This study was performed on patients who attended Shanghai Ninth People’s Hospital affiliated with Shanghai Jiao Tong University School of Medicine from April 2023 to September 2024. Patients were selected according to the following criteria (1): patients who were diagnosed with congenital microtia through clinical presentation, physical signs, and imaging examinations (16) (2); patients aged between 8 and 18 years who underwent ear reconstruction surgery 3); patients who possessed adequate reading comprehension to complete the survey (4); patients and their guardians agreeing to participate in this study. Exclusion criteria included (1): patients with other severe comorbidities (2); patients with a history of mental illness or cognitive and consciousness impairments (3); patients with communication disorders.

Additionally, 1,583 healthy subjects aged 5–18 years were selected from the Chinese study by Hao et al. (17) as the norm group, comprising 766 males and 817 females. They were recruited via convenient sampling from kindergartens and primary schools in Guangzhou and Shanghai. All students in randomly selected grades were included, except those self-reporting or physician-confirmed acute or chronic illnesses. They completed the same PedsQL 4.0 scale used in our study.

Participants were recruited during their hospital stay. The baseline characteristics of the patients included gender, age, educational level, residence, family structure, site of the affected ear, main type and hearing status of the affected ear, and facial asymmetry. Surgery type, pain scores, anxiety, depression, and HRQoL data were collected through questionnaires administered one day after surgery. The selection of demographic and clinical variables was guided by established literature on social determinants of health in pediatric populations and clinical factors known to impact QoL in patients with microtia (8–10). All scales used in this study were self-completed by the patients. To minimize researcher influence, our standard procedure was for the researcher to leave after providing instructions for completing the questionnaires. However, in cases where patients or their family members requested assistance or clarification, the researcher would remain at the bedside. Baseline characteristic information was obtained through interviews with the patients and by reviewing their electronic medical records. The legal guardians were present during these interviews and questionnaire surveys.

The Numeric Rating Scale (NRS) was employed to assess postoperative pain intensity in patients, with scores ranging from 0 to 10 representing different degrees of pain (18). Patients circle a number that most accurately reflects their perceived pain level. The scoring system is stratified as follows: 0–3 points indicate mild pain, 4–6 points indicate moderate pain, and 7–10 points indicate severe pain.

The anxiety and depression levels of patients were assessed using the Hospital Anxiety and Depression Scale (HADS), which was developed by Zigmond and Snaith in 1983 (19). The HADS is a generalized scale with good reliability and validity that is mainly used to screen patients for anxiety and depressive symptoms (20, 21). The HADS comprises two subscales: the Anxiety Subscale (HADS-A) and the Depression Subscale (HADS-D), each containing seven items, resulting in a total of 14 standardized assessment components (20). Each item is scored on a 0–3 point scale, with total subscale scores ranging from 0 to 21. A cutoff score of 8 serves as the clinical threshold for symptom detection, with elevated scores indicating greater severity of anxiety or depressive symptoms (21).

The Pediatric Quality of Life Inventory Version 4.0 (PedsQL 4.0) Generic Core Scales were used to assess the HRQoL in children (22). The PedsQL is a 23-item generic measure that includes four age-specific scales for children aged 2-4, 5-7, 8-12, and 13–18 years. This study used reports from children aged 8 to 12 and adolescents aged 13 to 18, collecting data through self-assessment questionnaires. It assesses four domains: physical health (8 items), emotional functioning (5 items), social functioning (5 items), and school functioning (5 items). Emotional, school, and social functioning can be combined into a psychosocial health domain. Each item is rated on a 5-point Likert scale from 0 to 4, which is subsequently reverse scored and linearly transformed to a scale of 0 to 100 points (0 = 100, 1 = 75, 2 = 50, 3 = 25, 4 = 0). Therefore, a higher converted score indicates a better HRQoL (23). The reliability and validity of the Chinese translations of the PedsQL 4.0 scale have been reported for Chinese children (24). In the current study, the Cronbach’s α for the full scale was 0.894.

This study was conducted according to the principles of the Declaration of Helsinki and was approved by the Ethics Committees of Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine (SH9H-2024-T102-1). Written informed consent was obtained from the patient’s parent or legal guardian before collecting the data.

Data analysis was conducted using SPSS 26.0 statistical software. Quantitative data that followed a normal distribution were described using the mean ± standard deviation (SD), while non-normally distributed data were presented as the median and interquartile range. Qualitative data were described in terms of frequency, percentage, or constituent ratio (percentage). The independent sample t-test and one-way analysis of variance (ANOVA) were performed for intergroup comparison. Correlation analysis was performed to examine the correlation of HRQoL with anxiety and depression, respectively. Multiple linear stepwise regression analyses were performed with the HRQoL total and domain scores as the dependent variable and the statistically significant variables from the univariate analysis as the independent variables. The independent variables include age, residence, hearing status of the affected ear, pain score, surgery type, anxiety score, and depression score. R² and ANOVA were used to assess model fit, and fulfillment of assumptions (Durbin Watson, normality of residuals, variance inflation factor and independence) were examined. All tests were performed two-tailed and p values < 0.05 were considered significant.

Among the 158 eligible participants, six of them had their surgeries suspended due to colds, while the remaining 152 patients agreed to participate and complete the questionnaires. Table 1 presents the demographic and clinical characteristics of the participants. For 152 participants, the mean age was 13.53 (± 2.23) years, 107 were males (70.4%) and 45 females (29.6%). Nearly half (48.0%) of participants had an education level of junior high school. More than half (53.3%) of participants lived in the countryside. Most (56.6%) of participants had a nuclear family structure. The majority of participants had congenital absence of the external auditory canal on the affected side, accompanied by impaired hearing and asymmetrical craniofacial development. Regarding the surgery type, 56.6% of participants underwent Stage I ear reconstruction surgery. The average postoperative pain score of the patients was 5.48 (± 2.09) points. Of these participants, 21.7% had postoperative symptoms of anxiety, and 17.8% had postoperative symptoms of depression. More detailed baseline characteristics were listed in Table 1.

In addition, Table 1 presents the univariate analysis of factors associated with the total HRQoL score. We found that residence, hearing status of the affected ear, surgery type, pain score, symptoms of anxiety and depression were associated with HRQoL in patients with congenital microtia after ear reconstruction surgery (p < 0.001).

Table 2 presents the descriptive statistics determined using independent t tests. Compared with healthy adolescents, patients with congenital microtia had significantly lower total HRQoL scores and lower scores in each dimension (p < 0.001). Additionally, we calculated Cohen’s d as the effect size for the comparisons (Table 2). We found that all Cohen’s d values were greater than 0.8, indicating that the statistically significant differences (p < 0.001) were not only due to the large sample size but also represented substantial and clinically meaningful differences in HRQoL between patients with congenital microtia and healthy adolescents.

Table 3 shows that patients with symptoms of anxiety had significantly lower total scores and domain scores of HRQoL compared to those without symptoms of anxiety (p < 0.05). Similarly, patients with depressive symptoms showed markedly lower total HRQoL scores and psychosocial health scores (including emotional, social, and school functioning) than those without depressive symptoms (p < 0.05). The comparison of physical health scores between patients with and without depressive symptoms did not reach a statistically significant difference (p = 0.076), indicating no difference between the two groups.

The inter-correlation coefficients among symptoms of anxiety, depressive symptoms and HRQoL are shown in Table 4. Postoperative symptoms of anxiety were significantly negatively correlated with the total and dimension scores of HRQoL (r = -0.433, r = -0.218, r = -0.464, r = -0.422, r = -0.430, r = -0.314, separately, all p < 0.001). A similar result was also observed for postoperative depressive symptoms. With reference to Cohen (25), correlation coefficients of 0.10 to 0.29, 0.30 to 0.49 and 0.50 to 1.0 are interpreted as small, medium and large, respectively. There was a moderately negative correlation between total HRQoL score and both symptoms of anxiety (r = -0.433, p < 0.001) and symptoms of depression (r = -0.486, p < 0.001). A high negative correlation was found between psychosocial health and depression symptoms (r = -0.511, p < 0.001), as well as between social functioning and depressive symptoms (r = -0.507, p < 0.001).

Table 5 presents the variables that might contribute to decreased HRQoL of patients with congenital microtia. Stepwise multivariate linear regression analysis showed that residence (95% CI: -6.661, -0.902, p = 0.010), surgery type (95% CI: 2.113, 9.496, p = 0.002), pain score (95% CI: -1.836, -0.031, p = 0.043) and depression score (95% CI: -1.644, -0.318, p = 0.004) were independently associated with the total HRQoL score of microtia patients. We analyzed the influencing factors of various dimensions of HRQoL and found that age (p = 0.001), surgery type (p < 0.001) and pain score (p = 0.001) were significantly associated with the physical health of microtia patients. Residence (p = 0.021), surgery type (p = 0.031) and depression score (p < 0.001) were significantly associated with the psychosocial health of microtia patients.

Surgery type (p = 0.009) and depression score (p < 0.001) were significantly associated with the emotional functioning of microtia patients. Residence (p = 0.008) and depression score (p = 0.001) were significantly associated with the social functioning of microtia patients. Age (p = 0.013), hearing status of the affected ear (p = 0.002) and depression score (p = 0.004) were significantly associated with the school functioning of microtia patients.

Multivariate regression analysis revealed that factors such as rural residence, early surgical stages (Stage I), high pain scores, and depressive symptoms were significantly associated with poorer QoL. Rural patients had significantly lower HRQoL than urban patients (β = -0.172, p = 0.010). This disparity might be related to the inequitable distribution of healthcare resources and insufficient social support. Patients in rural areas faced greater challenges in postoperative follow-up feasibility, limited access to psychological interventions, and potentially heavier financial burdens, which affected recovery outcomes (33). Future interventions should incorporate regional characteristics, such as providing regular psychological assessments through telemedicine or collaborating with community healthcare providers to conduct mental health education, aiming to alleviate the psychological stress of rural patients and improve their HRQoL.

Patients undergoing Stage I surgery demonstrated significantly lower HRQoL compared to those undergoing Stage II surgery (β = 0.262, p = 0.002). This difference is likely attributable to the nature of Stage I surgery, which involves harvesting several pieces of costal cartilage for the auricular framework. This procedure results in greater surgical trauma in both thoracic and auricular regions, prolonged recovery, and consequently, more intense postoperative pain (13). Indeed, postoperative pain was a key factor significantly associated with lower HRQoL in our study. Our finding of moderate postoperative pain (mean score 5.48 ± 2.09) is consistent with previous research, such as that by Woo et al. (13), who evaluated pain in microtia patients postoperatively using the visual analogue scale, reporting mean chest pain scores of 5.1 ± 1.6 points at rest and 5.8 ± 2.1 points during coughing, alongside auricular wound pain averaging 4.1 ± 1.4 points. These findings from many studies indicate that patients with microtia experience moderate postoperative pain after ear reconstruction surgery. This underscores that effective management of postoperative pain is a critical component in improving patient HRQoL.

Therefore, multifaceted interventions are crucial, especially following Stage I surgery. We recommend combining proactive pain management with psychological support. Healthcare providers should assist patients in using a thoracic band with compression bandaging at the site of the chest incision to limit thoracic mobility during breathing; they can also instruct patients to press their chest with both hands when coughing. Concurrently, healthcare providers should help patients adopt comfortable positions and recommend distraction techniques such as watching television, listening to music, and socializing (34). For younger patients with low pain tolerance, healthcare providers should offer frequent reassurance and encouragement, administering analgesics as prescribed when necessary. Furthermore, enhancing preoperative education using tools like 3D imaging simulations can help establish realistic expectations. Integrating these strategies should be implemented to facilitate a phased and better-tolerated recovery across treatment stages.

In summary, our study suggests that it is necessary to adopt a comprehensive nursing model and precise interventions, including psychological support, surgical intervention, and pain management, to improve patient’s QoL.

A key strength of this study is its use of validated tools (HADS and PedsQL 4.0), which enhances the reliability of our findings. Furthermore, our use of both univariate and multivariate analysis allowed for a comprehensive exploration of factors associated with HRQoL. Additionally, the comparison with a healthy norm group provided valuable context for interpreting the HRQoL scores of our patient cohort.

This study has several limitations. First, as a cross-sectional design was employed, all data were collected at only one time point. The transient nature of psychological states and QoL metrics in microtia patients may vary over time in intensity and fluctuation depending on different situations. A future longitudinal study to collect data over an extended period is therefore required to evaluate the long-term and dynamic changes in congenital microtia patients’ psychological health and QoL. Second, convenience sampling from a single center may introduce selection bias that limits the generalizability of findings. Future multi-center investigations with expanded sample sizes are warranted to enhance external validity. Third, the children with microtia were 8–18 years old, but the norm group was 5–18 years old, which had a broader age range. The age discrepancy may affect the comparison between the two groups. Lastly, there may be some potential confounding factors such as analgesic regimen or anesthesia type, that were not included in this study. Future investigations should implement more comprehensive covariate selection protocols to strengthen causal inference.