eMedicine Specialties > Dermatology > Pediatric Diseases

Preauricular Sinuses: Treatment & Medication

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Valerie Nozad, DO, Staff Physician, Beth Israel Medical Center, Department of Internal Medicine, University Hospital for the Albert Einstein College of Medicine; Jeffrey Weinberg, MD, Director, Clinical Research Center, Department of Dermatology, St Luke's; Assistant Clinical Professor, Department of Dermatology, Columbia University College
Contributor Information and Disclosures

Updated: Mar 18, 2008

Treatment

Medical Care

In one large study, 52% of patients had inflammation of their sinuses, 34% had their sinus abscesses drained, and 18% of sinuses were infected. Infectious agents identified included Staphylococcus epidermidis (31%), Staphylococcus aureus (31%), Streptococcus viridans (15%), Peptococcus species (15%), and Proteus species (8%). Once a patient acquires infection of the sinus, he or she must receive systemic antibiotics. If an abscess is present, it must be incised and drained, and the exudate should be sent for Gram staining and culturing to ensure proper antibiotic coverage.

Surgical Care

Once infection occurs, the likelihood of recurrent acute exacerbations is high, and the sinus tract should be surgically removed. Surgery should take place once the infection has been treated with antibiotics and the inflammation has had time to subside. Controversy regarding indications for surgery exists. Some believe that the sinus tract should be surgically extirpated in patients who are asymptomatic because the onset of symptoms and subsequent infection cause scarring, which may lead to incomplete removal of the sinus tract and postoperative recurrences. The recurrence rate after surgery is 13-42% in smaller studies and 21% in one large study.

Most postoperative recurrences occur because of incomplete removal of the sinus tract. One way to prevent incomplete removal is to properly delineate the tract during surgery. Some surgeons cannulate the orifice and inject methylene blue dye into the tract 3 days prior to surgery under sterile conditions. The opening is then closed with a purse-string suture. This technique distends the tract and its extensions by its own secretion stained with methylene blue.

During surgery, some surgeons use either a probe or an injection of methylene blue dye for cannulation of the orifice. The most successful method is to use both modalities to delineate the entire tract.

Other surgical techniques have been studied. The standard technique for extirpation of the sinus tract involves an incision around the sinus and subsequent dissection of the tract to the cyst near the helix. A supposedly more successful technique is the supra-auricular approach, which unlike the former technique, does not allow for difficulties in properly identifying the entire tract. The supra-auricular approach extends the incision postauricularly. Once the temporalis fascia is identified, dissection of the tract begins. A portion of the auricular cartilage, which is attached to the tract, is also removed, decreasing the incidence of recurrence to 5%.

Tan et al5 reported the most current data in 2005, which suggested that the definitive surgical intervention that promises the best outcome is wide local excision of the sinus, not simple sinectomy. To minimize the risk of recurrence, Tan et al5 suggest using magnification and intraoperatively opening the sinus and then following from the inside of the sinus to the outside branching tracts of the sinus.

Similarly, Chang and Wu6 stated in 2005 that the use of an operating microscope can enhance the effectiveness of surgery to remove remnants and help prevent recurrence of a preauricular cyst.

Yeo et al7 found that in a case series of 191 patients with preauricular sinuses (206 surgeries), the recurrence rate following surgery was 4.9%, with surgery under local anesthesia being a risk factor for recurrence (P = .009). Additionally, the cases that involved local infiltrative anesthesia had an increased rate of recurrence compared with surgery performed with the patient under general anesthesia (odds ratio, 6.875).

In a 2007 study from a referral center in Malaya, Tang et al8 reviewed cases of 71 patients with 73 preauricular sinuses. They found an overall recurrence rate of 14.1% and that 16% of sinuses required drainage of an abscess prior to definitive surgery. Additionally, preauricular sinuses with a previous history of infection or those actively infected during the definitive surgery seemed to be associated with a higher tendency for recurrence. Surgical demonstration of the sinus tract by probing with lacrimal probes or sinus probes, followed by injection of methylene blue, reduces the recurrence rate.

Consultations

Consult plastic surgeons or otolaryngologists for surgical treatment.

More on Preauricular Sinuses

Overview: Preauricular Sinuses
Differential Diagnoses & Workup: Preauricular Sinuses
Treatment & Medication: Preauricular Sinuses
Follow-up: Preauricular Sinuses
Multimedia: Preauricular Sinuses
References
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References

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  2. Saltzmann RM, Lissner GS. Familial absence of lacrimal puncta associated with preauricular sinuses. J Pediatr Ophthalmol Strabismus. Jul-Aug 2006;43(4):233-5. [Medline].

  3. Choi SJ, Choung YH, Park K, Bae J, Park HY. The variant type of preauricular sinus: postauricular sinus. Laryngoscope. Oct 2007;117(10):1798-802. [Medline].

  4. Martin-Granizo R, Pérez-Herrero MC, Sánchez-Cuéllar A. Methylene blue staining and probing for fistula resection: application in a case of bilateral congenital preauricular fistulas. Int J Oral Maxillofac Surg. Aug 2002;31(4):439-41. [Medline].

  5. Tan T, Constantinides H, Mitchell TE. The preauricular sinus: A review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol. Nov 2005;69(11):1469-74. [Medline].

  6. Chang PH, Wu CM. An insidious preauricular sinus presenting as an infected postauricular cyst. Int J Clin Pract. Mar 2005;59(3):370-2. [Medline].

  7. Yeo SW, Jun BC, Park SN, Lee JH, Song CE, Chang KH, et al. The preauricular sinus: factors contributing to recurrence after surgery. Am J Otolaryngol. Nov-Dec 2006;27(6):396-400. [Medline].

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  12. Currie AR, King WW, Vlantis AC, Li AK. Pitfalls in the management of preauricular sinuses. Br J Surg. Dec 1996;83(12):1722-4. [Medline].

  13. Lam HC, Soo G, Wormald PJ, Van Hasselt CA. Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope. Feb 2001;111(2):317-9. [Medline].

  14. Leung AK, Robson WL. Association of preauricular sinuses and renal anomalies. Urology. Sep 1992;40(3):259-61. [Medline].

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Further Reading

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Keywords

congenital aural sinuses, preauricular fistula, congenital preauricular cysts, congenital ear pit, preauricular pits

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Valerie Nozad, DO, Staff Physician, Beth Israel Medical Center, Department of Internal Medicine, University Hospital for the Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

Jeffrey Weinberg, MD, Director, Clinical Research Center, Department of Dermatology, St Luke's; Assistant Clinical Professor, Department of Dermatology, Columbia University College
Jeffrey Weinberg, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Julie C Harper, MD, Assistant Program Director, Assistant Professor, Department of Dermatology, University of Alabama at Birmingham
Julie C Harper, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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