International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543

Development of a screening service for neonatal ear deformity using neonatalhearing screeners and an information leaflet

Lyndsay Fraser *, Nicola Starritt, Louise Melia, Haytham Kubba

Department of Otolaryngology, Royal Hospital for Sick Children, Dalnair Street, Glasgow G3 8SJ, United Kingdom

A R T I C L E I N F O

Article history:

Received 23 October 2012

Received in revised form 15 December 2012

Accepted 21 December 2012

Available online 11 February 2013

Keywords:

Ear splinting

Congenital ear deformity

Screening

Prominauris

Lop ear

Cup ear

Stahl’s ear

Prominent ears

A B S T R A C T

Objectives: Early splinting of neonatal ear deformities has been proven to be successful but the

opportunity to splint is frequently missed due to lack of awareness amongst healthcare personnel. We

aimed to develop a regional screening service using neonatal hearing screeners and an information

leaflet to allow for the early detection and treatment of such children.

Methods: We created an information leaflet that was distributed by hearing screeners to all parents in

Greater Glasgow at the time of the child’s neonatal hearing assessment, with a contact number allowing

parents to self refer. All neonates referred were seen at a dedicated clinic within a week and suitability

for splints determined. We aimed to assess acceptability of the service, splinting result as rated by

parents and otolaryngologist and also costs involved.

Results: Over a 15 month period, 13,403 leaflets were distributed. 88 babies were referred (0.7%) and 54

were found suitable for splinting. 78% of parents rated the efficacy of splints as either excellent or very

good and 96% said they would recommend the service to a friend. Median age at first review was 4 days.

We found a weak but statistically significant correlation between age at first review and the surgeon

rated outcome from splinting (Spearman’s rho = �0.321, p = 0.038), with those babies commencing

treatment early generally having a better splinting result. We also found that age at first review

correlated with duration of splinting required (Spearman’s rho = 0.357, p = 0.008), with younger babies

generally requiring shorter splinting times. Cost analysis revealed a saving of £482.76 per child when

comparing splint treatment to potential later corrective ear surgery costs.

Conclusions: Our screening service is both acceptable to parents and efficient in allowing for early

correction of ear deformity in the majority of cases. By detecting treatable children early, we propose that

the introduction of routine screening and splinting on a wider basis will avoid the psychological burden

of ear deformity in childhood and also avoid the need for later corrective surgery.

� 2013 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier . c om / lo cat e/ i jp o r l

1. Introduction

Ear deformities are common in neonates and represent aspectrum of different disorders including prominent ears, Stahlsbars, rim kinks, cryptotia and lop ears. Although true incidence isunknown, estimates suggest between 1 and 5% of the populationare affected [1,2]. Such deformities can be corrected surgicallywhen the child is older, although this can be with variable results[3,4] and occasionally significant complications [4].

The cartilage of the newborn ear is incredibly pliable due to theinfluence of circulating maternal oestrogen [5] and can be easilymoulded to change appearance. Non-surgical correction of eardeformities with splints was first developed in the 1980s byJapanese plastic surgeons [6] and since then has been proven to be asafe and effective non-surgical treatment [2,7–10]. Although some

* Corresponding author. Tel.: +44 141 201 0000.

E-mail address: LyndsayFraser@doctors.org.uk (L. Fraser).

0165-5876/$ – see front matter � 2013 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijporl.2012.12.033

authors have reported success with splints in older children, generalopinion remains that treatment is more effective when commencedearly, ideally within the first few weeks of life [1,6–8,10].

In our large Scottish tertiary referral paediatric otolaryngologyservice, we had found that awareness of splint treatment was lowamongst parents and other healthcare personnel. We received only3–4 referrals each year for splinting and almost all were referredroutinely, often missing the narrow window of opportunity to starttreatment. In Glasgow 97% of all newborns undergo hearing testingby a hearing screener, usually 24–48 h after birth [11]. We felt thatthis was an ideal time and opportunity to screen for deformity toallow for earlier identification and treatment of affected children.

2. Methods

2.1. Developing a screening tool

First we consulted with the Glasgow neonatal hearing screeningteam to develop a method by which to screen. At first, we

Fig. 1. Information leaflet handed out to parents at time of neonatal hearing assessment. Back and front pages (top) and inner pages (bottom).

L. Fraser et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543 539

considered training the hearing screeners to identify commontreatable pinna deformities at the time of performing AABR(automated auditory brainstem response). However the group feltuncomfortable with this, as they were concerned that someparents may take offence to having a deformity pointed out.Likewise, many felt uncomfortable at the thought of fitting splintsor answering questions as they are trained solely to performhearing screening and have no other medical or nursing training.

Instead the group suggested developing an information leafletthat could be handed out to all parents at the time of hearingscreening. In response to this, we developed a leaflet containingphotos of common correctable ear deformities, some backgroundinformation about splints and a contact phone number allowingparents to self-refer their baby for assessment by an otolaryngolo-gy doctor if they wished (Fig. 1). The study design was submitted to

the local research and ethics committee and was approved asclinical audit.

2.2. Screening process

The leaflet was given out to all new mothers in Greater Glasgowbetween 1 December 2010 and 24 February 2012 by the baby’shearing screener at the time of the neonatal hearing assessment.All new referrals were seen within 1 week at the Otolaryngologyclinic, at which point the child’s ears were assessed and suitabilityfor splint treatment determined. If suitable, photographs wereorganised and the parents were provided with splints and shownhow to reapply the splint and tapes. We used Ear BuddiesTMsplints,which are commercially available in the UK and consist of a wirecore segment in a 6-French silastic tube held in place with adhesive

13403 Leaflets handed out at time of

Universal Neonatal Hearing Screening

88 Babies referred to clinic

54 Splinted

Types of deformit y

Prominent ea rs n=19

Rim kink s n=16

Cup ea r n=5

Stahl’s bar n=5

Lop ea r n=4

Mixed n=5

34 Not splinted

Reason s:

Spon taneou s correcti on n=5

Normal ea r/ mino r deformit y n=9

Deformit y no t correc tab le n=20

• 4 Anteverted lobu les

• 5 Shall ow scapho id foss a

• 1 Prominent anti heli x

• 5 Extra crus

• 2 Extra tiss ue on helical fold

• 1 Flat helical rim

• 2 Irr egu lar inn er rim of helical fold

44 Completed treatment 10 Did not complete

treatment

42 Post-splinting

photographs

49 Completed parental

satisfaction questionnaire

Fig. 2. Flow chart showing number of babies referred and splinted.

L. Fraser et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543540

skin strips. Parents were asked to observe for any skin irritation orulceration. Babies were reviewed back initially after 2 weeks andsplinting was continued until correction was felt to be complete byboth the parents and reviewing doctor, or discontinued if no

Fig. 3. Example of s

improvement was observed after 4 weeks of continuous splinting.Post-splinting photographs were organised and the parentswere asked to complete a parental satisfaction questionnaire onthe day of final splint removal. A Consultant Otolaryngologist

plinting results.

Fig. 6. Correlation between age at first consultation and surgeon rating of splinting

outcome. Surgeon rating was graded 1 = looks worse, 2 = no change, 3 = good,

4 = very good, 5 = excellent.

L. Fraser et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543 541

independently reviewed each of the pre- and post-splintingimages and scored the splinting result from 1 (looks worse) to 5(excellent).

2.3. Outcomes measured

Our primary outcome measure was to assess overall accept-ability of the service to parents. Secondary outcome measuresthat we aimed to assess were splinting result as rated by parentsand otolaryngologist, presence of complications and also costsinvolved. Data were analysed using SPSS V.16.

3. Results

Fig. 2 demonstrates the number of children referred, numberand types of deformity splinted and the number and reasons fornot splinting. Our overall referral rate was 0.7%. Examples ofsplinting outcomes are demonstrated in Fig. 3. 67% (n = 36) of thosesplinted had bilateral deformity and 33% (n = 18) unilateral. Familyhistory of ear deformity was reported by 13% (n = 11) of parentsattending the clinic. Median age at first review was 4 days (range3–189, mean 26). Splinting time ranged from 1–17 weeks (median2, mean 4), depending on the age of the child at first presentation,deformity encountered and response to treatment. 10 babies didnot complete treatment and of the 9 parents we were able tocontact, the reasons for this included splints falling off frequently(n = 3), child pulling splints off (n = 3), parental difficulty inapplying splints (n = 1) and the child being admitted to hospitalwith other illness (n = 2).

90% (n = 44) of the parents who completed our parentalsatisfaction questionnaire admitted they had never heard of ear

Fig. 4. Parental rating of the ease of use of ear splints.

Fig. 5. Parental rating of effectiveness of splint treatment.

splints before and 80% (n = 39) felt they would not have triedsplints had they not received the information leaflet. The majorityof parents (73% (n = 36)) rated ease of use of the splints as eithereasy or incredibly easy (Fig. 4) and when asked to rate the overalleffectiveness of splinting, 78% (n = 38) rated outcome as either verygood or excellent (Fig. 5). 96% felt that they would recommend theservice to a friend. No complaints from parents were receivedduring the study period. The hearing screening team was alsoregularly consulted and no adverse feedback was received.

11 (22%) parents noted their child to have minor skin irritationat some point during the splinting period. Skin irritation was notedobjectively on review in only 4 babies and was treated in each casesuccessfully by topical Metanium ointment (Titanium dioxide 20%w/w, Titanium peroxide 5% w/w and Titanium salicylate 3% w/w).

A Consultant Otolaryngologist independently reviewed the preand post-splinting images available and scored the outcome from 1(looks worse) to 5 (excellent). We found that there was a weak butstatistically significant correlation between age at first review andthe surgeon rated outcome from splinting (Spearman’srho = �0.321, p = 0.038) (Fig. 6), with those babies commencingtreatment early generally having a better splinting result. No

Fig. 7. Correlation between age at first consultation and duration of splinting

required.

Table 1Costs involved in ear screening and splinting versus daycase pinnaplasty.

Ear splinting Daycase pinnaplasty

Ear Buddies splints £35.39 Pre-operative assessment £14.00

Leaflet £0.03 Theatre nursing £101.00

Outpatient visits � 2 £36.00 Recovery nursing £65.00

Photographs � 2 £6.00 Surgeon time £92.00

Anaesthetist time £92.00

Equipment £50.00

Overheads £86.20

Outpatient visits � 3 £54.00

Photographs � 2 £6.00

Total £77.42 Total £560.20Cost difference £482.76

Personal communication received from David MacKichan, accountant for NHS Greater Glasgow & Clyde, January 2012.

L. Fraser et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543542

correlation was found between age at first review and parentalrating of splinting outcome (Spearman’s rho = 0.023, p = 0.876).

We also found that age at first review correlated with durationof splinting required (Spearman’s rho 0.357, p = 0.008) (Fig. 7),with younger babies generally requiring shorter splinting times.No statistically significant relationship was found between type ofdeformity and parental or surgeon reported outcome althoughanecdotally we found lop and cup ear splinting outcomes to scorefairly low by both groups. Lastly we compared the costs involved inscreening and splinting for neonatal ear deformity versus the costsinvolved in daycase pinnaplasty (Table 1).

4. Discussion

4.1. Synopsis of key/new findings

We have shown that an information leaflet given out at the timeof neonatal hearing screening is an effective and acceptablescreening tool for neonatal ear deformity. With the median age atfirst review in our series being only 4 days, the leaflet allows forearlier detection and treatment of affected neonates leading toimproved splinting results and shorter splinting times. Although itis difficult to predict what proportion of children treated withsplints would be prevented from seeking later corrective earsurgery, our cost comparison demonstrates a clear theoreticalfinancial advantage from splinting compared to the costs of latercorrective ear surgery.

4.2. Strengths

As far as we are aware, this is the first screening service of itskind in the UK for neonatal ear deformity. We have demonstratedthat the service was both acceptable to parents and hearingscreeners and efficient in achieving correction of ear deformity inthe majority of cases.

Early in the study we realised that not all parents of childrenwith prominent or folded ears would wish treatment, as some maynot view the ears as a problem or may wish to leave any decisionsabout their baby’s ears to the child once they are older. The use ofan information leaflet as a screening tool was therefore an idealcompromise for approaching this sensitive issue as it gave parentsthe flexibility of choosing whether they wished review or not andwas careful in stressing that any treatment decision wascompletely up to them.

4.3. Weaknesses

We cannot reasonably predict what proportion of childrenwould have grown up to be dissatisfied with their ears or soughtlater corrective surgery had they not been splinted. Also to be ableto fully assess the acceptability of using the information leaflet as a

screening tool, we would ideally have surveyed all parentsreceiving the leaflet but this was simply not feasible given thescale of the project and numbers involved. However it is reassuringthat no complaints were received regarding the service or leafletdistribution.

5 neonates referred to the clinic were found to have hadspontaneous correction of their ear deformity by the time of firstreview and it is difficult to predict how many others may havespontaneously corrected if left untreated. Although one Japaneselongitudinal study showed that the incidence of some auricularanomalies decreases with age, the authors were not able to predictspecifically which anomalies would resolve spontaneously [2].Indeed with prominent ears, the incidence only seems to increasewith age and no spontaneous improvements are generally noted[12]. With current knowledge therefore and lack of data to allow usto predict which deformities may improve, we feel it is reasonableto carry out non-surgical correction on all deformities that aresignificant and treatable as soon as possible.

4.4. Comparisons

A fast-track referral system utilising specialist nurses hasalready been piloted in New Zealand with good effect in 2003 [9].This study included 30 babies and involved the authors developinga protocol encouraging GPs, neonatologists and midwives to lookout for pinna abnormalities and refer babies via a fast-track service.Average age at first splinting was similar to our series. Like theauthors of the New Zealand study, we too had previously tried toimprove awareness of splint treatment and encourage earlyreferral at various educational meetings via protocols and posters,but constant staff turnover in units meant that the message wasoften quickly lost.

More recently, the Mayo Clinic have published a pilot studyutilising hearing screeners to identify neonates with eardeformity [13]. In this small study, the hearing screeners weregiven specific training to recognise correctable ear deformity andwould notify the child’s family doctor, who would then notify theparents that an otolaryngologist would review their child’s eardue to concern over the shape. Of the 15 babies that were referredfor splinting, 2 were found to be unsuitable for treatment by thereviewing otolaryngologist and 3 sets of parents refused splintingaltogether.

We feel our screening leaflet method is superior as it avoids thepotential for offence being caused to parents by healthcarepersonnel pointing out a problem with the newborn’s ears, orthe unnecessary worry caused by a screener suggesting that thechild has a correctable deformity that is then later deemed asuntreatable. We feel that parental satisfaction is key to the successof splinting, as is co-operation and agreement on the part of thehearing screeners involved in the screening process. Neither ofthese appear to have been measured as part of the Mayo Clinic pilot

L. Fraser et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 538–543 543

study and it is interesting that our screeners objected to screeningby this method when our study was initially under design.

Although the true incidence of neonatal ear deformity remainsunknown, our overall referral rate of 0.7% falls slightly short of thefigures quoted in existing literature (1–5%) [1,2]. This may reflect ageographic variation in incidence or more likely reflects the factthat some parents chose simply not to seek treatment for theirchild’s ears. Indeed much of the existing literature on incidence isbased on long-term observational data rather than reflecting ‘real-life’ referral rates.

Our data add to existing literature suggesting that earlysplinting improves splinting results. This is likely due to acombination of factors including the less pliable nature of cartilagein older children, longer splinting times required and also thedifficulty maintaining splints in place in older babies who arebecoming more aware of their ears. It is interesting that parentalrating of outcome did not correlate well with age at first review aswe found for surgeon rating, but this perhaps reflects the fact thatparents were less focused on the technical outcome from splintingand were instead more generally satisfied that they had donesomething positive to improve the appearance of their child’s earsby self-referral to the service.

Some authors have suggested variability in the maintenance ofear shape after splint removal. To take account of this possibility,we asked parents to contact the service if there should be anyrecurrence of deformity after splint removal but received nofurther calls.

4.5. Clinical applicability

Our screening service has now been given full funding tocontinue in view of the potential cost savings and benefit to childand parent. We propose that our service model could be employedby other otolaryngology units as a cost effective way of screeningfor neonatal ear deformity. If introduced on a wider scale, we feelthat screening and early treatment of pinna deformity would avoidthe psychosocial morbidity associated with pinna deformity inchildhood [14] and subsequent need for corrective surgery later inlife, with its potential risks and significant cost implications.

5. Conclusions

Early splinting of neonatal ear deformity has been proven to besuccessful but the opportunity to splint is often missed due to lackof awareness amongst healthcare personnel. Our screening service,utilising an information leaflet given out by hearing screeners atthe time of newborn hearing screening, is both acceptable toparents and efficient in allowing for early correction of eardeformity in the majority of cases. By detecting treatable childrenearly, we propose that the introduction of routine screening andsplinting on a wider basis will avoid the psychological burden ofear deformity in childhood and also avoid the need for later

corrective surgery, with significant cost implications for healthcareproviders.

Conflict of interest

None declared.

Acknowledgements

We would like to acknowledge the Scottish OtolaryngologicalSociety Guthrie Fund and Yorkhill ENT Research Fund for theirresearch grants supporting the project and purchasing of splints.Both funding resources had no influence on study design or datacollection/analysis/interpretation.

We would like to thank Leigh Hamilton and Karen Boyle (SeniorAudiologists at Royal Hospital for Sick Children, Glasgow) and theGreater Glasgow Neonatal Hearing Screening team. We would alsolike to acknowledge Laura Baxter and the Medical Illustration teamat Royal Hospital for Sick Children, Glasgow for their help withphotographs. We would also like to thank David Gault and EarBuddies for permission to reuse the photographs that was used inour leaflet.

References

1 F. Schonauer, I. La Rusca, G. Molea, Non-surgical correction of deformationalauricular anomalies, J. Plast. Reconstr. Aesthet. Surg. 62 (2009) 876–883.

2 K. Matsuo, R. Hayashi, M. Kiyono, T. Hirose, Y. Netsu, Nonsurgical correction forcongenital auricular deformities, Clin. Plast. Surg. 17 (2) (1990) 383–395.

3 M. Ngouchi, K. Matsuo, Y. Imai, S. Furata, Simple surgical correction of Stahl’s ear, Br.J. Plast. Surg. 47 (1994) 570–572.

4 J.C. Calder, A. Naasan, Morbidity of otoplasty: review of 562 consecutive cases, Br. J.Plast. Surg. 47 (1994) 170–174.

5 F.M. Kenny, K. Angsusungha, D. Stinson, J. Hotchkiss, Unconjugated Estrogens in thePerinatal Period, Medical Examination Publishing Co, New York, 1978.

6 K. Matsuo, T. Hirose, T. Tomono, M. Iwasawa, S. Katohda, N. Takahashi, et al., Nonsurgical correction of auricular deformities in the early neonate: a preliminaryreport, Plast. Reconstr. Surg. 73 (1984) 38–51.

7 S.T. Tan, D.L. Abramson, D.M. MacDonald, J.B. Mulliken, Molding therapies forinfants with deformational auricular anomalies, Ann. Plast. Surg. 38 (1997) 263–268.

8 S.T. Tan, M. Shibu, D.T. Gault, A splint for the correction of congenital ear deformi-ties, Br. J. Plast. Surg. 47 (1994) 575–578.

9 S. Tan, A. Wright, A. Hemphill, K. Ashton, J. Evans, Correction of deformationalauricular anomalies by molding – results of a fast-track service, N. Z. Med. J. 116(1181) (2003) U584.

10 Y. Ullmann, S. Blazer, Y. Ramon, I. Blumenfeld, I.J. Peled, Early nonsurgical correc-tion of congenital auricular deformities, Plast. Reconstr. Surg. 109 (2002) 907–915.

11 Greater Glasgow and Clyde Public Health Screening Programmes Annual Report 1April 2010 to 31 March 2011. http://library.nhsggc.org.uk/mediaAssets/Board%20-Papers/12-04.pdf (accessed 1.09.12).

12 S.T. Tan, D.T. Gault, When do ears become prominent? Br. J. Plast. Surg. 47 (1994)573–574.

13 R.S. Petersson, C.A. Recker, J.R.K. Martin, C.L.W. Driscoll, O. Friedman, Identificationof congenital auricular deformities during newborn hearing screening allows fornon-surgical correction: a Mayo Clinic Pilot study, Int. J. Pediatr. Otorhinolaryngol.76 (2012) 1406–1412.

14 E.T. Bradbury, J. Hewison, M.J. Timmons, Psychological and social outcome ofprominent ear correction in children, Br. J. Plast. Surg. 45 (2) (1992) 97–100.