- Email: [email protected]
Clinical efficacy of standard simple elliptical incision following drain-less and subcutaneous suture technique in preauricular sinus surgery
Am J Otolaryngol xxx (xxxx) xxxx
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Clinical efficacy of standard simple elliptical incision following drain-less and subcutaneous suture technique in preauricular sinus surgery Mohsen Hussain Khardali, Jae Sang Han, Sun-Ik Kim, Ho Joon Jin, Seoung Min Lee, Jung Ju Han, ⁎ Jung Mee Park, Kyoung Ho Park Department of Otolaryngology Head & Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
A R T I C LE I N FO
A B S T R A C T
Keywords: Preauricular sinus Drain-less Standard simple elliptical incision Subcutaneous suture technique
Background: The purpose of this study was to review our surgical strategy and outcomes of drain-less, subcutaneous suture technique in standard simple elliptical incision on preauricular sinus (PAS) cases. Methods: The clinical records of 198 patients (247 ears) with PASs who were operated via standard simple elliptical incision with drain-less, subcutaneous suture technique by a single surgeon (K.H.P.) between January 2008 and December 2018 were reviewed for analysis. Patients' demographics, location of PASs, previous incision and drainage (I&D) history, previous surgical excision history, duration of follow-up, postoperative infection after surgery, and recurrence after surgery were analysed. Results: Out of 247 PASs, 18 (7.3%) cases had postoperative infections and 11 (4.5%) cases showed recurrence. Postoperative infection rate were higher in previous I&D groups (PIDGs, 9.8%) and previous fistulectomy groups (PFGs, 10%), and also recurrence rates of PFGs (10%) was higher than those of fresh cases. However, there were no statistically significant differences between these groups. In addition, PAS patients with postoperative complications such as infection and recurrence were more common in male patients. Conclusion: We report a method of drain-less standard simple elliptical incision for the surgical removal of PAS and the outcomes of the surgery. Our method showed a low recurrence rate and low chance of wound infection postoperatively not only in fresh cases but also in pre-operative I&D cases and even previous fistulectomy cases. In conclusion, our method is proposed as an effective and safe method in all kind of patient groups, without presenting post-operative discomfort to patients.
1. Introduction Incidence of preauricular sinus (PAS) is known as 1–2% of individuals worldwide [1]. PASs are more often seen as unilateral sided and more involved in women than men. This malformation is associated with a defect in the development of the first brachial arch during the sixth week of gestation and sometimes related with syndromes such as Branchio-Oto-Renal syndrome [2]. PAS occurs either sporadically or hereditary, but it tends to be inherited when it is bilateral [3]. PAS is located more superficially than the temporalis fascia, laterally and superiorly from the parotid gland and facial nerve. And the terminal cutaneous portion of PAS is in close proximity and often adheres to the cartilage of the first portion of the helix [4]. Most of PASs is clinically silent. Most of PASs is clinically silent. The appearance of symptoms is related to an infectious process. The basic treatment modality is to surgically remove all pathologic tissues, but the incidence of recurrence
has been reported to be between 9 and 42% based on a standard surgical technique; simple sinectomy [4–6]. Recently, several studies have shown that it is effective not to put in postoperative drain [7,8]. However, it has not been reported yet whether these surgical techniques are equally effective in patients who have undergone incision and drainage (I&D) and fistulectomy before surgery. The purpose of this study was to review our surgical strategy and outcomes of drain-less, standard simple elliptical incision approach with subcutaneous suture technique on PAS cases with pre-operative I& D or previous excision. 2. Materials and methods 2.1. Patients The clinical records of PAS patients who underwent surgery were
⁎ Corresponding author at: Department of Otolaryngology-Head & Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea. E-mail address: [email protected] (K.H. Park).
https://doi.org/10.1016/j.amjoto.2020.102465 Received 16 March 2020 0196-0709/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Mohsen Hussain Khardali, et al., Am J Otolaryngol, https://doi.org/10.1016/j.amjoto.2020.102465
Am J Otolaryngol xxx (xxxx) xxxx
M.H. Khardali, et al.
reviewed retrospectively. All patients were treated by the same surgeon (K.H.P.) via standard elliptical incision approach with drain-less subcutaneous suture technique between January 2008 and end of December 2018. Patient demographics, sinus location, documentation of previous I&D or previous fistulectomy, duration of follow-up, postoperative complications and recurrence after surgery.
Table 2 Comparison of clinical characteristics between PAS patients without postoperative complications (non-complication groups) and patients with complications (complication groups).
Age (year, mean ± SD)a Gender (M:F)b Site of sinus (right:left:bilateral)b Previous incision and drainageb Previous fistulectomyb Follow-up duration (month, mean ± SD)a
2.2. Surgical techniques The preauricular area was infiltrated with Xylocaine 2% with epinephrine 1:100,000 to reduce intraoperative bleeding. Methylene blue was instilled into the orifice to mark the branches of the sinus tract. A standard elliptical incision was made around the orifice. The dissection was done along the sinus tract, superficial to the temporalis fascia medially and to the perichondrium of the anterior helical cartilage posteriorly. The fistula and surrounding subcutaneous tissues were excised completely using sharp bipolar diathermy because author tried to reduce the bleeding during the dissection. The related perichondrium (sometimes with part of cartilage) of the helix at the base of the fistula was dissected and removed along with the specimen to ensure complete removal of the epithelial lining. The wound bed was irrigated with saline and hemostasis was done. In the drain-less group, the wound was closed with absorbable subcutaneous sutures in a medial to lateral direction, which better ensured complete removal of the dead space. For tight subcutaneous closure, a suture should involve the subcutaneous tissue, fascia of the temporalis muscle, and sometimes part of cartilage. A simple wound dressing and compression using an elastic bandage was applied for 1 day.
Complication groups (n = 18)
p-Values
25.2 ± 15.5 82:147 68:72:89
19.6 ± 15.3 15:3 2:7:9
0.135 0.000 0.250
48 (21.0%)
6 (33.3%)
0.239
9 (3.9%) 3.5 ± 8.3
1 (5.6%) 3.7 ± 3.5
1.000 0.951
SD; standard deviation, M; male, F; female. a Unpaired t-test. b Chi-square test.
require revision surgery, were minor infections such was stitch abscess, and were controlled with antibiotics without recurrence. To compare the complication rate based on the presence or absence of past procedures, the subjects were divided into three groups depending on whether I&D or fistulectomy was implemented or not. The postoperative infection rate (9.8%, p = 0.411) and re-operation rate (3.9%, p = 0.905) of the preoperative I&D groups (PIDGs; n = 51) was higher than those of fresh groups (non I&D or fistulectomy groups, NPIDFGs; n = 168), but there were no statistically significant differences. In addition, comparison was conducted between NPIDFGs and previous fistulectomy groups (PFGs; n = 10). All PFG cases were unilateral, which was observed for statistical differences from NPFGs (p = 0.007). However, there was no significant difference between the two groups in other parameters, including post-operative infection (p = 0.505) and recurrence cases (p = 0.382) in which revision operation was need (Table 3). The comparative data of the surgical outcomes between groups according to postoperative complications is summarized in Fig. 1.
2.3. Statistics The statistical analysis and comparison were performed utilizing SPSS 24.0 statistical software for Windows (IBM, Armonk, NY, USA). The significance level was set at p < 0.05. 3. Results A total of 247 ears of 198 patients were managed at our hospital between January 2008 and December 2018. We found 70 (35.3%) for right, 79 (39.8%) for left, and 49 (24.7%) for both side, respectively. A first single-stage procedure was adopted in 238 (96.4%) PAS cases. 18 (7.3%) had postoperative infections and 11 (4.5%) had recurrence and needed a revision operation. The mean ± standard deviations (SD) follow-up period was 3.79 ± 8.74 months (Table 1). The clinical characteristics of patients with postoperative infection or recurrence were compared with those who recovered without any complications. Mean age of postoperative complication group (19.6 ± 15.3 years) was younger than non-complication group (25.2 ± 15.5 years) without statistically significant difference (p = 0.135). In complication group, more male patients were included (83.3%), which was statistically significant (p = 0.000). No statistically significant differences were observed for other parameters, including previous I&D history (p = 0.239) or previous fistulectomy history (p = 1.000) (Table 2). All postoperative infection cases, which did not
4. Discussion The surgical treatment of PAS have problem of high recurrence rate following standard technique [4–6]. It is caused by the variability of the tract of the PASs, which makes it difficult to remove all pathologic tissues during surgery. In particular, the infection history can alter the path of the PASs, making it difficult to completely [9]. A histopathological analysis of revision PAS surgeries conducted by Kim WJ et al. showed that remnant PAS in 73.7% of the cases, mostly attached to the cartilage of the ascending helix. In addition, inflammatory tissue remained in all cases, suggesting wide local resection, including inflammatory soft tissues, and partial removal of ascending helix cartilage [10]. Some techniques have been suggested for correct identification of the PAS tracts, such as using small lacrimal probe and the use of methylene blue injection during the surgery. However, these techniques have their limits. That is, the lacrimal probe not only cannot identify small ramifications, but can also lead to inaccurate paths, and methylene blue can be diffused to tissues, making it difficult to accurately identify the smallest ramifications [11]. In 1990, supra-auricular approach was first introduced by Prasad et al. [12]. This surgical approach has better surgical view than standard elliptical incision approach. A systemic review which was conducted by Bruijnzeel et al., supra-auricular approach was shown better surgical outcome [13]. But we introduced that even the standard elliptical incision approach has good results as same as supra-auricular approach in this article. It may due to meticulous surgical removal of PAS with bloodless bipolar dissection and effective prevention of soft
Table 1 Overall clinical characteristics of subjects. Number of cases (total n = 247) Age (year, mean ± SD) Gender (M:F) Site of sinus (right:left:bilateral) Post-operative infection Recurrence Follow-up duration (month, mean ± SD)
Non-complication groups (n = 229)
25.2 ± 15.8 78:120 70:79:49 18 (7.3%) 11 (4.5%) 3.8 ± 8.7
SD; standard deviation, M; male, F; female. 2
Am J Otolaryngol xxx (xxxx) xxxx
M.H. Khardali, et al.
Table 3 Comparison of clinical characteristics and surgical results between non incision and drainage (I&D), fistulectomy groups (NIDFGs), and previous I&D groups (PIDGs) and previous fistulectomy groups (PFGs).
Age (year, mean ± SD)a Gender (M:F)b Site of sinus (right:left:bilateral)b Post-operative infectionb Recurrenceb Follow-up duration (month, mean ± SD)a
Fresh group (NPIDFG, n = 186)
Previous I&D group (PIDG, n = 51)
Previous fistulectomy group (PFG, n = 10)
24.4 ± 15.1 76:117 47:58:81 12 (6.5%) 8 (4.3%) 3.5 ± 8.1
24.3 ± 14.8 (p = 0.964) 21:33 (p = 1.000) 18:16:17 (p = 0.296) 5 (9.8%, p = 0.411) 2 (3.9%, p = 0.905) 3.8 ± 8.7 (p = 0.830)
34.2 ± 23.1 (p = 0.221) 7:3 (p = 0.052) 5:5:0 (p = 0.007) 1 (10%, p = 0.505) 1 (10%, p = 0.382) 2.3 ± 3.4 (p = 0.506)
SD; standard deviation, M; male, F; female. a Unpaired t-test. b Chi-square test. Fig. 1. Comparative data of surgical outcomes. Postoperative infection rates were higher in PIDGs and PFGs than in NPIDFGs, and recurrence rates were higher in PFGs. No statistically significant differences were observed in both the PIDGs and PFGs comparing NPIDFs (NPIDFGs: Non I&D or fistulectomy groups, PIDGs: preoperative I&D groups, PFGs: previous fistulectomy groups).
technique, including preoperative I&D and preoperative fistulectomy cases. In addition, more meticulous surgery should be considered for male patients due to the higher postoperative complication rates.
tissue dead space with the drain-less, subcutaneous suture technique. Sometimes we applied helix cartilage suture technique to reduce the postoperative dead space [14]. This approach, following drain-less and subcutaneous suture technique has many advantages. First, it can reduce the wound infection. The rate of the wound infection can be increased due to large postoperative dead space and the use of drain. However, our subcutaneous suture technique can be used to solve problems caused by the large dead space and the insertion of the drain. Second advantage is the better aesthetic results. Drain insertion usually requires compressive dressing that can cause skin necrosis, alopecia, and allergic reactions around preauricular area. Also, this technique can prevent the scar formation due to drain itself. Finally, our study has confirmed that this is a sufficiently effective method of surgery for patients who have previously received I&D or fistulectomy, as well as a fresh case. Not only was the low overall postoperative complication rate (infection, 7.3%; recurrence 4.5%), but also no significant difference in the complication rate in the PIDGs (infection, 9.8%; recurrence 3.9%) and PFGs (infection, 10%; recurrence, 10%). In our study, it was confirmed that the rate of postoperative complications in male patients was higher, in contrast to the high prevalence of PAS for women. This is thought to be the first time reported results, and given this fact, more precise surgery should be considered in male patients to avoid postoperative complications.
Author contributions M.-H Khardali and J.-S. Han contributed equally to this work. Declaration of competing interest All authors approved this manuscript and there is no conflict of interest. References [1] Isaacson G. Comprehensive management of infected preauricular sinuses/cysts. Int J Pediatr Otorhinolaryngol 2019;127:109682. [2] Hosokawa T, Takahashi H, Miyasaka Y, et al. Ultrasound evaluation of dermal sinuses/fistulas in pediatric patients. J Ultrasound Med 2019;38(12):3107–22. [3] An SY, Choi HG, Lee JS, et al. Analysis of incidence and genetic predisposition of preauricular sinus. Int J Pediatr Otorhinolaryngol 2014;78:2255–7. [4] Tan T, Constantinides H, Mitchell TE. The preauricular sinus: a review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol 2005;69:1469–74. [5] Gan EC, Anicete R, Tan HK, et al. Preauricular sinuses in the pediatric population: techniques and recurrence rates. Int J Pediatr Otorhinolaryngol 2013;77:372–8. [6] Lee KY, Woo SY, Kim SW, et al. The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea. Otol Neurotol 2014;35:1835–8. [7] Bae SC, Yun SH, Park KH, et al. Preauricular sinus: advantage of the drainless minimal supra-auricular approach. Am J Otolaryngol 2012;33:427–31. [8] Choo OS, Kim T, Jang JH, et al. The clinical efficacy of early intervention for infected preauricular sinus. Int J Pediatr Otorhinolaryngol 2017;95:45–50. [9] Leopardi G, Chiarella G, Conti S, et al. Surgical treatment of recurring preauricular sinus: supra-auricular approach. Acta Otorhinolaryngol Ital 2008;28:302–5. [10] Kim WJ, Lee YM, Kim DH, et al. Causes and prevention of revision surgery for
5. Conclusion We report a drain-less, subcutaneous suture technique in standard simple elliptical incision and the outcome of the surgical removal of PAS by following the proposed method. Low recurrence and postoperative wound infection rate were observed in PAS patients with this 3
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[13] Bruijnzeel H, van den Aardweg MT, Grolman W, et al. A systematic review on the surgical outcome of preauricular sinus excision techniques. Laryngoscope 2016;126:1535–44. [14] Chan KC, Kuo HT, Wai-Yee Ho V, et al. A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus. Int J Pediatr Otorhinolaryngol 2018;114:147–52.
preauricular sinus: a histopathological analysis. Int J Pediatr Otorhinolaryngol 2019;116:199–203. [11] Kumar Chowdary KV, Sateesh Chandra N, Karthik Madesh R. Preauricular sinus: a novel approach. Indian J Otolaryngol Head Neck Surg 2013;65:234–6. [12] Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990;100:320-1.
4
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Clinical efficacy of standard simple elliptical incision following drain-less and subcutaneous suture technique in preauricular sinus surgery Mohsen Hussain Khardali, Jae Sang Han, Sun-Ik Kim, Ho Joon Jin, Seoung Min Lee, Jung Ju Han, ⁎ Jung Mee Park, Kyoung Ho Park Department of Otolaryngology Head & Neck Surgery, College of Medicine, The Catholic University of Korea, Republic of Korea
A R T I C LE I N FO
A B S T R A C T
Keywords: Preauricular sinus Drain-less Standard simple elliptical incision Subcutaneous suture technique
Background: The purpose of this study was to review our surgical strategy and outcomes of drain-less, subcutaneous suture technique in standard simple elliptical incision on preauricular sinus (PAS) cases. Methods: The clinical records of 198 patients (247 ears) with PASs who were operated via standard simple elliptical incision with drain-less, subcutaneous suture technique by a single surgeon (K.H.P.) between January 2008 and December 2018 were reviewed for analysis. Patients' demographics, location of PASs, previous incision and drainage (I&D) history, previous surgical excision history, duration of follow-up, postoperative infection after surgery, and recurrence after surgery were analysed. Results: Out of 247 PASs, 18 (7.3%) cases had postoperative infections and 11 (4.5%) cases showed recurrence. Postoperative infection rate were higher in previous I&D groups (PIDGs, 9.8%) and previous fistulectomy groups (PFGs, 10%), and also recurrence rates of PFGs (10%) was higher than those of fresh cases. However, there were no statistically significant differences between these groups. In addition, PAS patients with postoperative complications such as infection and recurrence were more common in male patients. Conclusion: We report a method of drain-less standard simple elliptical incision for the surgical removal of PAS and the outcomes of the surgery. Our method showed a low recurrence rate and low chance of wound infection postoperatively not only in fresh cases but also in pre-operative I&D cases and even previous fistulectomy cases. In conclusion, our method is proposed as an effective and safe method in all kind of patient groups, without presenting post-operative discomfort to patients.
1. Introduction Incidence of preauricular sinus (PAS) is known as 1–2% of individuals worldwide [1]. PASs are more often seen as unilateral sided and more involved in women than men. This malformation is associated with a defect in the development of the first brachial arch during the sixth week of gestation and sometimes related with syndromes such as Branchio-Oto-Renal syndrome [2]. PAS occurs either sporadically or hereditary, but it tends to be inherited when it is bilateral [3]. PAS is located more superficially than the temporalis fascia, laterally and superiorly from the parotid gland and facial nerve. And the terminal cutaneous portion of PAS is in close proximity and often adheres to the cartilage of the first portion of the helix [4]. Most of PASs is clinically silent. Most of PASs is clinically silent. The appearance of symptoms is related to an infectious process. The basic treatment modality is to surgically remove all pathologic tissues, but the incidence of recurrence
has been reported to be between 9 and 42% based on a standard surgical technique; simple sinectomy [4–6]. Recently, several studies have shown that it is effective not to put in postoperative drain [7,8]. However, it has not been reported yet whether these surgical techniques are equally effective in patients who have undergone incision and drainage (I&D) and fistulectomy before surgery. The purpose of this study was to review our surgical strategy and outcomes of drain-less, standard simple elliptical incision approach with subcutaneous suture technique on PAS cases with pre-operative I& D or previous excision. 2. Materials and methods 2.1. Patients The clinical records of PAS patients who underwent surgery were
⁎ Corresponding author at: Department of Otolaryngology-Head & Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea. E-mail address: [email protected] (K.H. Park).
https://doi.org/10.1016/j.amjoto.2020.102465 Received 16 March 2020 0196-0709/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Mohsen Hussain Khardali, et al., Am J Otolaryngol, https://doi.org/10.1016/j.amjoto.2020.102465
Am J Otolaryngol xxx (xxxx) xxxx
M.H. Khardali, et al.
reviewed retrospectively. All patients were treated by the same surgeon (K.H.P.) via standard elliptical incision approach with drain-less subcutaneous suture technique between January 2008 and end of December 2018. Patient demographics, sinus location, documentation of previous I&D or previous fistulectomy, duration of follow-up, postoperative complications and recurrence after surgery.
Table 2 Comparison of clinical characteristics between PAS patients without postoperative complications (non-complication groups) and patients with complications (complication groups).
Age (year, mean ± SD)a Gender (M:F)b Site of sinus (right:left:bilateral)b Previous incision and drainageb Previous fistulectomyb Follow-up duration (month, mean ± SD)a
2.2. Surgical techniques The preauricular area was infiltrated with Xylocaine 2% with epinephrine 1:100,000 to reduce intraoperative bleeding. Methylene blue was instilled into the orifice to mark the branches of the sinus tract. A standard elliptical incision was made around the orifice. The dissection was done along the sinus tract, superficial to the temporalis fascia medially and to the perichondrium of the anterior helical cartilage posteriorly. The fistula and surrounding subcutaneous tissues were excised completely using sharp bipolar diathermy because author tried to reduce the bleeding during the dissection. The related perichondrium (sometimes with part of cartilage) of the helix at the base of the fistula was dissected and removed along with the specimen to ensure complete removal of the epithelial lining. The wound bed was irrigated with saline and hemostasis was done. In the drain-less group, the wound was closed with absorbable subcutaneous sutures in a medial to lateral direction, which better ensured complete removal of the dead space. For tight subcutaneous closure, a suture should involve the subcutaneous tissue, fascia of the temporalis muscle, and sometimes part of cartilage. A simple wound dressing and compression using an elastic bandage was applied for 1 day.
Complication groups (n = 18)
p-Values
25.2 ± 15.5 82:147 68:72:89
19.6 ± 15.3 15:3 2:7:9
0.135 0.000 0.250
48 (21.0%)
6 (33.3%)
0.239
9 (3.9%) 3.5 ± 8.3
1 (5.6%) 3.7 ± 3.5
1.000 0.951
SD; standard deviation, M; male, F; female. a Unpaired t-test. b Chi-square test.
require revision surgery, were minor infections such was stitch abscess, and were controlled with antibiotics without recurrence. To compare the complication rate based on the presence or absence of past procedures, the subjects were divided into three groups depending on whether I&D or fistulectomy was implemented or not. The postoperative infection rate (9.8%, p = 0.411) and re-operation rate (3.9%, p = 0.905) of the preoperative I&D groups (PIDGs; n = 51) was higher than those of fresh groups (non I&D or fistulectomy groups, NPIDFGs; n = 168), but there were no statistically significant differences. In addition, comparison was conducted between NPIDFGs and previous fistulectomy groups (PFGs; n = 10). All PFG cases were unilateral, which was observed for statistical differences from NPFGs (p = 0.007). However, there was no significant difference between the two groups in other parameters, including post-operative infection (p = 0.505) and recurrence cases (p = 0.382) in which revision operation was need (Table 3). The comparative data of the surgical outcomes between groups according to postoperative complications is summarized in Fig. 1.
2.3. Statistics The statistical analysis and comparison were performed utilizing SPSS 24.0 statistical software for Windows (IBM, Armonk, NY, USA). The significance level was set at p < 0.05. 3. Results A total of 247 ears of 198 patients were managed at our hospital between January 2008 and December 2018. We found 70 (35.3%) for right, 79 (39.8%) for left, and 49 (24.7%) for both side, respectively. A first single-stage procedure was adopted in 238 (96.4%) PAS cases. 18 (7.3%) had postoperative infections and 11 (4.5%) had recurrence and needed a revision operation. The mean ± standard deviations (SD) follow-up period was 3.79 ± 8.74 months (Table 1). The clinical characteristics of patients with postoperative infection or recurrence were compared with those who recovered without any complications. Mean age of postoperative complication group (19.6 ± 15.3 years) was younger than non-complication group (25.2 ± 15.5 years) without statistically significant difference (p = 0.135). In complication group, more male patients were included (83.3%), which was statistically significant (p = 0.000). No statistically significant differences were observed for other parameters, including previous I&D history (p = 0.239) or previous fistulectomy history (p = 1.000) (Table 2). All postoperative infection cases, which did not
4. Discussion The surgical treatment of PAS have problem of high recurrence rate following standard technique [4–6]. It is caused by the variability of the tract of the PASs, which makes it difficult to remove all pathologic tissues during surgery. In particular, the infection history can alter the path of the PASs, making it difficult to completely [9]. A histopathological analysis of revision PAS surgeries conducted by Kim WJ et al. showed that remnant PAS in 73.7% of the cases, mostly attached to the cartilage of the ascending helix. In addition, inflammatory tissue remained in all cases, suggesting wide local resection, including inflammatory soft tissues, and partial removal of ascending helix cartilage [10]. Some techniques have been suggested for correct identification of the PAS tracts, such as using small lacrimal probe and the use of methylene blue injection during the surgery. However, these techniques have their limits. That is, the lacrimal probe not only cannot identify small ramifications, but can also lead to inaccurate paths, and methylene blue can be diffused to tissues, making it difficult to accurately identify the smallest ramifications [11]. In 1990, supra-auricular approach was first introduced by Prasad et al. [12]. This surgical approach has better surgical view than standard elliptical incision approach. A systemic review which was conducted by Bruijnzeel et al., supra-auricular approach was shown better surgical outcome [13]. But we introduced that even the standard elliptical incision approach has good results as same as supra-auricular approach in this article. It may due to meticulous surgical removal of PAS with bloodless bipolar dissection and effective prevention of soft
Table 1 Overall clinical characteristics of subjects. Number of cases (total n = 247) Age (year, mean ± SD) Gender (M:F) Site of sinus (right:left:bilateral) Post-operative infection Recurrence Follow-up duration (month, mean ± SD)
Non-complication groups (n = 229)
25.2 ± 15.8 78:120 70:79:49 18 (7.3%) 11 (4.5%) 3.8 ± 8.7
SD; standard deviation, M; male, F; female. 2
Am J Otolaryngol xxx (xxxx) xxxx
M.H. Khardali, et al.
Table 3 Comparison of clinical characteristics and surgical results between non incision and drainage (I&D), fistulectomy groups (NIDFGs), and previous I&D groups (PIDGs) and previous fistulectomy groups (PFGs).
Age (year, mean ± SD)a Gender (M:F)b Site of sinus (right:left:bilateral)b Post-operative infectionb Recurrenceb Follow-up duration (month, mean ± SD)a
Fresh group (NPIDFG, n = 186)
Previous I&D group (PIDG, n = 51)
Previous fistulectomy group (PFG, n = 10)
24.4 ± 15.1 76:117 47:58:81 12 (6.5%) 8 (4.3%) 3.5 ± 8.1
24.3 ± 14.8 (p = 0.964) 21:33 (p = 1.000) 18:16:17 (p = 0.296) 5 (9.8%, p = 0.411) 2 (3.9%, p = 0.905) 3.8 ± 8.7 (p = 0.830)
34.2 ± 23.1 (p = 0.221) 7:3 (p = 0.052) 5:5:0 (p = 0.007) 1 (10%, p = 0.505) 1 (10%, p = 0.382) 2.3 ± 3.4 (p = 0.506)
SD; standard deviation, M; male, F; female. a Unpaired t-test. b Chi-square test. Fig. 1. Comparative data of surgical outcomes. Postoperative infection rates were higher in PIDGs and PFGs than in NPIDFGs, and recurrence rates were higher in PFGs. No statistically significant differences were observed in both the PIDGs and PFGs comparing NPIDFs (NPIDFGs: Non I&D or fistulectomy groups, PIDGs: preoperative I&D groups, PFGs: previous fistulectomy groups).
technique, including preoperative I&D and preoperative fistulectomy cases. In addition, more meticulous surgery should be considered for male patients due to the higher postoperative complication rates.
tissue dead space with the drain-less, subcutaneous suture technique. Sometimes we applied helix cartilage suture technique to reduce the postoperative dead space [14]. This approach, following drain-less and subcutaneous suture technique has many advantages. First, it can reduce the wound infection. The rate of the wound infection can be increased due to large postoperative dead space and the use of drain. However, our subcutaneous suture technique can be used to solve problems caused by the large dead space and the insertion of the drain. Second advantage is the better aesthetic results. Drain insertion usually requires compressive dressing that can cause skin necrosis, alopecia, and allergic reactions around preauricular area. Also, this technique can prevent the scar formation due to drain itself. Finally, our study has confirmed that this is a sufficiently effective method of surgery for patients who have previously received I&D or fistulectomy, as well as a fresh case. Not only was the low overall postoperative complication rate (infection, 7.3%; recurrence 4.5%), but also no significant difference in the complication rate in the PIDGs (infection, 9.8%; recurrence 3.9%) and PFGs (infection, 10%; recurrence, 10%). In our study, it was confirmed that the rate of postoperative complications in male patients was higher, in contrast to the high prevalence of PAS for women. This is thought to be the first time reported results, and given this fact, more precise surgery should be considered in male patients to avoid postoperative complications.
Author contributions M.-H Khardali and J.-S. Han contributed equally to this work. Declaration of competing interest All authors approved this manuscript and there is no conflict of interest. References [1] Isaacson G. Comprehensive management of infected preauricular sinuses/cysts. Int J Pediatr Otorhinolaryngol 2019;127:109682. [2] Hosokawa T, Takahashi H, Miyasaka Y, et al. Ultrasound evaluation of dermal sinuses/fistulas in pediatric patients. J Ultrasound Med 2019;38(12):3107–22. [3] An SY, Choi HG, Lee JS, et al. Analysis of incidence and genetic predisposition of preauricular sinus. Int J Pediatr Otorhinolaryngol 2014;78:2255–7. [4] Tan T, Constantinides H, Mitchell TE. The preauricular sinus: a review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol 2005;69:1469–74. [5] Gan EC, Anicete R, Tan HK, et al. Preauricular sinuses in the pediatric population: techniques and recurrence rates. Int J Pediatr Otorhinolaryngol 2013;77:372–8. [6] Lee KY, Woo SY, Kim SW, et al. The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea. Otol Neurotol 2014;35:1835–8. [7] Bae SC, Yun SH, Park KH, et al. Preauricular sinus: advantage of the drainless minimal supra-auricular approach. Am J Otolaryngol 2012;33:427–31. [8] Choo OS, Kim T, Jang JH, et al. The clinical efficacy of early intervention for infected preauricular sinus. Int J Pediatr Otorhinolaryngol 2017;95:45–50. [9] Leopardi G, Chiarella G, Conti S, et al. Surgical treatment of recurring preauricular sinus: supra-auricular approach. Acta Otorhinolaryngol Ital 2008;28:302–5. [10] Kim WJ, Lee YM, Kim DH, et al. Causes and prevention of revision surgery for
5. Conclusion We report a drain-less, subcutaneous suture technique in standard simple elliptical incision and the outcome of the surgical removal of PAS by following the proposed method. Low recurrence and postoperative wound infection rate were observed in PAS patients with this 3
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[13] Bruijnzeel H, van den Aardweg MT, Grolman W, et al. A systematic review on the surgical outcome of preauricular sinus excision techniques. Laryngoscope 2016;126:1535–44. [14] Chan KC, Kuo HT, Wai-Yee Ho V, et al. A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus. Int J Pediatr Otorhinolaryngol 2018;114:147–52.
preauricular sinus: a histopathological analysis. Int J Pediatr Otorhinolaryngol 2019;116:199–203. [11] Kumar Chowdary KV, Sateesh Chandra N, Karthik Madesh R. Preauricular sinus: a novel approach. Indian J Otolaryngol Head Neck Surg 2013;65:234–6. [12] Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990;100:320-1.
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