Taylor G Lackey MD1,2, Saied Ghadersohi MD3,4, Sarah A Gitomer MD1,2

1. University of Colorado School of Medicine, Department of Otolaryngology—Head and Neck Surgery, Aurora, CO, USA
2. Children’s Hospital of Colorado, Division of Pediatric Otolaryngology, Aurora, CO, USA
3. Northwestern University, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, USA
4. Lurie's Children Hospital of Chicago, Division of Pediatric Otolaryngology, Chicago, IL, USA

Corresponding Author: Taylor G Lackey (taylor.lackey@cuanschutz.edu)
12631 East 17th Ave 3001, Aurora CO 80045

Procedure: Taping of the Lop Ear

Introduction: Lop ear is a type of congenital external ear deformation with folding over of the upper third of the ear. Children are often bullied for these noticeable anomalies. Successful management depends on early initiation and parental persistence. We present a nonsurgical, easily replicable and cost-effective method using a dental wax splint secured with steri-strips.

Indications/Contraindications: Taping of the lop ear is indicated in infants within the first 6 months of life, with better outcomes noted with earlier intervention. Similar techniques may be used for other external ear deformations. Relative contraindications include older children as the success rate is low.

Materials and Methods: Patients are seen in clinic with a complete history and physical exam identifying a lop ear. A small piece of dental wax is molded to resemble the shape of the superior rim. The dental wax is placed in the upper portion of the scapha against the helical rim and secured with steri-strips along the superior helix. Families are taught in clinic how to replace the wax and tape as necessary, and followed with weekly photos to ensure improvement over time.

Results: A 16-day-old female was seen in clinic for lop ear of the left pinna. A dental wax splint was placed and secured during that clinic visit. Parents were able to replace steri-strips as needed at home. Follow-up at 2 weeks demonstrated resolution of lop ear. Telephone follow up 3 months later confirmed long-term success and parental satisfaction.

Conclusion: Use of a dental wax splint secured with steri-strips is an easily replicated and cost-effective nonsurgical technique for treatment of Lop ear. This video can be used as an adjunct for telehealth appointments in parent education to reduce delay in treatment and to promote therapy maintenance.

Ear deformation is a form of congenital external ear anomalies in which the ear bends abnormally without loss of skin or cartilage, as seen in microtia. Variants include prominent ear, lop ear, Stahl’s ear, and cryptotia. It is believed to occur in 11.5% per 10,000 births and has a predilection for boys.¹ Hypothesized pathogenesis results from external pressure prior or during birth, or due to the abnormal insertion of muscles in a fully developed pinna.^1–3 Lop ear, a type of external ear deformation, constitutes a folding over the upper third of the ear.⁴

Treatment of external ear deformities is recommended as children are bullied for these noticeable anomalies. Ear deformations spontaneously resolve in 30-85% of patients.^2,4 But, it is difficult to predict which ears will spontaneously improve. Furthermore, delayed treatment typically results in poorer outcomes.² As these deformations have normal anatomy, they are amenable to simple measures: taping, splinting or molding. Higher success seen with non-operative techniques in newborns is due to the relative pliability of neonatal cartilage. Pliability of the ear is thought to correspond to elevated levels of estrogen as it upregulates the hyaluronic acid content. Estrogen levels are highest over the first few days of life and reach normal levels by 6 weeks old.^2–4 As these levels decrease the cartilage thickens producing a more permanent shape.

Ear splinting is most successful in newborns within the first 1-2 months of life, though it is often attempted in older children prior to surgical intervention, thus older age is not a contraindication. A splint is used to fold the rim and ear back into expected anatomic position and to reconstruct the superior crus of the triangular fossa in lop ear. Various splint materials have been used including dental wax, soft putty, and wired catheters or silastic tubes.^1,2,4–8 The splint is then taped to the ear. Splints are initially placed by the physician and continued for 2-8 weeks (depending on the age of the child). Parents may change the tape when it comes loose. We present the use of a dental wax splint secured with steri-strips as an easily replicated and cost-effective technique, that parents may easily replace and continue as long as indicated. This non-invasive technique has few disadvantages and a high success rate as long as the splint therapy is maintained correctly. Complications with this type of technique include skin necrosis (rare), transient skin irritation (uncommon), and recurrence of ear deformity (7-12%).^1,2,5,8

In the ambulatory in-office setting, a history and physical exam are completed, confirming lop ear. After consent is obtained, a small amount of dental wax is taken and rolled into a cigar-shape. This is bent to a soft-U, to resemble the shape of the superior rim. Using digital manipulation and a cotton swab the dental wax mold is placed in the upper portion of the scapha, against the inferior aspect of the helical rim, folding the helix over the stent and back into position. This is secured with steri-strips from anterior to posteriorly along the superior helix, opening the lop ear fold and securing it from the scaphoid fossa over the helical rim into the sulcus.

A 16-day-old female was seen in clinic for lop ear of the left pinna. A dental wax splint was placed and secured during that clinic visit. Parents were able to replace steri-strips as needed at home. Follow-up at 1 week demonstrated improvement of pinna shape, and at 2 weeks demonstrated resolution of lop ear. In telephone follow up 3 months later, family reported persistent improvement and happiness with the overall result.

Correction of external auricular deformities has a high success rate with conservative taping/molding if initiated within the first months of life due to cartilage pliability and the infant’s lack of motor coordination limiting displacement of the mold. Other options, such as otoplasty, are considered for older children and/or after conservative management does not achieve desired results.⁹ Critical steps are recognition of the ear anomaly and creation and placement of the appropriate splint. Patients with lop ear, as demonstrated, require splint placement in the scapha and tape placement to “pull-back” the helix. Whereas Stahl’s ear has an abnormal vertical fold in the scapha, the tape needs to “pull-over” the helix and flatten the abnormal fold.

Duration of the stenting varies, in general if initiated within the first weeks of life, stenting for 2-4 weeks will yield good results.^2,5,6,8 Modifications are often made for older infants with splinting for 2-3 months. Different types of molds or splints may be used, depending on surgeon preference and typically firmer stents, such as wired catheters or sialastic tubes are used in older children.^1,2,4–8

Parent persistence is critical to success of treatment, as success decreases in partial or discontinued treatment.² Etiologies include lack of patience, children removing the device, concern for foreign body events, and skin irritation.⁵ Paramount to success is education, as deficiency may require more clinic visits to replace tape increasing risk of treatment discontinuation. Parents can be instructed on how to modify the dental mold at home over the course of treatment to achieve the desired shape. In addition, keeping the ear clean and dry with replacement of tape will improve adherence.

We present the use of a dental wax splint secured with steri-strips as an easily replicated and cost-effective technique, that parents may easily replace and continue as long as indicated. While other commercial ear molding devices are available in the market, this technique is equally as effective and less expensive for parents. Limitations include poorer outcomes in older children with decreased inherent pliability of the pinna. We aim to study the use of this video as an adjunct for telehealth appointments in parent education to reduce delay in treatment initiation as well as promote maintenance of therapy.

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