What is a pre-auricular sinus?

The preauricular sinus is a relatively common physical finding especially in the pediatric population. It is defined as a congenital lesion in which a small skin opening located in front of the external ear communicates with a subcutaneous network of cysts. The vast majority are benign in nature and require no intervention. Draining sinus tracts are prone to infection and should be excised. Complete excision of the pit and sinus tract provides the only definitive cure. To prevent problematic recurrence, we recommend wide exposure of the lesion by the technique described.

The Background

Preauricular sinuses are common congenital malformations first described by Heusinger in 1864. They are frequently noted on routine physical examination as small dells adjacent to the external ear, usually at the anterior margin of the ascending limb of the helix. However, they have been reported to occur along the lateral surface of the helicine crus and the superior posterior margin of the helix, the tragus, or the lobule. Anatomically, they are lateral and superior to the facial nerve and the parotid gland.
Preauricular sinuses are inherited in an incomplete autosomal dominant pattern, with reduced penetrance and variable power of expression. They can arise spontaneously. The sinus may be bilateral in 25-50% of cases, and bilateral sinuses are more like to be hereditary. In unilateral cases, the left side is more commonly affected.

What is the chance of getting this?

Frequency:

• In the US: In one study, the incidence in the United States is estimated to be 0-0.9%, and the incidence in New York State is estimated to be 0.23%.


• Internationally: In Taiwan, the incidence is estimated to be 1.6-2.5%; in Scotland, 0.06%; and in Hungary, 0.47%. In some parts of Asia and Africa, the incidence is estimated to be 4-10%.

Race: The incidence of preauricular sinuses in whites is 0.0-0.6%, and the incidence in African Americans and Asians is 1-10%.
Sex: Both men and women are affected equally.
Age: Preauricular sinuses arise in the antenatal period and are usually present at birth, but they can become apparent later in life.

Any chance of dying?

• Preauricular sinuses have no associated mortality.


• Morbidity includes recurrent infections at the site, ulceration, scarring, pyoderma, and facial cellulitis. Specifically, the following conditions may occur: abscesses at and anterior to the involved ear, chronic and recurrent drainage from sinus orifices, malar ulceration, otitis externa, and unilateral facial cellulitis.


• Surgical treatment has its own associated morbidity, with the possibility of postoperative recurrence.

What Causes this?

Preauricular sinuses are malformations that result from incomplete fusion of 2 of the 6 hillocks that arise from the first and second branchial arches.

Surgical Care

Once infection occurs, the likelihood of recurrent acute exacerbations is high, and the sinus tract should be surgically removed. 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 either use 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.
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. 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%.

Consultations: Consult plastic surgeons or otolaryngologists for surgical treatment.

Further Inpatient Care:

• If the sinus reoccurs, it should be fully removed.

Further Outpatient Care:

• 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.

In/Out Patient Meds:

• Usually, no medications must be given, but if infection occurs, antibiotics can be given. The contents of the sinus should be cultured before antibiotics are prescribed.

Deterrence/Prevention:

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

Complications:

• Patients may develop infection of the tract with abscess formation.


• 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%.

Prognosis:

• Preauricular sinuses generally have a good prognosis.

Medical/Legal Pitfalls:

• Failure to recognize that a preauricular sinus can cause facial abscess and ulceration


• Failure to recognize that a preauricular sinus can recur after surgery


• Failure to recognize that a preauricular sinus can be associated with congenital deafness


• Failure to recognize that a preauricular sinus can result in facial palsy by impinging on facial nerves


• Failure to recognize that a preauricular sinus can lead to infection if facial surgery is performed proximal to it


• Failure to consider audiologic or renal evaluation if a preauricular sinus is present


• Failure to identify an infected preauricular sinus and not treating it with proper antibiotics and/or surgery (A preauricular sinus may be confused with a cyst when infected.)

Pre-auricular sinus. Notice the small hole above the ear.

Infected Pre-auricular sinus.


On January 20, 2005 I started preparing for the operation for the excision of my pre-auricular sinus. My dad went with me to Mercury Drugstore to buy the things necessary for the operation.

Things Needed For PAS:
5 ml Syringe
Needle g25
Vicryl or Chronic 4-0 w/ round needle
Nylon 5-0 with cutting needle
Penrose Drain
Lidocaine 2%
Epinephrine

We went to 2 Mercury Drugstore branches and still we lack 3 items. We decided to buy the items left tomorrow. Here's the rundown of expenses:

Things Needed For PAS (Price):
5 ml Syringe (Php6.50)
Needle g25 (Php1.95)
Vicryl or Chronic 4-0 w/ round needle (Php240.00)
Nylon 5-0 with cutting needle
Penrose Drain
Lidocaine 2% (in vial Php25.50)
Epinephrine

Before going to bed, I did my nails. Well, no polish but I cleaned it. :)

Yesterday, January 21, 2005, I woke up at around 4:45 am. My dad, who was supposed to accompany me to the hospital was on graveyard shift and probably would overtime. So my mom told me that she would be the one to accompany me. Soon, we're ready and we went out of the house. We were in great luck that day because we saw our neighbor's car backing out of the driveway. Our neighbor works at Philippine General Hospital (PGH) and their daughter is one of my close friends. So, we rode with them to the hospital. I was trying to sleep inside the car but I was really nervous of the upcoming operation.

At around 7:00 am we're already in front of the OPD of PGH. We dropped by first at the nearest pharmacy to buy the necessary things needed.

Things Needed For PAS (Price):
5 ml Syringe (Php6.50)
Needle g25 (Php1.95)
Vicryl or Chronic 4-0 w/ round needle (Php240.00)*Nylon 5-0 with cutting needle (Php200.00)
*Penrose Drain(Php35.00)
*Lidocaine 2% (in vial Php25.50) (in ampule Php30.50)
*Epinephrine (Php17.00)

After that, we hurried back to the Operating Room of the ENT-OPD we were told to come there by 7:00 am.

The receptionist there checked our things and then asked my mom to leave. Waah. I'm so getting nervous. We were also asked to sign on some papers. Soon, I'm walking by myself to Room 225 (Minor Operation). Upon entering the door, I removed my shoes and put on my clean slippers, as asked. I went inside the double door and there I was greeted by some resident doctors and other patients as well. They were all asking about me and my case. Everyone was making small talk.

I was there at around 7:20 am and I was called 3 hours later. During the wait, I was changing positions (my feet). Sometimes, I'm sitting cross-legged, or Indian style, or the normal. It's also very cold there. I was near shivering state. By that time, my fear was gone and how to make myself warm was all I'm thinking of. I was then asked to enter a semi-kind-of ward and I was asked to unhook my bra. (It was for the cautery.) Anyway, I lie down the bed and a lady there wiped my outer ears with Betadine (to clean it). After 5 minutes, I think, 2 doctors came in. They are Dr. Saquian and Dr. Alban, and they're about to perform the operation.

They first injected anesthesia on my left ear. I'm telling you, it hurts a lot. But after that, I can feel no more pain. They first made an incision and followed the sinus tract. Then they removed/ scraped it. Sometimes, the doctor explained, the sinus tract is sticking to the cartilage. So they have to remove some cartilage too. After that, they stitched it. I have no idea how many stitches they made because they didn't tell me. So they're done with the left ear. They proceeded to my right ear and did the same procedures. They said it was easier with my right ear because the sinus tract was shorter and there was no previous infection.

After 2 hours, the operation was done. They put a bandage on both of my ears. And then the doctor gave me prescriptions. They got the whole of my sinus tract. Thanks to them. But, they didn't let me see the removed pre-auricular sinus. I so wanted to see them. Anyway, I think they thought that I might freak out so they just kept it. haha. Minutes later, the left ear was starting to throb. Oww!

After that, I went outside to my mom and told her everything that happened inside. Then we went to Robinson's Place to eat. We ate lunch at Chef D'Angelo. Yummy! We ordered Great White Pizza, Caesar's Salad and 2 Iced Teas. Yummy! I was having a little bit of hard time chewing. I was afraid that my stitches would open.

After Chef D'Angelo, we headed to Mercury Drugstore to buy the prescripted drugs. Painkillers, ointments, and antibiotics.

Prescription:
Cloxacillin [Oxyclen] 500 mg (Php12.50 each) 1 capsule every 6 hours x 7 days
Mupirocin [Bactroban] (Php247.50) apply after cleaning wound
Etoricoxib [Arcoxia] (Php63.50 each) 1 tablet once a day x 3 days

Conclusion: The operation done by the residents was way much cheaper than if done by a consultant.

Anyway, I wanted to rest early so we went home in a taxi. I was able to sleep during the ride and I immediately took some pictures with my webcam.

I'm rushing this because I want to rest immediately but I want to let you know first what happened. So I'll edit this later to fill in some details.

Here's my picture taken with a webcam. January 21, 2005. 2:50 PM.



So long guys, I'm gonna rest for a while. See you soon! :)

Currently listening to: Ikaw Nga by Southborder
Currently reading: Dancing In The Light by Shirley Maclaine

Currently watching: someone play MU Online