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Preauricular Cysts, Pits, and Fissures Treatment & Management

  • Author: Samuel T Ostrower, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 31, 2016
 

Medical Therapy

Consultations with the following specialists may be beneficial:

  • Otolaryngologist
  • Audiologist: Although most neonates are screened in the United States, confirming normal hearing in any infant who presents with external ear deformities is prudent. No definitive studies, however, have demonstrated that isolated preauricular pits necessitate hearing assessment.
  • Craniofacial teams: Consult these teams in the presence of multiple organ system abnormalities and for children thought to have syndromic features.

Antibiotics (eg, cephalexin [Keflex], amoxicillin and clavulanate potassium [Augmentin], erythromycin) are indicated in patients with cellulitis from infected preauricular pits.

Incision and drainage procedures may be required for patients with abscess formation. Staphylococcus aureus is the most common bacteria found in these infections followed by Proteus, Streptococcus, and Peptococcus species.

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Surgical Therapy

Sinuses, cysts, and pits

The authors discourage standard incision and drainage in the setting of abscess formation within a preauricular sinus tract or cyst. A potential alternative to incision and drainage is the use of a blunt-ended lacrimal probe inserted into the preauricular pit in order to open the abscess cavity. However, acute inflammation usually makes this option both technically difficult and painful. Aspiration with a 21-gauge needle reliably provides at least temporary relief, eases pain, and provides purulent material for culture and sensitivity. Needle aspiration may need to be repeated if an abscess reaccumulates, but needle aspiration reliably leads to a better cosmetic result than incision and drainage.

Complete surgical excision, as shown below, of a preauricular sinus tract or cyst is indicated in the setting of recurrent or persistent infection. The operation is typically performed when the acute infection has subsided. Recurrence rates following excision range from 0-42%. Factors that reportedly reduce the risk of recurrence include complete excision of the sinus and tract with associated perichondrium, dissection down to temporalis fascia, closure of dead space, and avoidance of sinus rupture.

Preauricular sinus tract, cyst, and granulation re Preauricular sinus tract, cyst, and granulation removed. The skin was closed with slight undermining and no tension. Sutures are removed 7-10 days later.

Inflammation always exists to varying degrees around the cyst wall in the surgical field. Using auricular cartilage as a posterior boundary and the preparotid fascia as a medial boundary helps to assure complete excision when edema and fibrosis obscure the cyst wall. Some authorities recommend methylene blue injection into the cyst to caution against cyst wall violation, but the dye invariably leaks out of the tract into the surgical field, offsetting its benefit. The authors favor the use of a lacrimal probe during the procedure to help define the cyst's periphery.

Tags

An elliptical incision is made around tag at the base, and the skin is closed primarily.

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Preoperative Details

The infectious process should be optimally controlled prior to excision of the tract or cysts.

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Intraoperative Details

Although several techniques for excision have been described, the following is a standard approach:

  • The pit is excised with a rim of normal tissue.
  • Dissection onto temporalis fascia allows identification of normal tissue plane
  • A probe may be placed to follow the tract down to the base.
  • Blue dye may be used to document the extent of the tract.
  • A rim of auricular cartilage may be taken near the base of the tract to reduce recurrence.
  • Avoid violating the skin of the auricle.
  • Try to preserve skin that overlies the cyst, even if it looks nonviable.
  • If greater exposure is required, the incision may be extended into the postauricular groove.
  • Bipolar cautery and blunt dissection facilitate tissue plane preservation.
  • The wound is irrigated and closed with absorbable sutures.
  • A small rubber band drain may be used and is removed the next day.
  • A flexible dressing may be applied over the ear and around the head. The dressing is removed the next day.
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Postoperative Details

Passive drain should be removed on the first postoperative day. Keep the wound dry for 3 days. Watch for bleeding, erythema, and fever. Patients should report any of these unusual symptoms. Purulent drainage is uncommon. Children usually resume normal activities by the following day.

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Follow-up

A follow-up visit should occur 7-14 days after surgery for wound evaluation.

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Complications

Bleeding and infection are the most common complications. Incomplete control of bleeding with failure to close the wound sufficiently may allow bacteria to flourish under the skin, causing infection and wound breakdown.

A seroma may form but typically responds to simple needle drainage or observation. A thick scar may form in wounds closed with too much tension. Scar formation is associated with skin of moderate or high melanin content. Keloid formation, as shown below, is also possible.

Keloid scar formed several months after removal of Keloid scar formed several months after removal of preauricular sinus tract. Intralesional steroids and close observation are indicated.

Incomplete removal of a sinus tract may lead to recurrence.

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Outcome and Prognosis

The prognosis is excellent if the tract, fissure, and/or cyst is completely removed. Cosmesis is dependent on surgical knowledge and the scar-forming attributes of the patient. Previously infected cysts and tracts may cause deeper tissue damage that requires rotational and or advancement flap procedures for improved cosmetic outcome.

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Future and Controversies

Routine renal ultrasonography has been advocated as a result of several studies that suggest a higher incidence of renal anomalies among patients with ear anomalies, and specifically those with preauricular pits. Cost-effectiveness data to support this practice, however, is lacking, and routine renal ultrasonography has yet to become the standard of care in the workup of patients with isolated preauricular pits.

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Contributor Information and Disclosures
Author

Samuel T Ostrower, MD Staff Physician, Department of Otorhinolaryngology, Albert Einstein College of Medicine

Samuel T Ostrower, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

John P Bent, III, MD Professor, Director of Pediatric Otolaryngology, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Albert Einstein School of Medicine; Director, Airway Clinic, Cochlear Implant Program, Children's Hospital at Montefiore

John P Bent, III, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael J Biavati, MD, FACS, FAAP Clinical Assistant Professor of Otolaryngology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Private Practice, ENT Care for Kids, Dallas, TX

Michael J Biavati, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, American Academy of Pediatrics, American Cleft Palate-Craniofacial Association, American College of Surgeons, The Triological Society, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Mitchell B Austin, MD Director, Associate Professor, Department of Pediatrics, Division of Otolaryngology, Children's Medical Center, Medical College of Georgia

Mitchell B Austin, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American College of Surgeons

Disclosure: Nothing to disclose.

References
  1. An SY, Choi HG, Lee JS, Kim JH, Yoo SW, Park B. Analysis of incidence and genetic predisposition of preauricular sinus. Int J Pediatr Otorhinolaryngol. 2014 Dec. 78 (12):2255-7. [Medline].

  2. Lee KY, Woo SY, Kim SW, Yang JE, Cho YS. The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea. Otol Neurotol. 2014 Dec. 35 (10):1835-8. [Medline].

  3. Zou F, Peng Y, Wang X, et al. A locus for congenital preauricular fistula maps to chromosome 8q11.1-q13.3. J Hum Genet. 2003. 48(3):155-8. [Medline].

  4. Beleza-Meireles A, Hart R, Clayton-Smith J, et al. Oculo-auriculo-vertebral spectrum: Clinical and molecular analysis of 51 patients. Eur J Med Genet. 2015 Sep. 58 (9):455-65. [Medline].

  5. Andersen SL, Olsen J, Wu CS, et al. Severity of Birth Defects After Propylthiouracil Exposure in Early Pregnancy. Thyroid. 2014 Jun 25. [Medline].

  6. Scheinfeld NS, Silverberg NB, Weinberg JM, Nozad V. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol. 2004 May-Jun. 21(3):191-6. [Medline].

  7. Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol. 2003 Dec. 117(12):983-4. [Medline].

  8. Firat Y, Sireci S, Yakinci C, et al. Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment?. Eur Arch Otorhinolaryngol. 2008 Sep. 265(9):1057-60. [Medline].

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

 
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Preauricular ear tag. Image courtesy of Jack Yu, MD.
Multiple tags in a child with oculoauriculovertebral dysplasia. Note the hemifacial atrophy, retrognathia, and lower set ear. Image courtesy of Jack Yu, MD.
Uninfected preauricular pit. Image courtesy of Ed Porubsky, MD.
Close-up image of preauricular pit. Image courtesy of Ed Porubsky, MD.
Infected preauricular cyst with swelling and erythema toward the cartilage of the ear.
A preauricular sinus tract is probed with a blunt needle, and methylene blue dye is injected. Note the region in front of the pit, where previous abscess formation, spontaneous drainage, and residual scarring and granulation have occurred. This circumstance requires a more complex procedure. Removal of the entire sinus tract and the granulation disease is essential. Image courtesy of Ed Porubsky, MD.
Preauricular sinus tract, cyst, and granulation removed. The skin was closed with slight undermining and no tension. Sutures are removed 7-10 days later.
Keloid scar formed several months after removal of preauricular sinus tract. Intralesional steroids and close observation are indicated.
 
 
 
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