|Year : 2011 | Volume
| Issue : 2 | Page : 63-65
Preauricular sinus: When to operate?
Anuj Kumar Goel1, Subhash Chand Sylonia2, Ajay Garg3, Kamal Rattan4
1 Department of ENT, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad, Uttar Pradesh, India
2 Department of Radiodiagnosis, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad, Uttar Pradesh, India
3 Department of ENT, PGIMS, Rohtak, India
4 Department of Paediatric Surgery, PGIMS, Rohtak, India
|Date of Web Publication||20-Dec-2011|
Anuj Kumar Goel
112, Ramganj, Professor Colony, Railway Road, Hapur - 245101, Distt. Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: Experiences with preauricular sinus (PAS) excision in pediatric age group. Materials and Methods: A retrospective analysis of 110 patients who underwent PAS excision was done. A total of 112 excisions (63 left, 49 right) were performed by standard surgical technique. All the patients were operated upon in an infection-free period under general anesthesia. Results: A total of 32 excisions had bad surgical results in the form of bad scar or recurrence, out of which 28 had history of symptomatic sinus infection preoperatively. Conclusions: Surgical excision of PAS should be done in quiescent phase; once infected, it becomes very difficult to eradicate the infection and also the chances of bad surgical results (bad scar or recurrence) increase manifold.
Keywords: Excision, preauricular sinus, recurrence
|How to cite this article:|
Goel AK, Sylonia SC, Garg A, Rattan K. Preauricular sinus: When to operate?. Indian J Otol 2011;17:63-5
| Introduction|| |
Preauricular sinus (PAS), first described by Van Heusinger,  is a benign, congenital malformation of preauricular soft tissue, located at the anterior margin of the ascending limb of the helix, and marks the entrance to a sinus tract. The most accepted theory attributes the development of PAS to incomplete or defective fusion of the six hillocks of His. , The other less-known theory states that PAS develops as a result of isolated ectodermal folding. ,
Clinically, PAS may remain asymptomatic throughout life; but once infected, it causes pain, swelling and abscess formation. PAS is notorious for its troublesome and recurrent infective episodes, even after its surgical excision. Symptomatic PAS warrants surgical excision aiming at complete extirpation of squamous lined deep branching ramification of the sinus. Various modifications in the surgical procedure have been advocated by the authors to decrease the chances of recurrence and bad surgical scar, but controversy still exists whether PAS should be excised when symptomatic or silent. The objective of our study was to evaluate the time of surgery so as to decrease the chances of recurrence and bad surgical scar.
| Materials and Methods|| |
A retrospective evaluation of the records of 110 patients operated upon for PAS was done.
| Results|| |
One hundred and ten patients were operated for PAS. All the patients were in pediatric age group. Seventy-one (64%) were males and 39 (36%) were females. In 62 (56%) patients PAS was left sided, while in the remaining 48 (44%) patients it was right sided. Two (18%) patients had bilateral PAS, out of which one was diagnosed as a case of branchio-oto-renal syndrome. Various presenting symptoms are tabulated in [Table 1].
Patients who presented with infected PAS were put on broad-spectrum antibiotics to achieve an infection-free sinus. The time taken to achieve infection-free PAS in patients who presented with an episode of infection is tabulated in [Table 2].
The mean time period to achieve an infection-free interval was 6 weeks (ranging from 1 week to a year). PAS was extirpated in an infection-free interval under general anesthesia. Local anesthesia with 2% lignocaine and adrenaline was given to achieve a bloodless field. In all the cases, the PAS was located at the level of crus helicis. In 103 cases, fistula led to a single tract which coursed toward helix so a portion of helical perichondrium or cartilage was also excised along with tract, while only 9 patients had multiple tracts. Final results after a mean follow-up period of 6 weeks interval are given in [Table 3].
Among the 32 patients who had either bad scar or recurrence, 26 had history of infection in the preoperative period, 4 had multiple tracts preoperatively, while the other 2 were operated upon by an inexperienced surgeon, thus suggesting that infection plays a major role in determining the results of surgery.
| Discussion|| |
PAS is known to be sporadic or inherited. It occurs more commonly on the right side  and bilateral lesions are more likely to be inherited;  inherited PAS shows an incomplete autosomal dominant pattern with reduced penetrance and variable expression. , Prevalence of PAS is low and variable in different ethnic groups. Incidence of 4-10% has been reported in some parts of Asia and Africa. PAS may be associated with other congenital anomalies such as deafness and renal anomalies (branchio-oto-renal syndrome). ,
Clinically, PAS may remain asymptomatic throughout life. Yellowish white secretions consisting of cellular debris are the commonest presenting symptom. Infected sinus presents with swelling, pain, and abscess in the preauricular region. PAS has a high susceptibility to get infected. Proximity to the hair line may be the answer. In our study, 4% patients had infected PAS. The colonizing species most frequently described in the literature are Streptococcus salivaris, Staphylococcus pyogenes, gram +ve cocci and gram -ve bacilli. 
Gohary et al.  in 1983 described the standard procedure of fistula excision as circumscription of the sinus and subsequent extirpation of duct. Various surgical modifications have been advocated by Gohary et al. with varying degrees of success. Preoperative injection of methylene blue to delineate the whole tract and its ramifications resulted in improved outcome of surgery. Use of blunt probe resulted in higher rate of recurrence owing to narrow communications between the loculations which could not be negotiated by the probe. Lam et al.  in 2001 and Prasad et al.  in 1990 advocated supra-auricular (wide local excision) approach for complete excision of the sinus tract to minimize the risk of recurrence. Tan et al.  suggested the use of peroperative magnification for the complete removal of squamous lined tract. Taneja  suggested that bloodless field and exenteration under microscope with demarcation by methylene blue and using a probe results in success to almost 100%. Baatenburg de Jong et al.  in 2005 described a new technique "inside out" for the complete removal of sinus with 0% recurrence rates. Various factors studied which resulted in good surgical results are good surgical technique, infection-free period, and use of general anesthesia, while revision surgery, pre- and postoperative wound sepsis, surgery under local anesthesia increase the chances of recurrence.
Controversy exists whether PAS should be excised when symptomatic or silent. Various studies have been conducted confirming the hypothesis that inflammation of a fistula may lead to its elongation, thus increasing the chances of residual tract and recurrence. Furthermore, once PAS gets infected, it becomes very difficult to eradicate the infection and subsequently closure of dead space becomes difficult in the infected tissue, resulting in higher recurrence rates. In our study, the mean time taken to achieve an infection-free PAS was 6 weeks; two of our patients took about a year to achieve the same. Recurrence rates varying from nil to 42% have been reported, resulting from residual squamous epithelium as the sinus is usually multiloculated. Out of 32 excisions who had bad surgical results (bad scar or recurrence), 28 were having had history of symptomatic sinus infection preoperatively as compared to 4 who were asymptomatic preoperatively.
| Conclusion|| |
Treatment of choice of PAS is surgical excision. Complete surgical excision of PAS should be done in quiescent stage, as it become very difficult to eradicate the infection completely and chances of recurrence and bad surgical scar increase manifold.
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[Table 1], [Table 2], [Table 3]