In this article, I have not used jargon because I want everyone to be able to figure out these issues in a simple and clear way. Parents of children with small ears should read it to gain a better understanding of their child’s condition so that they can lead their child, on the path of plastic and hearing rehabilitation, in the right direction and get an early recovery. We hope to help you get out of the confusion that comes with small ears.
1. The physiological role of the ear canal
The human ear includes three parts: the outer ear, the middle ear and the inner ear. The outer ear includes the auricle and the external auditory canal. The auricle collects sound, conducts it inward along the outer ear canal to the eardrum, and then passes through the auditory chain of the middle ear and into the inner ear. In this way the person hears sound.
Therefore, the external auditory canal is the conduit for sound transmission throughout the process.
2. Problems that occur when a small-eared child has no ear canal
Quite simply, the sound from the outside world cannot be transmitted into the middle and inner ear, and the child cannot hear the sound, and conductive deafness occurs. At this point, the child’s hearing (air conduction threshold) is usually around 60-70 decibels.
For most children with small ears, not only do they have no external auditory canal, but they may also have no tympanic membrane and no auditory chain, or the auditory chain may be malformed. This also does not conduct sound signals. Therefore, when I consider opening the external ear canal, I need to consider the reconstruction of the eardrum and the auditory chain as well as the external ear canal implant. This is something that most parents should be unaware of: opening the ear canal is only one part of the hearing reconstruction surgery.
3. Why do we need to open the ear canal?
The purpose is twofold: first, to reconstruct hearing, and second, for cosmetic reasons.
By opening the ear canal (while usually also reconstructing the tympanic membrane and auditory chain, and then adding an external ear canal implant), I reconstruct a pathway for sound signals to pass from the outside world to the inner ear in order to eliminate the child’s moderate to severe conductive deafness, to allow the child to hear clearly and easily, to allow the younger child to learn to speak quickly and accurately, and to allow the older child to communicate with others easily. In a word, to rebuild normal hearing for the child. But opening the ear canal is only one way to rebuild hearing, not the only way.
Also, the ear canal is part of the normal human ear. If there is only an auricle without an ear canal, the child’s appearance, upon closer inspection, will look a bit unnatural. If hearing reconstruction is not considered, but only aesthetics, the appearance of the ear canal can be created by making a shallow, inwardly depressed fossa after the auricle is reconstructed.
For a normal child, the auditory function of the ear canal comes first and the aesthetic appearance is secondary. Therefore, when dealing with the issue of opening the ear canal, clinically, doctors consider hearing reconstruction as the first purpose of opening the ear canal, followed by aesthetic considerations.
4. Which children can have their ears opened
Based on my experience of consulting in outpatient clinics, wards, and public micro-signals, I can say that parents are most concerned about this question: Can my child have an open ear canal?
As we said before, opening the ear canal is to reconstruct hearing, but opening the ear canal is not the only way to reconstruct hearing. So, what methods do we currently have to rebuild hearing in children with small ears?
The first is a non-surgical method: wearing an air-conduction hearing aid or a bone-conduction hearing aid. An audiologist will recommend air-conduction hearing aids when the difference in air-bone conduction does not exceed 30 decibels; if it is greater than 30 decibels, the audiologist will recommend a bone-conduction hearing aid. In addition to the traditional hairpin or spectacle bone conduction hearing aids, the mainstream bone conduction hearing aids in China include: softband BAHA, softband Ponto and softband Bone Bridge. These three types of hearing aids are all bone-conduction hearing aids with similar parameters and performance; they can be worn by children with small ears if they have atresia.
Next is the surgical approach. Surgical modalities include the following three major categories.
1. External ear canal – tympanic chamber reconstruction surgery: that is, we often talk about opening the ear canal. This surgery is roughly as follows: reconstruction of the external auditory canal, tympanic membrane and auditory chain, as well as external ear canal implantation.
2. Implantation of artificial middle ear, which is known as sound bridge in China.
3. Implantable bone conduction device, including BAHA and bone bridge.
How to choose between non-surgical and surgical approaches? The current consensus in the medical community is that bone-conduction hearing aids are only a transitional option, and that surgical approaches are considered when a child with small ears reaches the appropriate age. The reasons for this are: bone-conduction hearing aids require a visible hairband or hairpin for fixation, which aggravates the abnormal shape of the child (the ear is already deformed); and they are inconvenient to use and can cause a lot of inconvenience to the child’s school life.
What are the criteria used by doctors to determine the plan for children with small ears, based on the three surgical procedures? The simple answer is: for children with a mild temporal bone deformity, the doctor will open the ear canal (external ear canal tympanic chamber reconstruction); for children with a more severe deformity, the doctor will implant an artificial middle ear due to the instability of the reconstructed ear canal (it usually narrows or even closes again in 1-1/2 years); if the deformity is further aggravated and the temporal bone development is particularly poor, then a conduction device will have to be implanted. Bottom line: The decision to operate is based on the degree of development/deformity of the child’s temporal bones. One must keep this in mind.
If we go from a professional point of view, which I guess some parents of small ears already know, it is the scoring of the child’s temporal bone development according to the Jahrsdoerfer scoring system. A score of 10 out of 10 is for a child with normal development; a minimum score of 0 indicates that the child has a particularly severe temporal bone deformity. In children with a score of 8 and 9, an open ear canal is usually preferred; in children with a score of 7, the reconstructed ear canal and tympanic chamber may be unstable, and the doctor needs to consider the possibility of opening the ear canal; in children with a score of 5 and 6, the doctor implants an artificial middle ear; in children with a score of 4, the deformity is already severe, and the implantation of an artificial middle ear also needs to be considered; in children with a score of 3 or less, the deformity is particularly severe. A score of 7 and 4 are the two cut-off points.
To summarize: I usually take a CT of the temporal bone at the age of about 4 years for children with small ears and then make a score. For children scoring 8 and 9, I would start the child with a bone-conduction hearing aid (children with bilateral small ears should wear a bone-conduction hearing aid at a very young age even if they don’t have a temporal bone CT) and wait until they are 6-8 years old, when they can have an ear canal opened along with the otoplasty. Other children with lower scores are not recommended to have an open ear canal.
5. Effect of opening the ear canal on otoplasty
When opening an ear canal, the skin flap of the temporal bone area (in order from outside to inside: skin, subcutaneous fat, temporal muscle and periosteum) needs to be cut, then holes are made in the deformed temporal bone straight to the tympanic cavity, then the auditory chain and tympanic membrane are built in the cavity, and then skin is grafted on the surface of the bony orifice. As you can see, the integrity and blood supply of the skin flap in the temporal bone area has been destroyed in this process.
We all know that to reconstruct the auricle with autologous rib cartilage, an intact flap with good blood supply in the temporal bone area is required. If the integrity and blood supply of this flap is disrupted, the reconstructed auricle will be difficult to survive or prone to problems later on. To a certain extent, open ear canal and autologous rib cartilage reconstruction of the auricle are a contradiction in terms. If an open ear canal ruins a child’s chance to rebuild an auricle, I am afraid that this will become a lifelong regret for parents of small ears.
6. The age of the open ear
Obviously, for a child with small ears who is suitable for an open ear canal, the appropriate time to open the ear canal is at least at the same time as the otoplasty, or only after the otoplasty is completed and the reconstructed ear is well established. In other words, the opening of the external ear canal should be done at least after the completion of otoplasty at the age of 6-10.
7. Daily care after opening the ear canal
After the open ear surgery, the child’s reconstructed ear canal is filled with a lot of medical material to support the implanted flap to ensure viability. In some cases, a rigid ear mold is inserted into the ear canal for a long time after the child is discharged from the hospital to prevent narrowing of the ear canal. This process is carried out by the surgeon and takes about six months to a year.
At the end of this process, the child’s reconstructed ear canal is basically stable. Parents need to keep their child’s ear (reconstructed auricle and ear canal) clean and hygienic, and seek medical attention for any redness, swelling, or infection. Take your child for regular follow-up visits to have the doctor clean up any dander and secretions that have accumulated in the ear canal.
In addition, parents need to pay attention to their child’s hearing. An audiogram is the most sensitive indicator of the status of the ear canal. As we said before, the reconstruction of the ear canal actually includes the reconstruction of the external auditory canal, the tympanic membrane and the auditory chain. When there is an abnormality in these three structures, although there appears to be no significant change in the appearance of the ear canal, there will be a significant change in the air conduction threshold of the audiogram. Therefore, the child’s ear canal can be monitored through regular audiological examinations (including pure tone audiometry with air conduction and bone conduction). If the child’s air-conduction threshold is significantly lower than postoperatively (e.g., more than 15-20 dB), it goes without saying that there must be a change in the reconstructed ear canal-ear tympanic membrane – auditory bone chain.
Recommendation: Parents of children with reconstructed ear canals should have their child’s hearing checked every six months.
8. What should I do if my child’s hearing decreases again after the ear canal is opened?
At this point, there are two cases to discuss: 1. children with mild temporal bone deformity (Jahrsdoerfer score above 7); 2. children with severe temporal bone deformity (score below 7).
For children with a score of 7 or more, they are, in principle, suitable for open ear canals. Therefore, when there is an abnormality in the reconstructed ear canal (hearing loss is the most sensitive indicator), the first step is to review and analyze it to find out the cause: is it an acute infection? Is it a displaced tympanic membrane? Is the reconstructed auditory chain fixed again? Once the cause is found, medication or re-surgery to repair the ear canal usually results in a stable external auditory canal and stable hearing.
For children with a score of 7 or less, they are, in principle, not suitable for open ear canals. Therefore, reconstructed ear canals are often destined to be problematic; also, instead of reconstructing the ear canal – tympanic membrane – auditory bone chain again, artificial hearing implants should be considered.
According to the medical literature, and also combined with my experience in dealing with thousands of children with small ears, for children with scores below 7, surgically reconstructed external ear canals usually last only six months to 1.5 years, followed quickly by narrowing of the ear canal opening and hearing loss, and the effect and significance of the open ear canal disappears. For these children under 7 points, is it better to give them general anesthesia to do the surgery again and again to open the ear canal implant and make the child suffer over and over again? Or do we give them artificial hearing implants and get normal hearing all at once? I believe every parent, like me, will make the right choice.
9. Actual cases, children who should not have their ear canals opened
Case 1: This is my case. This child was 24 years old the last time she came to my clinic. She has had a total of 3 ear canal reconstructions with me, the first one being about 10 years ago. When she made it to the last stage of her otoplasty, I was faced with the problem of how to reconstruct her hearing. This child’s temporal bone deformity was relatively severe, and if we were to follow the Jahrsdoerfer score we use today, she would have only scored a 6. More than 10 years ago, the clinical methods available for hearing reconstruction in China were extremely limited; we did not have bone conduction hearing aids, let alone artificial middle ear and bone conduction implant devices as methods. So during the second stage of otoplasty, I opened her ear canal and performed two more surgeries over the next 10 years to reestablish the open ear canal. If this child were here today, I would not have opened her ear canal; based on her scores, I would have given her an auditory implant. This is the best option for her.
Case 2: This is a 4 year old with bilateral microtia (both grade 3, striae). When he came to my clinic, he actually had his right ear canal open, when it was infected and draining. A 4 year old who actually had an open ear canal before he had an otoplasty! I don’t have much to say to the parents of this child, but really feel for this child! This child will definitely need otoplasty in the future, but with the open ear canal, the integrity of the skin flap and blood supply in the plastic area has been destroyed, so how can otoplasty be done in the future? The complexity and risk of the entire reconstructive surgery will increase a lot, and what good will this do to the child? What I must tell the parents through this case is that the child (whose auricular deformity is grade 2-4) has gone through temporal bone scoring and if an open ear canal is appropriate, it must be done only after the reconstruction of the auricle (after 6-8 years of age).
Case 3: This is an older child with bilateral deformities. After his otoplasty with me when he was 9 years old, I opened the ear canal to restore hearing on the side of his temporal bone where the deformity was less severe (score 7) and the other side where the deformity was so severe that I did not move it. As you remember, according to the Jahrsdoerfer score, a score of 7 is a cut-off point. For children with a score of 7, a comprehensive evaluation and consideration is needed before opening the ear canal to make the final surgical decision. At the time, we considered all factors, but missed one thing: this child and his family had poor hygiene awareness and conditions. This child went home after the last stage of otoplasty and did not come for regular follow-ups. One day, about a year or so later, suddenly his mother brought him to the clinic: his entire ear was a dirty, black mess, and the open ear canal was infected and dripping with pus. The reconstruction of his ear and ear canal that I had given him before was basically for nothing! How can a parent be so uncaring about their child! Since then we have started to pay attention to the fact that the decision to open the ear canal is not only determined by the child’s temporal bone score, but also by whether the parents can take the child to regular follow-up appointments and whether the parents care about the child’s hygiene. We have to take into account both the child’s home environment and condition. So I’m cautious about being able to open the ear canal in cases where the parents are not able to pay good attention to their child.
I’m done talking.
The only purpose of such a long article is that I hope that parents will understand more about the basics and take the right path and less wrong path on the road to recovery of their children. A parent’s wrong decision often affects the child’s life; a moment of careless negligence often leaves a lifetime of regret. I hope you can share this article with the little ear families you know and have a proper understanding of opening the external ear canal.
For your convenience and to emphasize a few of the most important concepts, please keep the following points in mind.
1. The purpose of opening the ear canal is to restore hearing.
2. The methods of restoring hearing include: opening the ear canal, bone conduction hearing aids and auditory implants.
3.Temporal bone CT will be taken at the age of 3-4 years to score the child and then determine whether to open the ear canal or use another method.
4. If the child is scored for open ear canal, then after the otoplasty is completed (6-10 years old), the ear canal is opened.