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The clinical efficacy of early intervention for infected preauricular sinus
International Journal of Pediatric Otorhinolaryngology 95 (2017) 45e50
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: http://www.ijporlonline.com/
The clinical efficacy of early intervention for infected preauricular sinus Oak-Sung Choo a, Top Kim a, Jeong Hun Jang a, Yun-Hoon Choung a, b, * a b
Department of Otolaryngology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Republic of Korea Bk21 Plus Research Center for Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 October 2016 Received in revised form 31 January 2017 Accepted 31 January 2017 Available online 4 February 2017
Objective: The study was designed to evaluate the outcomes of early surgical intervention, and to suggest the accurate operation time and surgical strategies. Methods: A total of 190 cases (144 patients) of PAS excision were classified into 2 groups according to their time of surgery; early intervention group (n ¼ 53), and non-early intervention group (n ¼ 137). Early intervention was defined as excision performed within 3 weeks from their first hospital visit, and after acute infection control, surgical removal was followed regardless of their infection status. The mean age of patients was 18.3 ± 15.7 years old (62 male, 82 female). During surgery, a parallel incision was added when iatrogenic fistula due to incision and drainage (I &D) or additionally opened wounds caused by infection was present. Results: Cases of I & D history, revision cases, use of preoperative antibiotics were significantly higher in the early intervention group compared to the non-early intervention group, however, the time of surgery did not affect the complication rate (p ¼ 0.533). Within the infected cases, only 1 patient from the nonearly intervention group showed a minor complication of keloid scar. During our follow up period of minimum of 6 months, there was no recurrence in either groups. Conclusion: The early intervention of PASs does not seem to increase postoperative complication or recurrence rates. A double parallel skin incision is a simple but adequate technique to treat infected PASs. © 2017 Elsevier B.V. All rights reserved.
Keywords: Preauricular sinus Infection Early intervention Excision
1. Introduction Preauricular sinus (PAS) is a congenital malformation of the preauricular soft tissues which was first described by Van Heusinger in 1864 [1]. The origin of PAS is closely related with the embryonal auricular development during the sixth week of gestation which is described by three different theories [2]. Among them, the most widely accepted theory is the incomplete or defective fusion of the six auditory hillocks also known as the Hillock of His [3]. The prevalence of PAS, ranging from 0.1% to 10%, varies among countries and their races with higher incidence reported in Asia (1e6%) and African regions (4e10%) than the Western populations
* Corresponding author. Department of Otolaryngology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Republic of Korea. E-mail addresses: [email protected] (O.-S. Choo), [email protected] (T. Kim), [email protected] (J.H. Jang), [email protected] (Y.-H. Choung). http://dx.doi.org/10.1016/j.ijporl.2017.01.037 0165-5876/© 2017 Elsevier B.V. All rights reserved.
(0.1e0.9%) [4,5]. Classically, PAS is sited in the anterior margin of the ascending limb of the helix however, variant types of PAS exist including the superior regions to the auricle, posterior surface of cymba concha, lobule, and even in the postauricular area [6]. Although asymptomatic PASs do not require treatments, patients with signs of infection such as chronic recurrent discharges, erythematous change, swelling, and pain with or without abscess formation are recommended to perform surgical resection of the sinus tracts (Fig. 1). Surgical intervention of PAS is generally considered to be held after complete infection control. Previous studies have claimed that proceeding the surgery after the infection is subsided by antibiotics and/or incision and drainage (I & D) results in better outcomes and prognosis [7e9]. However, there is no established method to prove that the infection has been completely “subsided” or “controlled”. And the proper timing of surgery to minimize any possible postoperative complications and recurrence have not been accurately descripted. This may raise questions of how long one should wait for the operation after infection control. Therefore, we have attempted to manage
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Fig. 1. Presentation of PASs according to their inflammatory status. (a) Asymptomatic case (b) Infection and recurrence after previous sinusectomy (c) infected PAS with abscess formation.
infected PASs with an early intervention protocol after immediate infection control. The recurrence rate of PAS ranges 9e42% [2e5]. To reduce the recurrence, various techniques including inside-out technique and supra-auricular approach have been introduced [10,11]. Choung et al. also reported that there was no recurrence after operations even in cases of postauricular sinuses, which are considered as a variant of PAS [6]. However, it is not easy to operate infected PASs with a classical technique due to abundant granulation tissues that are sometimes spilled out through infected wounds or necrotic skins of the infected PASs. Thus, certain operation techniques for the management of infected PASs are required. In the present study, a double parallel incision via an anterior descending approach was developed and performed for infected PASs. The purposes of the present study were to evaluate the outcomes of early surgical intervention, and to introduce new surgical strategies for infected PASs.
2. Material and methods 2.1. Patients From January 2010 to June 2014, a total of 190 cases (144 patients) diagnosed with PAS underwent surgical treatments by a single surgeon at the Department of Otolaryngology, Ajou University Hospital, Suwon, Republic of Korea. By approval from the Institutional Review Boards of the Ajou University School of Medicine, medical charts of these patients were reviewed retrospectively including patients' demographics, infection status during hospital visit, indication for surgery, time of surgery, surgical technique, postoperative complications, and recurrence rates. All patients included in the study were followed up for at least for 6 months. The cases were divided into two groups based on the time of surgery, and regardless of the inflammatory condition. Patients who underwent the surgery within 3 weeks from their 1st hospital visit were classified as the early intervention group (53 cases), and the others that performed the operation after 3 weeks from their 1st hospital visit were included in the non-early intervention group (137 cases). In both groups, all cases that showed acute infection were treated with oral antibiotics, and immediate I & D was performed when abscess formation was present (Fig. 2). Before performing the surgery, the infection status of the PASs was reexamined to select the surgical techniques for
complete excision (Fig. 3a). During surgery, only patients under the age of 12 received general anesthesia. 2.2. Surgical techniques All cases equally started the surgery with infiltration of 2% xylocaine/epinephrine 1:100,000 surrounding the sinus. Then, the direction and depth of the sinus tract were identified by a lacrimal duct probe and insertion of gentian violet solution into the sinus opening (Fig. 3b). An elliptical skin incision was designed around the sinus orifice identical to the standard technique of sinusectomy, and throughout the entire procedure the dissection of the tract was done using a no.15 blade rather than Metzenbaum scissor (Fig. 3c). For the asymptomatic cases, the classic technique was performed with minimal incision and noninvasive techniques. In cases of infected PASs with iatrogenic fistula due to I & D or additionally opened wounds caused by infection, a second incision parallel to the first elliptical incision was designed (Fig. 3e). The main purpose of the parallel incision was to completely remove the deep sinus tracts and their branches, and to clear all inflamed granulation tissues using a wider surgical view. This additional but focal incision also considered postoperative cosmetic concerns as it was parallel to the original elliptical incision. Since the infection sites were frequently detected in the anterior of the original sinus tracts, most of the additional parallel incisions were made anterior to the initial elliptical incisions (Fig. 3d). The elimination of inflamed tissues was completed by simply using a curette (Fig. 3f). Finally, bleeding control was accomplished by bipolar cautery and subcutaneous wound closure was done with absorbable sutures with caution to avoid dead space formation. None of the cases required drain insertion, and all patients received local compression dressing for a single day. The aim of our surgical technique was to first meticulously remove the sinus tract and branches, and extirpate all inflamed tissues from the operation site without extended procedures or aid of extra materials including inconvenient surgical tools. 2.3. Statistical analysis All analysis to evaluate the statistical differences of each group including history of I & D, history of previous sinusectomy, preoperative use of antibiotics, time of intervention along with complication and recurrence rates were done by Chi-squared test using SPSS software (version 18; SPSS Inc., Chicago, IL, USA). P
O.-S. Choo et al. / International Journal of Pediatric Otorhinolaryngology 95 (2017) 45e50
47
Fig. 2. Study design for PASs. All cases of infected PASs were treated with antibiotics, and I & D was additional performed when abscess formation was present. A total of 190 cases underwent surgical treatment, and cases were classified according to the time of surgery. (*early intervention: surgical excision performed within 3 weeks from their 1st hospital visits regardless of their infection status).
values < 0.05 were considered to be statistically significant. 3. Results Among 144 patients (62 male, 82 female) who were enrolled in the study, the age ranged from 5 months to 63 years with a mean age of 18.3 years. The site of the sinus was more dominant unilaterally (68.1%) than bilaterally (31.9%), and evenly distributed on both sides in cases of unilateral PASs (Table 1). Early intervention was conducted in 53 cases (29.7%) and nonearly intervention was performed in 137 cases (72.1%). The incidence of I &D history in the early intervention group and non-early intervention group was 34 cases (64.2%) and 48 cases (35.0%), respectively, indicating a significantly higher rate of I & D history in the early intervention group (p ¼ 0.000). Revision sinusectomy was done in 8 cases (15.1%) from the early intervention group, and in 4 cases (2.9%) from the non-early intervention group which showed that the recurred cases were significantly more frequent in the early intervention group (p ¼ 0.002) (Fig. 4). During the time of surgery, infected PASs were present in 35 cases (66.0%) from the early intervention group and 51 cases (37.2%) from the non-early intervention group. Despite the inflammatory condition, only 1 case of infected PAS from the non-early intervention group showed a minor complication of keloid scar 2 weeks after the surgery, which was treated using triamcinolone. During our follow up period of minimum of 6 months, there was no recurrence in either group (Table 2). 4. Discussion The only definitive treatment to prevent complications and recurrence of PASs is through complete surgical excision [2e5]. And determining the appropriate time of surgery is one of the most
important decisions to make. Typically, the procedure is proceeded when the condition is stable. Infectious status is managed by antibiotics and/or I & D but surgical treatment is avoided during or shortly after this period [9,12]. Based on this concept, some patients suffer from repetitive infections or persistent open wounds with necrotic skins which are difficult to heal. From the results of our study, the time of intervention did not affect the complication or recurrence rate. The only minor complication that was noted was a keloid scar from the non-early intervention group which was cured by triamcinolone. Even within the early intervention group, the infection status did not alter these rates. The next critical decision point is the surgical strategy for PAS. The original technique to remove the PAS is simple sinusectomy where the surgery begins with an elliptical incision around the sinus opening, and dissection along the sinus tract [13]. However, the recurrence rate of the standard method has been reported to be as high as 9e42% [2e5]. Since these rates have been revealed, many studies and reports have aimed to reduce the recurrence rate of PAS excision. In 2005, Baatenburg de Jong RJ introduced a surgical technique called the inside-out technique using stay sutures to facilitate the dissection of the tract, opening the sinus, and dissecting the tract by glistening the inside lining and outer wall under a microscope [10]. Later, in 2001 Lam et al. reported the comparison between the standard technique and the supra-auricular approach and demonstrated the lower recurrence rate (3.7% vs. 32%) concluding on the greater efficacy of the supra-auricular technique which was latter followed and modified by Leopardi G et al. and Bae SC et al. [11,14e17]. Other minor modifications and suggestions were using methylene blue staining and probing for fistula resection, and others also advised in using a microscope as a guidance to reduce the overall recurrence rate after surgery [4,18]. Other recent studies classified the PASs according to the severity of their infection status and introduced more extended incisions, and use of
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Fig. 3. Surgical techniques of infected PAS. (a) Black arrow indicates the site of I & D. (b) Lacrimal duct probe and gentian violet solution was used to identify the sinus tract. (c) Dissection of the tract was done by a no. 15 blade. (d) The direction of the tract is pointing downwards. (e) An additional parallel incision is designed for better exposure of the surgical field which enables complete removal of deep tracts and exuberant granulation tissues, and for postoperative cosmetic concerns. (f) Granulation tissues are removed by a curette. (g) Wound closure is done without drain insertion. (h) Two weeks after operation.
Table 1 Patients' demographics. No. of patients Gender Male Female Total patients Age age 12yrs age >12yrs Mean Age (±SD) Site of sinus Right Left Both Total cases
62 (43.1%) 82 (56.9%) 144 68 (47.2%) 76 (52.8%) 18.3 ± 15.7 yrs 45 (31.3%) 53 (36.8%) 46 (31.9%) 190
cottonoid® soaked with gentian violet solution for clear visualization of the main sinus tract and distal branches mostly commonly in the patients with PAS with abscess formation [19,20]. The novel approach for PAS excision in this study is the
additional parallel incision in infected cases and the removal of the remnant tissues using a curette. A single incision may be inadequate to remove the entire sinus tract, their branches, and the surrounding tissues, especially in infected PASs. By an additional but focal incision, which is parallel to the original elliptical incision, provides a wider surgical view enabling meticulous excision of the PAS and its surrounding inflamed tissues. This particular parallel incision was designed in consideration to cosmetic outcomes as well. The surrounding infectious tissues were also excised or removed by the use of a curette. This surgical step is simple but requisite because these remaining tissues are the main cause of postoperative complications such as non-healing wounds. Extra materials or devices to detect the lesions or drain insertion were not used in any of the cases in this study. Local anesthesia was also recommended during surgery unless the patient was under the age of 12, not only to avoid complications of anesthesia but because this factor was not recognized to influence the prognosis of the surgery. “The limitation of this study was the follow up period of 6 months. Long-term complications such as wound dehiscence or infection, and recurrences presenting with swelling, tenderness or erythematous change of the operation sites are possible but rare.
O.-S. Choo et al. / International Journal of Pediatric Otorhinolaryngology 95 (2017) 45e50
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Fig. 4. Clinical manifestations and management of PAS according to time of surgery. I & D history and revision cases, and acute infection control were significantly more frequent in the early intervention group compared to the non-early intervention group (p ¼ .000, p ¼ .000). Statistical analysis of complication and recurrence rates were insignificant.
Table 2 Cases of infected PASs. Groups
Number of infected cases
History of I & D
Revision cases
Complications
Recurrence
Early intervention Non-early intervention
35 (66.0%) 51 (37.2%)
23 (65.7%) 26 (51.0%)
8 (22.9%) 2 (1.5%)
0 1 (2.0%)
0 0
None of the patients from our study revisited the hospital with these recurrent symptoms even after 6 months from surgery.” 5. Conclusion For complete surgical removal of PAS, identification of its inflammatory condition is important. Immediate infection control such as antibiotics and I & D is also required however, the time of surgery after acute infection control does not seem to affect the complication or recurrence rate of sinusectomy. Furthermore, the key point of the surgical procedure includes complete removal of all sinus tracts, branches, and infectious tissues. Thus, the parallel incision is rather relevant to eliminate all structures of infected PAS, not only enabling the surgeon to remove remnant granulation tissues by using a curette but also considering cosmetic satisfactions. In conclusion, early intervention of infected PAS is possible followed by acute infection control with a simple but accurate additional parallel incision. Funding This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI15C-0968-000015). Conflict of interest The authors have no conflict of interest to disclose. References [1] R.G. Chami, J. Apesos, Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom, Ann. Plast. Surg. 23 (1989) 406e411.
[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) 1469e1474. [3] M. Ellies, R. Laskawi, C. Arglebe, C. Altrogge, Clinical evaluation and surgical management of congenital preauricular fistulas, J. Oral. Maxillofac. Surg. 56 (1998) 827e830. [4] 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) 372e378. [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) 1835e1838. [6] S.J. Choi, Y.H. Choung, K. Park, J. Bae, H.Y. Park, The variant type of preauricular sinus: postauricular sinus, Laryngoscope 117 (2007) 1798e1802. [7] S.W. Yeo, B.C. Jun, S.N. Park, et al., The preauricular sinus: factors contributing to recurrence after surgery, Am. J. Otolaryngol. 27 (2006) 396e400. [8] N.S. Scheinfeld, N.B. Silverberg, J.M. Weinberg, V. Nozad, The preauricular sinus: a review of its clinical presentation, treatment, and associations, Pediatr. Dermatol. 21 (2004) 191e196. [9] P.J. Cruse, R. Foord, The epidemiology of wound infection. A 10-year prospective study of 62, 939 wounds, Surg. Clin. North. Am. 60 (1980) 27e40. [10] R.J. Baatenburg de Jong, A new surgical technique for treatment of preauricular sinus, Surgery 137 (2005) 567e570. [11] G. Leopardi, G. Chiarella, S. Conti, E. Cassandro, Surgical treatment of recurring preauricular sinus: supra-auricular approach, Acta. Otorhinolaryngol. Ital. 28 (2008) 302e305. [12] D.S. Chang, H.Y. Lee, M.S. Choi, et al., Intralesional triamcinolone injections for the treatment of preauricular sinus infections, Am. J. Otolaryngol. 37 (2016) 523e527. [13] 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) 1405e1408. [14] 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) 317e319. [15] S.C. Bae, S.H. Yun, K.H. Park, K.H. Chang, D.H. Lee, E.J. Jeon, et al., Preauricular sinus: advantage of the drainless minimal supra-auricular approach, Am. J. Otolaryngol. 33 (2012) 427e431. [16] V. S. Kumar Chowdary Kavuturu, Sateesh Chandra Nelakurthi, Karthik Madesh Ratnavelu, Preauricular sinus: a novel approach, Indian. J. Otolaryngol. Head. Neck Surg. 65 (2013) 234e236. [17] H. Bruijnzeel, M.T. van den Aardweg, W. Grolman, et al., A systematic review on the surgical outcome of preauricular sinus excision techniques, Laryngoscope 126 (2016) 1535e1544.
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rez-Herrero, A. S llar, Methylene blue [18] R. Martín-Granizo, M.C. Pe anchez-Cue staining and probing for fistula resection: application in a case of bilateral congenital preauricular fistulas, Int. J. Oral. Maxillofac. Surg. 31 (2002) 439e441. [19] W.J. Huang, C.H. Chu, M.C. Wang, C.L. Kuo, A.S. Shiao, Decision making in the
choice of surgical management for preauricular sinuses with different severities, Otolaryngol. Head. Neck Surg. 148 (2013) 959e964. [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. Otorhinolaryngol. 270 (2013) 3127e3131.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: http://www.ijporlonline.com/
The clinical efficacy of early intervention for infected preauricular sinus Oak-Sung Choo a, Top Kim a, Jeong Hun Jang a, Yun-Hoon Choung a, b, * a b
Department of Otolaryngology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Republic of Korea Bk21 Plus Research Center for Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 October 2016 Received in revised form 31 January 2017 Accepted 31 January 2017 Available online 4 February 2017
Objective: The study was designed to evaluate the outcomes of early surgical intervention, and to suggest the accurate operation time and surgical strategies. Methods: A total of 190 cases (144 patients) of PAS excision were classified into 2 groups according to their time of surgery; early intervention group (n ¼ 53), and non-early intervention group (n ¼ 137). Early intervention was defined as excision performed within 3 weeks from their first hospital visit, and after acute infection control, surgical removal was followed regardless of their infection status. The mean age of patients was 18.3 ± 15.7 years old (62 male, 82 female). During surgery, a parallel incision was added when iatrogenic fistula due to incision and drainage (I &D) or additionally opened wounds caused by infection was present. Results: Cases of I & D history, revision cases, use of preoperative antibiotics were significantly higher in the early intervention group compared to the non-early intervention group, however, the time of surgery did not affect the complication rate (p ¼ 0.533). Within the infected cases, only 1 patient from the nonearly intervention group showed a minor complication of keloid scar. During our follow up period of minimum of 6 months, there was no recurrence in either groups. Conclusion: The early intervention of PASs does not seem to increase postoperative complication or recurrence rates. A double parallel skin incision is a simple but adequate technique to treat infected PASs. © 2017 Elsevier B.V. All rights reserved.
Keywords: Preauricular sinus Infection Early intervention Excision
1. Introduction Preauricular sinus (PAS) is a congenital malformation of the preauricular soft tissues which was first described by Van Heusinger in 1864 [1]. The origin of PAS is closely related with the embryonal auricular development during the sixth week of gestation which is described by three different theories [2]. Among them, the most widely accepted theory is the incomplete or defective fusion of the six auditory hillocks also known as the Hillock of His [3]. The prevalence of PAS, ranging from 0.1% to 10%, varies among countries and their races with higher incidence reported in Asia (1e6%) and African regions (4e10%) than the Western populations
* Corresponding author. Department of Otolaryngology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Republic of Korea. E-mail addresses: [email protected] (O.-S. Choo), [email protected] (T. Kim), [email protected] (J.H. Jang), [email protected] (Y.-H. Choung). http://dx.doi.org/10.1016/j.ijporl.2017.01.037 0165-5876/© 2017 Elsevier B.V. All rights reserved.
(0.1e0.9%) [4,5]. Classically, PAS is sited in the anterior margin of the ascending limb of the helix however, variant types of PAS exist including the superior regions to the auricle, posterior surface of cymba concha, lobule, and even in the postauricular area [6]. Although asymptomatic PASs do not require treatments, patients with signs of infection such as chronic recurrent discharges, erythematous change, swelling, and pain with or without abscess formation are recommended to perform surgical resection of the sinus tracts (Fig. 1). Surgical intervention of PAS is generally considered to be held after complete infection control. Previous studies have claimed that proceeding the surgery after the infection is subsided by antibiotics and/or incision and drainage (I & D) results in better outcomes and prognosis [7e9]. However, there is no established method to prove that the infection has been completely “subsided” or “controlled”. And the proper timing of surgery to minimize any possible postoperative complications and recurrence have not been accurately descripted. This may raise questions of how long one should wait for the operation after infection control. Therefore, we have attempted to manage
46
O.-S. Choo et al. / International Journal of Pediatric Otorhinolaryngology 95 (2017) 45e50
Fig. 1. Presentation of PASs according to their inflammatory status. (a) Asymptomatic case (b) Infection and recurrence after previous sinusectomy (c) infected PAS with abscess formation.
infected PASs with an early intervention protocol after immediate infection control. The recurrence rate of PAS ranges 9e42% [2e5]. To reduce the recurrence, various techniques including inside-out technique and supra-auricular approach have been introduced [10,11]. Choung et al. also reported that there was no recurrence after operations even in cases of postauricular sinuses, which are considered as a variant of PAS [6]. However, it is not easy to operate infected PASs with a classical technique due to abundant granulation tissues that are sometimes spilled out through infected wounds or necrotic skins of the infected PASs. Thus, certain operation techniques for the management of infected PASs are required. In the present study, a double parallel incision via an anterior descending approach was developed and performed for infected PASs. The purposes of the present study were to evaluate the outcomes of early surgical intervention, and to introduce new surgical strategies for infected PASs.
2. Material and methods 2.1. Patients From January 2010 to June 2014, a total of 190 cases (144 patients) diagnosed with PAS underwent surgical treatments by a single surgeon at the Department of Otolaryngology, Ajou University Hospital, Suwon, Republic of Korea. By approval from the Institutional Review Boards of the Ajou University School of Medicine, medical charts of these patients were reviewed retrospectively including patients' demographics, infection status during hospital visit, indication for surgery, time of surgery, surgical technique, postoperative complications, and recurrence rates. All patients included in the study were followed up for at least for 6 months. The cases were divided into two groups based on the time of surgery, and regardless of the inflammatory condition. Patients who underwent the surgery within 3 weeks from their 1st hospital visit were classified as the early intervention group (53 cases), and the others that performed the operation after 3 weeks from their 1st hospital visit were included in the non-early intervention group (137 cases). In both groups, all cases that showed acute infection were treated with oral antibiotics, and immediate I & D was performed when abscess formation was present (Fig. 2). Before performing the surgery, the infection status of the PASs was reexamined to select the surgical techniques for
complete excision (Fig. 3a). During surgery, only patients under the age of 12 received general anesthesia. 2.2. Surgical techniques All cases equally started the surgery with infiltration of 2% xylocaine/epinephrine 1:100,000 surrounding the sinus. Then, the direction and depth of the sinus tract were identified by a lacrimal duct probe and insertion of gentian violet solution into the sinus opening (Fig. 3b). An elliptical skin incision was designed around the sinus orifice identical to the standard technique of sinusectomy, and throughout the entire procedure the dissection of the tract was done using a no.15 blade rather than Metzenbaum scissor (Fig. 3c). For the asymptomatic cases, the classic technique was performed with minimal incision and noninvasive techniques. In cases of infected PASs with iatrogenic fistula due to I & D or additionally opened wounds caused by infection, a second incision parallel to the first elliptical incision was designed (Fig. 3e). The main purpose of the parallel incision was to completely remove the deep sinus tracts and their branches, and to clear all inflamed granulation tissues using a wider surgical view. This additional but focal incision also considered postoperative cosmetic concerns as it was parallel to the original elliptical incision. Since the infection sites were frequently detected in the anterior of the original sinus tracts, most of the additional parallel incisions were made anterior to the initial elliptical incisions (Fig. 3d). The elimination of inflamed tissues was completed by simply using a curette (Fig. 3f). Finally, bleeding control was accomplished by bipolar cautery and subcutaneous wound closure was done with absorbable sutures with caution to avoid dead space formation. None of the cases required drain insertion, and all patients received local compression dressing for a single day. The aim of our surgical technique was to first meticulously remove the sinus tract and branches, and extirpate all inflamed tissues from the operation site without extended procedures or aid of extra materials including inconvenient surgical tools. 2.3. Statistical analysis All analysis to evaluate the statistical differences of each group including history of I & D, history of previous sinusectomy, preoperative use of antibiotics, time of intervention along with complication and recurrence rates were done by Chi-squared test using SPSS software (version 18; SPSS Inc., Chicago, IL, USA). P
O.-S. Choo et al. / International Journal of Pediatric Otorhinolaryngology 95 (2017) 45e50
47
Fig. 2. Study design for PASs. All cases of infected PASs were treated with antibiotics, and I & D was additional performed when abscess formation was present. A total of 190 cases underwent surgical treatment, and cases were classified according to the time of surgery. (*early intervention: surgical excision performed within 3 weeks from their 1st hospital visits regardless of their infection status).
values < 0.05 were considered to be statistically significant. 3. Results Among 144 patients (62 male, 82 female) who were enrolled in the study, the age ranged from 5 months to 63 years with a mean age of 18.3 years. The site of the sinus was more dominant unilaterally (68.1%) than bilaterally (31.9%), and evenly distributed on both sides in cases of unilateral PASs (Table 1). Early intervention was conducted in 53 cases (29.7%) and nonearly intervention was performed in 137 cases (72.1%). The incidence of I &D history in the early intervention group and non-early intervention group was 34 cases (64.2%) and 48 cases (35.0%), respectively, indicating a significantly higher rate of I & D history in the early intervention group (p ¼ 0.000). Revision sinusectomy was done in 8 cases (15.1%) from the early intervention group, and in 4 cases (2.9%) from the non-early intervention group which showed that the recurred cases were significantly more frequent in the early intervention group (p ¼ 0.002) (Fig. 4). During the time of surgery, infected PASs were present in 35 cases (66.0%) from the early intervention group and 51 cases (37.2%) from the non-early intervention group. Despite the inflammatory condition, only 1 case of infected PAS from the non-early intervention group showed a minor complication of keloid scar 2 weeks after the surgery, which was treated using triamcinolone. During our follow up period of minimum of 6 months, there was no recurrence in either group (Table 2). 4. Discussion The only definitive treatment to prevent complications and recurrence of PASs is through complete surgical excision [2e5]. And determining the appropriate time of surgery is one of the most
important decisions to make. Typically, the procedure is proceeded when the condition is stable. Infectious status is managed by antibiotics and/or I & D but surgical treatment is avoided during or shortly after this period [9,12]. Based on this concept, some patients suffer from repetitive infections or persistent open wounds with necrotic skins which are difficult to heal. From the results of our study, the time of intervention did not affect the complication or recurrence rate. The only minor complication that was noted was a keloid scar from the non-early intervention group which was cured by triamcinolone. Even within the early intervention group, the infection status did not alter these rates. The next critical decision point is the surgical strategy for PAS. The original technique to remove the PAS is simple sinusectomy where the surgery begins with an elliptical incision around the sinus opening, and dissection along the sinus tract [13]. However, the recurrence rate of the standard method has been reported to be as high as 9e42% [2e5]. Since these rates have been revealed, many studies and reports have aimed to reduce the recurrence rate of PAS excision. In 2005, Baatenburg de Jong RJ introduced a surgical technique called the inside-out technique using stay sutures to facilitate the dissection of the tract, opening the sinus, and dissecting the tract by glistening the inside lining and outer wall under a microscope [10]. Later, in 2001 Lam et al. reported the comparison between the standard technique and the supra-auricular approach and demonstrated the lower recurrence rate (3.7% vs. 32%) concluding on the greater efficacy of the supra-auricular technique which was latter followed and modified by Leopardi G et al. and Bae SC et al. [11,14e17]. Other minor modifications and suggestions were using methylene blue staining and probing for fistula resection, and others also advised in using a microscope as a guidance to reduce the overall recurrence rate after surgery [4,18]. Other recent studies classified the PASs according to the severity of their infection status and introduced more extended incisions, and use of
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Fig. 3. Surgical techniques of infected PAS. (a) Black arrow indicates the site of I & D. (b) Lacrimal duct probe and gentian violet solution was used to identify the sinus tract. (c) Dissection of the tract was done by a no. 15 blade. (d) The direction of the tract is pointing downwards. (e) An additional parallel incision is designed for better exposure of the surgical field which enables complete removal of deep tracts and exuberant granulation tissues, and for postoperative cosmetic concerns. (f) Granulation tissues are removed by a curette. (g) Wound closure is done without drain insertion. (h) Two weeks after operation.
Table 1 Patients' demographics. No. of patients Gender Male Female Total patients Age age 12yrs age >12yrs Mean Age (±SD) Site of sinus Right Left Both Total cases
62 (43.1%) 82 (56.9%) 144 68 (47.2%) 76 (52.8%) 18.3 ± 15.7 yrs 45 (31.3%) 53 (36.8%) 46 (31.9%) 190
cottonoid® soaked with gentian violet solution for clear visualization of the main sinus tract and distal branches mostly commonly in the patients with PAS with abscess formation [19,20]. The novel approach for PAS excision in this study is the
additional parallel incision in infected cases and the removal of the remnant tissues using a curette. A single incision may be inadequate to remove the entire sinus tract, their branches, and the surrounding tissues, especially in infected PASs. By an additional but focal incision, which is parallel to the original elliptical incision, provides a wider surgical view enabling meticulous excision of the PAS and its surrounding inflamed tissues. This particular parallel incision was designed in consideration to cosmetic outcomes as well. The surrounding infectious tissues were also excised or removed by the use of a curette. This surgical step is simple but requisite because these remaining tissues are the main cause of postoperative complications such as non-healing wounds. Extra materials or devices to detect the lesions or drain insertion were not used in any of the cases in this study. Local anesthesia was also recommended during surgery unless the patient was under the age of 12, not only to avoid complications of anesthesia but because this factor was not recognized to influence the prognosis of the surgery. “The limitation of this study was the follow up period of 6 months. Long-term complications such as wound dehiscence or infection, and recurrences presenting with swelling, tenderness or erythematous change of the operation sites are possible but rare.
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Fig. 4. Clinical manifestations and management of PAS according to time of surgery. I & D history and revision cases, and acute infection control were significantly more frequent in the early intervention group compared to the non-early intervention group (p ¼ .000, p ¼ .000). Statistical analysis of complication and recurrence rates were insignificant.
Table 2 Cases of infected PASs. Groups
Number of infected cases
History of I & D
Revision cases
Complications
Recurrence
Early intervention Non-early intervention
35 (66.0%) 51 (37.2%)
23 (65.7%) 26 (51.0%)
8 (22.9%) 2 (1.5%)
0 1 (2.0%)
0 0
None of the patients from our study revisited the hospital with these recurrent symptoms even after 6 months from surgery.” 5. Conclusion For complete surgical removal of PAS, identification of its inflammatory condition is important. Immediate infection control such as antibiotics and I & D is also required however, the time of surgery after acute infection control does not seem to affect the complication or recurrence rate of sinusectomy. Furthermore, the key point of the surgical procedure includes complete removal of all sinus tracts, branches, and infectious tissues. Thus, the parallel incision is rather relevant to eliminate all structures of infected PAS, not only enabling the surgeon to remove remnant granulation tissues by using a curette but also considering cosmetic satisfactions. In conclusion, early intervention of infected PAS is possible followed by acute infection control with a simple but accurate additional parallel incision. Funding This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI15C-0968-000015). Conflict of interest The authors have no conflict of interest to disclose. References [1] R.G. Chami, J. Apesos, Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom, Ann. Plast. Surg. 23 (1989) 406e411.
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