or sinuses.1,5 deformations.11 Examples of deformations are conchal crus, cryptotia, Although the incidence of ear anomalies is variable in literature,12–17 ear anomalies are widely known as conse- quential birth defects. These anomalies may have a lasting on From the *Department of Plastic Surgery, Zuyderland Medical 12/16/2020 psychosocial impact as a consequence of teasing during Center, Geleen, the Netherlands; †Department of Plastic Surgery, childhood.17–19 Otoplasty is currently still the most acknowl- The Craniofacial and Plastic Surgery Center Houston, Houston, edged treatment, performed the earliest at age 5–7.16,20,21 Tex.; and ‡Department of Plastic Surgery, Maastricht University Complications of such a procedure may be dreadful and Medical Center, Maastricht, the Netherlands. may include tissue necrosis, hematoma, bleeding, infec- Received for publication August 3, 2020; accepted September 14, tion, or hypertrophic scarring, with complication rates 2020. varying from 0% to 10%.22,23 Furthermore, psychosocial Drs. Feijen and van Cruchten contributed equally to the article and are both to be considered as the !rst author. Disclosure: Drs. Feijen is a subdistributor of the Earwell Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Infant Corrective System in the Netherlands. She is not paid Inc. on behalf of The American Society of Plastic Surgeons. This for this position, nor has she received any !nancial aid for is an open-access article distributed under the terms of the Creative writing this article. This disclosure only concerns the use of Commons Attribution-Non Commercial-No Derivatives License 4.0 the speci!c non-operative treatment method for congenital ear (CCBY-NC-ND), where it is permissible to download and share the anomalies in children in the af!liated work location. All the work provided it is properly cited. The work cannot be changed in other authors have no !nancial information to disclose. No any way or used commercially without permission from the journal. funding was received for this article. DOI: 10.1097/GOX.0000000000003250 www.PRSGlobalOpen.com 1 PRS Global Open • 2020 Fig. 1. Diagram representing the normal anatomy of a neonatal ear. Fig. 3. Diagram displaying the cryptotia deformity. There is no retro- A: helix. B: triangular fossa. C: antihelix superior crus. D: antihelix auricular skin sulcus. inferior crus. E: root of helical crus. F: concha. G: tail of antihelix. H: tragus. I: antitragus. Fig. 2. Image depicting the conchal crus deformity. A cartilaginous Fig. 4. Illustration of the helical rim deformity. The helical rim may convex crus extends into the vertical wall of the concha and may be absent or folded. cause outward bulging of the concha. 2 Feijen et al. • Ear Molding: A Review Fig. 5. Diagram representing the lidding/lop ear deformity. The heli- Fig. 7. Illustration of a prominent ear deformity in which the antihe- cal rim and sometimes scapha is folded over the rest of the ear. lical fold is absent. Fig. 6. Image depicting the Stahl’s/Spock ear deformity. A cartilagi- Fig. 8. Illustration of a prominent ear deformity in which the con- nous crus extends from the antihelix into the helical rim. chal-mastoid angle is widened. 3 PRS Global Open • 2020 consequences will be mitigated, but will not always fully The search provided 200 results, of which 16 articles disappear by performing an otoplasty.18,19 were included after application of the exclusion criteria by Ear molding was popularized in the 1980s14,24–26 and has 3 authors independently. There were no disagreements in been an upcoming method of treatment. Due to this treat- grading of the eligibility of the articles. From the reviewed ment being initiated at an early age, children are no lon- articles, the treatment materials or devices and duration ger exposed to the psychosocial consequences of having were listed (Table 1). The number of ears treated, the dif- an ear anomaly. Furthermore, surgery will have psychoso- ferent kinds of deformations or malformations, the age cial implication, whereas molding does not. Unfamiliarity at initiation of treatment, the results, complications, the about the technique, the duration of treatment, the age follow-up period and the recurrence of the anomaly were at which molding should be initiated, and what kind of also listed (Table 2). ear anomalies can be treated have long been the reasons In this table, a differentiation was made between three for a delay in the implementation of this technique.6,17,27–29 different outcomes. The outcome could be excellent To "nd a general consensus about these different aspects (indicating that treatment had resulted in a normal ear of treatment, this review was conducted, including articles shape), good (indicating there had been improvement, which was considered successful), or poor (indicating no published during the last decade. or very little improvement). These treatment outcomes were based on the classi"cation used by Tan et al41 and METHODS implemented for all articles to create uniformity and eas- A literature search was performed in December 2019 ily comparable outcomes. Finally, the absolute number of using the PubMed database of the US National Library deformities, rather than percentages, was listed, if given. If of Medicine, reviewing articles published between the the article listed assessor differences or results speci"cally fourteenth of December 2009 and the fourteenth of for each deformity, these were listed too (Table 3). December 2019. The following search terms were used: ear, auricle, non-surgical ear treatment, non-surgical RESULTS ear correction, ear molding, ear splinting, ear anomaly, ear deformity, congenital ear deformity, congenital ear Ear Molding Materials and Method of Treatment anomaly, auricular anomaly, auricular deformity, con- Treatment methods (Tables 1, 4) were not always genital auricular deformity, and congenital auricular similar. Parents were sometimes taught how to apply the anomaly. molding material.20,35,37,40 If the material would come off, Articles were excluded if they were literature reviews or parents could reapply the material themselves. did not concern research on the non-surgical correction Byrd et al6 and Daniali et al31 used additional reten- of anomalies of the external ear in neonates, when the tion taping for large ears and for severe deformations or article concerned only