Ethical Considerations in Pediatric External Ear Surgery

Abstract

The distinction between reconstructive and aesthetic surgery becomes less apparent when body image and self-esteem secondary to congenital deformities affect psychosocial well-being. Parents and plastic surgeons debate the appropriate age to correct non-life-threatening congenital defects to avoid a psychologically distressing event to the child. Furthermore, an ethical debate emerges when parents make decisions on behalf of children below the age of consent and lack the necessary cognitive development. This challenging responsibility then rests upon the operating practitioner to prioritize the child's best interests. This paper examines three hypothetical cases to explore the psychosocial and ethical aspects of conducting external ear surgery in the pediatric population and determining the ideal timing.

Introduction

According to the American Society for Aesthetic Plastic Surgery, 2% of cosmetic surgeries performed in 2016 were performed on children, amounting to 39 709 surgical procedures. ¹ The count rises when considering those undergoing elective surgeries. ² The recent shift in public attitudes toward physical appearance has not solely been confined to adults and is extending toward teenagers.^1,3,4

In pediatrics, the boundary between reconstructive and esthetic surgery is ambiguous, and these categories frequently intersect. While repairing cleft lip and palate to allow a child to feed in the first few months of life ⁵ and cranial vault remodeling in a child with craniosynostosis to allow for brain growth and avoid intracranial hypertension are essential surgeries, cosmetic surgeries are conducted on children to attain psychosocial advantages, as the connection between a positive body image and elevated self-esteem in the pediatric population has been firmly established. ⁶ This is based on findings that the presence of congenital deformities correlates with increased psychosocial morbidity following children into adulthood.^7‐9 Parents and plastic surgeons often elect to surgically correct non-life-threatening congenital defects to reduce psychological trauma in the child.^8,10

Even in the case of cranial vault remodeling, it is crucial to acknowledge that not all cases of craniosynostosis lead to elevated intracranial pressure (ICP), which mandates surgical intervention. This variation has fueled discussions regarding the potentially cosmetic nature of craniosynostosis surgery in certain instances. This diversity in perspectives underscores the complexity inherent in pediatric surgical decision-making. To strike a balance between medical necessity and cosmetic considerations, individualized evaluations are pivotal, considering the child's well-being, medical viewpoints, and ethical dimensions that guide such decisions.

The differentiation between reconstructive and cosmetic surgery holds significance in pediatrics when parents seek surgeries for children who are undergoing cognitive development. In situations where the necessity of surgery is not evident, the suitable age for intervention becomes a subject of debate.^11,12 The implications of performing cosmetic surgeries on patients who are experiencing cognitive, psychological, and physical changes are not well comprehended.^13,14 Our comprehension of the psychology of children undergoing esthetic surgeries is constrained, ¹³ as we lack well-defined guidelines that establish the criteria and the suitable age for performing these procedures, all the while reducing risks and ensuring the best possible outcome. ¹⁴

Herein, we review ethical considerations surrounding three hypothetical cases discussing psychosocial and ethical factors of performing external ear surgery in the pediatric population and the controversy surrounding the optimal timing of the procedure. Many prefer to operate on patients at an early age to reduce psychological trauma and allow for earlier recovery, while others prefer to wait for the child to develop maturity to perceive their condition and participate in the decision-making.

Case 1

A mother brings in her 3-year-old son, who was adopted as a baby from Asian origins, for a consultation concerning his left ear. The child's hair has been grown out to hide his ears, and he has been wearing a large cap that covers his head. During the interview with his mother, concerns were expressed about the child's social and academic prospects. Additionally, there were discussions about the delays in his language development and attention-deficit disorders. ¹⁵ This is because the child is diagnosed with conductive hearing loss on the left side and is currently awaiting a bone-anchored hearing aid.

Examination of the left ear revealed a grade III microtia with a remanence of the ear lobule, a well-formed lobule, and an absent external auditory canal. Microtia reconstruction is a complex procedure demanding both artistic flair and technical expertise. It involves creating a structural framework that accurately mirrors the three-dimensional design of the ear. This framework aims to match the size and contours of the opposite ear (in instances of unilateral microtia) and ultimately produce an ear that harmonizes proportionally with the child's facial features. ¹¹

The conversation with the mother encompassed the diagnosis, the nature of the anomaly, and the available treatment options. The mother was taken aback when we suggested waiting until the patient reached 9 years old to perform ear reconstruction using a rib cartilage graft. She was eager to have the ear reconstructed as soon as possible. She recounted comments from her family and friends about the “missing ear” and her frustration over the asymmetry between his perfect right ear and the underdeveloped left ear. She mentioned a procedure she had come across from her own research that involved using a Medpor implant to construct the ear's framework. This approach could be undertaken as early as 3 years of age, completed in a single outpatient surgery, ¹⁶ thereby avoiding the wait for chest wall development and potential pulmonary complications. A discussion followed regarding the surgeon's preference for alternative techniques, along with the pros and cons of each approach, the most appropriate age for the surgery, and the rationale behind the recommendations.

Case 2

A 6-year-old boy arrived at the clinic accompanied by both of his parents to discuss his bilateral prominent ears. Both parents have voiced their worries about the shape of his ears. When asked if the issue “bothers him,” the boy denied any concern and did not acknowledge the matter. He exhibited no awareness of his condition and was not troubled by it.

During the examination, it was observed that the angle between the auricle and the head was approximately 35° on both sides. No discomfort or pain was detected when manipulating the ears. The surgeon proceeded to explain to the parents the available surgical options to address the prominent ears, outlining the associated risks and benefits of the procedure, as well as the postoperative care requirements. Additionally, the possibility of waiting until the child can make an informed decision about the surgery was discussed.

It became apparent that the parents are preoccupied with their son's appearance and have expressed interest in pursuing otoplasty surgery to correct the condition, even though the patient himself seems unaffected by the prominence of his ears. They were insistent on proceeding with the surgery, citing their desire to prevent potential bullying that their child might encounter in school. The surgeon then elaborated to the parents that the decision to perform surgery on a child who is not personally troubled by his appearance raises ethical considerations.

Case 3

A 9-year-old girl diagnosed with trisomy 21 and a ventricular septal defect visited the plastic surgery clinic accompanied by her father, who expressed concerns about his daughter's bilateral constricted ears. Despite the girl not experiencing any functional limitations and her audiology tests showing normal results, her father was resolute in seeking surgical correction to achieve what he considered a “perfect” appearance for his daughter.

Upon examination, it was evident that the girl had bilateral constricted ears characterized by a reduced helix and scapha, resulting in a “cupped” appearance. The surgeon proceeded to discuss with the father the available surgical options for addressing his daughter's constricted ears. Additionally, the benefits, potential complications, and risks associated with administering general anesthesia to a child with a ventricular septal defect and trisomy 21 were explained.

Following the consultation, the father persisted in his desire to proceed with the surgery, emphasizing his wish for his daughter to have “perfect” ears. The surgeon then conveyed to the father that making the decision to perform surgery on a child without functional impairments and with underlying medical conditions raises ethical considerations.

Current Management

The contemporary management of congenital ear anomalies involves a nuanced approach, dictated by the specific anatomical characteristics and severity of the malformation. While a conservative strategy for minor anomalies requiring observation and parental counseling may be deemed appropriate, a more pronounced deformity necessitates surgical intervention, which remains the principal therapeutic avenue.

Prominent ear management involves a systematic and evidence-based approach. Otoplasty remains a cornerstone of treatment, aiming to modify the cartilaginous framework of the external ear to achieve a more harmonious position relative to the cranial contour. In parallel, non-surgical interventions, such as ear molding, appears to be an effective method for achieving complete correction or enhancement of congenital ear anomalies in newborns. The choice of management strategy depends on individual preferences, anatomical considerations, and the extent of the ear's prominence. ¹⁷

Microtia encompasses a range of anomalies that span from mild structural irregularities to the complete absence of the ear. ¹⁸ This defect can manifest in isolation or as a component of craniofacial syndrome.^19,20 Management options include careful observation, the use of ear prostheses, or surgical reconstruction. ²¹ Presently, the preferred method of treatment involves techniques that utilize the patient's own cartilage as the standard of care.^22‐24 In this procedure, the timing of the reconstruction is determined by factors such as the growth of rib cartilage, the maturation of the opposite ear, and the psychosocial development of the patient. ²¹ The primary constraint typically revolves around the growth of rib cartilage. Information about the development of costochondral cartilage is limited, although the consensus is that most patients will not have an adequate amount of cartilage until they are at least 6 years old. ²⁵

Harvesting rib cartilage prematurely can lead to inadequate volume and length for creating the necessary framework, potentially resulting in deformities of the chest wall.^26,27 Numerous surgeons are of the opinion that more favorable cosmetic outcomes can be attained by postponing the surgery until the child reaches ages 9-10 or reaches a specific chest circumference. This approach involves techniques that necessitate a larger quantity of cartilage.^22,28,29

In cases of unilateral microtia, there's a debate about allowing time for the opposite ear to develop. While the auricle continues growing until the age of 10, it reaches 85% of its adult size at 3 years and 95% at 5 years.^30,31 Research indicates that when using the patient's own cartilage, the reconstructed ear tends to grow at a similar rate as the unaffected ear. However, in individuals below the age of 8, the growth of the reconstructed ear might be comparatively less compared to the normal ear. As a result, the framework is usually constructed to match the current size of the opposite ear, or it might be slightly larger.^32,33

Another crucial factor influencing the ideal timing of intervention is the child's cognitive development. Undertaking the procedure at an earlier stage might help minimize psychosocial distress, as it's believed that children start noticing their physical disparities as young as 3-4 years old. The psychological effects related to ear deformity tend to arise between the ages of 7 and 10, when the child begins attending school and becomes vulnerable to teasing. This perspective is supported by research from various sources.^10,11,34

On the other hand, the age at which a child develops appropriate cognition to provide assent for treatment is debated, with no set guidelines for obtaining it. ³⁵ Adolescents over 14 years of age have demonstrated equal decision-making capacity to that of adults, while children as young as 9 were shown capable of making sound decisions despite having less reasoning abilities than adults. ³⁶ For instance, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research suggests that a child over the age of seven with normal cognition is capable of providing assent for research participation. ³⁷ The concept of delaying non-urgent surgical interventions on children until cognitive maturity has been reached has been advised repeatedly in various settings as well.^13,38,39

Bearing in mind these considerations, the optimal time to perform auricular reconstruction is controversial. The psychosocial benefits of an early intervention need to be balanced by the superior cosmetic results obtained by delaying the surgery, while considering the child's right to participate in the decision-making process. Tanzer prefers operating during the preschool age of 5-6 years old. ³³ Brent concurs but prefers to wait until the age of 7–8, when the child can better participate in the decision-making process.^10,40 Nagata prefers to wait until the child is 10 years old or has a chest circumference of 60 cm at the level of the xiphoid process, to ensure sufficient rib cartilage growth.^22,28 Studies looking at satisfaction rates of various techniques, regardless of the age, showed equivalent rates of satisfaction and lack of regret among children with reconstructed ears.^39,41‐44

Autogenous costal cartilage grafts remains the standard for microtia reconstruction; disadvantages of the technique including multi-stage procedures, donor site morbidity, and inconsistent outcomes have led to the emergence of new technologies, such as the use of alloplastic implants,^22,25 as they provide more consistent outcomes and avoid donor-site morbidity of the chest wall, all in a single-stage procedure.^22,25 Though early results showed high-failure rates from implant exposure, ⁴⁵ using a temporoparietal fascial (TPF) flap^25,46,47 has appeared to significantly reduce these rates. ⁴⁸ Studies comparing the use of autologous rib cartilage grafts with alloplastic implants using a TPF flap have shown both techniques to be equivalent.^49,50 As long-term safety outcomes continue to be reported, the use of alloplastic implants may become increasingly used in surgical practice. With these alternate methods, auricular reconstruction is feasible at earlier ages (as early as 3 years old), as rib cartilage growth is no longer a limiting factor.

Ethical Considerations

Autonomy

Autonomy, as defined in the medical context, signifies the right of competent individuals to make informed decisions about their own medical care. This principle rests on the premise that patients possess the necessary capacity to comprehend their medical condition, the proposed procedure, and the potential outcomes, while making choices free from external pressure or coercion. ⁵¹

However, the landscape of autonomous decision-making in pediatric cases is distinctly intricate, particularly when it pertains to conditions that aren’t life-threatening. ⁵² Children's cognitive limitations can substantially hinder their active participation in decision-making processes. This hurdle arises due to their evolving cognitive abilities, making it challenging for them to fully understand the nuances of medical situations. This complexity is further amplified when addressing elective surgical interventions, where the risk–benefit assessment might not be as straightforward as in life-threatening cases.

In non-life or limb-threatening cases involving children, the process of determining the appropriate course of action involves a meticulous evaluation of the risk–benefit balance. Unlike critical situations, where urgency often dictates the decision-making process, these cases demand a more nuanced approach. Medical professionals must weigh the potential benefits of intervention against the associated risks, considering the child's well-being, their future quality of life, and the implications of various treatment options. This intricate calculation requires a comprehensive understanding of the child's cognitive development, the extent of parental involvement, and the child's capacity to actively participate in the decision-making process. Moreover, the principle of autonomy remains a guiding principle, even though its application can be complex in cases where children's cognitive limitations hinder their ability to fully comprehend the medical situation. As such, striking a careful balance between these factors is crucial to ensuring the best possible outcome for the child's health and overall development.

Key concepts within pediatric decision-making include surrogate decision-making, the best interest standard, capacity assessment in children, and the concept of assent. In cases where a child lacks the cognitive capacity to make decisions, a designated surrogate, usually a parent or legal guardian, is entrusted with making choices on their behalf. The best interest standard requires that decisions are made in consideration of what would be most beneficial for the child's overall well-being. Capacity assessment involves evaluating a child's cognitive, emotional, and intellectual capabilities to gauge their ability to participate in decision-making. Assent is a crucial aspect where children, even if not legally competent to make decisions, are encouraged to express their preferences and thoughts about their medical care.

Within the context of microtia repair, the principle of autonomy faces unique challenges. An earlier intervention, when the child has limited awareness of their condition, may seem to infringe upon their autonomy, as they are unable to fully comprehend the procedure and its implications. Conversely, waiting until the child is older and possesses a more developed cognitive capacity engages them in the decision-making process and acknowledges their growing autonomy. This dichotomy is observed across various elective surgeries in the realm of pediatric plastic surgery.

During the medical consultation, a significant aspect involves assessing the child's perspective by observing their body language and understanding their feelings about their physical difference. It is essential to ensure that these observations are free from parental influence, as children often absorb and reflect their parents’ anxieties or preferences.

Overreliance on parental impressions can lead to missing important cues and unnecessarily delaying surgery. ¹¹ Conversely, parental anxiety might drive earlier interventions. Interestingly, adult patients who declined surgery during their childhood often express no regrets about their choice and tend to exhibit higher self-esteem and coping skills before undergoing surgery. ⁵³ This underscores the notion that involving a competent child in decision-making can provide an objective measure for determining the necessity of surgery.

Shared decision-making involving parents is also crucial. The role of parents in pediatric decision-making, as demonstrated by Hong et al's study on pediatric otoplasty, highlights the importance of parental involvement. ⁵⁴ Despite low levels of parental regret, the study revealed significant parental decision conflicts, regardless of parental, child, or surgeon-related factors. This conflict was mitigated when parents were engaged in the decision-making process.

In the case of children whose stance is unclear, surgeons must understand the extent of the child's and parents’ involvement in decision-making and act in the patient's best interest. For instance, in Case 2, where the primary concern is the autonomy of the child, the surgeon must ensure that the parents are informed about potential risks and benefits, offering alternative options like waiting until the child is older and capable of making an informed decision. Ensuring that surgery isn’t conducted without a compelling medical rationale is paramount to upholding the child's autonomy and well-being.

In essence, while autonomy remains a cornerstone of medical ethics, its application in pediatric cases demands an intricate balance between cognitive development, parental involvement, and the child's evolving capacity for decision-making.

Determining the point at which cosmetic surgery becomes acceptable for non-life or limb-threatening conditions in children is a multifaceted consideration. It hinges on a thorough evaluation of the child's cognitive maturity, their capacity to comprehend the procedure, and their ability to actively participate in the decision-making process. Equally important is the extent of parental involvement, ensuring that their preferences align with the best interests of the child. Additionally, the potential psychosocial impact of the condition on the child's well-being and development should be carefully assessed. Cosmetic surgery becomes ethically viable when it is pursued with a comprehensive understanding of these factors, prioritizing the child's autonomy, minimizing potential risks, and aiming to enhance their overall quality of life. Ultimately, the decision should reflect a collaborative effort among medical professionals, parents, and the child, all with the shared goal of promoting the child's physical and emotional well-being.

Non-Maleficence, Beneficence, Equitability, and Distributive Justice

A fundamental principle in medicine is primum non nocere: “first, do no harm.” The obligation not to inflict harm applies to both acts of commission or omission. Potential harm from surgical complications must be countered by potential psychological harm from delaying surgery.

The beneficence principle urges physicians to act in the patient's best interest, advocating for their well-being and maximizing benefits to the patient while minimizing risks, while justice accounts for both the duty to treat patients equitably and fair allocation of healthcare resources. In certain healthcare jurisdictions, the cost of ear reconstructive surgery is only partially covered for those who have insurance plans. In the publicly funded Canadian healthcare system, Medpor implants are not covered, eliminating the option for early intervention.

Conclusion

Surgeons hold differing viewpoints on the timing of external ear surgery in the pediatric population, with some advocating for early intervention, while others suggest waiting until the child develops cognitive maturity to comprehend their condition and actively engage in decision-making. As is often the case with ethical deliberations, there isn’t a definitive answer, and the choice ultimately rests with the surgeon, shaped by their interpretation of the individual case and its contextual factors. We present an ethical discourse aimed at assisting plastic surgeons in their decision-making and underscoring the significance of involving the child in the process of shared decision-making. We encourage colleagues and readers to contribute by sharing their own case studies.