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

Preauricular Cysts, Pits, and Fissures: Treatment

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

Treatment

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.

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 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.

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.

Preoperative Details

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

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.

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.

Follow-up

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

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 is also possible.

Incomplete removal of a sinus tract may lead to recurrence.

More on Preauricular Cysts, Pits, and Fissures

Overview: Preauricular Cysts, Pits, and Fissures
Workup: Preauricular Cysts, Pits, and Fissures
Treatment: Preauricular Cysts, Pits, and Fissures
Follow-up: Preauricular Cysts, Pits, and Fissures
Multimedia: Preauricular Cysts, Pits, and Fissures
References
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References

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  13. Rothschild MA, ed. Syndromic and Other Congenital Anomalies of the Head and Neck. Otolaryngol Clin North Am. Dec 2000;33(6).

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

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Further Reading

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Keywords

preauricular tags, preauricular pits, preauricular fissures, epithelial mounds, pedunculated skin, preauricular sinus pit, sinus tracts, subcutaneous cysts, branchiootorenal syndrome, BOR syndrome, Beckwith-Wiedemann syndrome, mandibulofacial dysostosis, oculoauriculovertebral dysplasia, chromosome arm 11q duplication syndrome, chromosome arm 4p deletion syndrome, chromosome arm 5p deletion syndrome

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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 and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

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
John P Bent lll, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

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.

Medical Editor

Michael J Biavati, MD, Clinical Assistant Professor, Department of Otolaryngology, University of Texas Southwestern
Michael J Biavati, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of 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 Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Speaking and teaching; Insight vision Consulting fee Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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