Prominent Ears

Synonyms: protruding ears, bat ears, jug ears

The physical problem

Prominent ears are an inherited problem affecting 1-2% of the population (although its diagnosis is somewhat subjective and this figure depends on what is considered to be a prominent ear).¹ This may be unilateral or bilateral and arises as a result of lack (or malformation) of cartilage during primitive ear development in intrauterine life. 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 breast-feeding. There are no functional problems associated with prominent ears.

The psychological problem

The psychological distress caused by prominent ears can be considerable. Teasing at school causes both short-term unhappiness and can have a long-term impact on perception of self-image and self worth.² This is not a uniquely British phenomenon as is testified by the range of names attributed to this condition among a number of different countries: teapot ears (Austrian, German), pig's ears (Polish), cabbage leaf ears (French)³ ... Even the famous could not escape torment: "His ears make him look like a taxi cab with both doors open." (Howard Hughes about Clark Gable).⁴

Prior to six months of age, the ear cartilage is very soft and may be amenable to moulding and splinting.^1,5 Bandaging and taping have been used in the past but now sophisticated splints have been designed to correct problems more specifically. These have been successful when used in the young baby so lessening the need for surgery.⁶ After six months, surgical correction is the only option.

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 are more likely to be co-operative with surgery and to be happier with results.⁵ Some surgeons have suggested operating before the age of 4⁷ but this is not standard practice in this country. The operation can just as well be carried out on adult patients. Once the decision is made, referral can be made either to the local ENT team or plastic surgeon. The procedure is 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.

The procedure⁸

• Anaesthetic - usually done under general anaesthesia in children and local anaesthesia in adults.⁹
• Procedure - this may be carried out on one or both ears. It takes about an hour to complete (if bilateral) and involves an incision posteriorly, removal of a small amount of skin and refashioning of the underlying cartilage.
• Closure - the skin defect will be sutured (generally but not always absorbable sutures) and the ear(s) will be bandaged.
• Post-operative care - this procedure is usually done as a day case but patients should be advised to take at least 10 days off school / work.⁹ Regular simple analgesia is suitable but avoid NSAIDs (increased risk of bleeding). Post-operative care varies according to local practice but generally. Traditionally, the dressing has been kept on for about 7 days⁹ (the importance being to keep the ear in place following the surgery). However, a recent paper has recommended that it need not stay on any longer than 24 hours.¹⁰ The best thing is to follow the advice of your local team and contact local them if the dressing comes off before recommended time. Some patients may be advised to wear a protective headband for several weeks thereafter (particularly at night).¹ 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 2 weeks¹ (ideally wait 4-6 weeks¹¹) and contact sports for 8 weeks. Patients can fly any time after the procedure. Follow up is 2-3 months after the procedure.

• Generally rare (no more than 5% in total).
• Those associated with a general anaesthetic.
• Development of keloid scars (3%).
• Numbness of the ear(s), which may take several weeks to resolve.⁵
• Asymmetry between the ears.
• Haematoma - seek advice from operating team (these patients sometimes need to go back 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.
• Recurrence.

This condition does not resolve of its own accord. After the age of six 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.^2,12