Beyond Ear Molding: Microtia, Hearing Function & Future Horizons

[Dr. Gopi Shah]:
In terms of your physical exam, take me through your physical exam. Are you doing photos? Do you photo-document as well?

[Dr. Jason Qian]: That's a great question. The physical exam for these, other than my general newborn ENT exam, if they do have a typical contralateral ear, I'm really looking at that. If the parents have bilateral concerns and we're putting on the bilateral molds, then there's not necessarily one that we're trying to create symmetric-- I guess it's similar to how you would think about an otoplasty, but in a newborn, I am actively trying to be better at taking photos because a lot of times you come in, you're starting the counseling, you're examining the baby. A lot of times, I have the baby on the bed and the medical assistant is holding the head, and I just start molding right away.

[Dr. Gopi Shah]:
Yes. Okay. The babies in your clinic, which babies are good candidates for your molding and which babies would you say, "You know what, this is something that we can observe. It should get better with time"?

[Dr. Jason Qian]:
I think having one of the obvious, more named auricular anomalies are good candidates. Then, a lot of times, it comes down to the parent motivation. I do now get some patients in my clinic where the pediatrician sent them just because they were like, "The helical rim looks a little bit flat. I think you should get it checked out." The parents aren't really that bothered by it. If the parents aren't bothered, and it is pretty subtle to me because newborn ears are a little bit weird looking, unless it's one of those really obvious ones, I tend to just be really realistic. It's like, "I think this isn't something we can have a huge improvement on." If the parents aren't also super motivated, then we're good to-- They're like, "I just want to be here to have it checked out. Just want to be reassured. If you don't think there's an issue, we don't have an issue," those I won't mold.

I would say the vast majority that are coming into my practice are very parent-driven, that, "I've looked this up. This is something I want molded. I'm very concerned about it." Setting the expectation with parents about what our outcomes are going to be, and then I'm happy to try this with them. I make no guarantees that it's going to look exactly how they want it to. Most parents, they just want it a little bit better. It's actually easy that way because you take the molds off, and with most cases, it looks a little bit better or a lot better. Parents are very happy, and they're like, "Thank you for doing this," and they're on their way.

[Dr. Jason Qian]:
With the isolated ear molding, like a lot of cases, if there's no other concerns with hearing or no other craniofacial concerns, it's just a standalone thing, again, I always offer to these parents, "If this is something that you're still unhappy with at age five, you're happy to come back to see me," I do otoplasty. That's a need within our group that I have the training, and I'm happy to fill. Most of that conversation is happening for the kids who are beyond the window, who then get referred to me. It's more of, "We'll see what happens. There's nothing to do now, but come back to see me."

When it does get a bit more complicated, like microtia, I do collaborate. I do the hearing for microtia. That's a whole other conversation, because with the microtia, that's an external ear issue, but very often comes with canal and middle ear anomalies and conductive hearing loss. It's a really big effort, not only surgically to do the microtia, but also with the wound care afterwards and the coordination with the hearing. I do collaborate with our craniofacial clinic and plastic surgery for total auricular reconstruction, which is what you would need for most cases of microtia.

Now, the landscape; it's a really interesting time because my primary concern, especially early in life with the microtia kids, is the hearing. The goal is, and anyone who sees ear molding, you have to identify, "Well, this is not moldable and actually this is going down microtia pathway." We have to get them plugged in. The goal is to identify any conductive hearing loss and get a soft band conduction hearing aid on by six months. Historically, the hearing reconstruction would be a canalplasty for stenosis or atresiaplasty for atresia. Now, I still offer canalplasty for stenosis and OCR if they are a good candidate. I use a modification of the Jahrsdoerfer score.

For me, it's really important to have that stapes. Traditionally, they teach us that the stapes counts for two points in the Jahrsdoerfer score, but if there's no stapes, it's a no-go for me. Without getting too much into that, I'll still offer the canalplasty for certain kids with stenosis and OCR for hearing. Atresiaplasty is very controversial. There's a very high complication rate of creating a hole out of nothing and doing circumferential skin grafts that can't self-clean itself, and it's like a lifetime commitment to seeing an otologist. Even the most experienced atresia surgeons, the best outcomes are expected to be still around a 20 to 30 decibel loss.

Now we're in an exciting time where we have these bone conduction implants. Osia, made by Cochlear corp is right now the most popular bone conduction implant. It recently, in the past couple of months, was FDA-approved down to age five, which is around the earliest time that you start thinking about doing a microtia reconstruction. There's also now a competitor on the market called Sentio, made by Oticon. Now Oticon makes the Ponto hearing aid device, which is really popular because it has a huge range and great sound quality. I understand they're doing FDA trials to approve the Sentio down to age three.

This is a big game changer for atresia because it can give normal levels of hearing. In the microtia world, historically, the hearing has come during or after the auricular reconstruction. Even with these implants, it would still come during or after because monopolar cautery is contraindicated. Raising any flap, you wouldn't want to do with an Osia or a Sentio in. Although there are some plastic surgeons out there that say they do and it's fine, but it's not. It's just not. We're seeing those patients afterwards and the devices are all wonky. There are ways now to raise the flap with a harmonic scalpel blade, which is not monopolar cautery. It is an interesting time now that I'm sure we'll see some groups try to implant before auricular reconstruction, but it is a big coordinated effort.

Then again, for the kids who have not isolated microsia, but if they do have very severe hemifacial microsomia, they'll need a mandible later, that's plastics for us here. We have to make sure that we're not going to do anything with a hearing and putting an implant in if they're like, "No, we're going to do a mandible after, so there's no point in putting it in now." Being involved with the craniofacial clinic is important in some cases.