eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > External Ear Diseases

Preauricular Cysts, Pits, and Fissures

Author: Samuel T Ostrower, MD, Staff Physician, Department of Otorhinolaryngology, Albert Einstein College of Medicine
Coauthor(s): John P Bent lll, MD, Associate Professor, Director of Medical Student Education, Departments of Otolaryngology - Head and Neck Surgery and Pediatrics, Albert Einstein School of Medicine; Director, Airway Clinic, Children's Hospital at Montefiore; Mitchell B Austin, MD, Director, Associate Professor, Department of Pediatrics, Division of Otolaryngology, Children's Medical Center, Medical College of Georgia
Contributor Information and Disclosures

Updated: Feb 12, 2009

Introduction

Preauricular cysts, pits, fissures, and sinuses are benign congenital malformations of the preauricular soft tissues first described by Van Heusinger in 1864. Preauricular pits or fissures are located near the front of the ear and mark the entrance to a sinus tract that may travel under the skin near the ear cartilage. These tracts are lined with squamous epithelium and may sequester to produce epithelial-lined subcutaneous cysts or may become infected, leading to cellulitis or abscess.

Preauricular tags are epithelial mounds or pedunculated skin that arise near the front of the ear around the tragus. They have no bony, cartilaginous, or cystic components and do not communicate to the ear canal or middle ear.

Simple preauricular cysts should not be confused with first branchial cleft cysts. Branchial cleft anomalies are closely associated with the external auditory canal, tympanic membrane, angle of the mandible, and/or facial nerve. Misinterpreting a first brachial abnormality for a simple sinus tract may place the unsuspecting physician at risk for damaging the facial nerve, incompletely excising the lesion, or both.

Patients identified with preauricular pits or cysts should be examined for other congenital anomalies.

Frequency

Malformations of the external ear are not uncommon. Generally, they occur in 1 of every 12,500 births. Incidence of spontaneous formation of ear pits in the nonsyndromic population ranges from 0.3-0.9%.

These conditions affect males and females equally and have no race predilection.

Etiology

Embryology and branchial arch development

The auricle forms during the sixth week of gestation. The first and second branchial arches give rise to a series of 6 mesenchymal proliferations known as the hillocks of His, which fuse to form the definitive auricle. The first arch gives rise to the first 3 hillocks, which form the tragus, helical crus, and the helix. The second arch gives rise to the second 3 hillocks, which form the antihelix, scapha, and the lobule.

Defective or incomplete hillock fusion during auricular development is postulated as the source of the preauricular sinus. Another theory suggests that localized folding of ectoderm during auricular development is the cause of preauricular sinus formation. The first 3 hillocks are most often linked to supernumerary hillocks, leading to preauricular tag formation.

Genetics

Correct sequential gene activation is required for normal ear and facial development. Interrupting the gene activation sequence in laboratory animals disrupts ear development.

Genetic linkage analysis studies have suggested that congenital preauricular sinus localizes to chromosome 8q11.1-q13.3.¹

The inner neurological hearing apparatus, cochlea, and auditory nerve form in conjunction with the outer ear structures during the early developmental stages. External deformities may be associated with an inner neurological deformity and, hence, suggest a possible deafness.

Associated syndromes

Syndromic expression of pits, tags, and fissures occurs at much higher frequencies in certain craniofacial dysmorphisms. Minor anomalies of the head and neck may aid the clinician in developing a presumptive diagnosis during the initial examination. Additional ear anomalies include helical fold abnormalities, asymmetry, posterior angulation, small size, absent tragus, and narrow external auditory meatus. Some syndromes with characteristic ear anomalies are as follows:

• Branchiootorenal syndrome (BOR) - Preauricular sinus
• Beckwith-Wiedemann syndrome - Preauricular sinus with asymmetric earlobes
• Mandibulofacial dysostosis - Auricular pits/fistulas
• Oculoauriculovertebral dysplasia - Preauricular tags
• Chromosome arm 11q duplication syndrome - Preauricular tags or pits
• Chromosome arm 4p deletion syndrome - Preauricular dimples or skin tags
• Chromosome arm 5p deletion syndrome - Preauricular tags

Pathophysiology

Preauricular sinuses may be asymptomatic for life. An infection arises when the opening of the pit seals bacteria within the sinus tract along with desquamated skin. Early signs and symptoms of swelling, pain, and erythema should prompt the practitioner to begin antibiotic therapy directed at common skin bacterial organisms. Surgical drainage may be indicated if obvious abscess formation occurs or swelling progresses despite antibiotic therapy. Toxic-appearing and immunocompromised patients may require observation, intravenous antibiotic therapy, and surgical drainage. Complete surgical removal is the treatment of choice for recurrent infection and drainage problems.

Ear tags alone pose no threat to any structure and are usually merely a cosmetic deformity. They are usually excised in young patients by qualified surgeons who treat head and neck abnormalities. General anesthesia is typically required. Recurrence rates are low.

Smaller, narrowly based tags are tied at their bases with thread or suture in infants during office visits. Simple excision at the base may be performed using topical EMLA cream. Larger, broad-based, multiple, or complex tags may require elliptical excision and plastic closure, which requires general anesthesia.

Presentation

Clinical presentation of various ear anomalies may be summarized as follows:

• Noninfected pits - Pinpoint hole in front of the ear or above tragus
  • Nondraining
  • Lacks swelling
• Infected pits - Cellulitis and abscess
  • Red, swollen
  • Draining purulent material
  • Granulation around pit
  • Tender
  • Previous surgical scar with underlying swelling
• Cysts - Slowly enlarging preauricular mass
  • Usually nontender if uninfected
  • Associated pit usually adjacent to cyst
• Tags - Fleshy knobs of skin in front of the ear
  • Nontender
  • Nondraining
  • Color similar to surrounding skin
  • Appears to be attached on the surface of the cheek, pinna, tragus, or lobe
  • No rapid growth

Differential diagnoses

• Preauricular swelling/infection
• Parotid swelling/mass/tumor
• First branchial cleft cyst
• Duplication of ear canal
• Trauma
• Cellulitis from otitis externa
• Trauma
• Body piercing
• Previous surgical site

Indications

Most patients with preauricular pits in the typical location are asymptomatic and require no surgical intervention. Needle aspiration is indicated for abscess that fails to respond to antibiotics. Incision and drainage complicates later excision and should be reserved for abscess that recurs after needle aspiration.

Complete excision of the cyst or sinus tract may be undertaken in cases of recurrent infection.

Ear tags are removed for cosmetic reasons.

Relevant Anatomy

A preauricular pit may mark the entrance to a sinus tract, which can vary in length, follow a tortuous course, and branch extensively. Preauricular sinuses and cysts have a component of close association with the auricular perichondrium. For this reason, some argue that complete removal of a sinus tract or cyst should also include a portion of the auricular perichondrium at the base of the lesion.

Preauricular sinuses or cysts are found lateral and superior to the facial nerve and parotid gland, whereas first branchial cleft malformations are found in close association with these structures, as well as with the external auditory canal.

Excision of complex or broad-based tags requires the knowledge of relaxed skin lines and wound tension in the region of the face and ear.

Contraindications

An infected cyst or tract may be considered a relative contraindication to excision of a sinus tract or cyst. Antibiotics and, occasionally, steroids should be considered to control any residual inflammation prior to surgery.

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