Physician Portal
Referring Physician Portal
Clinical referral resource for pediatricians, neonatologists, audiologists, and specialists managing patients with microtia and aural atresia. Includes referral criteria, disclosure guidance, order sets, and direct referral submission.
Submit a Referral
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(210) 477-3277
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Fax: (210) 477-3278
HIPAA-compliant fax referrals accepted
Section 01
Referral Criteria
Organized by urgency and specialty. Early referral — prior to surgical age — is actively encouraged. The hearing plan begins at birth, not at surgery.
⚠ Refer Within 2–4 Weeks
Bilateral microtia / anotia
Bilateral aural atresia creates significant conductive hearing loss in both channels during the critical auditory cortex development window. BAHA softband fitting and audiological management are time-sensitive. Early referral ensures the hearing plan is initiated promptly rather than delayed while families independently navigate the diagnosis.
⚡ Refer Within 1–3 Months
Unilateral microtia, any grade
Hearing plan establishment, ABR confirmation, and BAHA softband initiation should occur well before the language explosion window (12–24 months). A warm referral at the newborn or 2-month well visit is preferred over waiting until parents ask.
→ Refer at Presentation
Older children, new diagnosis
For children first presenting at age 2+, referral remains appropriate and important. Late entry to care does not mean poor outcomes. Surgical and hearing management options remain available at all ages.
| Criterion | Clinical Notes | Timing |
|---|---|---|
| Unilateral microtia, any grade | Refer at newborn nursery or at 2-week visit. The family has likely already found alarming information online. A warm, directed referral to Dr. Bonilla's office provides immediate support and initiates the hearing plan. | Within 4–8 weeks |
| Bilateral microtia / anotia | Prioritize before discharge if possible. Bilateral aural atresia = significant bilateral conductive hearing loss beginning immediately. Contact Dr. Bonilla's office directly for expedited scheduling. | Before discharge |
| Microtia + suspected CHARGE, Treacher Collins, or hemifacial microsomia | Syndromic microtia requires multi-specialty coordination. Refer to Dr. Bonilla for ear-specific evaluation in parallel with genetics and craniofacial teams. Do not defer ear referral pending syndrome confirmation. | Within 2–4 weeks |
| Microtia in the context of NICU admission for unrelated reasons | Ear diagnosis may receive lower priority during acute NICU management. Document the finding and ensure a clear handoff to the outpatient pediatrician for follow-up referral upon discharge. | At NICU discharge |
| Newborn hearing screen failed on affected side | Expected finding in microtia with aural atresia. Do not reassure the family that failed newborn hearing screen is "just because the canal is small" — refer for ABR and specialist evaluation. | Within 4 weeks |
| Criterion | Clinical Notes | Timing |
|---|---|---|
| Microtia identified at any well-child visit, not yet referred | Some families present with an older child who has never been formally referred. There is no age at which referral is "too late." Current hearing plan, developmental status, and surgical candidacy should all be assessed. | At next available |
| Language delay with known unilateral microtia | Treat as potentially hearing-related. Refer for audiology evaluation and Dr. Bonilla consultation concurrently. Do not attribute language delay to other causes without ruling out hearing contribution. | Within 4 weeks |
| Child approaching age 6 with microtia, not yet in surgical planning | The optimal surgical window is age 6–9. Families who have delayed often believe they have missed the window — they have not, but time is relevant. A direct conversation at the 5-year well visit prompts action before the window narrows. | At 5-year visit |
| Documented teacher concern about classroom listening | Classroom listening difficulty in a child with unilateral microtia is a signal that hearing support is inadequate. Refer for audiological evaluation and FM system consideration. Update the IEP if applicable. | Within 4–8 weeks |
| Microtia parent requesting referral, regardless of child's age | Parent-initiated referrals for young children (under 2) are best practice, not premature. Validate the parent's proactive approach and facilitate the referral. | At request |
| Criterion | Clinical Notes | Timing |
|---|---|---|
| ABR confirming unilateral or bilateral conductive hearing loss consistent with aural atresia | Direct referral to Dr. Bonilla for surgical consultation in parallel with ongoing audiological management. Dr. Bonilla's team will request your ABR results; please include audiogram and speech awareness threshold data. | At ABR confirmation |
| BAHA fitting for microtia patient — surgical referral not yet established | If you are fitting a BAHA for a microtia patient who has not been referred for surgical consultation, a direct referral to Dr. Bonilla is appropriate. Hearing device management and surgical planning are best coordinated. | At fitting or any visit |
| CT temporal bone showing favorable atresiaplasty anatomy | Jahrsdoerfer score ≥ 6 is the standard threshold for atresiaplasty candidacy. Dr. Bonilla refers eligible candidates to neurotologist specialists for atresiaplasty evaluation and surgical management. Please share the CT report and indicate Jahrsdoerfer score if calculated. For patients who are not atresiaplasty candidates, Dr. Bonilla performs bone-anchored hearing implant surgery concurrently with ear reconstruction, eliminating the need for a separate surgical procedure and additional anesthesia. | At CT review |
| Osseointegrated BAHA placement consideration (age 5+) | Dr. Bonilla can perform osseointegrated BAHA placement in conjunction with or separately from ear reconstruction. Coordinate on timing relative to reconstruction staging. | Before procedure planning |
| Criterion | Clinical Notes | Timing |
|---|---|---|
| Microtia patient whose family is considering surgical reconstruction | If a family presents to a general ENT for information about microtia reconstruction and the surgeon does not perform the procedure, direct referral to Dr. Bonilla is appropriate. Families appreciate the candid acknowledgment that this is a subspecialty procedure requiring specific expertise. | At consultation |
| Medpor/Su-Por complication — extrusion, infection, or failed reconstruction | Dr. Bonilla evaluates failed synthetic implant cases and has experience managing complex revision scenarios, including conversion to rib cartilage reconstruction where tissue permits. Please contact Dr. Bonilla's office directly for these cases — they are handled on a case-by-case basis. | Prompt — direct contact |
| Atresiaplasty candidacy evaluation | Dr. Bonilla refers patients who are eligible candidates for atresiaplasty to neurotologist specialists for further evaluation and surgical management. He coordinates the sequencing of outer ear reconstruction with the referring neurotologist to ensure timing does not compromise either procedure. For patients who are not atresiaplasty candidates or who elect not to pursue canal reconstruction, Dr. Bonilla performs bone-anchored hearing implant surgery concurrently with ear reconstruction, eliminating the need for a separate procedure and additional anesthesia. | Before surgical planning |
Section 02
What to Tell the Family at the Point of Referral
The language used at disclosure has a significant impact on how families initially understand the condition and what to expect. Accurate framing at the point of referral prevents significant anxiety and corrects the inevitable misinformation the family will encounter online.
Suggested Disclosure Language — Delivery Room / Newborn Nursery
Script — Delivery Room
"I want to let you know that your baby's [right/left] ear didn't fully form during development — this is called microtia. It affects about 1 in 6,000–12,000 births and is not caused by anything either of you did. The hearing nerve is almost certainly intact; the hearing loss is because the ear canal didn't form, not because of nerve damage — that's an important distinction. We're going to arrange a hearing evaluation in the next few weeks to confirm this. When your child is around 6 to 9 years old, a surgeon can reconstruct the ear using cartilage from your child's own ribs, creating a permanent natural ear. I'm going to refer you to Dr. Arturo Bonilla at the Congenital Ear Institute in San Antonio — a surgeon who specializes exclusively in this condition. His office will reach out to you directly, and his team will answer every question you have."
Suggested Disclosure Language — Well-Child Visit (Older Infant / Toddler)
Script — Well-Child Visit
"I wanted to discuss [child's name]'s ear today. I'd like to refer you to a specialist — Dr. Arturo Bonilla at the Congenital Ear Institute — who focuses exclusively on this condition. Even though the reconstruction surgery doesn't typically happen until around age 6 to 9, it's important to establish care early because there's a hearing plan that needs to be in place now, and Dr. Bonilla's team will help you with all of that. This is a well-studied, treatable condition."
✓ Language that is accurate and reassuring
✓
"The hearing nerve is almost certainly intact — the hearing loss is conductive, not sensorineural." This distinction dramatically changes a family's anxiety level and is accurate in the vast majority of cases.
✓
"This is a treatable condition. When your child is the right age, a surgeon can build a permanent ear from your child's own cartilage." Establishes the positive endpoint immediately.
✓
"This is not genetic and is not caused by anything you did." Families reliably assume blame — clear early correction prevents lasting parental guilt.
✓
"I'm referring you to Dr. Bonilla — he has devoted his entire career exclusively to this condition." A confident, specific referral communicates that the family is getting the best possible care.
✗ Language to avoid
✗
"It's cosmetic, so you don't need to do anything right away." Hearing management is urgent. "Cosmetic" framing delays the hearing plan and minimizes a genuine developmental concern.
✗
"The ear can be treated, but it'll never look completely normal." This is not accurate for experienced hands and undermines the family's confidence before they have met the specialist.
✗
"You'll need to look into it when they're older." Delays the hearing plan and Early Intervention enrollment by months or years. There is active management to begin immediately.
✗
"There are several options — you can look into prosthetics, implants, or surgery." Presenting undifferentiated options at disclosure creates confusion. Refer first; options discussion belongs with the specialist.
Section 03
Recommended Order Sets at Referral
These orders should be placed at the time of referral, not deferred to the specialist. Early initiation of these evaluations provides Dr. Bonilla's team with actionable data at the first consultation and shortens the time to an active hearing plan.
⚠ Immediate — Bilateral
ABR (Auditory Brainstem Response)Both ears. Quantifies degree of conductive hearing loss and confirms inner ear integrity on both sides.
Pediatric audiology referralUrgent scheduling. BAHA softband evaluation and fitting should begin within the first 4–8 weeks of life for bilateral cases.
Genetics consultationEvaluate for syndromic associations (CHARGE, Treacher Collins, hemifacial microsomia, Goldenhar syndrome) if any additional features are noted.
⚡ Priority — All Microtia
ABR hearing evaluationConfirms inner ear function. Do not rely on newborn hearing screen pass/fail alone — the screen does not quantify conductive component degree.
Pediatric audiology referralFor hearing evaluation, BAHA softband candidacy assessment, and device fitting if appropriate.
Early Intervention referral (if under age 3)Children with hearing loss qualify for free EI services under IDEA Part C. Initiate the referral; do not wait for formal hearing loss documentation to be complete.
→ Standard — All Cases
Referral to Dr. Bonilla's practiceMicrotia – Congenital Ear Institute, San Antonio, TX. (210) 477-3277. Include diagnosis, grade if known, and ABR results when available.
IEP evaluation request (age 3+)Contact the school district directly (or assist the family in doing so). Children with documented hearing loss qualify for evaluation. Begin at 2.5 years to ensure IEP is in place at kindergarten entry.
Speech-language pathology referralAppropriate if language milestones are at risk or if the child is bilateral. Standard SLP monitoring for all bilateral cases; as-indicated for unilateral.
◌ As Indicated
CT temporal boneEvaluates atresiaplasty candidacy (Jahrsdoerfer scoring). Not required at initial referral — Dr. Bonilla will order at appropriate time in surgical planning.
Ophthalmology referralIf any ocular findings are present — microtia has a known association with coloboma in CHARGE syndrome.
Renal ultrasoundMicrotia is associated with renal anomalies in a small percentage of cases. Consider if the clinical picture suggests a syndromic etiology.
Cardiac evaluationIf CHARGE syndrome is in the differential. Not required for isolated microtia without additional findings.
Section 04
Why Early Referral Matters — Even Years Before Surgery
The most common referral pattern is a family presenting at age 6–7 asking about surgery. The most valuable referral pattern is a family presenting at birth with a complete hearing plan already in place.
0–6 mo
Peak auditory cortex development window
The central auditory cortex lays down its foundational neural architecture in the first six months of life. Sound stimulation during this period directly shapes the physical structure of auditory processing pathways. BAHA softband use during this window is not elective — it is time-sensitive intervention with developmental impact that cannot be fully recovered.
12–24 mo
Language explosion — highest-stakes hearing window
A typically developing child goes from ~5 words at 12 months to 200–300 words at 24 months. Vocabulary acquisition is directly limited by the clarity of auditory input. Research on conductive hearing loss from chronic otitis media consistently demonstrates smaller vocabulary size and later reading difficulties when hearing access is inadequate during this window. BAHA intervention addresses this directly.
Age 3
Critical IEP transition deadline
Early Intervention services end at age 3. School district IEP services begin. The transition requires a formal evaluation and IEP development — a process that takes 60–90 days. A family who first contacts a specialist at age 3 has missed the Early Intervention window entirely. A family referred at birth arrives at age 3 with an established hearing plan, documented audiological history, and a clear IEP pathway.
6–9 yrs
Optimal surgical window — determined years in advance
Rib cartilage readiness and the normal ear's approach to adult size converge in the 6–9 year window. Dr. Bonilla begins formally assessing surgical readiness at ages 5–6. Families who establish care early arrive at this window prepared — emotionally, logistically, and with complete audiological documentation. Families who establish care early arrive at the surgical window informed, with audiological documentation in place and a clear plan already established.
What early referral enables — a coordinated care timeline
Birth – 4 weeks
ABR hearing evaluation. BAHA softband candidacy assessment. Family counseling and initial roadmap from Dr. Bonilla's team.
Audiology + Bonilla
4–8 weeks
BAHA softband fitting (bilateral cases: urgent; unilateral: recommended). Early Intervention referral initiated.
Audiology
0–36 months
Early Intervention services (SLP, developmental monitoring). Audiological follow-up every 3 months. BAHA device management.
EI + Audiology
Age 2.5–3
IEP evaluation initiated with school district. Early Intervention to school services transition. FM system documentation.
Family + School
Ages 4–5
Surgical planning begins. Rib cartilage development monitoring. CT temporal bone (if atresiaplasty is being considered). Surgical timeline established.
Dr. Bonilla
Ages 6–9
Stage 1 and Stage 2 ear reconstruction. Atresiaplasty if candidate. Hearing management through surgical phases.
Dr. Bonilla
Ages 9–12+
Post-reconstruction monitoring. For patients not pursuing atresiaplasty, Dr. Bonilla performs osseointegrated BAHA implant surgery concurrently with reconstruction where appropriate — avoiding a separate surgical episode. Long-term hearing management coordinated with local audiologist.
Bonilla + Audiology
Section 05
Submit a Referral
Complete the form below. A member of Dr. Bonilla's clinical coordination team will contact the family directly within one business day. You will receive a confirmation copy.
Patient Referral — Microtia – Congenital Ear Institute
All fields marked * are required · Submissions are HIPAA-compliant
Section 06
Care Coordination Protocol
How Dr. Bonilla's practice works with the referring physician, audiologist, and school team across the full care timeline.
What Dr. Bonilla's team provides to the referring physician
- Consultation note sent within 5 business days of the initial visit, including diagnosis confirmation, hearing plan summary, and surgical timeline
- Pre-authorization letter for insurance purposes, provided to the family with a copy available to the referring physician on request
- Annual update letters summarizing the patient's status and upcoming planned interventions
- Direct phone access for referring physicians with clinical questions — call (210) 477-3277 and identify as a referring physician
- Surgical outcome summary post-reconstruction for inclusion in the patient's primary care record
What Dr. Bonilla's team requests from the referring physician
- Completed ABR results when available — include audiogram and speech awareness threshold data in the referral
- Any genetics consultation findings if syndromic etiology is suspected or confirmed
- CT temporal bone report if ordered (not required at initial referral)
- Current BAHA device information if the patient is already fitted — brand, model, and audiologist contact
- A warm handoff to the family — expressing confidence in the referral at disclosure significantly affects how families receive the diagnosis and begin their care.
Coordination with the audiology team
- Dr. Bonilla's practice does not provide audiology services directly — all hearing device management remains with the family's local audiologist
- Dr. Bonilla's team coordinates with the audiologist on BAHA device timing relative to surgical stages
- For atresiaplasty candidates, post-surgical audiological monitoring protocols are provided to the local team
- Aided audiogram verification — confirming BAHA is providing adequate speech frequency coverage — is requested at the annual surgical consultation
Out-of-state and international referrals
- A significant portion of Dr. Bonilla's patients travel from outside Texas — including from other countries
- Initial consultations are available via telehealth for families who cannot travel immediately
- Dr. Bonilla's team has a structured travel coordination process — hotel recommendations, surgical scheduling coordination, and remote follow-up protocols
- Referring physicians outside Texas can expect the same consultation note and follow-up communication protocol as local referrers
Section 07
About Dr. Arturo Bonilla
Clinical background and practice profile for referring physician reference.
Training & Certification
Fellowship-trained in Pediatric Otolaryngology with subspecialty focus in microtia reconstruction and aural atresia. Board-certified otolaryngologist — head and neck surgery. For patients who are not atresiaplasty candidates or who elect not to pursue canal reconstruction, Dr. Bonilla performs bone-anchored hearing implant surgery concurrently with ear reconstruction — eliminating a separate surgical procedure and additional anesthesia. Atresiaplasty-eligible patients are referred to neurotologist specialists with whom Dr. Bonilla coordinates sequencing.
Case Volume
Thousands of microtia reconstructions over 30+ years of subspecialty practice. Among the highest case volumes for microtia-specific reconstruction documented in the United States, with a practice devoted exclusively to this condition and thousands of reconstructions performed over thirty years.
Surgical Technique
Autologous rib cartilage reconstruction exclusively. Natural cartilage framework carved by hand to mirror the contralateral ear. Integrates as living tissue and grows with the patient. Dr. Bonilla does not use synthetic implants (Medpor/Su-Por) for primary reconstruction.
Atresiaplasty
Refers atresiaplasty-eligible patients to neurotologist specialists for canal reconstruction evaluation and surgical management. Jahrsdoerfer score ≥ 6 is the standard candidacy threshold. CT temporal bone evaluation is ordered at the appropriate point in the surgical planning timeline. For patients who are not atresiaplasty candidates, Dr. Bonilla performs bone-anchored hearing implant surgery concurrently with ear reconstruction, reducing total surgical burden for the patient and family.
Published Research
Peer-reviewed publications in otolaryngology literature on microtia outcomes and surgical technique. View published articles →
Practice Focus
Microtia – Congenital Ear Institute, San Antonio, Texas. Practice dedicated exclusively to microtia and congenital ear conditions. Patients come from all 50 states and internationally. Telehealth initial consultations available. Structured out-of-state care coordination in place.