A different type of 'glue ear': report of an unusual case of prominent ears.

Abstract

Prominent ears is a condition that can cause extreme psychological distress in young people. This cosmetic deformity can be corrected by otoplasty, an outpatient surgical procedure that is associated with a high rate of patient satisfaction. We report the unusual case of a teenage boy who had repeatedly applied cyanoacrylate adhesive ("superglue") to his postauricular skin in an attempt to pin back his prominent ears. This case of "glue ear" was ultimately resolved by successful otoplasty, although the residual effects of the glue resulted in delayed healing of the surgical wound.

Introduction

Prominent ears ("bat ears") affect approximately 5% of the population, and this condition occurs in males and females equally. (1) This condition can be psychologically damaging to young people. Prominent ears have been corrected surgically lot about a century. Surgeons have addressed the problems of abnormal ear shape by creating the absent antihelical fold and reducing conchal protrusion. The procedure can be performed on an outpatient basis under general or local anesthesia. According to Caouette-Laberge et al, overall patient satisfaction with surgical outcomes is high (94.8%). (1)

In this article, we report a case of prominent ears that was unusual in that the patient had attempted to self-treat his condition by gluing his ears to the side of his head.

Case report

A 16-year-old boy, accompanied by his father, came to our department requesting to have his "ears pinned back." His prominent ears had caused him much embarrassment, so much so that for the past several years he had refused to appear in family photographs. On examination, his postauricular skin was noted to be excoriated and inflamed. Further questioning revealed that the patient had resorted to fixing his ears against his head with cyano-acrylate adhesive ("superglue"). The patient was asked to refrain from further gluing for 6 weeks to allow the skin to heal so that corrective surgery could be performed. However, at the preoperative assessment, we noted that the skin had not recovered. The patient admitted that he had continued to apply the superglue topically.

Faced with the likelihood that the patient would not refrain from using the glue, we decided to proceed with surgery. We performed a bilateral Chongchet-type pinnaplasty in the usual fashion. The surgical wounds were dressed with petroleum-jelly gauze and acriflavine-soaked cotton wool and covered with an elastic headband. The patient had refused to allow pre- or postoperative photographs. At the 2-week postoperative review, the position and symmetry of the ears were satisfactory, but the surgical wounds had not healed. At the 6-week postoperative visit, his wounds had healed completely and he was satisfied with the outcome.

The excised postauricular skin was sent for histologic analysis. Examination of the specimen revealed the presence of hyperkeratosis and irregular acanthosis, which produced a partly psoriaform appearance. Also noted were established dermal fibrosis and moderately severe chronic inflammatory cell infiltration.

Discussion

This case illustrates how severe a negative body image associated solely with a cosmetic deformity can be in a teenager. To our knowledge, this is the first case reported in the otolaryngology literature in which a patient deliberately applied a known irritant to the ears and caused such an injury. One report of a similar "auto-otoplasty" performed by two patients was published in the plastic surgery literature in 2001. (2) Successful cosmetic correction procedures not only improve a patient's subjective perceptions of body image, they can also promote patterns of positive thinking, emotion, and behavior. (3) Thus, cosmetic procedures offer much more than a change in appearance. Ear surgery is the second most common cosmetic procedure carried out in teenagers in the United States, surpassed only by rhinoplasty. (3)

Superglue is the strongest of the commercially avail able adhesives. Cyanoacrylate is a known irritant, and manufacturers are required by law to place on the container's label a warning advising users that applying this substance to the skin is dangerous. The Plastic Surgery Educational Foundation recently published a review of the adaptation of cyanoacrylate glue for use ill wound healing. (4) In 1984, Galil et al reported that healing properties were similar in hamster cutaneous wounds fixed with n-butyl-2-cyanoacrylate and those fixed with silk sutures. (5) A greater inflammatory response was seen in the sutured wounds because great care was taken to prevent the glue from coming into contact with the subcutaneous tissues; such contact induces a histotoxic response.

Problems related to the intense tissue inflammatory response and the fracturing of this fixative led to the development of a more flexible compound (octyleyanoacrylate) for cutaneous application. (6) The U.S. Food and Drug Administration (FDA) has approved the use of 2-octyl-cyanoacrylate (Dermabond: Ethicon; Somerville, N.J.) but warns that the glue should not come into contact with subcutaneous tissues because of its potential toxicity. Before the glue is applied, wound edges should be closely approximated. Prospective comparison studies of octylcyanoacrylate vs suturing fur the closure of cutaneous lacerations and elective head and neck incisions have shown that the glue was associated with significantly less pain, more rapid wound healing, and equivalent cosmetic outcomes at 3 months postoperatively. (7, 8)

In our unusual case of "glue ear," prolonged application of cyanoacrylate to the skin induced inflammatory and fibrotic histologic changes, which led to delayed wound healing. This case also highlights the intensity of a teenager's dissatisfaction with his cosmetic deformity.

References

(1.) Caouette-Laberge L. Guay N, Bortoluzzi P, Belleville C. Otoplasty: Anterior scoring technique and results in 500 cases. Plast Reconstr Surg 2000;105:504-15.

(2.) Perez-Barrero P, Rodrigo J, Elena E, Marques MD. Auto-otoplasty using cyanoacrylate. Plast Reconstr Surg 2001;108:2157-8.

(3.) McGrath MH. Mukerji S. Plastic surgery and the teenage patient. J Pediatr Adolese Gynecol 2000;13:105-18.

(4.) Gosain AK, Lyon VB; Plastic Surgery Educational Foundation DATA Committee, The current status of tissue glues: Part II. For adhesion of soft tissues. Plast Reconstr Surg 2002;110:1581-4.

(5.) Galil KA, Schofield II), Wright GZ. Effect of n-butyl-2-cyanoacry late (histoacryl blue) on the healing of skin wounds. J Can Dent Assoc 1984;50:565-9.

(6.) Perry LC. An evaluation of acute incisional strength with Traumaseal surgical tissue adhesive wound closure. Leonia, N.J.: Dimensional Analysis Systems. 1995.

(7.) Quinn J, Wells G. Sutcliffe T, et al. A randomized trial comparing octyleyanoacry late tissue adhesive and sutures in the management of lacerations. JAMA 1997:277:1527-30,

(8.) Maw JL, Quinn JV, Wells GA. et al. A prospective comparison of octylcyanoactylate tissue adhesive and suture for the closure of head and neck incisions. J Otolaryngol 1997:26:26-30.

From the Department of Plastic and Reconstructive Surgery, University College Hospital, Galway, Ireland.

Reprint requests: Dr. Elizabeth M. Purcell, 2 Oxford Rd., Ranelagh, Dublin 6, Ireland. Phone: [phone]; fax: [phone]; e-mail: [e-mail]