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A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus
International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus
T
Kai-Chieh Chana,b, Han-Tse Kuob, Valerie Wai-Yee Hoc, Wen-Yu Chuangb,d, Zung-Chung Chenb,e,∗,1 a
Division of Otology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taiwan School of Medicine, Chang Gung University, Taoyuan, Taiwan c Division of Plastic and Reconstructive Surgery, Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong, China d Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan e Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan b
A R T I C LE I N FO
A B S T R A C T
Keywords: Preauricular sinus Supra-auricular approach Recurrence Helix cartilage suture
Objective: Several surgical techniques and modifications have been described to reduce the high recurrence rate after excision of preauricular sinus (PAS). This study was designed to evaluate the surgical outcomes of PAS excision using a new modified supra-auricular approach (SAA) and to assess the predisposing factors for recurrence. Methods: A total of 175 (158 patients) PAS excision procedures were performed from 2007 to 2016 in a single institute using this modified SAA with helix cartilage suture to obliterate the dead space. The specimens were assessed to measure the closest distance between the squamous tract and the excised auricular cartilage (sinocartilaginous distance). We also evaluated the surgical outcomes and investigated the predisposing factors for recurrence, including gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or local), history of infection, and history of incision and drainage (I&D) for abscess. Results: Patients were followed up for a median duration of 45 months (range from 6 months to 10 years). There was a 2.3% (4 ears) recurrence rate and a 1.7% (3 ears) complication rate in our series. The average sinocartilaginous distance was 0.44 mm (median distance, 0.3 mm) and this value was less than 0.5 mm in 66% of cases. Recurrence was not significantly affected by gender, lesion laterality, etiology of surgery, anesthesia method, or a history of infection or preoperative I&D for abscess. Conclusions: Surgical PAS excision using the modified SAA with cartilage suture of dead space yielded low overall recurrence and complication rates in this series. Cosmesis was maintained due to a smaller incision. No significant predisposing factors for recurrence were identified. Thus, the modified technique described in the present study can be regarded as a simple, effective and reproducible surgical treatment for PAS.
1. Introduction The preauricular sinus (PAS) is a congenital tract lined by squamous epithelium with hyperkeratosis and parakeratosis and was first described by Van Heusinger in 1864 [1]. Embryonically, the external ear is formed from six hillocks of His, which arise from the first and second branchial arches. Failure of complete fusion of the six hillocks or entrapment of ectodermal epithelium during auricular development is believed to result in the formation of a PAS. The prevalence of PAS is 0.1–0.9% in the United States, 0.9% in England, 1.6%–2.5% in Taiwan,
1.91% in South Korea and 4%–10% in some regions of Africa [2–6]. Although PAS is frequently asymptomatic and does not require treatment, surgical management is indicated when the PAS becomes infected. Patients may present with local cellulitis or abscess in the acute inflammatory stage or chronic intermittent discharge from the sinus opening. Antibiotics and/or adequate incision and drainage (I&D) can usually control the infection. Once infection occurs, the risk of recurrent infection is increased. Therefore, the entire sinus tract should be excised completely to eradicate the disease. Traditional sinusectomy for PAS had been widely adopted in the
∗
Corresponding author. Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University, Linkou, Taiwan. E-mail addresses: [email protected], [email protected] (Z.-C. Chen). 1 Address: Din Hu Rd No. 123, Gweishan, Taoyuan, Taiwan. https://doi.org/10.1016/j.ijporl.2018.08.041 Received 1 May 2018; Received in revised form 31 August 2018; Accepted 31 August 2018 Available online 05 September 2018 0165-5876/ © 2018 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
K.-C. Chan et al.
past, but a high rate of recurrence (19–40%) had been reported [7,8]. It is believed that unidentified branching of the sinus, remnants of the sinus wall, and infection with or without formation of abscesses can lead to disease recurrence. Thus, various modified surgical techniques for PAS excision have been proposed to achieve a lower recurrence rate, such as the supra-auricular approach (SAA) [8,9], inside-out technique [10] or Fig. 8 excision method [11]. Of these, the SAA introduced by Prasad et al. has been one of the most favorable and widely used methods since 1990 [8]. The recurrence rate of the SAA ranges between 0 and 23%, with an average rate of 2.2% [12]. However, the main drawback of the SAA is the large dead space that results from resecting the PAS with the surrounding subcutaneous tissue via an extended supra-auricular and postauricular incision. Postoperative drain insertion and compression dressing are usually required for complete closure of the dead space. Bae et al. [13] designed a drainless minimal SAA with meticulous subcutaneous mattress suture to obliterate the dead space for treatment of PAS, and there was no postoperative recurrence or other serious complication in their study. Additionally, recurrence after PAS excision was found to be correlated with certain factors, such as preoperative infection status, preoperative I&D [14], or local anesthesia technique [15–18]. Thus, the purposes of the present study were to introduce a modified SAA surgical technique with helix cartilage suture to minimize the dead space without drainage or dressing and to survey the surgical results for PAS. Moreover, we also examined various predisposing factors for recurrence after the surgery in a 10-year retrospective study period.
Fig. 1. A vertical elliptical incision was made around the sinus opening and extended upward to the supra-auricular region for 5 mm without postauricular extension.
the creation of false passages. In the case of revision surgery, probing was not conducted. After the skin incision, en bloc resection of the PAS with surrounding subcutaneous tissue between the temporalis fascia and the helix was performed (Fig. 2), taking care not to injure the superficial temporal vessels. A small portion of helix cartilage adjacent to the PAS tract was routinely resected (Fig. 3a). After complete excision, the wound was irrigated copiously with dilute povidone-iodine solution to prevent surgical site infection. Then, absorbable sutures were used to suture the distal remnant subcutaneous tissue, temporalis fascia, and helix cartilage in a vertical mattress manner and in a lateral-to-medial direction to tightly obliterate the dead space (Fig. 3b). A schematic illustration of the helix cartilage suture technique is shown in Fig. 4. Finally, a local pressure dressing was applied using adhesive bandage strips. No drains or mastoid dressing was needed (Fig. 5). The bandage was removed after 48 h. Postoperative oral antibiotics and analgesics were prescribed for 1 week.
2. Materials and methods A retrospective review of the clinical records of consecutive patients with PAS who underwent the surgery with the modified SAA between July 2006 and June 2016 was conducted. The study was approved by the institutional review board of Chang Gung Memorial Hospital in Linkou, Taiwan (IRB No.201800424B0). All the PAS cases were of the classic type, with the sinus opening located at the anterior margin of the ascending limb of the helix. Indications for this surgery were cases of PAS with a history of persistent purulent discharge or recurrent infection or asymptomatic patients with cosmetic concerns because of an apparent PAS opening. Each ear involved in the bilateral procedures was regarded as a separate operation. All patients were followed for at least 6 months postoperatively, with the longest follow-up being 10 years. Postoperative complications and recurrence were documented. Preoperative predisposing factors were collected, and their association with recurrence was analyzed. These factors included gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or local), history of infection, and history of I&D for abscess. Chi-square test or Fisher's exact test was performed using SPSS statistical software (SPSS Inc., Chicago, IL), and P < 0.05 was considered statistically significant.
3. Results There were 175 ears with PAS (152 patients) in this review. The study cohort included 59 males and 93 females with a median age of 22.5 years (range: 1–78). A total of 88 right ears, and 87 left ears were operated on (23 patients had bilateral operations). A total of 162 ears had no previous PAS surgeries (labeled as primary), while 13 ears had a history of PAS surgery (labeled as revised). There were 96 and 79 ears treated under LA and GA, respectively. A total of 161 ears had a history of preoperative infection, while 14 ears were asymptomatic. A total of 20 ears had undergone I&D for abscess, while 155 cases had not (Table 1). The median follow-up duration was 45 months (range: 6–120). The diagnosis of PAS was confirmed histopathologically. Pathological analysis typically showed that the sinus tracts were in close proximity to the helix cartilage (Fig. 6). A total of 138 specimens were retrieved to measure the closest distance between the squamous tract and the excised auricular cartilage. The average sinocartilaginous distance was 0.44 mm, ranging from 0.1 to 1.9 mm (median distance, 0.3 mm). In 66% (91 cases) of the specimens, the sinocartilaginous distance was less than 0.5 mm. There were 4 cases of recurrence among 175 operated ears (2.3%). Two cases presented as epidermoid cyst formation at 12 months and 14 months postoperatively, one presented as a postoperative nonhealing wound, and one presented as new aperture formation with discharge at one month after surgery. Three patients reported complications (1.7%). Two patients had wound dehiscence, and one had wound infection. However, no cases of postoperative seroma/hematoma, perichondritis or chondritis were identified in this series. Cosmesis was good without any auricular deformity. The potential predisposing factors for recurrence after surgery,
2.1. Surgical technique At our institution, surgical excision of the PAS is usually performed about one month after the resolution of an acute infection. An acutely infected PAS is first treated with a course of antibiotics. If an abscess is present, I&D is performed. All subjects underwent PAS excision by the senior authors (K.C. Chan & Z.C. Chen) under general anesthesia (GA) or local anesthesia (LA). The operations were performed under GA for patients under 12 years old and under LA for most adult and adolescent patients unless they could not comply. The surgical procedure was modified from the SAA described by Prasad et al. [8]. Local anesthetic containing epinephrine was infiltrated subcutaneously at the lesion to include auriculotemporal nerve block. A vertical elliptical incision was made around the sinus opening and extended upward to the supraauricular region for 5 mm without postauricular extension (Fig. 1). A lacrimal probe was then used to locate the sinus tract gently to avoid 148
International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
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Fig. 2. En bloc resection of the sinus tract with the surrounding subcutaneous tissue between the temporalis fascia (deep boundary, 2b) and the helix (posterior boundary, 2a) was performed. Of note, caution is required to avoid injury of the superficial temporal vessels (anterior boundary). S: sinus tract, C: helix cartilage, and F: temporalis fascia.
complication rate. According to a systemic review [12], the recurrence rate of the SAA for PAS excision ranged between 0 and 23%, with an average recurrence rate of 2.2%. The present surgical result is in accordance with that report. Because the presence of dead space after the original SAA is associated with wound complications, we advocated closing the dead space by suturing the helix cartilage, temporalis fascia and residual subcutaneous tissue. Therefore, this approach contributed to a low complication rate in our study. Furthermore, the recurrences in the study were not related to factors including gender, lesion laterality, anesthesia technique, history of previous sinus excision, history of I&D or etiology of PAS surgery. Hence, this modified SAA is indeed a reliable, effective and safe surgical technique for PAS excision. The original SAA procedure involved a wide exposure with supraauricular extension of the preauricular incision and the identification of landmarks, including the temporalis fascia (deep boundary), superficial temporal vessels (anterior boundary), and the cartilage of the anterior helix (posterior boundary). These landmarks are important in revision cases or in the acute infection stage. Entire sinus tracts and surrounding subcutaneous tissue within these landmarks were excised completely. In our modified surgical method, a 5-mm skin incision is extended superiorly, similar to that described by Bae et al. [13], without further postauricular extension. This technique helps to minimize the dead space while still maintaining an adequate view for complete excision of the sinus tract. This modified SAA approach also offered better aesthetic results than the original SAA due to a smaller incision [13]. Several authors [15] have reported that there are no significant differences in recurrence rates between the groups with and without excision of the perichondrium of helix cartilage. However, Dunham
including gender, lesion laterality, etiology, anesthesia techniques, history of preoperative infection, and history of preoperative I&D for abscess formation, were also analyzed (Table 2). Recurrence occurred in two ears among 93 female patients (1.9%) and in 2 ears among 59 male patients (2.9%); the difference was not statistically significant. There were 87 left-sided lesions and 88 right-sided lesions, and 2 cases from each side experienced recurrence (2.3% and 2.2%, respectively). No statistically significant difference was noted between these two groups. Regarding etiology, recurrence occurred in 3 ears among 162 primary cases (1.9%), while recurrence occurred in 1 ear among the 13 ears of revised cases (7.7%). No statistically significant difference between these two groups was demonstrated. There were 96 and 79 procedures performed under LA and GA, respectively. Three cases of recurrence were noted in the LA group (3.1%), and 1 case of recurrence was noted in the GA group (1.3%). No statistically significant difference was shown. A total of 161 ears had a history of preoperative infection, among which 4 ears (2.5%) experienced postoperative recurrence. However, there were no cases of recurrence among the 14 asymptomatic ears. There was no statistically significant difference between these two groups. Recurrence was noted in one ear among 20 ears (5%) that had undergone I&D for abscess. Three cases of recurrence were noted among the other 155 cases (1.9%) without a history of I&D. No statistically significant difference was shown between these two groups.
4. Discussion In this study, utilization of the modified SAA resulted in effective surgical outcomes, with a 2.3% recurrence rate and a 1.7%
Fig. 3. A small part of the helix cartilage adjacent to the sinus tract was routinely resected (3a). Then, the dead space was closed tightly by absorbable stitches via suturing of the remnant subcutaneous tissue, temporalis fascia and helix cartilage with the vertical mattress technique in a lateral-to-medial direction (3b). 149
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Table 1 Patient demographics. No. (%) Total ears Gender Male Female Lesion laterality Right Left Anesthesia technique General anesthesia Local anesthesia Etiology Primary Revised History of infection Yes No Preoperative incision & drainage Yes No
175(100.0) 68(38.9) 107(61.1) 87(49.7) 88(50.3) 79(45.1) 96(54.9) 162(92.6) 13(7.4) 161(92.0) 14(8.0) 20(11.4) 155(88.6)
cartilage adjacent to the sinus tract is suggested to ensure thorough excision and to reduce recurrence rates [10,11,20]. Methylene blue was not routinely used to mark the sinus tract, as methylene blue may diffuse into tissues and affect the accurate dissection of all the complicated branches [16]. Regional auriculotemporal nerve block is important during PAS surgery, especially under LA, since the preauricular region is innervated by this nerve. Caution should be taken to avoid injury to the superficial temporal artery because the auriculotemporal nerve usually presents within the initial loop of the superficial temporal artery. Previous reports [15–18] have shown that dissection of the PAS under GA has a lower recurrence rate compared with that under LA, because patients under GA had better tolerance and allowed a more complete dissection and excision of the PAS. However, there was no statistically significant difference between these two groups in this study, although the LA patients had a higher recurrence rate (3.1%) than the GA patients (1.3%). We postulated that this finding is due to the effective local regional auriculotemporal nerve block, allowing the procedures to be performed smoothly. The present study found that patients with a history of infection or I &D of the PAS show a higher rate of recurrence than patients without these conditions (5% vs.1.9% and 2.5% vs. 0%, respectively), but there was no statistically significant difference. The debate on whether a history of PAS infection or I&D for abscess is associated with a high rate of recurrence has been controversial due to mixed reports in the literature [14,15,17,21]. Thus, no conclusions can be drawn from the differing results; it is possible that the overall recurrence rate is low and that most studies are not adequately powered. The recurrence rate in the revised group was higher than that in the primary group (7.7% vs. 1.9%); however, these results did not show any statistically significant
Fig. 4. Schematic illustration of the helix cartilage suture technique. A vertical mattress suture was placed to obliterate the dead space after excision of the sinus structure and the adjacent helix cartilage.
et al. [19] indicated that the distance between excised preauricular epithelial sinus tracts and adjacent auricular cartilage measured < 0.5 mm in > 50% of cases and that the epithelial tract was in continuity with stromal tissue and histologically indistinguishable from the perichondrium in nearly all cases. The pathological results of the present study are also consistent with this finding. Furthermore, the presence of multiple protruding pouches associated with the fistula wall and their firm adhesion to the cartilage make complete removal of the sinus wall difficult, which is especially true when inflammation is present. Therefore, resection of a small portion of auricular helix
Fig. 5. Finally, the surgical wound was closed and locally compressed by adhesive bandage strips (not shown) without drainage or mastoid dressing. 150
International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
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Fig. 6. The specimen opened along the sinus tract (a). Microphotograph showing small unidentified branches of the sinus tract in close proximity to the cartilage (H& E stain; original magnification ×200) (b). C: helix cartilage and S: sinus tract. Table 2 Recurrence rate based on different variations of clinical presentation. Gender Male Recurrent ears (No.) Total ears Recurrence rate (%) p-value
Female
2 2 68 107 2.9 1.9 p = 0.644
Lesion laterality
Etiology
R
L
Primary
2 87 2.3 p = 0.99
2 88 2.2
3 162 1.9 p = 0.175
Anesthesia technique
History of infection
Preoperative I&D
Revised
GA
LA
Yes
No
Yes
No
1 13 7.7
1 79 1.3 p = 0.413
3 96 3.1
4 161 2.5 p = 0.551
0 14 0.0
1 20 5.0 p = 0.388
3 155 1.9
p < 0.05 indicates a statistically significant difference. Abbreviations: R: right; L: left; GA: general anesthesia; LA: local anesthesia; and I&D: incision and drainage.
Financial disclosure statement
between-group difference. Although it is believed that most cases of recurrence occur in the early postoperative period within one month of the surgical procedure, two of the four recurrent cases in our series developed one year after surgery. This result suggests that a long-term follow up for at least one year may be necessary. Recurrence should be highly suspected when there is persistent discharge from the wound or painful swelling around the surgical site. Additionally, some authors [10,18] have advocated the use of a microscope or magnifying glasses to reduce the risk of recurrence, as blood vessels and surgical planes can be clearly identified intraoperatively without any unintended disturbance of the sinus sac. Because no magnifying tools were used in the current study, we hypothesized that the application of these tools in the future will help during dissection, especially in the chronically inflamed or recurrent cases, hence further lowering the recurrence rate. There are a few limitations in this study. The retrospective study design resulted in inadequate data collection and a potential information bias. Although the patients were routinely followed for at least 6 months, some cases of recurrence may have occurred after the followup period. Furthermore, the low rate of recurrence might preclude statistical analysis of factors contributing to recurrence.
The authors have no financial or commercial associations that might create a conflict of interest with the information presented in this article. Author contributions Study conception and design: Dr. Kai-Chieh Chan and Dr. ZungChung Chen. Acquisition of data: Dr. Han-Tse Kuo Pathology review and analysis: Dr. Wen-Yu Chuang. Analysis and interpretation of data: Dr. Han-Tse Kuo and Dr. KaiChieh Chan. Drafting of manuscript: Dr. Kai-Chieh Chan and Dr. Zung-Chung Chen. Critical revision: Dr. Valerie Wai-Yee Ho. References [1] R.G. Chami, J. Apesos, Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom, Ann. Plast. Surg. 23 (1989) 406–411. [2] T. Tan, H. Constantinides, T.E. Mitchell, The preauricular sinus: a review of its aetiology, clinical presentation and management, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1469–1474. [3] M.R. Ewing, Congenital sinuses of the external ear, J. Laryngol. Otol. 61 (1946) 18–23. [4] F.J. Tsai, C.H. Tsai, Birthmarks and congenital skin lesions in Chinese newborns, J. Formos. Med. Assoc. 92 (1993) 838–841. [5] K.Y. Lee, S.Y. Woo, S.W. Kim, J.E. Yang, Y.S. Cho, The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea, Otol. Neurotol. 35 (2014) 1835–1838. [6] I. Aird, Ear-pit (congenital aural and preauricular fistula), Edinb. Med. J. 53 (1946) 498–507. [7] A.R. Currie, W.W. King, A.C. Vlantis, A.K. Li, Pitfalls in the management of preauricular sinuses, Br. J. Surg. 83 (1996) 1722–1724. [8] S. Prasad, K. Grundfast, G. Milmoe, Management of congenital preauricular pit and sinus tract in children, Laryngoscope 100 (1990) 320–321. [9] H.C. Lam, G. Soo, P.J. Wormald, C.A. Van Hasselt, Excision of the preauricular sinus: a comparison of two surgical techniques, Laryngoscope 111 (2001) 317–319. [10] R.J. Baatenburg de Jong, A new surgical technique for treatment of preauricular sinus, Surgery 137 (2005) 567–570. [11] W.J. Huang, C.H. Chu, M.C. Wang, C.L. Kuo, A.S. Shiao, Decision making in the
5. Conclusion Based on a histopathological study and clinical observation, surgical PAS excision with the modified SAA and helix cartilage suture of dead space in our series yielded a low overall recurrence rate and minimal complications while maintaining cosmesis due to a small incision. The recurrence rate was not significantly affected by gender, lesion laterality, anesthesia methods, etiology of surgery, or a history of infection or preoperative I&D for abscess. Thus, our modified technique is a simple, effective and reproducible surgical treatment for PAS.
Ethical statement This study was approved by the Institutional Review Board Ethical Committee of Chang Gung Memorial Hospital. 151
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[12]
[13]
[14]
[15]
[16]
302–305. [17] I.P. Tang, S. Shashinder, S. Kuljit, K.G. Gopala, Outcome of patients presenting with preauricular sinus in a tertiary centre–a five year experience, Med. J. Malaysia 62 (2007) 53–55. [18] E.C. Gan, R. Anicete, H.K. Tan, A. Balakrishnan, Preauricular sinuses in the pediatric population: techniques and recurrence rates, Int. J. Pediatr. Otorhinolaryngol. 77 (2013) 372–378. [19] B. Dunham, M. Guttenberg, W. Morrison, L. Tom, The histologic relationship of preauricular sinuses to auricular cartilage, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 1262–1265. [20] H.S. Shim, D.J. Kim, M.C. Kim, J.S. Lim, K.T. Han, Early one-stage surgical treatment of infected preauricular sinus, Eur. Arch. Oto-Rhino-Laryngol. 270 (2013) 3127–3131. [21] E. Gur, A. Yeung, M. Al-Azzawi, H. Thomson, The excised preauricular sinus in 14 years of experience: is there a problem? Plast. Reconstr. Surg. 102 (1998) 1405–1408.
choice of surgical management for preauricular sinuses with different severities, Otolaryngol. Head Neck Surg. 148 (2013) 959–964. H. Bruijnzeel, M.T. van den Aardweg, W. Grolman, I. Stegeman, E.L. van der Veen, A systematic review on the surgical outcome of preauricular sinus excision techniques, Laryngoscope 126 (2016) 1535–1544. S.C. Bae, S.H. Yun, K.H. Park, K.H. Chang, D.H. Lee, et al., Preauricular sinus: advantage of the drainless minimal supra-auricular approach, Am. J. Otolaryngol. 33 (2012) 427–431. H. Rataiczak, J. Lavin, M. Levy, J. Bedwell, D. Preciado, et al., Association of recurrence of infected congenital preauricular cysts following incision and drainage vs fine-needle aspiration or antibiotic treatment: a retrospective review of treatment options, JAMA Otolaryngol. Head Neck Surg. 143 (2017) 131–134. S.W. Yeo, B.C. Jun, S.N. Park, J.H. Lee, C.E. Song, et al., The preauricular sinus: factors contributing to recurrence after surgery, Am. J. Otolaryngol. 27 (2006) 396–400. G. Leopardi, G. Chiarella, S. Conti, E. Cassandro, Surgical treatment of recurring preauricular sinus: supra-auricular approach, Acta Otorhinolaryngol. Ital. 28 (2008)
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus
T
Kai-Chieh Chana,b, Han-Tse Kuob, Valerie Wai-Yee Hoc, Wen-Yu Chuangb,d, Zung-Chung Chenb,e,∗,1 a
Division of Otology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taiwan School of Medicine, Chang Gung University, Taoyuan, Taiwan c Division of Plastic and Reconstructive Surgery, Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong, China d Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan e Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan b
A R T I C LE I N FO
A B S T R A C T
Keywords: Preauricular sinus Supra-auricular approach Recurrence Helix cartilage suture
Objective: Several surgical techniques and modifications have been described to reduce the high recurrence rate after excision of preauricular sinus (PAS). This study was designed to evaluate the surgical outcomes of PAS excision using a new modified supra-auricular approach (SAA) and to assess the predisposing factors for recurrence. Methods: A total of 175 (158 patients) PAS excision procedures were performed from 2007 to 2016 in a single institute using this modified SAA with helix cartilage suture to obliterate the dead space. The specimens were assessed to measure the closest distance between the squamous tract and the excised auricular cartilage (sinocartilaginous distance). We also evaluated the surgical outcomes and investigated the predisposing factors for recurrence, including gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or local), history of infection, and history of incision and drainage (I&D) for abscess. Results: Patients were followed up for a median duration of 45 months (range from 6 months to 10 years). There was a 2.3% (4 ears) recurrence rate and a 1.7% (3 ears) complication rate in our series. The average sinocartilaginous distance was 0.44 mm (median distance, 0.3 mm) and this value was less than 0.5 mm in 66% of cases. Recurrence was not significantly affected by gender, lesion laterality, etiology of surgery, anesthesia method, or a history of infection or preoperative I&D for abscess. Conclusions: Surgical PAS excision using the modified SAA with cartilage suture of dead space yielded low overall recurrence and complication rates in this series. Cosmesis was maintained due to a smaller incision. No significant predisposing factors for recurrence were identified. Thus, the modified technique described in the present study can be regarded as a simple, effective and reproducible surgical treatment for PAS.
1. Introduction The preauricular sinus (PAS) is a congenital tract lined by squamous epithelium with hyperkeratosis and parakeratosis and was first described by Van Heusinger in 1864 [1]. Embryonically, the external ear is formed from six hillocks of His, which arise from the first and second branchial arches. Failure of complete fusion of the six hillocks or entrapment of ectodermal epithelium during auricular development is believed to result in the formation of a PAS. The prevalence of PAS is 0.1–0.9% in the United States, 0.9% in England, 1.6%–2.5% in Taiwan,
1.91% in South Korea and 4%–10% in some regions of Africa [2–6]. Although PAS is frequently asymptomatic and does not require treatment, surgical management is indicated when the PAS becomes infected. Patients may present with local cellulitis or abscess in the acute inflammatory stage or chronic intermittent discharge from the sinus opening. Antibiotics and/or adequate incision and drainage (I&D) can usually control the infection. Once infection occurs, the risk of recurrent infection is increased. Therefore, the entire sinus tract should be excised completely to eradicate the disease. Traditional sinusectomy for PAS had been widely adopted in the
∗
Corresponding author. Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University, Linkou, Taiwan. E-mail addresses: [email protected], [email protected] (Z.-C. Chen). 1 Address: Din Hu Rd No. 123, Gweishan, Taoyuan, Taiwan. https://doi.org/10.1016/j.ijporl.2018.08.041 Received 1 May 2018; Received in revised form 31 August 2018; Accepted 31 August 2018 Available online 05 September 2018 0165-5876/ © 2018 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
K.-C. Chan et al.
past, but a high rate of recurrence (19–40%) had been reported [7,8]. It is believed that unidentified branching of the sinus, remnants of the sinus wall, and infection with or without formation of abscesses can lead to disease recurrence. Thus, various modified surgical techniques for PAS excision have been proposed to achieve a lower recurrence rate, such as the supra-auricular approach (SAA) [8,9], inside-out technique [10] or Fig. 8 excision method [11]. Of these, the SAA introduced by Prasad et al. has been one of the most favorable and widely used methods since 1990 [8]. The recurrence rate of the SAA ranges between 0 and 23%, with an average rate of 2.2% [12]. However, the main drawback of the SAA is the large dead space that results from resecting the PAS with the surrounding subcutaneous tissue via an extended supra-auricular and postauricular incision. Postoperative drain insertion and compression dressing are usually required for complete closure of the dead space. Bae et al. [13] designed a drainless minimal SAA with meticulous subcutaneous mattress suture to obliterate the dead space for treatment of PAS, and there was no postoperative recurrence or other serious complication in their study. Additionally, recurrence after PAS excision was found to be correlated with certain factors, such as preoperative infection status, preoperative I&D [14], or local anesthesia technique [15–18]. Thus, the purposes of the present study were to introduce a modified SAA surgical technique with helix cartilage suture to minimize the dead space without drainage or dressing and to survey the surgical results for PAS. Moreover, we also examined various predisposing factors for recurrence after the surgery in a 10-year retrospective study period.
Fig. 1. A vertical elliptical incision was made around the sinus opening and extended upward to the supra-auricular region for 5 mm without postauricular extension.
the creation of false passages. In the case of revision surgery, probing was not conducted. After the skin incision, en bloc resection of the PAS with surrounding subcutaneous tissue between the temporalis fascia and the helix was performed (Fig. 2), taking care not to injure the superficial temporal vessels. A small portion of helix cartilage adjacent to the PAS tract was routinely resected (Fig. 3a). After complete excision, the wound was irrigated copiously with dilute povidone-iodine solution to prevent surgical site infection. Then, absorbable sutures were used to suture the distal remnant subcutaneous tissue, temporalis fascia, and helix cartilage in a vertical mattress manner and in a lateral-to-medial direction to tightly obliterate the dead space (Fig. 3b). A schematic illustration of the helix cartilage suture technique is shown in Fig. 4. Finally, a local pressure dressing was applied using adhesive bandage strips. No drains or mastoid dressing was needed (Fig. 5). The bandage was removed after 48 h. Postoperative oral antibiotics and analgesics were prescribed for 1 week.
2. Materials and methods A retrospective review of the clinical records of consecutive patients with PAS who underwent the surgery with the modified SAA between July 2006 and June 2016 was conducted. The study was approved by the institutional review board of Chang Gung Memorial Hospital in Linkou, Taiwan (IRB No.201800424B0). All the PAS cases were of the classic type, with the sinus opening located at the anterior margin of the ascending limb of the helix. Indications for this surgery were cases of PAS with a history of persistent purulent discharge or recurrent infection or asymptomatic patients with cosmetic concerns because of an apparent PAS opening. Each ear involved in the bilateral procedures was regarded as a separate operation. All patients were followed for at least 6 months postoperatively, with the longest follow-up being 10 years. Postoperative complications and recurrence were documented. Preoperative predisposing factors were collected, and their association with recurrence was analyzed. These factors included gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or local), history of infection, and history of I&D for abscess. Chi-square test or Fisher's exact test was performed using SPSS statistical software (SPSS Inc., Chicago, IL), and P < 0.05 was considered statistically significant.
3. Results There were 175 ears with PAS (152 patients) in this review. The study cohort included 59 males and 93 females with a median age of 22.5 years (range: 1–78). A total of 88 right ears, and 87 left ears were operated on (23 patients had bilateral operations). A total of 162 ears had no previous PAS surgeries (labeled as primary), while 13 ears had a history of PAS surgery (labeled as revised). There were 96 and 79 ears treated under LA and GA, respectively. A total of 161 ears had a history of preoperative infection, while 14 ears were asymptomatic. A total of 20 ears had undergone I&D for abscess, while 155 cases had not (Table 1). The median follow-up duration was 45 months (range: 6–120). The diagnosis of PAS was confirmed histopathologically. Pathological analysis typically showed that the sinus tracts were in close proximity to the helix cartilage (Fig. 6). A total of 138 specimens were retrieved to measure the closest distance between the squamous tract and the excised auricular cartilage. The average sinocartilaginous distance was 0.44 mm, ranging from 0.1 to 1.9 mm (median distance, 0.3 mm). In 66% (91 cases) of the specimens, the sinocartilaginous distance was less than 0.5 mm. There were 4 cases of recurrence among 175 operated ears (2.3%). Two cases presented as epidermoid cyst formation at 12 months and 14 months postoperatively, one presented as a postoperative nonhealing wound, and one presented as new aperture formation with discharge at one month after surgery. Three patients reported complications (1.7%). Two patients had wound dehiscence, and one had wound infection. However, no cases of postoperative seroma/hematoma, perichondritis or chondritis were identified in this series. Cosmesis was good without any auricular deformity. The potential predisposing factors for recurrence after surgery,
2.1. Surgical technique At our institution, surgical excision of the PAS is usually performed about one month after the resolution of an acute infection. An acutely infected PAS is first treated with a course of antibiotics. If an abscess is present, I&D is performed. All subjects underwent PAS excision by the senior authors (K.C. Chan & Z.C. Chen) under general anesthesia (GA) or local anesthesia (LA). The operations were performed under GA for patients under 12 years old and under LA for most adult and adolescent patients unless they could not comply. The surgical procedure was modified from the SAA described by Prasad et al. [8]. Local anesthetic containing epinephrine was infiltrated subcutaneously at the lesion to include auriculotemporal nerve block. A vertical elliptical incision was made around the sinus opening and extended upward to the supraauricular region for 5 mm without postauricular extension (Fig. 1). A lacrimal probe was then used to locate the sinus tract gently to avoid 148
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Fig. 2. En bloc resection of the sinus tract with the surrounding subcutaneous tissue between the temporalis fascia (deep boundary, 2b) and the helix (posterior boundary, 2a) was performed. Of note, caution is required to avoid injury of the superficial temporal vessels (anterior boundary). S: sinus tract, C: helix cartilage, and F: temporalis fascia.
complication rate. According to a systemic review [12], the recurrence rate of the SAA for PAS excision ranged between 0 and 23%, with an average recurrence rate of 2.2%. The present surgical result is in accordance with that report. Because the presence of dead space after the original SAA is associated with wound complications, we advocated closing the dead space by suturing the helix cartilage, temporalis fascia and residual subcutaneous tissue. Therefore, this approach contributed to a low complication rate in our study. Furthermore, the recurrences in the study were not related to factors including gender, lesion laterality, anesthesia technique, history of previous sinus excision, history of I&D or etiology of PAS surgery. Hence, this modified SAA is indeed a reliable, effective and safe surgical technique for PAS excision. The original SAA procedure involved a wide exposure with supraauricular extension of the preauricular incision and the identification of landmarks, including the temporalis fascia (deep boundary), superficial temporal vessels (anterior boundary), and the cartilage of the anterior helix (posterior boundary). These landmarks are important in revision cases or in the acute infection stage. Entire sinus tracts and surrounding subcutaneous tissue within these landmarks were excised completely. In our modified surgical method, a 5-mm skin incision is extended superiorly, similar to that described by Bae et al. [13], without further postauricular extension. This technique helps to minimize the dead space while still maintaining an adequate view for complete excision of the sinus tract. This modified SAA approach also offered better aesthetic results than the original SAA due to a smaller incision [13]. Several authors [15] have reported that there are no significant differences in recurrence rates between the groups with and without excision of the perichondrium of helix cartilage. However, Dunham
including gender, lesion laterality, etiology, anesthesia techniques, history of preoperative infection, and history of preoperative I&D for abscess formation, were also analyzed (Table 2). Recurrence occurred in two ears among 93 female patients (1.9%) and in 2 ears among 59 male patients (2.9%); the difference was not statistically significant. There were 87 left-sided lesions and 88 right-sided lesions, and 2 cases from each side experienced recurrence (2.3% and 2.2%, respectively). No statistically significant difference was noted between these two groups. Regarding etiology, recurrence occurred in 3 ears among 162 primary cases (1.9%), while recurrence occurred in 1 ear among the 13 ears of revised cases (7.7%). No statistically significant difference between these two groups was demonstrated. There were 96 and 79 procedures performed under LA and GA, respectively. Three cases of recurrence were noted in the LA group (3.1%), and 1 case of recurrence was noted in the GA group (1.3%). No statistically significant difference was shown. A total of 161 ears had a history of preoperative infection, among which 4 ears (2.5%) experienced postoperative recurrence. However, there were no cases of recurrence among the 14 asymptomatic ears. There was no statistically significant difference between these two groups. Recurrence was noted in one ear among 20 ears (5%) that had undergone I&D for abscess. Three cases of recurrence were noted among the other 155 cases (1.9%) without a history of I&D. No statistically significant difference was shown between these two groups.
4. Discussion In this study, utilization of the modified SAA resulted in effective surgical outcomes, with a 2.3% recurrence rate and a 1.7%
Fig. 3. A small part of the helix cartilage adjacent to the sinus tract was routinely resected (3a). Then, the dead space was closed tightly by absorbable stitches via suturing of the remnant subcutaneous tissue, temporalis fascia and helix cartilage with the vertical mattress technique in a lateral-to-medial direction (3b). 149
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Table 1 Patient demographics. No. (%) Total ears Gender Male Female Lesion laterality Right Left Anesthesia technique General anesthesia Local anesthesia Etiology Primary Revised History of infection Yes No Preoperative incision & drainage Yes No
175(100.0) 68(38.9) 107(61.1) 87(49.7) 88(50.3) 79(45.1) 96(54.9) 162(92.6) 13(7.4) 161(92.0) 14(8.0) 20(11.4) 155(88.6)
cartilage adjacent to the sinus tract is suggested to ensure thorough excision and to reduce recurrence rates [10,11,20]. Methylene blue was not routinely used to mark the sinus tract, as methylene blue may diffuse into tissues and affect the accurate dissection of all the complicated branches [16]. Regional auriculotemporal nerve block is important during PAS surgery, especially under LA, since the preauricular region is innervated by this nerve. Caution should be taken to avoid injury to the superficial temporal artery because the auriculotemporal nerve usually presents within the initial loop of the superficial temporal artery. Previous reports [15–18] have shown that dissection of the PAS under GA has a lower recurrence rate compared with that under LA, because patients under GA had better tolerance and allowed a more complete dissection and excision of the PAS. However, there was no statistically significant difference between these two groups in this study, although the LA patients had a higher recurrence rate (3.1%) than the GA patients (1.3%). We postulated that this finding is due to the effective local regional auriculotemporal nerve block, allowing the procedures to be performed smoothly. The present study found that patients with a history of infection or I &D of the PAS show a higher rate of recurrence than patients without these conditions (5% vs.1.9% and 2.5% vs. 0%, respectively), but there was no statistically significant difference. The debate on whether a history of PAS infection or I&D for abscess is associated with a high rate of recurrence has been controversial due to mixed reports in the literature [14,15,17,21]. Thus, no conclusions can be drawn from the differing results; it is possible that the overall recurrence rate is low and that most studies are not adequately powered. The recurrence rate in the revised group was higher than that in the primary group (7.7% vs. 1.9%); however, these results did not show any statistically significant
Fig. 4. Schematic illustration of the helix cartilage suture technique. A vertical mattress suture was placed to obliterate the dead space after excision of the sinus structure and the adjacent helix cartilage.
et al. [19] indicated that the distance between excised preauricular epithelial sinus tracts and adjacent auricular cartilage measured < 0.5 mm in > 50% of cases and that the epithelial tract was in continuity with stromal tissue and histologically indistinguishable from the perichondrium in nearly all cases. The pathological results of the present study are also consistent with this finding. Furthermore, the presence of multiple protruding pouches associated with the fistula wall and their firm adhesion to the cartilage make complete removal of the sinus wall difficult, which is especially true when inflammation is present. Therefore, resection of a small portion of auricular helix
Fig. 5. Finally, the surgical wound was closed and locally compressed by adhesive bandage strips (not shown) without drainage or mastoid dressing. 150
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Fig. 6. The specimen opened along the sinus tract (a). Microphotograph showing small unidentified branches of the sinus tract in close proximity to the cartilage (H& E stain; original magnification ×200) (b). C: helix cartilage and S: sinus tract. Table 2 Recurrence rate based on different variations of clinical presentation. Gender Male Recurrent ears (No.) Total ears Recurrence rate (%) p-value
Female
2 2 68 107 2.9 1.9 p = 0.644
Lesion laterality
Etiology
R
L
Primary
2 87 2.3 p = 0.99
2 88 2.2
3 162 1.9 p = 0.175
Anesthesia technique
History of infection
Preoperative I&D
Revised
GA
LA
Yes
No
Yes
No
1 13 7.7
1 79 1.3 p = 0.413
3 96 3.1
4 161 2.5 p = 0.551
0 14 0.0
1 20 5.0 p = 0.388
3 155 1.9
p < 0.05 indicates a statistically significant difference. Abbreviations: R: right; L: left; GA: general anesthesia; LA: local anesthesia; and I&D: incision and drainage.
Financial disclosure statement
between-group difference. Although it is believed that most cases of recurrence occur in the early postoperative period within one month of the surgical procedure, two of the four recurrent cases in our series developed one year after surgery. This result suggests that a long-term follow up for at least one year may be necessary. Recurrence should be highly suspected when there is persistent discharge from the wound or painful swelling around the surgical site. Additionally, some authors [10,18] have advocated the use of a microscope or magnifying glasses to reduce the risk of recurrence, as blood vessels and surgical planes can be clearly identified intraoperatively without any unintended disturbance of the sinus sac. Because no magnifying tools were used in the current study, we hypothesized that the application of these tools in the future will help during dissection, especially in the chronically inflamed or recurrent cases, hence further lowering the recurrence rate. There are a few limitations in this study. The retrospective study design resulted in inadequate data collection and a potential information bias. Although the patients were routinely followed for at least 6 months, some cases of recurrence may have occurred after the followup period. Furthermore, the low rate of recurrence might preclude statistical analysis of factors contributing to recurrence.
The authors have no financial or commercial associations that might create a conflict of interest with the information presented in this article. Author contributions Study conception and design: Dr. Kai-Chieh Chan and Dr. ZungChung Chen. Acquisition of data: Dr. Han-Tse Kuo Pathology review and analysis: Dr. Wen-Yu Chuang. Analysis and interpretation of data: Dr. Han-Tse Kuo and Dr. KaiChieh Chan. Drafting of manuscript: Dr. Kai-Chieh Chan and Dr. Zung-Chung Chen. Critical revision: Dr. Valerie Wai-Yee Ho. References [1] R.G. Chami, J. Apesos, Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom, Ann. Plast. Surg. 23 (1989) 406–411. [2] T. Tan, H. Constantinides, T.E. Mitchell, The preauricular sinus: a review of its aetiology, clinical presentation and management, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1469–1474. [3] M.R. Ewing, Congenital sinuses of the external ear, J. Laryngol. Otol. 61 (1946) 18–23. [4] F.J. Tsai, C.H. Tsai, Birthmarks and congenital skin lesions in Chinese newborns, J. Formos. Med. Assoc. 92 (1993) 838–841. [5] K.Y. Lee, S.Y. Woo, S.W. Kim, J.E. Yang, Y.S. Cho, The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea, Otol. Neurotol. 35 (2014) 1835–1838. [6] I. Aird, Ear-pit (congenital aural and preauricular fistula), Edinb. Med. J. 53 (1946) 498–507. [7] A.R. Currie, W.W. King, A.C. Vlantis, A.K. Li, Pitfalls in the management of preauricular sinuses, Br. J. Surg. 83 (1996) 1722–1724. [8] S. Prasad, K. Grundfast, G. Milmoe, Management of congenital preauricular pit and sinus tract in children, Laryngoscope 100 (1990) 320–321. [9] H.C. Lam, G. Soo, P.J. Wormald, C.A. Van Hasselt, Excision of the preauricular sinus: a comparison of two surgical techniques, Laryngoscope 111 (2001) 317–319. [10] R.J. Baatenburg de Jong, A new surgical technique for treatment of preauricular sinus, Surgery 137 (2005) 567–570. [11] W.J. Huang, C.H. Chu, M.C. Wang, C.L. Kuo, A.S. Shiao, Decision making in the
5. Conclusion Based on a histopathological study and clinical observation, surgical PAS excision with the modified SAA and helix cartilage suture of dead space in our series yielded a low overall recurrence rate and minimal complications while maintaining cosmesis due to a small incision. The recurrence rate was not significantly affected by gender, lesion laterality, anesthesia methods, etiology of surgery, or a history of infection or preoperative I&D for abscess. Thus, our modified technique is a simple, effective and reproducible surgical treatment for PAS.
Ethical statement This study was approved by the Institutional Review Board Ethical Committee of Chang Gung Memorial Hospital. 151
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