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Year : 2017  |  Volume : 23  |  Issue : 3  |  Page : 193-196

Preauricular sinus: A comparative study between different surgical approaches

Department of Otorhinolaryngology, Head and Neck Surgery, Zagazig University, Zagazig, Egypt

Date of Web Publication31-Aug-2017

Correspondence Address:
Ahmed Shaker ElAassar
2 El-Gergawy St., Mesaha, Dokki, Giza
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_69_17

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Background: The preauricular sinus is a congenital abnormality of the external ear that is usually asymptomatic. However, if recurrent infection, persistent discharge or abscess formation occurs, complete surgical excision of the sinus is required. Objective: The objective of the study is to compare the long-term results of the preauricular sinus excision by simple sinectomy, microscopic-assisted sinectomy, and supra-auricular approach. Patients and Methods: Patients who had symptomatic preauricular sinus scheduled for surgical excision were randomly categorized into three groups: Group A (sinectomy) for whom preauricular sinus was excised by simple sinectomy using methylene blue; Group B (microscopic-assisted sinectomy) treated by simple sinectomy using the microscopic to follow, dissect out and excise the sinus tract(s); and Group C (supra-auricular approach) treated by the supra-auricular approach. Results: Excisions of 68 preauricular sinuses were carried out in 58 patients. The mean follow-up period was 19.7 months with a range of 9–30 months. The overall recurrence rate was 13.4% (9 cases). The timing of recurrence ranged from 3 to 6 months (3–12 months). The simple sinectomy technique had the highest recurrence rate (28%). The recurrence rate of the microscopic-assisted technique was 15% while the supra-auricular approach had the lowest recurrence rate (3.4%). Conclusion: The supra-auricular approach offers the most favorable outcome for the management of the preauricular sinus.

Keywords: Microscopic-assisted sinectomy, preauricular sinus, simple sinectomy, supra-auricular approach

How to cite this article:
ElAassar AS, Abd-El Hady M, Askar SM, Amer HS, El-Anwar MW. Preauricular sinus: A comparative study between different surgical approaches. Indian J Otol 2017;23:193-6

How to cite this URL:
ElAassar AS, Abd-El Hady M, Askar SM, Amer HS, El-Anwar MW. Preauricular sinus: A comparative study between different surgical approaches. Indian J Otol [serial online] 2017 [cited 2023 Feb 5];23:193-6. Available from: https://www.indianjotol.org/text.asp?2017/23/3/193/213874

  Introduction Top

Heusinger (1864) was the first to describe the preauricular sinus as a common congenital ear abnormality.[1] Males and females are equally affected.[2] Over 50% of cases are unilateral, on the right side, and most often sporadic. Bilateral cases are more likely to be inherited in a pattern of incomplete autosomal dominance with reduced (around 85%) penetrance.[3]

Preauricular sinus is usually asymptomatic requiring no treatment. However, when infected, these sinuses become painful, swollen, and discharging.[4],[5],[6]

The ultimate goal of treatment is complete excision of the sinus sac or fistula.[7] Several surgical techniques were described. Unfortunately, recurrence still occurs after excision.[8]

The current study aimed to compare the long-term results of the preauricular sinus excision by simple sinectomy, microscopic-assisted sinectomy, and supra-auricular approach.

  Patients and Methods Top

This prospective study was carried out in Otorhinolaryngology, Head and Neck Surgery Department over a period from November 2013 to December 2016. The Institutional Review Board approval had been taken from the institute before starting this research. Patients with symptomatic preauricular sinus scheduled for surgical excision were included in the current study. Revision cases were excluded from the study.

A thorough history and head and neck examination was performed for all patients. Surgeries were conducted in an infection-free interval and under general anesthesia. Written consent was obtained from each patient according to the policy of the hospital.

Surgical technique

The preauricular area was infiltrated with Xylocaine 2% with epinephrine 1:100.000 to reduce intraoperative bleeding.

Patients were randomly categorized into three groups as follows: (1) Group A (sinectomy): Preauricular sinus was excised by simple sinectomy using methylene blue.[9] The preauricular sinus was first filled with methylene blue. Then, a vertical elliptical skin incision was made around the sinus orifice followed by naked eye dissection of the sinus tract and excision of the entire length of the sinuses. (2) Group B (microscopic-assisted sinectomy):[10] After vertical elliptical incision around the orifice of the preauricular sinus, the operating microscope (Ziess, 200 mm wave length) was used to follow, dissect out, and excise the sinus tract(s). (3) Group C (supra-auricular approach):[11] Treated by the supra-auricular approach on which a vertical elliptical incision was made around the orifice of the sinus. Then, the incision was extended supra-auricularly. Dissection was carried out to identify the temporalis fascia that was the medial limit of the dissection and continues over the cartilage of the anterior helix that was regarded as the posterior margin of dissection. Tissue superficial to the temporalis fascia was removed together with the preauricular sinus [Figure 1].
Figure 1: (a) Preauricular sinus. (b) Mark for the incision and injection. (c) Complete dissection. (d) The operative field after excision

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In all cases of the three groups, the related perichondrium (± cartilage) of the helix at the base of the sinus was dissected and removed with the specimen to ensure complete removal of the epithelial lining. Finally, the wound was closed in layers.

All patients were discharged on the same day of surgery. One week postoperatively, the stitches were removed. Then, the patients were followed up once every 2 weeks for 1 month, monthly for 6 months, and then once every 3 months later.

Statistical analysis

The statistical analysis and comparison were performed utilizing SPSS 14.0 statistical software for Windows (SPSS Inc., Chicago, IL, USA). The significance level was set at P < 0.05.

  Results Top

Sixty-six patients were operated for symptomatic preauricular sinus (22 in each group). From them, 58 patients (92%) were available to follow-up postoperatively and included in this study: 35 males (60.3%) and 23 females (39.2%). Their ages ranged from 7 to 17 years with a mean of 11.4 years. The right side was involved in 27 cases, the left side was involved in 22 cases, and bilateral involvement was detected in 9 cases, so 67 operations were performed [Table 1].
Table 1: Patient data

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The mean follow-up period was 19.7 months (range 9–36 months). Serious intraoperative or postoperative complications, such as bleeding, wound dehiscence, or facial nerve injury, were not reported. One case (5.6%) from Group A had postoperative wound infection and another case (5%) from Group B. Both cases cured after 5 days of systemic antibiotics and daily dressing. The criteria of recurrence were local inflammation, subcutaneous mass, or persistent draining sinus after initial healing.

The overall recurrence rate was 13.4% (9 cases). The timing of recurrence ranged from 3 to 6 months. In a simple sinectomy group, 5 of 18 cases (28%) recurred and 3 of 20 cases (15%) of microscopic-assisted sinectomy group recurred. Both sinectomy groups had recurrent rate (12/38 cases, 21%). In supra-auricular approach group, only one case out of 29 cases (3.4%) recurred. Hence, supra-auricular approach expresses significantly less recurrence rate than sinectomy approaches (χ2 = 4.384, P = 0.036). However, there was no significant difference between the recurrence rate after standard sinectomy and the microscopic-assisted technique (χ2 = 0.931, P = 0.3346) [Table 2].
Table 2: Postoperative recurrence rate

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  Discussion Top

Incomplete excision of the preauricular sinus tract(s) and the presence of residual viable squamous epithelium might be considered the main cause of recurrence after excision of preauricular sinus.[12] Furthermore, tortuous tract course, the high variability, and number of its ramifications which are difficult for the surgeon to follow [13],[14] and infectious episodes, possibly with abscess, increase the incidence of recurrence.[15]

Several tools and methods were introduced for proper tract(s) identification such as methylene blue staining, tract(s) probing, microscope, or magnifying glasses.[9],[10] However, the recurrence rate remains significant.

The supra-auricular approach, described by Prasad et al. in 1990, was based on the theory that a preauricular fistula is almost found in subcutaneous tissues between the temporalis fascia and perichondrium of the helical cartilage. The supra-auricular approach is assumed to have a lower recurrence risk.[11]

The concept of supra-auricular approach depends on identification of the temporalis fascia and the cartilage of the helix and auditory canal followed by an en bloc resection of the sinus, removing all involved subcutaneous tissue between the temporalis fascia and the helix.[16] Hence, identification of the entire sinus tract and its branches is not necessary.[13],[17]

In the current study, the supra-auricular approach had the lowest recurrence rate (3.4%). These results are in agreement with Prasad et al.[11] (5% recurrence) and Lam et al.[13] (3.7% recurrence rate) on using the supra-auricular approach for excision of preauricular sinus and also agree with the systematic review done by El-Anwar and El-Aassar [7] who found that the recurrence rate was 4/333 (1.2%) with the supra-auricular approach after reviewing nine researches using this technique. Another systematic review done by Bruijnzeel et al. reported 2.2% recurrence rate after supra-auricular approach.[18]

The supra-auricular approach allows the surgeon to excise the peri-preauricular sinus soft tissue in toto encapsulating the sinus itself and avoids the need for dissecting out every ramification. The excision of a portion of cartilage at the base of the sinus tract prevents the incomplete removal of the closely adherent epithelial lining. These factors may explain the lower observed recurrence rate of this approach.[13]

In the current study, simple sinectomy with methylene blue technique had a high recurrence rate (28%). These results are comparable to Lam et al.[13] and Currie et al.[19] who reported a recurrence rate of 32% and 19%, respectively, using the simple sinectomy technique.

Theoretically, the instillation of methylene blue makes sense; however, in daily practice, it often results in diffuse staining of the surgical field and the overlooking of small tracts. In addition, when tracts are filled with debris, the dye cannot fill the tract. Furthermore, surgical failure may be due to insufficient magnification during the operation. Excision of a simple, unilocular lesion may sometimes be performed successfully with the naked eye, but, when multiple tracts are involved, magnification is indispensable.[10] These factors could explain the high recurrence rate of the simple sinectomy technique.

In this study, the microscopic-assisted technique has a 15% recurrence rate. These results are in accordance with Ellies et al.[20] who reported a recurrence rate of 21%. With the microscopic-assisted technique, there is no need to use the methylene blue to delineate the tract of the sinus because the methylene blue does not stain the epithelium itself. Hence, the epithelium remnant can easily be identified with the operating microscope.[21] However, even with magnification, minor tracts may escape attention, making a recurrence inevitable.[1] Furthermore, it takes a longer time in dissection, especially when bilateral sinuses have been excised at one sitting.

Supra-auricular approach is simple, effective technique, with negligible recurrence and with no need for extra assisting tool (microscope, probe, or magnifying loop). Hence, it is better to be used regularly as standard procedure for preauricular sinus excision, especially that it showed no significant complications and less postoperative scar formation.[15] Furthermore, it is the ideal technique particularly for recurrent cases or cases doing sinectomy after abscess incision and drainage. Thus, it would be helpful for surgeons to be familiar with this approach.

  Conclusion Top

Supra-auricular approach had significantly lower recurrence rate than tract sinectomy approaches, so it is recommended to make it the standard primary procedure for preauricular sinus excision besides its use in recurrent cases. Thus, it would be helpful for surgeons to be familiar with this approach.

Financial support and sponsorship

This research is not funded by any resource except the authors themselves.

Conflicts of interest

There are no conflicts of interest.

  References Top

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;102:1405-8.  Back to cited text no. 1
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O'Mara W, Guarisco L. Management of the preauricular sinus. J La State Med Soc 1999;151:447-50.  Back to cited text no. 3
Kumar S, Marres HA, Cremers CW, Kimberling WJ. Autosomal-dominant branchio-otic (BO) syndrome is not allelic to the branchio-oto-renal (BOR) gene at 8q13. Am J Med Genet 1998;76:395-401.  Back to cited text no. 4
Fraser FC, Aymé S, Halal F, Sproule J. Autosomal dominant duplication of the renal collecting system, hearing loss, and external ear anomalies: A new syndrome? Am J Med Genet 1983;14:473-8.  Back to cited text no. 5
Clementi M, Mammi I, Tenconi R. Family with branchial arch anomalies, hearing loss, ear and commissural lip pits, and rib anomalies. A new autosomal recessive condition: Branchio-oto-costal syndrome? Am J Med Genet 1997;68:91-3.  Back to cited text no. 6
El-Anwar MW, El-Aassar AS. Supra-auricular versus sinusectomy approaches for preauricular sinuses. Int Arch Otorhinolaryngol 2016;20:390-3.  Back to cited text no. 7
Yeo SW, Jun BC, Park SN, Lee JH, Song CE, Chang KH, et al. The preauricular sinus: Factors contributing to recurrence after surgery. Am J Otolaryngol 2006;27:396-400.  Back to cited text no. 8
Huang WJ, Chu CH, Wang MC, Kuo CL, Shiao AS. Decision making in the choice of surgical management for preauricular sinuses with different severities. Otolaryngol Head Neck Surg 2013;148:959-64.  Back to cited text no. 9
Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery 2005;137:567-70.  Back to cited text no. 10
Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990;100:320-1.  Back to cited text no. 11
Kumar KK, Narayanamurthy VB, Sumathi V, Vijay R. Preauricular sinus: Operating microscope improves outcome. Indian J Otolaryngol Head Neck Surg 2006;58:6-8.  Back to cited text no. 12
Lam HC, Soo G, Wormald PJ, Van Hasselt CA. Excision of the preauricular sinus: A comparison of two surgical techniques. Laryngoscope 2001;111:317-9.  Back to cited text no. 13
Kavuturu VS, Chowdary K, Chandra NS, Madesh RK. Preauricular sinus: A novel approach. Indian J Otolaryngol Head Neck Surg 2013;65:234-6.  Back to cited text no. 14
Tang IP, Shashinder S, Kuljit S, Gopala KG. Outcome of patients presenting with preauricular sinus in a tertiary centre – A five year experience. Med J Malaysia 2007;62:53-5.  Back to cited text no. 15
Vijayendra H, Sangeetha R, Chetty KR. A safe and reliable technique in the management of preauricular sinus. Indian J Otolaryngol Head Neck Surg 2005;57:294-5.  Back to cited text no. 16
Hassan ME, Samir A. Pre-auricular sinus: Comparative study of two surgical techniques. Ann Pediatr Surg 2007;3:139-43.  Back to cited text no. 17
Bruijnzeel H, van den Aardweg MT, Grolman W, Stegeman I, van der Veen EL. A systematic review on the surgical outcome of preauricular sinus excision techniques. Laryngoscope 2016;126:1535-44.  Back to cited text no. 18
Currie AR, King WW, Vlantis AC, Li AK. Pitfalls in the management of preauricular sinuses. Br J Surg 1996;83:1722-4.  Back to cited text no. 19
Ellies M, Laskawi R, Arglebe C, Altrogge C. Clinical evaluation and surgical management of congenital preauricular fistulas. J Oral Maxillofac Surg 1998;56:827-30.  Back to cited text no. 20
Raman R. Excision of preauricular sinus. Arch Otolaryngol Head Neck Surg 1990;116:1452.  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2]

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