Download Treatment of Complicated and Uncomplicated Preauricular Pits

Treatment of Complicated and Uncomplicated Preauricular Pits
Richard J. Vivero, MD; Soham Roy, MD, FACS, FAAP
Department of Otolaryngology – Head and Neck Surgery
Leonard M. Miller School of Medicine, University of Miami
Miami, Florida, USA
ABSTRACT
DISCUSSION
Objectives: 1. To review the University of Miami experience with complicated and uncomplicated preauricular pits 2.
To review the relevant anatomy, embryology, and surgical technique.
Methods: A retrospective chart review from 2002 to 2007 was conducted at a tertiary care university hospital to
identify patients less than 18 years old undergoing surgical excision of a preauricular pit. Charts were reviewed for
patient age, presentation, complications, treatment algorithm, and outcome.
Results: 13 patients underwent surgical excision of a preauricular pit. The indication for excision was either
recurrent infection or recurrent drainage in all cases. Three of 13 patients had a presurgical complication of the
infection, including localized cellulitis of the preauricular skin or infection of the helical cartilage. These patients
were treated with a prolonged course of antibiotics prior to surgical excision. All 13 patients were treated with wide
surgical excision; in the 3 patients with pre-excision complications, careful attention was paid to meticulous incision
of all involved tissue. There were no postoperative complications. No recurrences were noted up to 3 year follow-up.
All patient’s parents were satisfied with the cosmetic outcome in all cases.
Conclusion: Preauricular pits are an important entity due to their potential for significant infectious morbidity.
Appropriate diagnosis and management with wide local excision, especially in the context of a complicated
presentation, can result in excellent cosmesis with minimal risk of recurrence. Relevant embryology, anatomy, and
surgical technique will be reviewed.
INTRODUCTION
Preauricular pits or sinuses are common congenital anomalies that predominantly affect
children. When asymptomatic, they are often not a concern to the parent or child and largely
ignored. However, when infected, they are profoundly bothersome to the child and prompt a visit
to an Otolaryngologist for evaluation and treatment. In this review, we present the University of
Miami experience of surgical management of preauricular pits, including a review of relevant
embryology, anatomy, and surgical technique.
Methods
A retrospective chart review from 2002 to 2007 was conducted at a tertiary care university hospital
to identify patients less than 18 years old undergoing surgical excision of a preauricular pit. Charts
were reviewed for patient age, presentation, complications, treatment algorithm, and outcome.
Results
A total of 13 children underwent surgical excision of a preauricular pit. Age at the time of excision
ranged from 2 years to 15 years (mean 8.75 years); 8 patients were female and 4 were male. Nine
of 13 children had bilateral preauricular pits; asymptomatic contralateral pits with no prior history
of infection or complications were not excised. Eight of the excised pits were from the right ear
and 5 from the left. In all cases, the excised pit had a history of recurrent or chronic drainage, or a
history of recurrent infection. Pits were all removed during a quiescent phase of infection; no
surgical excision was performed during an active infection.
In 3 of 13 cases the patient had a significant pre-excision infectious complication, including
localized cellulitis of preauricular skin (figure 1) and infection of the helical cartilage (figure 2). In
these patients, a two week course of antibiotic therapy was given prior to surgical excision to quiet
the infectious process. Wide surgical excision was performed in all cases with careful attention to
removing the entire tract of the preauricular pit in addition to any subcutaneous cyst that was
identified. A lacrimal probe was used to follow the extension of any additional tract (figure 3). A
shave excision of helical rim cartilage was performed when the tract extended to the helical root.
In the 3 cases with infectious complications prior to surgery, all involved infected tissue was
widely removed in addition to any identified cyst or sinus tract (figure 4). Primary closure was
performed in all cases.
The preauricular pit or sinus was first described in the German literature by Van Heusinger in
1864. It is a benign congenital malformation that affects the soft tissues anterior to the root of the
helix. The incidence is noted to be 0.1-0.9% in the United States, 0.47% in Hungary, 0.9% in
England, 2.5% in Taiwan, and 4-10% in some areas of Africa.1-3 For most patients, it is
asymptomatic and not an issue of concern. However, a large subset of patients note a history of
recurrent infections with discharge that are painful and bothersome requiring evaluation and
treatment.
Formation of the pit can be traced back to embryogenesis of the ear. The auricle arises from the
first and second branchial arches during the sixth week of gestation. Each arch provides three
mesenchymal proliferations, known as hillocks of His, which fuse to form the definitive auricle.1-4
Pit formation has been postulated to form by one of three theories. The most popular theory is the
interbular theory that postulates sinuses form due to incomplete fusion of two of the six hillocks.14 Less popular but persisting theories of formation include incomplete closure of the dorsal part of
the pharyngeal groove and isolated ectodermal folding during auricular development with
resultant pit formation.2
Preauricular sinuses can be inherited or sporadic. The inherited form shows an incomplete
autosomal dominant pattern with reduced penetrance (approximately 85%) and variable
expression.1-3 Studies from China have mapped a possible locus for fistula formation to
chromosome 8q11.1-q13.3.1 Sinuses can be either unilateral or bilateral with the latter more likely
genetic.2 Of concern to the practicing Otolaryngologist is the exceedingly small risk of
associated syndromes affecting the inner ear and kidneys. Branchio-oto-renal (BOR) syndrome is
the most well known and consists of conductive, sensorineural, or mixed hearing loss;
preauricular pits; structural defects of the outer, middle or inner ear; renal anomalies; lateral
cervical fistula, cysts, or sinus; and nasolacrimal duct stenosis or fistula.1-4 The incidence of
hearing impairment of all possible associated syndromes with preauricular pits in children has
been estimated to be as high as 15-30%.3 In our experience, 9 of 13 patients (69%) had bilateral
preauricular sinuses, which is suggestive of a genetic etiology. Unfortunately, however, our
records did not have genealogic evidence to assess familial inheritance of this trait
The typical presentation of a preauricular pit is an innocuous, asymptomatic cutaneous indentation
anterior to the auricle. Specifically, the pit may be located at the anterior margin of the ascending
helix.1 Anomalous openings in the posterosuperior margin of the helix, the tragus or lobule have
been reported.1 Patients often present at times of infection when there are signs of erythema and
drainage from the pit, which may be accompanied by constitutional symptoms. Preauricular
sinuses may also result in subcutaneous cyst formation and are almost always associated with the
perichondrium of the auricular cartilage.1-2,4 The sinus tract course is lateral and superior to the
facial nerve and parotid gland unlike branchial cleft anomalies, which are closely related to these
structures.1
Definitive management is achieved by complete excision of the preauricular pit and its sinus tract
following resolution of infection. The sinus tract should be probed with a lacrimal probe or
injected with methylene blue to ensure identification of all branches distal to the cutaneous pit.12,4-5 Some authors, including our group, advocate for the excision of a small cartilaginous cuff at
the end of the sinus tract, as the sinus is intimately associated with the perichondrium of the
auricle.1-2,4 The rate of recurrence ranges from 0 to 42% depending on the factors present at time
of excision.1,4 Lower recurrence rates are noted for patients who are not actively infected at time
of infection, who have the sinus probed at time of surgery, and who have a cuff of cartilage
excised in unison with the sinus.1,4 Our process and experience is consistent with reports from the
literature, and we have noted no recurrences at this time with follow-ups from 2 weeks to 3
years. None of the parents of our patients complained of the cosmetic outcome of the procedure
suggesting a simple wide local excision with attention to meticulous closure is sufficient to obtain
excellent cosmesis.
Postoperatively, all patients were treated with a one week course of oral antibiotics. A rubber band
drain was placed into the wound overnight and removed on postoperative day 1 if a cavity
remained after excision large enough to be concerned about postoperative hematoma development.
There were no postoperative complications in any of the cases. Follow-up time ranged from 2
weeks to 3 years; no recurrences or postoperative complications were reported. In all cases,
parents were satisfied with the cosmetic outcome after surgical removal and no further intervention
was required (figure 5).
CONCLUSION
Preauricular sinus or pits are often asymptomatic lesions associated with
the anterior aspect of the auricle. The etiology is associated with
auricular embryogenesis and can be either inherited or
sporadic. Practicing otolaryngologists must be cognizant of associated
syndromes, including brancho-oto-renal (BOR) syndrome. When
Figure 4
preauricular pits are complicated by infection, treatment of the active
infection followed by surgical resolution is the appropriate and definitive
treatment. When the sinus is fully probed and a cuff of cartilage is
resected at time of surgery, the rate of recurrence is low.
Figure 1. Preauricular pit of right ear
with localized infection complicated
by cellulitis.
Figure 2. Preauricular pit of left ear
with localized infection complicated by
helical cartilage involvement.
REFERENCES
[1] 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.
[2] 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.
[3] Huang XY, Tay GS, Wansaicheong GK, Low WK. Preauricular sinus: clinical course and
associations. Arch Otolaryngol Head Neck Surg. 2007 Jan;133(1):65-8.
Figure 3. Example of sinus
tract of left auricle
cannulated with lacrimal
probe to determine extent of
involvement.
Figure 4. Wide local
excision of left preauricular
pit with removal of all
involved tissues (same
patient as in Figure 2).
Figure 5. Two-month
posoperative photograph of
left ear demonstrating
excellent cosmesis.
[4] Gur E, Yeung A, Al-Azzawi M, Thomson H. The excised preauricular sinus in 14 years of
experience: is there a problem? Plast Reconstr Surg. 1998 Oct;102(5):1405-8.
[5] 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.
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