Edited by: Yu Sun, Huazhong University of Science and Technology, China
Reviewed by: Pengjun Wang, Shanghai Jiao Tong University, China; Shouqin Zhao, Beijing Tongren Hospital, China
This article was submitted to Pediatric Otolaryngology, a section of the journal Frontiers in Pediatrics
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Congenital auricle abnormalities are classified into two major categories: malformations and deformations. Auricle malformations are the result of an error in embryologic development and are characterized by the partial absence of the skin and/or cartilage. This results in an underdeveloped pinna that requires auricular reconstruction. Auricle deformations are characterized by a fully developed pinna without missing skin or cartilage (
The auricular deformation was diagnosed during the initial consultation. Clinical photographic documentation was obtained before, during, and after treatment. If the ear was amenable to molding, the benefits, risks, and alternatives of the procedure were discussed with the parents.
A retrospective review of a consecutive series of infants treated with the EarWell System from 2017 to 2020 was performed. Demographic and clinical data that were collected included age, adjusted age at the time of the initial treatment, a family history of ear anomalies, pretreatment deformation or malformation type (
Ear anomaly classification.
Prominent ear | Auricle inclines forward, cranial ear angle increases, and the auricle is large and flat. The normal anatomic morphology of the auricle and anti-auricle is unknown |
Cryptotia ear | The upper pole of the auricle is buried under the temporal subcutaneous tissues |
Stahl′s ear | The superior auricle is flat and has an abnormal bulge |
Cup ear | The auricle length becomes shorter, the triangular fossa become narrower but do not disappear, and the shape of the supine position is like a cup |
Lop ear | The upper part of the auricle is pendulous |
Conchal crus | The auricular foot is abnormally raised in the auricular cavity |
Helical rim deformity | The ear rim does not curl, and the ear wheel is flat or not present |
Constricted ear | The length of the auricle becomes shorter and the ring shrinks |
Mix ear deformation | Contains 2 or more deformities |
Grade I microtia | The auricle is slightly smaller but its shape is not significantly altered |
A total of 274 newborn ear anomalies (173 patients) were treated with the EarWell System. The mean age for starting ear molding with the EarWell System was 15 days (3 days−3 years) (
Patient characteristics.
Sex | male | 93 | 53.8 |
female | 80 | 46.2 | |
Side | uniaural | 72 | 41.6 |
biaural | 101 | 58.4 | |
Initial treatment age | ≤1w | 37 | 21 |
1–2w | 49 | 28 | |
2–3w | 19 | 11 | |
3–4w | 15 | 9 | |
4–8w | 23 | 13 | |
8–12w | 18 | 11 | |
≥12w | 12 | 7 |
SPSS 22.0 (IBM Corp., Armonk, NY, USA) and Stata version 16.0 (Stata Corp., College Station, TX, USA) were used for data analysis. The treatment cycles for different malformations were compared. The 14-day treatment cycle of different types of malformations and the qualitative index of the variation in the length and width of the treatment of mono-ear and binaural malformations were described by percentage. Quantitative data were described by x ± s. An independent sample
Few Conchal crus cases were included in this study. Except for the Conchal crus, different deformities had significantly different treatment periods (
Treatment cycles of different malformation types.
The treatment durations of patients who started treatment when they were older than 14 days old vs. <14 days old were compared. Eighty-seven patients had treatment initiated when they were older 14 days old, with a mean treatment duration of 40.29 ± 23.66 days. A total of 86 patients had treatment initiated within 14 days of birth, with a mean treatment duration of (35.88 ± 21.87) days. This difference was statistically significant (
When comparing patients with the same type of deformation, the treatment duration of patients younger than 14 days was shorter than that of patients older than 14 days. Notably, the initial treatment of conchal crus (
The treatment cycles of different malformations in different age groups (x ± s, days).
Cryptotia | 20 | 15 | 14.23 ± 10.91 | 5 | 44.06 ± 21.91 |
Lop ear | 50 | 38 | 27.11 ± 13.91 | 12 | 30.47 ± 17.79 |
Helical rim deformity | 111 | 70 | 36.11 ± 20.68 | 41 | 36.94 ± 18.27 |
Cup ear | 25 | 12 | 37.40 ± 33.43 | 13 | 43.57 ± 41.42. |
Constricted ear | 27 | 18 | 46.77 ± 26.95 | 9 | 54.62 ± 23.66 |
Stahl's ear | 17 | 12 | 24.40 ± 14.75 | 5 | 31.75 ± 4.57 |
Mixed ear deformity | 17 | 8 | 44.11 ± 23.88 | 9 | 58.12 ± 30.65 |
In participants with a unilateral ear deformity, both the deformed and contralateral normal ear lengths significantly increased over the first 1–3 weeks of treatment, and the difference between the ears gradually decreased and equalized. The affected ear's width increased rapidly during the first 1–2 weeks, reached peak change during the third week, and then tended to stabilize (
Variation in the length and width of both ears of participants with a unilateral ear deformity.
In patients with bilateral ear deformities, the gap between the ears in both length and width gradually decreased during the treatment cycle. Both ears' length increased rapidly during the first 3 weeks of treatment, while the length of both ears tended to be the same after treatment. The first 3 weeks of treatment also showed a rapid increase in ear width (
Variation in the length and width of the ears of patients with bilateral ear deformities.
The incidence of neonatal auricular malformations is reported to be 55.2–57.5% (
The causes of congenital auricle malformations can be divided into genetic factors (25%), environmental factors (10%), and interaction between genetic factors (65%). Congenital absence of important anatomical structures of the ear may occur during the fifth to the ninth week of pregnancy if the embryo is poorly developed. If auricle cartilage development is abnormal during the late stage of embryogenesis, auricle morphologic deformities such as prominent ear, cup ear, and lop ear can result. The pathogenesis for these deformities may be related to the loss and division of single or multiple hillocks (
The optimal time for non-invasive correction of auricle deformities is 5–7 days after birth. Residual maternal estrogen levels at birth peak within 72 h of birth and return to their baseline at 6 weeks. Estrogen can increase the content of hyaluronic acid and thus the plasticity of auricular cartilage. The auricle's plasticity greatly reduces after 6 weeks due to decreased estrogen and hyaluronic acid content in the child's blood circulation (
Different types of auricular deformities require different treatment cycles. The treatment cycles for the lop ear and Stahl's ear were the shortest. A lop ear is characterized by the folding of the helix itself and tentacle drooping of the upper part of the auricle to cover the opposite helix's upper leg, which eventually leads to a reduction in the length of the auricle. Lop ear morphology differs greatly from that of normal ears and it is generally quite obvious to parents at an early age. Therefore, compared with other types of malformations, lop ears are diagnosed at a younger age and have a shorter treatment duration. Cryptotia ears occur when the posterior cranial sulcus becomes shallow or disappears without an obvious posterior auricular sulcus. Pulling the upper auricle outward can recreate the auricle's complete appearance, but the deformity returns after the pull is released. Patients with severe cryptotia suffer from severe skin shortage of the auricle and chondrodysplasia of the upper auricle. The cryptotia ear is usually an upper auricle deformity that is difficult for parents to detect, and the treatment duration is longer when it is diagnosed at an older age (
Ear molding has a supportive effect on the auricle. The physiognomic ear length and breadth are main measuring index of auricle. In this study, we measured the physiognomic ear length and breadth weekly. The result showed that in patients with unilateral ear deformities the length and width of both the affected ear and the healthy ear increased over the course of treatment. Both ear lengths increased significantly over 1–3 weeks, the differences between the ears gradually decreased and equivalency was achieved. The affected ear's width also increased rapidly in 1–2 weeks, reached its maximum during the third week, and then grow steadily. In participants with bilateral ear deformities, the length and width of both ears gradually increased over the course of treatment, and the gap between the ear gradually decreased. The length of both ears increased rapidly during the first 3 weeks of treatment and tended to be the same after treatment (
Pretreatment (left in each pair) and posttreatment (right in each pair) photographs of a child with a lop ear (top left), cryptotia (top middle), cup ear (top right), helical rim deformity (middle left), constricted ear (middle middle), Stahl's ear (middle right), conchal crus (lower left), and a grade I microtia (lower middle).
Ear molding is non-invasive, has few complications and is low cost. It is an important method for treating neonatal auricle malformations and should be widely promoted clinically. Early identification and prompt initiation of treatment are crucial to its success.
The original contributions presented in the study are included in the article/
The studies involving human participants were reviewed and approved by Tianjin First Central Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.
WW and YW organized the database. XM performed the statistical analysis. YC wrote the first draft of the manuscript. WW, YW, YC, and XM wrote sections of the manuscript. All authors contributed to conception, design of the study and manuscript revision, read, and approved the submitted version.
This study was supported by Key Clinical Discipline of Tianjin; National Natural Science Foundation of China (81971698) and Tianjin Natural Science Foundation (19JCYBJC27200). The authors declare that they have no competing interests.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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The physiognomic ear length and breadth were measured. The length is the straight-line distance between the highest point of the upper margin of the auricle and the lowest point of the earlobe when the head is at Frankfurt level. The breadth is the straight-line distance between the point at which the upper edge of the auricle is attached to the cephalic side and the point at which the posterior edge of the auricle protrudes most backward when the head is at Frankfurt level.