- Email: [email protected]
cysts
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Comprehensive management of infected preauricular sinuses/cysts☆ Glenn Isaacson
T
∗
Departments of Otolaryngology, Head & Neck Surgery and Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
ARTICLE INFO
ABSTRACT
Keywords: Congenital auricular malformation Preauricular sinus Preauricular abscess
Objective: To review a single-surgeon, 16-year experience with the management of infected preauricular sinuses/ cysts. Methods: Computerized search of all office notes and operative reports during the years 2002–2018. Setting: Academic medical center and suburban office practice. Participants: Children from 0 to 18 years of age with symptomatic preauricular sinuses/cysts. Intervention: Children with symptomatic preauricular sinuses/cysts underwent surgical excision. Those presenting with infected cysts were treated with oral antibiotics, needle-aspiration and/or incision and drainage to control infection prior to surgery. The chronic preauricular abscesses were curetted without resection of overlying skin or the abscess walls. Main outcome measure: Control of infection without recurrence following surgery. Results: 415 patient encounters involved preauricular sinuses/cysts. These ultimately led to 56 surgical excisions. 28 of the sinuses/cysts were infected at presentation. All infected lesions were treated with oral antibiotics. 6 infected sinuses/cysts were needle aspirated. 2 infected sinuses/cysts required incision and drainage. 1 infected sinus/cyst could not be controlled by either drainage technique and was surgically excised while actively infected. Nine children presented with chronic preauricular abscesses. One the 28 infected sinuses/cysts (3.5%) recurred 10 years after surgery– it was cured with re-resection at the root of the helix. Conclusion: Treatment of infected preauricular sinuses/cysts remains controversial. Control of infection prior to definitive surgery is desirable, but not mandatory. Chronic preauricular abscesses can be managed by sinus/cyst excision and subcutaneous abscess curettage without resection of the abscess wall or overlying skin. This leads to consistent control and favorable cosmesis.
1. Introduction Preauricular sinuses are among the most common of congenital auricular abnormalities affecting 1–2% of individuals worldwide [1–17]. Most are asymptomatic and require no treatment. A minority of these sinuses becomes repeatedly infected with local inflammation around the associated subcutaneous cyst and purulent discharge from the sinus (Figs. 1, 2 and 3a). Complete excision of the cyst and sinus is indicated in such cases to control infection and to prevent complications. Despite careful surgical excision, recurrences are common – especially with infected lesions that required incision and drainage [2]. Several surgical modifications have been proposed to improve primary control and to deal with recurrent lesions. Some infected sinuses/cysts go on to cause chronic preauricular abscesses. This is thought to occur from rupture of the anterior wall of
the preauricular cyst with spillage of the infected squamous debris into the subcutaneous fat plane. Intense chronic inflammation and foreign body reaction ensue [3] with fat necrosis and eventual thinning and erosion of the overlying skin (Figs. 1 and 2). Several authors have advocated treating such chronic preauricular abscesses by en bloc resection of the preauricular sinus/cyst, the abscess wall and its overlying skin. While effective, this radical approach to treatment produces a large tissue defect, often requiring reconstruction with local flaps. The cosmetic results are less than optimal. Further, extensive preauricular dissection places the temporal branch of the facial nerve at risk as it travels just beneath the subcutaneous fat above the zygomatic arch [4]. Unhappy with the results of radical resection, we adopted a more conservative approach to the treatment of chronic preauricular abscesses. This included preoperative control of infection with antibiotics
Portions of this work were presented as a poster at the American Society of Pediatric Otolaryngology annual meeting, Austin TX, May 3–5, 2019. Corresponding author. Department of Otolaryngology, Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, 1077 Rydal Road, Suite 201, Rydal, PA, 19046, United States. E-mail address: [email protected]. ☆ ∗
https://doi.org/10.1016/j.ijporl.2019.109682 Received 9 August 2019; Received in revised form 29 August 2019; Accepted 11 September 2019 Available online 17 September 2019 0165-5876/ © 2019 Published by Elsevier B.V.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
2. Methods 2.1. Computerized chart review After receiving an exemption from Temple University's Human Research Protection Program (IRB protocol 24873) a computerized collection of patient office notes and operative reports was queried using the Microsoft Word “find” feature. The data collection was done in a manner that protected patient identity and privacy. All children who were evaluated for preauricular sinuses/cysts from January 2002–December 2018 were identified using the search terms “preauricular,” “pit” “cyst” “sinus” and “abscess”. Age at time of surgery, gender, surgical procedure, postoperative complications and need for reoperation were recorded. 2.2. Management and surgical technique Infected preauricular sinuses/cysts were treated in a consistent manner during the study period. Children presenting with an infected sinus/cyst were treated with oral antibiotics (usually amoxicillin – clavulanate) for 10–14 days. Infected cysts content were needle-aspirated at the beginning of therapy when possible. Incision and drainage was reserved for infections refractory to needle-aspiration and systemic antibiotics. In such cases the incision was placed in the future line of resection. (Fig. 2b). Some patients were placed on prophylactic cephalexin for 4–6 weeks prior to definitive resection. Once infection was controlled, the preauricular sinus/cyst was surgically resected using an elliptical incision around the sinus toward the root of the helix. The cyst's extent was determined by inserting a lacrimal probe into its sinus. The cyst was resected, including a contiguous portion of root of helix cartilage under loupe magnification. When scarring prevented easy identification of the temporalis fascia in the preauricular area, a supra-auricular extension of the cephalic portion of the incision was included as described by Prasad, Grundfast and Milmoe [6]. It was sometimes difficult to identify the anterior wall of the cyst following rupture and anterior abscess formation. In such cases the anterior cyst wall and adherent scar were sharply incised and separated from anterior soft tissues and the underlying temporalis fascia. In the cases complicated by preauricular abscesses, once the preauricular sinus/cyst was resected, blunt dissection was carried anteriorly to open the abscess cavity sparing the overlying skin – even if the dermis was attenuated. The abscess contents were scooped out with a large mastoid curette with care not to abrade the superficial (parotidtemporal) fascia above the zygoma. The abscess cavity was then repeated irrigated. A Penrose drain was placed and mastoid dressing applied.
Fig. 1. Infected preauricular sinus/cyst (dotted circle) with chronic preauricular abscess (arrows).
Fig. 2. a – infected preauricular sinus/cyst with abscess formation at root of helix. b – infected preauricular sinus/cyst after incision and drainage in future resection line.
and cyst drainage if necessary. Surgery included resection the preauricular sinus/cyst and curettage of the abscess cavity contents with preservation of the overlying skin [5]. This report describes our experience with this approach over the last 16 years.
3. Results Among 72,000 patient encounters between 2002 and 2018, 415 involved pre-auricular sinuses/cysts. These ultimately led to 56 surgical
Fig. 3. Infected preauricular sinus/cyst with chronic preauricular abscess a) persistence after incision and drainage; b) after sinus/cyst resection – note breakdown of thinned skin over preauricular abscess; c) healing by second intention with favorable cosmetic result. 2
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
Table 1 Results of comprehensive treatment of preauricular sinuses/cysts. 56 surgically treated children
Antibiotic treatment
Needle aspiration
Incision and drainage
Prophylactic antibiotics
Operated while infected
Recurrence requiring re-resection
28 infected 28 not infected
28 0
8 (6 controlled) 0
2 (not controlled by needle aspiration) 0
7 0
1 0
1 (at 10 years postop) 0
Results of comprehensive treatment of preauricular sinuses/cysts.
excisions. 28 of the sinuses/cysts were infected at presentation. All infected lesions were treated with oral antibiotics and 7 received antibiotic prophylaxis until surgery (mean duration 6 weeks). 6 infected cysts were controlled by needle-aspiration. 2 infected cysts required incision and drainage. 1 infected cyst could not be controlled by either drainage technique and was surgically excised while actively infected (). A single infected sinus/cyst recurred 10 years after initial surgery. It was cured with re-resection of the previous surgical site. The recurrence was identified at the root of the helix, rather than in the location of the previous preauricular abscess cavity (Table 1).
claimed no recurrences and good cosmetic results. While resection of actively infected lesions is possible, this runs against classical surgical teaching and, we believe, results in unnecessary sacrifice of cosmetically important tissues. We prefer to control infection preoperatively when possible with oral antibiotics and needle aspiration. We adopted the conservative, skin-sparing approach to chronic preauricular abscesses soon after Shu and Lin's description of the technique. Our results mirror those of the groups in Asia. While these preauricular abscesses likely result from spilled infectious material and dead squamous debris from the preauricular cyst, there is no evidence that abscess cavities contain viable squamous epithelium that might produce a recurrent cyst. Foreign body reaction, seen histologically within resected abscesses, responds to meticulous resection of the preauricular sinus/cyst and thorough cleaning of the abscess cavity without the need to resect the abscess wall or adjacent skin. The skin of the temple – the typical location chronic preauricular abscesses – is among the so-called the NEET sites (concave surface of the nose, eye, ear, and temple) that respond favorably to second intention healing [17]. Modest-sized surgical defects in these locations are less conspicuous when no attempt is made to approximate skin edges or perform local tissue rearrangements. This accounts for the favorable cosmetic results described by Shim et al. and experienced by those patients in our series with temporal skin defects (Fig. 3). Weaknesses of this study include its retrospective design and lack of control groups (infected lesions not treated with antibiotics; abscesses treated by radical resection of involved skin). Despite this, our approach resulted in a low rate of recurrence and excellent cosmesis compared to published series.
4. Discussion Optimum management of infected preauricular sinuses/cysts has been controversial since they were identified as a distinct entity a century ago [7]. By 1942, Pastore and Erich [8] recognized that complete surgical excision of the infected sinuses/cysts was ideal, but complained that, “extirpation of the entire sac or fibrous tract … is often difficult because of poor visualization of the tract”. They advocated use of a probe or methylene blue to identify the tract. Sclerosing agents and eletrodiathermy were added when complete excision was not possible. By the 1960s the complete surgical excision of the sinus/cyst in a clear operative field had become the standard of care. Singer [9] noted that it was important to hug the root of helix cartilage during resection and that … “occasionally, adhesions from previous infections may require the slicing off of a thin piece of cartilage.” Routine resection of root of helix perichondrium and/or cartilage did not become standard until the 1990s [10,11]. There are two schools of thought regarding the best approach to chronic preauricular abscesses associated with infect preauricular sinuses/cysts. On camp holds that radical resection of the sinus/cyst in continuity with the preauricular abscess and its overlying skin leads to the lowest recurrence rate [3]. Excision through parallel preauricular incisions [12], L-shaped skin resection [13] and en bloc resection with advancement [14] or rotation flap reconstruction have been advocated by different groups. While en bloc resection clears the operative field of infection, cosmetic results in this very visible facial region are less than perfect. Transposition of hair-bearing scalp may require subsequent depilatory treatment. In addition, dissection anterior to root of helix and cephalad to the zygomatic arch places the temporal branch of the facial nerve at risk of injury [15]. In 2001 Shu and Lin [5] described an alternative surgical technique for addressing preauricular abscesses. They performed a meticulous resection of the underlying sinus/cyst then curetted the abscess cavity preserving the overlying skin. They claimed superior cosmetic results. While case numbers were not provided, they stated that, “late recurrences are rare. When recurrence does occur, it mostly appears within the first 2 weeks … (as) a result of residual cyst wall inside the wound.” More recently Shim et al. [16] published a five-year series of 136 preauricular sinuses/cysts. Of these, 68 were infected at the time of surgery and 42 exhibited abscess formation. They operated on these lesions without attempting to control infection prior to surgery. The associated preauricular abscesses were treated with curettage and elliptical resection of overlying thinned skin. Any subsequent skin breakdown was treated conservatively and allowed to heal by second intention. They
5. Conclusion We present a 16-year, single-surgeon experience with infected preauricular sinuses/cysts. Active infection was controlled preoperatively in 27 of 28 lesions with oral antibiotics, sometimes in combination with needle-aspiration or incision and drainage. One infected lesion with a large associated preauricular abscess could not be controlled and was resected while infected. A single recurrence among the infected sinuses/cysts appeared 10-years after initial resection and was cured by re-resection at the root of helix. The approach we present results in consistent control of infected preauricular sinuses/cysts with minimal morbidity and excellent cosmetic results. Funding None. Conflicts of interest None. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijporl.2019.109682. 3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
References
(1966 Feb) 291–295. [10] 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 (5) (1998 Oct) 1405–1408. [11] B. Dunham, M. Guttenberg, W. Morrison, L. Tom, The histologic relationship of preauricular sinuses to auricular cartilage, Arch. Otolaryngol. Head Neck Surg. 135 (12) (2009) 1262–1265. [12] O.S. Choo, T. Kim, J.H. Jang, Y.H. Choung, The clinical efficacy of early intervention for infected preauricular sinus, Int. J. Pediatr. Otorhinolaryngol. 95 (2017 Apr) 45–50, https://doi.org/10.1016/j.ijporl.2017.01.037. [13] K.W. Heo, M.J. Baek, S.K. Park, Pressure dressing after excision of preauricular sinus: suture transfixion of silicone sheets, J. Laryngol. Otol. 123 (12) (2009 Dec) 1367–1370, https://doi.org/10.1017/S0022215109991162. [14] L. Wang, L. Wei, W. Lu, Z. Liu, M. Wang, Z. Wang, Excision of preauricular sinus with abscess drainage in children, Am. J. Otolaryngol. 40 (2) (2019 Mar Apr) 257–259, https://doi.org/10.1016/j.amjoto.2018.10.016. [15] B. Tan, T.S. Lee, I. Loh, Reconstruction of preauricular soft tissue defects using a superiorly based rotation advancement scalp flap - a novel approach to the surgical treatment of preauricular sinuses, Am. J. Otolaryngol. 39 (2) (2018 Mar - Apr) 204–207, https://doi.org/10.1016/j.amjoto.2017.11.003. [16] 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 (12) (2013 Nov) 3127–3131, https://doi.org/10.1007/s00405-013-2447-7. [17] K.J. Mott, D.P. Clark, L.S. Stelljes, Regional variation in wound contraction of mohs surgery defects allowed to heal by second intention, Dermatol. Surg. 29 (7) (2003 Jul) 712–722.
[1] 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 (10) (2014 Dec) 1835–1838, https://doi.org/10.1097/ MAO.0000000000000587. [2] H. Rataiczak, J. Lavin, M. Levy, J. Bedwell, D. Preciado, B.K. Reilly, 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 (2) (2017 Feb 1) 131–134, https:// doi.org/10.1001/jamaoto.2016.2988. [3] W.J. Kim, Y.M. Lee, D.H. Kim, S. Choe, D. Lee, S.Y. Park, M. Kang, H.J. Cho, K.W. Heo, Causes and prevention of revision surgery for preauricular sinus: a histopathological analysis, Int. J. Pediatr. Otorhinolaryngol. 116 (2019 Jan) 199–203, https://doi.org/10.1016/j.ijporl.2018.11.006. [4] J.X. O'Brien, M.W. Ashton, Relationship of the temporofrontal rami of the facial nerve to the fascial layers of the temporal region, Ann. Plast. Surg. 68 (6) (2012 Jun) 547–548, https://doi.org/10.1097/SAP.0b013e318221b563. [5] M.T. Shu, H.C. Lin, Extirpation of ruptured preauricular fistula, The Laryngoscope 111 (5) (2001 May) 924–926. [6] S. Prasad, K. Grundfast, G. Milmoe, Management of congenital preauricular pit and sinus tract in children, The Laryngoscope 100 (3) (1990 Mar) 320–321. [7] F.A.R. Stammers, Pre-auricular fistulae, brit, J. Surg. 14 (1926) 359–363 (Oct.). [8] P.N. Pastore, J.B. Erich, Arch. Otolaryngol. 36 (1) (1942) 120–125, https://doi.org/ 10.1001/archotol.1942.03760010130011. [9] R. Singer, A new technic for extirpation of preauricular cysts, Am. J. Surg. 111 (2)
4
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Comprehensive management of infected preauricular sinuses/cysts☆ Glenn Isaacson
T
∗
Departments of Otolaryngology, Head & Neck Surgery and Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
ARTICLE INFO
ABSTRACT
Keywords: Congenital auricular malformation Preauricular sinus Preauricular abscess
Objective: To review a single-surgeon, 16-year experience with the management of infected preauricular sinuses/ cysts. Methods: Computerized search of all office notes and operative reports during the years 2002–2018. Setting: Academic medical center and suburban office practice. Participants: Children from 0 to 18 years of age with symptomatic preauricular sinuses/cysts. Intervention: Children with symptomatic preauricular sinuses/cysts underwent surgical excision. Those presenting with infected cysts were treated with oral antibiotics, needle-aspiration and/or incision and drainage to control infection prior to surgery. The chronic preauricular abscesses were curetted without resection of overlying skin or the abscess walls. Main outcome measure: Control of infection without recurrence following surgery. Results: 415 patient encounters involved preauricular sinuses/cysts. These ultimately led to 56 surgical excisions. 28 of the sinuses/cysts were infected at presentation. All infected lesions were treated with oral antibiotics. 6 infected sinuses/cysts were needle aspirated. 2 infected sinuses/cysts required incision and drainage. 1 infected sinus/cyst could not be controlled by either drainage technique and was surgically excised while actively infected. Nine children presented with chronic preauricular abscesses. One the 28 infected sinuses/cysts (3.5%) recurred 10 years after surgery– it was cured with re-resection at the root of the helix. Conclusion: Treatment of infected preauricular sinuses/cysts remains controversial. Control of infection prior to definitive surgery is desirable, but not mandatory. Chronic preauricular abscesses can be managed by sinus/cyst excision and subcutaneous abscess curettage without resection of the abscess wall or overlying skin. This leads to consistent control and favorable cosmesis.
1. Introduction Preauricular sinuses are among the most common of congenital auricular abnormalities affecting 1–2% of individuals worldwide [1–17]. Most are asymptomatic and require no treatment. A minority of these sinuses becomes repeatedly infected with local inflammation around the associated subcutaneous cyst and purulent discharge from the sinus (Figs. 1, 2 and 3a). Complete excision of the cyst and sinus is indicated in such cases to control infection and to prevent complications. Despite careful surgical excision, recurrences are common – especially with infected lesions that required incision and drainage [2]. Several surgical modifications have been proposed to improve primary control and to deal with recurrent lesions. Some infected sinuses/cysts go on to cause chronic preauricular abscesses. This is thought to occur from rupture of the anterior wall of
the preauricular cyst with spillage of the infected squamous debris into the subcutaneous fat plane. Intense chronic inflammation and foreign body reaction ensue [3] with fat necrosis and eventual thinning and erosion of the overlying skin (Figs. 1 and 2). Several authors have advocated treating such chronic preauricular abscesses by en bloc resection of the preauricular sinus/cyst, the abscess wall and its overlying skin. While effective, this radical approach to treatment produces a large tissue defect, often requiring reconstruction with local flaps. The cosmetic results are less than optimal. Further, extensive preauricular dissection places the temporal branch of the facial nerve at risk as it travels just beneath the subcutaneous fat above the zygomatic arch [4]. Unhappy with the results of radical resection, we adopted a more conservative approach to the treatment of chronic preauricular abscesses. This included preoperative control of infection with antibiotics
Portions of this work were presented as a poster at the American Society of Pediatric Otolaryngology annual meeting, Austin TX, May 3–5, 2019. Corresponding author. Department of Otolaryngology, Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, 1077 Rydal Road, Suite 201, Rydal, PA, 19046, United States. E-mail address: [email protected]. ☆ ∗
https://doi.org/10.1016/j.ijporl.2019.109682 Received 9 August 2019; Received in revised form 29 August 2019; Accepted 11 September 2019 Available online 17 September 2019 0165-5876/ © 2019 Published by Elsevier B.V.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
2. Methods 2.1. Computerized chart review After receiving an exemption from Temple University's Human Research Protection Program (IRB protocol 24873) a computerized collection of patient office notes and operative reports was queried using the Microsoft Word “find” feature. The data collection was done in a manner that protected patient identity and privacy. All children who were evaluated for preauricular sinuses/cysts from January 2002–December 2018 were identified using the search terms “preauricular,” “pit” “cyst” “sinus” and “abscess”. Age at time of surgery, gender, surgical procedure, postoperative complications and need for reoperation were recorded. 2.2. Management and surgical technique Infected preauricular sinuses/cysts were treated in a consistent manner during the study period. Children presenting with an infected sinus/cyst were treated with oral antibiotics (usually amoxicillin – clavulanate) for 10–14 days. Infected cysts content were needle-aspirated at the beginning of therapy when possible. Incision and drainage was reserved for infections refractory to needle-aspiration and systemic antibiotics. In such cases the incision was placed in the future line of resection. (Fig. 2b). Some patients were placed on prophylactic cephalexin for 4–6 weeks prior to definitive resection. Once infection was controlled, the preauricular sinus/cyst was surgically resected using an elliptical incision around the sinus toward the root of the helix. The cyst's extent was determined by inserting a lacrimal probe into its sinus. The cyst was resected, including a contiguous portion of root of helix cartilage under loupe magnification. When scarring prevented easy identification of the temporalis fascia in the preauricular area, a supra-auricular extension of the cephalic portion of the incision was included as described by Prasad, Grundfast and Milmoe [6]. It was sometimes difficult to identify the anterior wall of the cyst following rupture and anterior abscess formation. In such cases the anterior cyst wall and adherent scar were sharply incised and separated from anterior soft tissues and the underlying temporalis fascia. In the cases complicated by preauricular abscesses, once the preauricular sinus/cyst was resected, blunt dissection was carried anteriorly to open the abscess cavity sparing the overlying skin – even if the dermis was attenuated. The abscess contents were scooped out with a large mastoid curette with care not to abrade the superficial (parotidtemporal) fascia above the zygoma. The abscess cavity was then repeated irrigated. A Penrose drain was placed and mastoid dressing applied.
Fig. 1. Infected preauricular sinus/cyst (dotted circle) with chronic preauricular abscess (arrows).
Fig. 2. a – infected preauricular sinus/cyst with abscess formation at root of helix. b – infected preauricular sinus/cyst after incision and drainage in future resection line.
and cyst drainage if necessary. Surgery included resection the preauricular sinus/cyst and curettage of the abscess cavity contents with preservation of the overlying skin [5]. This report describes our experience with this approach over the last 16 years.
3. Results Among 72,000 patient encounters between 2002 and 2018, 415 involved pre-auricular sinuses/cysts. These ultimately led to 56 surgical
Fig. 3. Infected preauricular sinus/cyst with chronic preauricular abscess a) persistence after incision and drainage; b) after sinus/cyst resection – note breakdown of thinned skin over preauricular abscess; c) healing by second intention with favorable cosmetic result. 2
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
Table 1 Results of comprehensive treatment of preauricular sinuses/cysts. 56 surgically treated children
Antibiotic treatment
Needle aspiration
Incision and drainage
Prophylactic antibiotics
Operated while infected
Recurrence requiring re-resection
28 infected 28 not infected
28 0
8 (6 controlled) 0
2 (not controlled by needle aspiration) 0
7 0
1 0
1 (at 10 years postop) 0
Results of comprehensive treatment of preauricular sinuses/cysts.
excisions. 28 of the sinuses/cysts were infected at presentation. All infected lesions were treated with oral antibiotics and 7 received antibiotic prophylaxis until surgery (mean duration 6 weeks). 6 infected cysts were controlled by needle-aspiration. 2 infected cysts required incision and drainage. 1 infected cyst could not be controlled by either drainage technique and was surgically excised while actively infected (). A single infected sinus/cyst recurred 10 years after initial surgery. It was cured with re-resection of the previous surgical site. The recurrence was identified at the root of the helix, rather than in the location of the previous preauricular abscess cavity (Table 1).
claimed no recurrences and good cosmetic results. While resection of actively infected lesions is possible, this runs against classical surgical teaching and, we believe, results in unnecessary sacrifice of cosmetically important tissues. We prefer to control infection preoperatively when possible with oral antibiotics and needle aspiration. We adopted the conservative, skin-sparing approach to chronic preauricular abscesses soon after Shu and Lin's description of the technique. Our results mirror those of the groups in Asia. While these preauricular abscesses likely result from spilled infectious material and dead squamous debris from the preauricular cyst, there is no evidence that abscess cavities contain viable squamous epithelium that might produce a recurrent cyst. Foreign body reaction, seen histologically within resected abscesses, responds to meticulous resection of the preauricular sinus/cyst and thorough cleaning of the abscess cavity without the need to resect the abscess wall or adjacent skin. The skin of the temple – the typical location chronic preauricular abscesses – is among the so-called the NEET sites (concave surface of the nose, eye, ear, and temple) that respond favorably to second intention healing [17]. Modest-sized surgical defects in these locations are less conspicuous when no attempt is made to approximate skin edges or perform local tissue rearrangements. This accounts for the favorable cosmetic results described by Shim et al. and experienced by those patients in our series with temporal skin defects (Fig. 3). Weaknesses of this study include its retrospective design and lack of control groups (infected lesions not treated with antibiotics; abscesses treated by radical resection of involved skin). Despite this, our approach resulted in a low rate of recurrence and excellent cosmesis compared to published series.
4. Discussion Optimum management of infected preauricular sinuses/cysts has been controversial since they were identified as a distinct entity a century ago [7]. By 1942, Pastore and Erich [8] recognized that complete surgical excision of the infected sinuses/cysts was ideal, but complained that, “extirpation of the entire sac or fibrous tract … is often difficult because of poor visualization of the tract”. They advocated use of a probe or methylene blue to identify the tract. Sclerosing agents and eletrodiathermy were added when complete excision was not possible. By the 1960s the complete surgical excision of the sinus/cyst in a clear operative field had become the standard of care. Singer [9] noted that it was important to hug the root of helix cartilage during resection and that … “occasionally, adhesions from previous infections may require the slicing off of a thin piece of cartilage.” Routine resection of root of helix perichondrium and/or cartilage did not become standard until the 1990s [10,11]. There are two schools of thought regarding the best approach to chronic preauricular abscesses associated with infect preauricular sinuses/cysts. On camp holds that radical resection of the sinus/cyst in continuity with the preauricular abscess and its overlying skin leads to the lowest recurrence rate [3]. Excision through parallel preauricular incisions [12], L-shaped skin resection [13] and en bloc resection with advancement [14] or rotation flap reconstruction have been advocated by different groups. While en bloc resection clears the operative field of infection, cosmetic results in this very visible facial region are less than perfect. Transposition of hair-bearing scalp may require subsequent depilatory treatment. In addition, dissection anterior to root of helix and cephalad to the zygomatic arch places the temporal branch of the facial nerve at risk of injury [15]. In 2001 Shu and Lin [5] described an alternative surgical technique for addressing preauricular abscesses. They performed a meticulous resection of the underlying sinus/cyst then curetted the abscess cavity preserving the overlying skin. They claimed superior cosmetic results. While case numbers were not provided, they stated that, “late recurrences are rare. When recurrence does occur, it mostly appears within the first 2 weeks … (as) a result of residual cyst wall inside the wound.” More recently Shim et al. [16] published a five-year series of 136 preauricular sinuses/cysts. Of these, 68 were infected at the time of surgery and 42 exhibited abscess formation. They operated on these lesions without attempting to control infection prior to surgery. The associated preauricular abscesses were treated with curettage and elliptical resection of overlying thinned skin. Any subsequent skin breakdown was treated conservatively and allowed to heal by second intention. They
5. Conclusion We present a 16-year, single-surgeon experience with infected preauricular sinuses/cysts. Active infection was controlled preoperatively in 27 of 28 lesions with oral antibiotics, sometimes in combination with needle-aspiration or incision and drainage. One infected lesion with a large associated preauricular abscess could not be controlled and was resected while infected. A single recurrence among the infected sinuses/cysts appeared 10-years after initial resection and was cured by re-resection at the root of helix. The approach we present results in consistent control of infected preauricular sinuses/cysts with minimal morbidity and excellent cosmetic results. Funding None. Conflicts of interest None. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijporl.2019.109682. 3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109682
G. Isaacson
References
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