Stahl's Ear Research Articles

Early nonsurgical correction of congenital auricular deformities.

Congenital auricular deformation is not an uncommon phenomenon, and it may cause substantial annoyance to the growing child. Many parents of affected children will seek surgical correction of the deformed auricles. The variety of techniques that have been described for the correction of this anomaly suggests that none has been considered satisfying. The consequent possible surgical complications should also be considered, when the surgical procedure can be replaced by an effective conservative treatment. The authors describe their experience using early splinting for congenital auricular deformities. Fifty-two newborn infants with lop, prominent, Stahl's, and constricted ears referred to us by the neonatal department staff were enrolled in this study. Putty Soft, a vinyl polysiloxane impression material, has been used for early molding of the auricles. Surgical tapes were used for the fixation of the mold and to fix the auricle to the scalp. The results were evaluated by one of the parents and by a layperson (medical student) 6 months after completion of the procedure. The above-described early splinting procedure was applied onto 92 auricles of 52 newborn infants aged 1 to 10 days, mostly around day 3. The mean treatment time was 6.8 weeks. All treated auricles were improved, 87 percent were rated as excellent improvement, and there were no complications related to the treatment. The authors conclude that early splinting of deformed auricles should be offered to parents of affected children, and the awareness of this procedure by neonatologists, pediatricians, and nursery staff should be increased.

Correction of Stahl's Ear.

Stahl's ear is a rare congenital anomaly difficult to correct surgically. This report presents the experience of the Division of Plastic Surgery, University of São Paulo Medical School for managing this anomaly. From January 1994 to September 1999, 15 patients underwent surgery (17 ears). Ages ranged from 7 to 22 (mean 15 years). Six patients were female. Four subjects were of Oriental descent, four were Negroes, and seven were Caucasians. Deformities included two bilateral, four on the left ear, and nine on the right one. Different methods were utilized for correction depending on the elasticity of the cartilage. In the presence of an elastic cartilage, sutures only are employed, otherwise the cartilage is repositioned, as described by Sugino et al. No standard characteristics were noted regarding gender or race, however, there were more unilateral cases and more on the right ear. The results were adequately satisfactory, with the two methods enabling us to recommend these surgical techniques for correction of Stahl's ear.

Video Superimposition at the C.A. Pound Laboratory 1987 to 1992

William R. Maples practiced many aspects of human identification using simple and relatively inexpensive video superimposition equipment. Identification of skulls by comparison to known photographs was a primary concern. Clear, smiling photographs revealing the spatial relationships of the teeth to one another led to uncomplicated positive identifications. However, without benefit of dentition, how accurate was an identification based on the alignment of soft tissues with the underlying skull? Most importantly, how often would a false positive result when anterior dentition were not available? A study conducted by this author and Dr. Maples used three human heads and 98 profile and full-face photographs. A 0.6% incidence of false match resulted when both views of the face were used. Lateral view and frontal view superimpositions were identified incorrectly in 9.6% and 8.5% of the sample respectively. As a result, multiple photographs from varying angles were requested for superimposition identity cases. Additional applications in laboratory case work were developed for the equipment. Light boxes under the television cameras allowed radiographic comparisons. Video taped comparisons of antemortem and postmortem radiographs were shown to medical examiners and families as proof of identification. Dr. Maples and this author were also involved in several cases in which photographs taken by a surveillance or ATM camera were compared to court ordered photographs of an alleged perpetrator. One case, which went to trial, led to the conviction of a habitual criminal under Florida statute. This individual had a condition known as Stahl's ear, a deformation of the cartilaginous structure. The ear was seen clearly in many of the ATM camera photographs and was aligned easily with the known photographic sample.

Nonsurgical correction of congenital auricular deformities in children older than early neonates.

It has been reported that nonsurgical correction of auricular deformities is not effective except in early neonates. We have succeeded in nonsurgical correction using thermoplastic splints for congenital auricular deformities on 50 ears of 45 patients without severe hypoplasia in children older than 1 year. Details of the types of ears we attempted to treat were 26 cryptotias, 5 lop ears, 5 Stahl's ears, 3 prominent ears, 3 shell ears, and 8 other miscellaneous conditions. The patients were between 1 and 14 years of age with an average age of 3.6 years. Our results were categorized as follows: excellent (the auricle was delicately corrected into a desirable form and satisfied the patient), improved (the auricle was corrected into a rough form that did not attain to a desirable shape and an irregular form still remained; however, its improvement satisfied the patient), recurrent (the auricle was initially corrected but the deformity recurred), not improved (the auricle was not corrected to the desired form and the result did not satisfy the patient), and gave up (the patient gave up before treatment could be completed). In our results, the average period of splint application was 2.1 months. In 27 of the 50 cases, the treated ears were excellent. Eleven ear cases showed improvement. Six cases showed recurrence. Three cases did not improve. Three patients gave up treatment. It is suggested that nonsurgical auricular correction is possible in almost all children, even if they are not early neonates, when corrections are made continuously and gradually.

耳介形状のスプライン近似表現と新生児耳介形状の比較

In Japan, 60% of neonates are born with auricular deformity. Therefore it is important to express the auricular shape numerically and utilize it for medical treatment. In this paper, the auricular shape is approximated by B-spline function of order four with four internal knots. Derived positions of control points are used as an indicator of auricular shape. Neonates' 490 auricular shapes are classified into following six groups : normal ear, upper folded helix, diagonal side folded helix, side folded helix, Stahl's ear and folded lobulus auriculae. Control points of each group are compared and it is revealed that every group can be characterized by those positions. Also discriminant analyses using the position and Mahalanobis generalized distance are performed. For folded lobulus auriculae, upper folded and side folded helix success ratio of more than 0.7 is obtained. However, as diagonal side folded helix and Stahl's ear are unable to distinguish from normal ear sufficiently, those success ratios are less than 0.7. Finally, target auricular shape after treatment is generated by moving control points gradually toward the direction where Mahalanobis distance between normal ear becomes the least.

Nonoperative treatment of congenital deformities of the ear

Selected congenital ear deformities particularly those of a deformational type (Stahl's ear, some cup and lop ears and ear prominence) as well as cryptotia may be corrected with early nonoperative splinting, avoiding later need for surgical correction. Nonoperative management of these deformities is possible because of the early malleability of cartilage during the neonatal period when the cartilage elasticity is affected by high levels of circulating maternal estrogens. Following 72 hours these levels drop and the cartilage becomes more firm. The splinting techniques, timing, and results of this treatment are reviewed.

Molding therapy for infants with deformational auricular anomalies.

Congenital auricular anomalies can be categorized as either malformed or deformational. Auricular deformations most commonly affect the helix and antehelix. Surgical correction involves sutural modeling, wedge excision, reshaping and reversing cartilage segments, and morselization. Since neonatal auricular cartilage is extremely pliable, we used early splinting to correct deformational ear anomalies. Splints were constructed of leadfree, soft soldering wire threaded into polyethylene tubing and held in place with Steri-Strips. From August 1995 through February 1996 we treated 19 infants with 32 deformed auricles: 10 infants were male and 9 were female, ranging in age from 1 day to 10 weeks. Thirteen infants had both ears affected. There were 8 prominent ears, 23 lop ears, 2 Stahl's ears, and 1 infant with an inverted concha. For prominent ears, the helical-mastoid distance decreased from an average of 16.8 to 12.2 mm, after an average of 13 weeks of splinting. Fourteen corrected lop ears had a normal appearance, and 9 were improved with minor residual deformity. There was only one complication: skin irritation requiring adjustment of the prosthesis. Five children had molding started after 3 months of age and all had no significant improvement. In addition, the parents of 5 children refused therapy and 12 children had either poor compliance to therapy or were lost to follow-up. Our experience with auricular molding confirmed that it is easy, effective, and inexpensive. If molded sufficiently early, most auricular deformations should not need surgical correction in childhood.

Development of computer assisted orthosis design and manufacturing system for malformed ears.

Most cases of malformed ears in neonates can be treated by mounting a suitably shaped orthosis. Our objective was to develop a computer-assisted orthosis design and manufacturing system for the treatment of malformed ears. Also, we aimed to manufacture a first experimental orthosis made of nitinol shape-memory alloy wire. First, the target posttherapeutic auricular shape is input from computed tomography scans, and characteristic points and contours are extracted. The shape of the orthosis is then created by tracing the necessary contours automatically. Finally, the orthosis shape data are projected onto one or more approximate planes and autoconverted into numerical control (NC) data for plate groove processing. The nitinol shape-memory alloy wires are inserted in the groove and the shape is memorized by heat treatment. The shape of the manufactured orthosis can be memorized from the generated NC data within 1.0 mm of error. Stahl's ear in a 9-month-old baby was treated 7 months ago by mounting the orthosis manufactured by the system. The developed system allows the design and manufacture of orthoses made of nitinol shape-memory alloy wire for the treatment of malformed ears.

Development of Computer Assisted Orthosis Design and Manufacturing System for Malformed Ears

Most cases of malformed ears in neonates can be treated by mounting a suitably-shaped orthosis. Our objective was to develop a computer-assisted orthosis design and manufacturing system for the treatment of malformed ears. Also, we aimed to manufacture a first experimental orthosis made of nitinol shape-memory alloy wire. First, the target posttherapeutic auricular shape is input from computed tomography scans, and characteristic points and contours are extracted. The shape of the orthosis is then created by tracing the necessary contours automatically. Finally, the orthosis shape data are projected onto one or more approximate planes and autoconverted into numerical control (NC) data for plate groove processing. The nitinol shape-memory alloy wires are inserted in the groove and the shape is memorized by heat treatment.The shape of the manufactured orthosis can be memorized from the generated NC data within 1.0 mm of error. Stahl's ear in a 9-month-old baby was treated 7 months ago by mounting the orthosis manufactured by the system. The developed system allows the design and manufacture of orthoses made of nitinol shape-memory alloy wire for the treatment of malformed ears.

An operation for Stahl's ear

We devised an operation to correct Stahl's ear, a rare but difficult to treat auricular malformation. First, a wedge excision is made of the anterior skin and cartilage of the abnormal, third crus prominence. The abnormal, flat part of the helix is excised. A conchal cartilage graft is used to support the area after closure of the defect, including advancement of the helical edges. The procedure has been used in five cases with satisfactory results.

Congenital anomalies of the auricle: correction using external splints

Congenital external ear anomalies can lead to severe psychological problems in children. These defects can be corrected by splinting in the first five days following the birth of the child, avoiding psychological problems and those arising from surgical treatment. An external prosthesis of flexible wire covered with a silicon tube is used. These are attached with surgical tape and are kept on for 2–3 weeks. This treatment has been performed on 45 external ears having several types of anomaly. In the cases reviewed the results were 70% good and 30% mediocre. This treatment is simple, atraumatic and gives good permanent results for most protruding ears, lop ears, Stahl's ears and lobe evertion, and mediocre results in all the cup ears. If used more frequently, it would avoid, to a large extent, the need for later surgical treatment and possible psychological, physical and financial problems for the patient and family.

Simple surgical correction of Stahl's ear

We describe a simple method of correction of the Stahl's ear deformity. The deformed portion of the auricular cartilage is cut into tiny pieces and put back into the abnormal area. The helix and the scapha are then moulded into a normal ear shape and maintained in position with a tie-over bolster. A gutta-percha splint is used for a further month. Over a 3-year period, 6 Stahl's ear deformities in 5 patients were treated with this procedure. All patients were followed up for at least 1 year. We believe that this procedure can be applied to other partial auricular deformities as well.

A new method for correction of Stahl's ear.

Stahl's ear is characterized by a third crus, a flat helix, hypoplasia or total absence of the superior crus, and deformity of the scaphoid fossa. There are various methods for the correction of Stahl's ear, but the surgical correction of this deformity is more difficult than it appears. We recently devised a new surgical method of our own. During the past 4 years, we treated 5 patients with Stahl's ear with this procedure. Our procedure can be used in every kind of deformity of Stahl's ear and can get satisfactory results.

Nonsurgical Correction of Congenital Auricular Deformities

Congenital auricular deformities are found in 55.2 per cent of neonates at birth. When the deformities are not hypoplastic, nonsurgical correction is very easy and reliable. Lop ear and Stahl's ear respond well to the nonsurgical correction only during the neonatal period, while protruding ears and cryptotia respond until approximately 6 months of age. We noticed that there are variations in the time period for response to nonsurgical correction in the different types of auricular deformities. We have continually observed the natural changes in 1000 babies' auricular shapes from birth to 1 year of age. Lop ear and Stahl's ear were auricular deformities that appeared in 47 per cent of all newborn babies. Eighty-four per cent of these deformities disappeared spontaneously during the first year of life. They were present in 7 per cent of the 1000 babies at 1 year of age. On the other hand, the percentage of protruding ears increases from 0.4 per cent at birth to 5.5 per cent at 1 year of age. Our observations show that most of the protruding ears are acquired deformities. If a baby is placed in a supine position, the weight of the baby's head will fold the ear forward when the baby turns its head to one side; this is the mechanism presented as the probable cause for the acquired protruding ear.

Surgical Correction of Stahlʼs Ear Using the Cartilage Turnover and Rotation Method

Various operative methods for the correction of Stahl's ear exist. We, however, have devised an alternative "turnover and rotation" procedure. In this procedure, the deformed cartilage itself is used in its original contour to form a new scaphoid fossa, thus simplifying the corrective procedure and establishing a reliable operative method in which reversion to the original state is thought to be highly unlikely.

A simple operative procedure for the treatment of Stahl's ear

Stahl's ear is a rather rare congenital deformity and operative procedures for its correction have seldom been reported. We recently devised a simple method of surgical treatment, which is briefly described as follows: incisions are made into the third crus cartilage to facilitate the formation of a helical fold, and the cartilage is sutured by means of a mattress suture. This method makes it possible to produce a natural helix, though it fails to eliminate the third crus.

Evaluation of Stahl's ear, third crus of antihelix: A. Yamada and O. Fukuda. Ann Plast Surg 511–515, (June), 1980

Evaluation of Stahl's ear, third crus of antihelix: A. Yamada and O. Fukuda. Ann Plast Surg 511–515, (June), 1980

Evaluation of Stahl's ear, third crus of antihelix.

In our unit, 38 patients with Stahl's ear were seen in thirteen years. We found no characteristic distribution, in terms of either sex or affected side. We classified the condition into four types, and corrected it by excision of a narrow strip of cartilage and mattress sutures or in some cases by turning over the elliptical cartilage.