Preauricular Sinuses Treatment & Management

Updated: Jan 27, 2020
  • Author: Jeffrey Weinberg, MD; Chief Editor: William D James, MD  more...
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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.

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Surgical Care

Once infection occurs, the likelihood of recurrent acute exacerbations is high, and the sinus tract should be surgically removed. [2] 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. One report described 141 successful, infection-free results in which a gentian violet – soaked Cottonoid, which has antibacterial effects, was used instead of methylene blue dye. [18]

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. [19] 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%. Leopardi et al report that they prefer the supra-auricular approach for the surgical treatment of recurring preauricular sinus. [20]

Tan et al [21] 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 al [21] 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 Wu [22] 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.

Baatenburg de Jong reports on an "inside-out" technique, which was deemed superior to the classic repair technique, with fewer recurrences, in a small, single-institution study. [23]

Yeo et al [24] 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 al [25] 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. Some have advocated a minimal supra-auricular approach without a surgical drain for removal of preauricular sinuses. [26]

Dickson et al found that methylene blue was a safe and useful means of demarcation of preauricular sinuses and branchial sinuses and fistulae in a series of 20 children with preauricular sinuses and 11 with branchial sinuses and fistulae, allowing for smaller incisions and minimal dissections. [27]

In 2010, Bajwa and Kumar reported on radiofrequency thermal ablation versus cold steel” excision for supra-auricular excision of preauricular sinuses. They concluded that radiofrequency-assisted local wide excision appeared to be superior to cold steel excision because the former offered better perioperative visualization, with minimal bleeding and easier dissection. Additionally, they reported that radiofrequency thermal ablation was associated with a lower recurrence rate. [28]

In a 2009 study of the histologic relationship of preauricular sinuses to auricular cartilage, Dunham et al found that sinocartilaginous distances may suggest it can be challenging to dissect most sinus tracts from the cartilage. Thus, the routine removal of a minimal portion of auricular cartilage in combination with the sinus tract can provide a more thorough excision and may stop recurrence. [29]

A group in Singapore found that microscope guidance using probe guidance with methylene blue yields a lower recurrence rate than simply using methylene blue with probe guidance. [30]

A report form Chowdary et al advocates use of magnification during surgery. The surgery involves a wide surgical technique accompanied with a postextended auricular incision through a supra-auricular approach (successful at 8 y follow-up). [31]

The state-of-the-art of surgery on preauricular sinuses has not advanced in 2015, and surgical treatment options reported previously to 2015 continue to be used. [32]

If the preauricular sinus recurs, it should be fully removed.

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Consultations

Consult plastic surgeons or otolaryngologists for surgical treatment.

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Complications

Patients may develop infection of the tract with abscess formation. Coatesworth et al described successful management of preauricular sinus abscess that allows drainage of pus with minimal or no disturbance of the sinus. [33]

Infections and ulcerations may occur at a site distant from the opening.

Postoperative recurrence is a complication of preauricular sinus tract extirpation. Several factors contribute to recurrence after surgery, as follows:

  • Previous attempt at surgical removal

  • Surgery under local anesthesia

  • Incomplete removal of the sinus tract

  • Active infection at the time of surgery

  • Drainage of an abscess prior to surgery

  • Poor delineation of the entire sinus tract during surgery

  • Failing to remove the auricular cartilage at the base of the sinus

  • Failing to identify the facial nerve because it lies close to the sinus

Most recurrences occur during the early postoperative period, within 1 month of the procedure. Recurrences should be suspected when discharge from the sinus tract opening persists. The overall incidence of recurrence varies among different studies and ranges from 5-42%.

Winkler et al noted a scalp arteriovenous malformation spontaneously hemorrhaging into a preauricular sinus; it was successfully treated with intravascular embolization and surgical ligation. [34]

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Prevention

If the preauricular sinus becomes repeatedly infected, it can be surgically removed.

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Long-Term Monitoring

If a preauricular sinus is repeatedly infected and the patient does not want surgery, its contents can be cultured and proper antibiotics to cover the pathogens can be given.

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