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BackTable / ENT / Podcast / Transcript #213
Podcast Transcript: Ear Molding for Infants
with Dr. Jason Quian
What should parents and pediatricians know about early ear molding interventions? In this episode of the BackTable ENT podcast, pediatric otolaryngologist Dr. Jason Qian discusses the practice of ear molding in infants and new advancements in the field with host Dr. Gopi Shah.
You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
Shaping Ears Without Surgery
Which Ears can be Molded?
The Window for Ear Molding
Physical Exam & Assessment
Framing the Conversation with Families
Types of Ear Molds
Monitoring Progress & Pitfalls
Billing & Reimbursement
When Ear Molding Isn’t Enough
Future Directions in Ear Molding
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[Dr. Gopi Shah]:
My name is Gopi Shah. I'm a pediatric ENT, and we have an awesome guest today. I have a fellow pediatric ENT, you all know I get super excited about that. We have Dr. Jason Qian. He's a surgeon-scientist at the University of California, San Diego. He's a pediatric otolaryngologist practicing at Rady Children's Hospital, and he's here to talk to us about ear molding in infants. Welcome to the show, Jason. How are you?
[Dr. Jason Qian]:
I'm good. Thank you so much for having me, Gopi.
[Dr. Gopi Shah]:
I'm so happy to have you. This is actually my first in-person, in-studio episode for ENT. It's a pleasure to have you on as our first guest in person.
[Dr. Jason Qian]:
Yes. This is super exciting. Never been on a podcast before. To be live here with you, it's really exciting.
[Dr. Gopi Shah]:
Awesome.
[Dr. Jason Qian]:
I'm honored to be here.
[Dr. Gopi Shah]:
Awesome. Thanks for coming on. Can you first tell us a little bit about yourself and your practice?
[Dr. Jason Qian]:
Yes. Thank you for the introduction. Again, I'm Jason Qian. I'm in my first year after fellowship. I spend 50% of my time trying to start a translational research lab at UCSD, where I study the immunogenetics of chronic otitis media. Then, my other 50% of my time, I dedicate to my clinical practice at Rady Children's Hospital, where Gopi and I are partners.
[Dr. Gopi Shah]:
Yes.
[Dr. Jason Qian]:
I have a special interest in ear. That includes congenital anomalies of the middle ear canal and the auricle. I'm the first one in our group that offers ear molding, which is a bit of how this came to be. It turned out it's this huge need that I'm happy to fill in San Diego and in our practice.
Shaping Ears Without Surgery
[Dr. Gopi Shah]:
That's awesome. In general, can you tell us how you explain what ear molding is? I know we were talking about this in the OR when we were together the other day, but how you explain it to whether it's your colleagues or families of what is ear molding in infants exactly, and what kind of deformities is it for?
[Dr. Jason Qian]:
Ear molding is a non-invasive way to permanently correct certain ear deformities or anomalies in infants. The idea of how it works is circulating maternal estrogen in the newborn keeps the cartilage soft and pliable. Of course, that aids in vaginal delivery, but we could leverage that to mold the ears into a more typical or desirable shape that could last permanently before that circulating maternal estrogen washes out and essentially the cartilage sets in its shape.
Now that washout typically happens between two to three months of age. Ideally, we start the ear molding process before six weeks of age, since the process itself can take two to six weeks of continuous molding. Essentially, what it is, a molding device is placed on the ear and continuously worn.
[Dr. Gopi Shah]:
Awesome. Before we get into it, how did you get training in this? I would say it's pretty niche, even within pediatric otolaryngology. How did you start to incorporate it into your practice?
[Dr. Jason Qian]:
I did my residency and fellowship at Stanford. I had a mentor there, Mai Thy Truong.
[Dr. Gopi Shah]:
Love Mai Thy.
[Dr. Jason Qian]:
Mai Thy essentially taught me how to do it her way, and her way of custom molding. We'll get into the different types of molding, what I based my practice on, the way I do it. Mai Thy oversees a lot of the ear molding at Stanford. Then there are two NPs, Summer and Charlie, who do a lot of it. I learned a lot from them, too.
With a custom molding technique, you do have to see many different ear deformities to know how to adjust the mold, but the general principle is the same. It did take over my residency and fellowship to be comfortable with it. Then, when I came into my practice, essentially, it's a funny story. I showed up, and in my first week of practice, I saw that on my Friday clinic, I had a patient referred for ear molding. He was three weeks old. In the referral, the pediatrician said the father is very interested in ear molding. I went around clinic to see what supplies we had. One of the supplies that I need is silicone putty, which is essentially like the swimming silicone earplugs. We didn't have that in clinic. I went to CVS and just bought it to have just in case.
I put the ear molds on when I saw that patient in clinic. When I saw the patient back, the results were really good. Dad was really happy. Then it was this organic process where the referring pediatricians, I think it was Scripps, they found out, "He's offering it. We didn't really have anywhere to send these kids." That group had started sending the patients to me. Then the other pediatrics groups have found out. Then, there were these inquiries made, and we had to make some adjustments to our clinical workflow to accommodate this practice. Now business is booming.
[Dr. Gopi Shah]:
That's amazing. It took one patient, one referral, and the word spread.
[Dr. Jason Qian]:
That's right.
[Dr. Gopi Shah]:
That's amazing.
[Dr. Jason Qian]:
I think it goes to show. As a new parent myself, we're always online looking stuff up. A lot of these parents, they're with their newborn and they're looking at the ears and they're looking this up and they know that ear molding is something that exists and it's something they're bringing to the pediatricians, and the pediatricians are desperate to see who they could refer to. It is something that a lot of us don't get in our traditional training pathway, but it's something that's becoming more desirable and something that I think a lot of people can integrate into their practice.
Which Ears can be Molded?
[Dr. Gopi Shah]:
When families come to you, like for example, the dad that came with this baby, what concerns do they have? I think in terms of specific deformities for ear molding would be "cup ear" or "Stahl's ear," all those buzzwords, but what are the families telling you?
[Dr. Jason Qian]:
To address two points, the families, they're really concerned, eventually, about the psychosocial impact. It's usually these otherwise well kids and the ears, they don't have a typical appearance, just say both of them, sometimes it's just one doesn't match the other. They're really afraid of bullying in the future. As a new parent myself, that's something I project into the future. If something like the ear is looking not typical and they go online and find out that there is an option for not surgery, a noninvasive option that could just fix this problem for life, a lot of parents come looking for that to prevent any potential future psychosocial issues.
[Dr. Gopi Shah]:
You said that this obviously presents very early. Have you ever gotten a referral for any ear deformity that was found on prenatal ultrasound, or have you ever been consulted, whether it was in your training or in practice, to the NICU or the newborn nursery for ear molding?
[Dr. Jason Qian]:
About the ultrasound question, the ears are not typically looked at in a typical 20-week anatomy scan. If there are concerns on the 20-week anatomy scan and they follow up with craniofacial investigations, you could see auricular anomalies, but usually they have to be a more major anomaly like microtia, where there is this absence of skin and cartilage. Whereas a lot of the ear molding deformities, what is moldable, are malformations in the folding or the shape, but there is no absence in skin or cartilage. I would say most times the ears are not picked up prenatally, and it's discovered on birth.
The NICU question is a good one, too. Most of my patients right now are being referred to by pediatricians from well-child visits in the newborn period. The director of the NICU here in San Diego is one of my scientific mentors, and we had talked about this on the side, and she does want me to present ear molding to the NICU, which I'm happy to do. That would also open up this other can of worms, which would be inpatient ear molding consults. We would have to sort of figure out how to incorporate that workflow into our consult service.
[Dr. Gopi Shah]:
Right. I guess the other question is, is there enough volume for that? What is the incidence? Just out of curiosity. Do we know?
[Dr. Jason Qian]:
I'm not actually too sure what the incidence of the moldable ears are, but for me, they're quite high.
[Dr. Gopi Shah]:
Everybody coming to you.
[Dr. Jason Qian]:
Pretty much every clinic that I have, I have an ear molding patient.
[Dr. Gopi Shah]:
That's amazing. It's one of those where it's like, if you build it, they will come. If you're not looking for it, you're going to miss it. It's right there. It's all around you, in a way.
[Dr. Jason Qian]:
Yes. I had a patient who, unfortunately, came to me at 11 weeks. As I said, this ideally starts before six weeks. The patient was referred to me at 11 weeks. I'm still happy to see these patients. A lot of times, even to talk about other options in the future. I begin to offer otoplasty at around age five. Now this patient had a Stahl's ear. That's one of our buzzwords. I guess we should also talk about first the deformities that can be molded. Again, it's the ones where there's not a lack of skin or cartilage. We're thinking prominent ear or prominauris, cup ear, lop ear, Stahl's ear, helical rim deformities.
Those are moldable, whereas deficiencies of skin and cartilage, like anything on the microtia spectrum is not moldable. You can't create something, reshape something out of nothing. This patient, this 11-week-old patient had a Stahl's ear. That's actually a very challenging otoplasty to do in the future. We're taught the traditional Mustardé and Furnas, that shows up on our boards, but that's really for prominent ear.
If you have like a Stahl bar, which is an extra fold between your antihelix to the helical rim that unfolds the helical rim, essentially, the otoplasty there is you have to cut that out to cut that folded cartilage out. A Mustardé suture is not going to do anything for that. You might have to actually cut out some other pieces of cartilage in order to reform the helical contour. The outcome isn't necessarily that great. Whereas molding these Stahl bars early enough, the results are so good, honestly, they've surprised me.
[Dr. Gopi Shah]:
The picture you sent me.
[Dr. Jason Qian]:
I think that was one of the before-and-afters I sent you. A lot of ear molding is about setting expectations, both for the family and for myself. We keep those expectations pretty low. We're just trying to make it a bit better than it already is, but sometimes it works fabulously well.
When I got the referral for Stahl's ear, an 11-week-old, I was still happy to see and set expectations with the mom, like, "Look, I give this less than 30% chance of really doing anything, but I'm happy to put it on." Mom was very, very motivated. I say this because his grandpa's actually a peds ENT and didn't even really notice or recommend anything earlier on. That was very frustrating for Mom because we're at a point now where-
[Dr. Gopi Shah]:
-we're about to miss the window.
[Dr. Jason Qian]:
Yes. Ultimately, there was a modest improvement, I would still say. This is Stahl's ear, but Mom was happy that there was a little bit of improvement.
The Window for Ear Molding
[Dr. Gopi Shah]:
You said that there is a window and it's within that two to three months. Ideally, when should you be seeing them? When should the device or the silicone putty get put on and how long do you keep it on for?
[Dr. Jason Qian]:
The younger the child is when we put the device on, the better the long-term outcome. Practically speaking, a lot of times our referrals are coming in the first or second week of life. The clinic rearranges the schedule to have them added on. I'm seeing them Week 3, 4, 5. There is that practical aspect. The clinic knows that these patients need to see me before six weeks. The earlier, the better, if possible.
[Dr. Gopi Shah]:
Just going back to that initial visit, is there anything specific as part of your history? Are there any risk factors that you're asking about, whether it's during the pregnancy or delivery?
[Dr. Jason Qian]:
Yes. The big thing for me is really the hearing, did they pass their newborn hearing screen? Newborn ears are sometimes hard to really even make sense. Like, is this a Grade 1 microtia, or does it just like look a little bit weird? If it is on the microtia spectrum, of course, we do want to. That's a whole other conversation in itself. It's really important to capture any conductive hearing loss and intervene early on. If they're passing their newborn hearing screen, the other thing would be, are there any other big syndromic features that make us concerned.
With the microtia kids, I like to make sure that they have a renal ultrasound because there has been an association between renal anomalies and microtia. One of the thoughts there is that the kidneys and the ears, they develop at the same gestational age. That's one of the reasons for the association. Outside of that, family history, although for the ear molding candidates, there's not always a good family history when it comes to lop ear, a lot of times, prominent ear, you can see it in the parents.
Then I do an ear exam. I don't know about you, though, but when I do a newborn otoscopy, I see an eardrum, but it's usually really floppy and gray. It's not like I'm seeing great landmarks to begin with. If you pass a newborn hearing and you have an eardrum, I'm like, "You're good for now."
[Dr. Gopi Shah]:
I just did a post to your team. I'm like, "All right. That looks good. We'll take it." Is there any risks associated with prematurity or traumatic delivery or anything like that, or no, because this is during the development in utero?
[Dr. Jason Qian]:
Not that I'm aware of. A traumatic delivery, even if your ear is a little bit bent, it's not going to permanently stay there. Our ear molding process, it is a device that has to be worn for weeks. We don't really know, but it was their position in utero, during the development for a long time that caused certain anomalies. I don't think it would necessarily be associated with the delivery itself.
Physical Exam & Assessment
[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.
I've realized I'm not capturing my before, and so I'm actively trying to improve my photo documentation. Something we should talk about later is we actually do not have a CPT code for ear molding. For reimbursement purposes, you don't really need photo documentation. It should really be more for yourself. There are some times where there are some parents after you do the ear molding, and you're like, "This looks really good." They're like, "Oh, but it's like a little bit--" Having that before photo to show them, "But it looked like 'this' before."
[Dr. Gopi Shah]:
"This is great."
[Dr. Jason Qian]:
I'm very happy with this result. That's another reason why it helps.
[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.
I always tell them, "If this is something that develops into a big psychosocial issue for the family, I'm happy to see them around age five," which is when I begin to offer otoplasty.
Framing the Conversation with Families
[Dr. Gopi Shah]:
That conversation, you mentioned setting the expectations. What is that conversation, whether it's outcomes, actual process, is there anything that they have to do at home? What's the spiel?
[Dr. Jason Qian]:
My spiel is that there's no such thing as a perfect ear, right? I don't want to say beauty is in the eye of the beholder, but there's no such thing as a perfect ear. Ears are also not perfectly symmetrical. It's unnatural for the ears to be perfectly symmetrical. What we can do is try to make the ear appear more "typical" is what I say, not appear more "normal." Just more typical. There is, again, no guarantee what our outcome is going to be. We're just going to try to make an improvement on what we have right now, while we're still within this window where we could do a non-invasive mold.
[Dr. Gopi Shah]:
That mold is something that the infant keeps on for two weeks, four weeks. Do they have to come back? Is there any adjustments, changes?
[Dr. Jason Qian]:
Great question. I guess we should talk about the molds themselves.
[Dr. Gopi Shah]: I'm like, "What supplies do you need?" I imagine you're settling with the putty right now, but it sounds like there's some devices, maybe some silk tape involved.
Types of Ear Molds
[Dr. Jason Qian]:
Yes. Essentially, there are two major categories of ear molding devices. One of them is the commercially available devices. Amongst the commercially available devices, the most popular is the EarWell. What the EarWell is, is a device that the clinic has to purchase from the manufacturer. It has several parts. There is a well that is a plastic well that sticks to the skin around the ear. This does involve having to shave the hair of the temporal parietal scalp so that the well can stick there.
Then there are small plastic pieces that are fitting on the auricle that do the shaping. There are ones that retract the helical rim. There are pieces that fit to form the conchal bowl. Then they're all secured with this anterior basket that squishes them into place against the ear and snaps into the well. After placement of an EarWell, you should be seeing the patient every two weeks to make sure that the pieces are still in place.
The big risk for ear molding, other than the risk of not having the desired outcome for the family, is skin breakdown. You're checking for skin irritation, ulceration, infection, in which case, of course, you would stop the molding process. The EarWell is worn for six weeks, and then everything comes off. Now, the major advantage of the EarWell, it's a one-size-fits-most device. It requires relatively less training and experience to put on. You just follow the instructions, and every ear gets the same treatment. The outcomes are pretty good. They're very consistent.
Now, there is one huge disadvantage of it, that is that it is cash pay for the vast majority of families. Because there is no CPT code for ear molding, it is very difficult to have insurance reimburse for the cost of the device. In our practice at Rady Children's, our clinic doesn't even have the mechanism to charge parents cash for a device. A lot of private practices can offer that. In our practice, we simply cannot offer it. It's not a viable solution. That's the big downside of that. There are some other commercially available devices, too, but the EarWell is more popular.
That brings us to this other category of custom-made molding devices, which is a generous and fancy way of saying we are essentially taking supplies that are more readily available in clinic, it's a bit of jerry-rigging and arts and crafts to make these custom molds that we then can place as the molding device. Again, the way that I learned how to do it is modified from my mentor in my training at Stanford, Dr. Mai Thy Truong. It starts with a piece of wire. I get that wire from nasopharyngeal Calgiswabs. I cut the swab end and the cap end off. I have this wire. It is shaped to the desired contour of the helical rim.
Now, I thread that wire then through silicon tubing in order to protect the skin from the metal wire. The silicon tubing, I actually get from a butterfly needle IV starter kit, because you have the butterfly needle and then you have that frosty silicon tubing. Then I cut the needle off and I cut the end off, and then we have this silicon tubing and I thread the wire through that. That wire is then placed in the scaphoid fossa, so on the inside of the helical rim, to reinforce that rim shape. I like to Dermabond that, in order to keep it down.
Now, I think a lot of us have Dermabonded ourselves and it can sting a lot. That stinging is because the Dermabond is cyanoacrylate, and it hardens by touching the moisture on your skin and creating an exothermic reaction. If you're putting it on a cut, that's a lot of moisture and we're usually putting a lot of Dermabond. That's going to sting. With an infant's dry ear skin, putting a little bit of Dermabond onto that dry skin really doesn't hurt. None of this really hurts the infant. Even a little bit of Dermabond is okay in my experience.
I like to Dermabond it to the scaphoid fossa and then reinforce the shape of it with a silicone putty in order to give the helical rim height. Then, in certain deformities like cup ears, so the cup ears when the conchal bowl can be constricted into a cup, the antihelix is pushed forward. With that pushed forward, the lobule can look like it's displaced forward. In those situations, I might put a piece of silicone into the conchal bowl in order to open it and push that antitragus back. That's where the silicone putty then comes in.
Then we have to anchor it with a bunch of tape. What I first like to do is to use Mastisol and place anchoring tape on the scalp behind the ear. Now, if this is a baby with tons of hair, then that hair has to be trimmed. In most babies, even a little bit of hair, you can manage it and stick it down with Mastisol, and then put the Steri-Strips behind the scalp. Then, to secure all the putty, I would do radial Steri-Strips going from the concha or near the auditory meatus, radially out over everything, and adhering posteriorly to the anchoring Steri-Strips.
That's the general protocol. With certain congenital anomalies, I modify it a bit, like with Stahl's ear, where we're trying to unfold that Stahl's bar and fold up the helical rim, I might extend the tape to the posterior skin. In general, that's sort of the protocol.
[Dr. Gopi Shah]:
That's amazing. With the Steri-Strips, how often do they call to say, "Hey, it's unfurling," the ends tend to unfurl, or it's not sticking? Any concerns with that? Have you faced any problems with that?
Monitoring Progress & Pitfalls
[Dr. Jason Qian]:
It's a great question. It's something that's actively evolving. What's the follow-up on this? I see them back about every two weeks. In order to make it last longer, I do like to use the extra Dermabond and then Dermabond the Steri-Strips to itself. Then I also tell parents at the two-week mark, usually it's starting to come off, right? I always give parents an extra packet of Steri-Strips and tell them to expect it to start coming off in about two weeks. If it starts coming off, we have that follow-up appointment set. You could just put tape over it to reinforce it until I see them, and I also give them that expectation.
It can be a lot of work if you're seeing this patient continuously for six weeks, it becomes two, three visits. In general, now I've been seeing the kids for two visits, the initial visit and then another visit in about two weeks. Sometimes it's shorter, sometimes it's longer. In that visit, I will take everything off. The parents will watch me take everything off. They know what goes in on it. I'm using either an alcohol swab or one of those adhesive removers. I gently take everything off. I make parents watch me. Then we decide, do I reapply it? If I reapply it, I tell them, "Try to keep this on as long as possible." By that time, they're usually aged past six weeks, and so I tell them, "I'm not going to put another one on, but keep it on as long as you see fit." Then, "Here are some extra Steri-Strips to reinforce it. You've watched me take it off. You can take it off when you're ready." Of course, to let me know if there are any problems with the skin breakdown or anything like that.
I haven't had any skin breakdown in my practice. Of course, if there was any, I wouldn't be really putting it on. In general, I've limited most cases now to about two visits spaced two weeks apart.
[Dr. Gopi Shah]:
Got it. Usually, the molds, depending on the age that they're put on for, stay on anywhere between two to four weeks. This is usually if you can get them into your clinic within that first two to four weeks of life. Because by the time we're at about eight weeks, that maternal estrogen we're thinking that was circulating has now been washed out and this might be the best we get.
[Dr. Jason Qian]:
Right.
[Dr. Gopi Shah]:
Okay, got it. Then, if they're seven, eight weeks, and they want to keep it on a little bit longer, you reapply it, give them that option, and then they can take it off themselves about two weeks later.
[Dr. Jason Qian]:
Correct, yes.
[Dr. Gopi Shah]:
In terms of ischemia or things like that, are you usually just going to see redness of the skin? Do the babies ever cry of pain? Have you ever had a case of weeping or drainage, or seen that before?
[Dr. Jason Qian]:
In my practice and in my training, I haven't seen any major skin breakdown. That, of course, is always the big thing we're worried about. I do give a lot of counseling to parents to be looking at that skin. Parents are usually very careful about it because while that custom mold is on, they ask a lot of questions, "Should they not lie on this side? Should they not do any of that stuff?"
[Dr. Gopi Shah]:
"Can you not get that side wet during bath time?"
[Dr. Jason Qian]:
Yes. I tell them to avoid getting it wet, for sure. If they do want to wash the hair, it's going to be with a little sponge. I think it's really hard to control how that baby is going to not put pressure on one side and sleep on the other side. Then, you might also have the two ear molds. Otherwise, I say just keep it on, keep it dry, as clean as possible. Look at the surrounding skin and let me know if there are any problems." The parents usually have no problems so I haven't had any complications from skin breakdown. Of course, I do see them in the two weeks to make sure. The process is really gentle. We do protect that wire with the silicon tubing. One of the things when you thread it in is you want to make the tubing a little bit longer than the wire itself so that there's no free ends. If there's concern for that, I also plug the ends with the silicone putty and tape. It's tight, but it's not so tight that it is causing ischemia. A lot of times, the glue and the Mastisol is not even allowing you to make it that tight. I'm not doing any head wrap or anything like that. It's otherwise loose enough.
Billing & Reimbursement
[Dr. Gopi Shah]:
You've mentioned there's no CPT code, so insurance doesn't cover it. In your practice, you're not using a commercial device such as EarWell, because you can't really charge for it. You figured out a creative way to get the supplies that you need, that sound pretty reasonable. It doesn't sound like anything super expensive here. These are routine things that you're using. How are you billing for it?
[Dr. Jason Qian]:
I went over how I, by happenstance, started doing this with my first patient, and then I had a lot of follow-up conversations with our finance and billing department. Now, when I had asked Mai Thy at Stanford how she was billing for this, she's able to bill the initial visit with the unlisted external ear code, which I believe is 69399, and then her follow-up visits by time.
In our practice, I was told we're not allowed to use the unlisted codes, and so there was no CPT code that I can use. After discussing this with our finance department extensively, I'm billing E&M by E&M code, and I bill Level 5 for time every time. Even though it doesn't take me that long to put the ear mold on, there's a lot of counseling involved in the appointment itself. Then, also, all of that work beforehand to coordinate urgent care of a newborn and to also have the clinic's supplies, which now, the clinic and the hospital are happy to buy the supplies I need,-
[Dr. Gopi Shah]:
You're not going to CVS on your way to work to get silicone putty.
[Dr. Jason Qian]:
-they're now ordering the earplugs, which is great. That's how we are pursuing it moving forward because they were like, "We absolutely cannot buy EarWells." Before I got here, there was a purchase of EarWells before that the hospital is taking it as a loss. They were like, "This is just not viable for us to do." I have a colleague in New York who has had success in getting some of her patients' insurers to reimburse EarWell. I wouldn't say it's impossible for everybody, but it is not possible in our practice in San Diego.
When Ear Molding Isn’t Enough
[Dr. Gopi Shah]:
Do you collaborate with other specialists? Are you doing microtia as well, Jason? Do you find that your colleagues across the States, across internationally who do do infant ear molding, do you have a craniofacial partner or a plastics partner, otologist? Is there a team involved?
[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.
Future Directions in Ear Molding
[Dr. Gopi Shah]:
Yes. That's pretty cool. As we start to round things out, are there any recent advancements specific to ear molding or new therapies or techniques? You had mentioned the different devices, it sounds like you've gotten gritty and creative with your own. I think you should have gotten your own in-office technique, but anything that's on the horizon for ear molding that's coming up?
[Dr. Jason Qian]:
I think one thing, moving forward, other than more otolaryngologists who see children recognizing it and maybe starting to be able to integrate it into their practice because with an increasing demand- it's always been there, there just wasn't anything to be offered- now we're in a new era, families are really looking for it, pediatricians now are looking for people to do it.
As it becomes more popular, it would be great if we could have a CPT code or a way to reimburse this in a more streamlined way. Then I think on the education front, talking with other people who do this across the country and seeing the need and wanting to share with our colleagues to make this a more common practice. We're going to try to do panels at our major meetings. There's even a very preliminary thought about now that we have simulation and 3D models being very easily accessible, having a newborn ear model just to practice applying the molds on, just because it could be daunting to do it on your first patient. Those are some things that could be coming up.
[Dr. Gopi Shah]:
That's really exciting, Jason. Any final pearls for our listeners, or if anybody has any questions for you, are you on any social media?
[Dr. Jason Qian]:
I have a private Instagram account. I don't have a professional social media. People are welcome to email me. My UCSD email is what I use, jaq001@ucsd.edu, or you can slide into my personal Insta, personal Insta DMs zjasonqian on Instagram.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, March 4). Ep. 213 – Ear Molding for Infants [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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