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The preauricular sinus: factors contributing to recurrence after surgery
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 396 – 400 www.elsevier.com/locate/amjoto
The preauricular sinus: factors contributing to recurrence after surgery Sang-Won Yeo, MD, Beom-Cho Jun, MD, Si-Nae Park, MD, Jung-Hak Lee, MD, Chang-Eun Song, MD, Ki-Hong Chang, MD, Dong-Hee Lee, MD4 Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
Abstract
Purpose: The objective of this study was to summarize clinical presentation, treatment, and recurrence of preauricular sinuses. Materials and methods: This retrospective, institutional review board-approved study reviewed the medical records of patients who underwent preauricular fistulectomy between January 1995 and June 2005 at university-based hospitals in South Korea. Only patients who underwent classic preauricular fistulectomy (not incision and drainage) and could be followed up for at least 3 months were included in the study. Results: A total of 191 patients (206 ears) were enrolled. The right and left ears were involved in 79 and 97 patients, respectively. The most common location of the preauricular pit was the anterior margin of the ascending limb of the helix (93.2%). The most common indication for surgery was the recurrent exacerbation of acute infection (58.3%). The recurrence rate after surgery was 4.9%. Surgery under local anesthesia contributed to recurrence after the procedure ( P = .009) and the cases that featured local infiltrative anesthesia had a higher rate of recurrence than the cases that had general anesthesia with an odds ratio of 6.875. Conclusions: Although this study showed that surgery under local anesthesia contributed to recurrence, it did not mean that it was only the anesthesia technique that influenced the recurrence. Surgeons should bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. The main limitation of this study was that recurrent cases were too few to allow a statistical analysis. D 2006 Elsevier Inc. All rights reserved.
Preauricular sinuses are common congenital malformations first described by Heusinger [1] in 1864. Most people with this malformation are asymptomatic. Some patients may present with facial cellulitis or ulcerations located anterior to the ear. Treatment of acute infection or abscess includes antibiotics and adequate drainage, as indicated. Some patients present with chronic intermittent drainage of purulent material from the opening. Once infection occurs, the likelihood of recurrent acute exacerbation is high. At this point, the sinus tract should be surgically removed. Complete removal of the epithelial lining of the sinus is very important.
4 Corresponding author. Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, 65-1 Gumoh-Dong, Uijeongbu City, Gyeonggi-Do, 480-717, South Korea. Tel.: +82 31 820 3564; fax: +82 31 847 0038. E-mail address: [email protected] (D.-H. Lee). 0196-0709/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.03.008
This study surveyed the clinical presentation as well as the factors contributing to the postoperative recurrence of preauricular sinuses in a Korean population. The specific goals of this study were to (1) summarize the clinical presentation and treatment of the preauricular sinuses and (2) evaluate the factors contributing to recurrence after extirpation. 1. Subjects and methods This retrospective, institutional review board-approved study reviewed the medical records of patients who presented with preauricular sinuses and underwent preauricular fistulectomy (excision or extirpation of the sinuses) between January 1995 and June 2005 at the otolaryngology-head and neck surgery department of 3 university-based hospitals: Kangnam St. Mary’s Hospital, St. Mary’s Hospital, and Uijeongbu St. Mary’s
S.-W. Yeo et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 396 – 400
Hospital. This study included only those patients who underwent the classic preauricular fistulectomy (not incision and drainage) and could be followed up for at least 3 months. Each ear involved in bilateral procedures was regarded as a separate operation. 2. Results A total of 191 patients (206 ears) were enrolled in this study, consisting of 84 males and 107 females. Their mean age at the time of surgery was 14.7 years (SD = 13.3 years, range = 0.7 – 66.1 years). The right and left ears were involved in 79 and 97 patients, respectively. Bilateral surgery was needed in 15 patients (7.9%). Postoperative antibiotics were administered intravenously during admission and orally during 5–7 days after discharge. If fistulectomy was performed in an outpatient basis, postoperative antibiotics were administered orally until stitch out. 2.1. Summary of clinical presentation, treatment, and association of preauricular sinuses The pit was located at the anterior margin of the ascending limb of the helix in 192 ears (93.2%). The second most common location of the pit was along the posterior surface of the helicine crus (cymba concha) (8 ears). In 3 cases, the pit was located superior to the ascending limb of the helix. In 2 cases the pit was located in the postauricular area, and in 1 case in the ear lobule (Fig. 1). The most common indication for surgery was recurrent acute exacerbations of infection (120 ears, 58.3%). In 49 ears that were asymptomatic, fistulectomy was performed to remove only the pit. Thirty-seven ears required fistulectomy, because of chronic intermittent drainage of foul-smelling material from the sinus orifice.
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Infectious agents were identified in 23 patients and included methicillin-resistant Staphylococcus aureus (2 patients), methicillin-sensitive S aureus (2 patients), Staphylococcus epidermidis (1 patient), Streptococcus (2 patients), Klebsiella pneumoniae (2 patients), and Citrobacter (1 patient). Thirteen patients had no growth on bacterial cultures. Most surgical procedures were performed when there was no infection or inflammation (137 ears). However, fistulectomy was performed in 43 ears that showed active infection at the time of surgery. In addition, fistulectomy was performed in 26 ears that had intractable discharge and granulation at the time of surgery. Ninety-one ears (44.2%) had a history of incision and drainage for a preauricular abscess or a previously attempted simple excision. The mean number of incision and drainage procedures were 1.0 (SD = 1.3 times, range = 1–10 times) and the mean interval between the last drainage and fistulectomy was 8.0 weeks (SD = 128.2 weeks, range = 1 week – 6.2 years). Fistulectomy was performed for the first time in 190 ears, and as revision in 16 ears. General anesthesia was used in 158 patients and local infiltrative anesthesia in the remainder (35 ears from 33 patients). All patients, except one, were admitted to the hospital for the procedure. Mean hospital stay was 4.8 days (SD = 2.1 days, range = 1–16 days). During the procedure, a portion of the conchal cartilage, which was attached to the sinus tract, was removed in 71 ears. In 100 ears, a silastic drain was inserted to prevent hematoma from occurring and was kept in place for 3.3 days (SD = 1.9 days, range = 1– 10 days). After fistulectomy, a standard compress dressing was used; except for 31 ears, it was kept in place for 2.9 days (SD = 1.7 days, range = 1–10 days). The mean period of follow-up was 26.1 weeks (SD = 36.9 weeks, range = 10 weeks –5.9 years). A wound infection developed in 10 cases; all infections resolved with conservative treatment. Ten (4.9%) of 206 ears that underwent surgical excision had a recurrence; the mean period between the surgery and recurrence was 9.5 weeks (SD = 91.3 weeks, range = 1–288 weeks). 2.2. Factors contributing to recurrence after surgery (preauricular fistulectomy)
Fig. 1. Locations of the preauricular pits (n = 206). The preauricular sinuses are noted (A) at the anterior margin of the ascending limb of the helix, (B) superior to the auricle, (C) along the posterior surface of the helicine crus (cymba concha), (D) at the lobule, and (E) posterior to the auricle.
In this study, the recurrence rate after surgery was 4.9%. To determine the factors contributing to recurrence after surgery, the following factors were considered: (1) the reason for surgery, (2) status of the sinus at the time of surgery, 3) a history of drainage of an abscess before surgery, (4) whether surgery was done under general or local anesthesia, (5) whether the conchal cartilage around the sinus was removed, (6) whether a drain was inserted, and (7) whether a compressive dressing was applied. Chi-square test including Fisher exact test was performed using the SPSS software program (SPSS Inc., Chicago, Il), and P b .05 was considered significant.
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2.2.1. Reasons for surgery: asymptomatic or infectious A total of 157 cases required fistulectomy because of infection, such as chronic intermittent drainage or foulsmelling discharge or recurrent acute exacerbations of the infection. Of these, 7 cases recurred. In 49 ears that were asymptomatic, there were 3 recurrences. There was no significant difference between these 2 groups ( P = .704). 2.2.2. Status of the sinus at the time of surgery: only a pit or infectious state At the time of surgery, there were 137 ears that represented an isolated pit without infection or inflammation. Of these, 6 cases recurred. Sixty-nine ears had an active infection or intractable discharge and granulation at the time of surgery, and in this group 4 cases recurred. There was no significant difference between these 2 groups ( P = .735).
there was no significant difference in the duration when the drain was kept in place between recurred and nonrecurred groups ( P = .398). 2.2.7. Compress or simple dressing The number of cases with a compress dressing was 175, and in 8 cases there was a recurrence. Thirty-one ears received a simple dressing and in this group 2 cases recurred. There was no significant difference in recurrence rates between these groups ( P = .649). In addition, in the group that required a compress dressing, there was no significant difference in the duration when a compress dressing was applied between recurred and nonrecurred groups ( P = .647). 3. Discussion
2.2.3. History of drainage of an abscess before surgery There were 91 ears that had a history of drainage of an abscess before surgery; 2 of these cases recurred. One hundred fifteen ears did not have a history of drainage of an abscess before surgery. Of these, 8 cases recurred. There was no significant difference between these 2 groups ( P = .191). In a group with a history of drainage, there was no significant difference in the frequency of incisional drainage between recurred and nonrecurred groups ( P = .464). In addition, there was no significant difference in the interval between the last drainage and the surgery between recurred and nonrecurred groups ( P = .843). 2.2.4. General or local anesthesia There were 158 ears that underwent general anesthesia for the procedure. In this group, there were 4 recurrences. There were 33 ears that were had the procedure under local infiltrative anesthesia. Of these, 5 cases recurred. There was a significant difference in the rates of recurrence between these 2 groups ( P = .009). In addition, the cases that had local infiltrative anesthesia had a higher rate of recurrence than the cases that had general anesthesia with an odds ratio of 6.875. 2.2.5. Removal of the conchal cartilage around the sinus or not There were 71 cases where the conchal cartilage was removed during surgery; 4 of these cases recurred. In 135 cases the conchal cartilage was not removed; of these, 6 cases recurred. There was no significant difference in the recurrence rates between these 2 groups ( P = .740). 2.2.6. Insertion of a drain or not A drain was inserted during surgery in 100 ears; of these, 6 cases recurred. A total of 106 ears did not have a drain, and of these 4 cases recurred. There was no significant difference in the rates of recurrence between these 2 groups ( P = .529). Moreover, in the group of ears with a drain,
Preauricular sinuses are common congenital malformations first described by Heusinger [1] in 1864. They are frequently noted during routine physical examination as small pits adjacent to the external ear, usually at the anterior margin of the ascending limb of the helix. However, they have also been reported to occur along the lateral or posterior surface of the helicine crus and the superior posterior margin of the helix, the tragus, or the lobule [2,3]. Most investigations [2-6] showed that men and women are equally affected; however, there is also literature that supports a more frequent occurrence in women [7,8]. In addition, these malformations are also more commonly observed in Asian and African ethnic groups when compared to Caucasians [2,7-9]. The rate of incidence has been reported to be 0.1–0.9% in the United States [10] (0.23% in New York [11]), 0.9% in England [10], 0.06% in Scotland [11], 0.47% in Hungary [12], and 1.6–2.5% in Taiwan [13]. In one study [14], the incidence rate was estimated to be 0.25% among Caucasians and 4–10% in some parts of Asia and Africa [4,8,15]. Preauricular sinuses are developmental anomalies and inherited in an incomplete autosomal dominant pattern, with reduced penetrance and variable expression [2]. Recently, a locus was found to map to chromosome 8q11.1-q13.3 [16]. The sinus may be bilateral in 33 –43% of cases, and bilateral sinuses are more likely to be hereditary [4,5,7]. In unilateral cases, both right and left ears are affected, with a slight predominance for the right ear [5,8,15]. Most people with preauricular sinuses are asymptomatic. Some patients present with chronic intermittent drainage of purulent material from the opening. Draining sinuses are prone to infection. Once infected, these sinuses rarely become asymptomatic and often develop recurrent acute exacerbations. Preauricular sinuses are usually narrow; they vary in length (usually they are short) and their orifices are usually minute. They may arborize and follow a tortuous course in the immediate vicinity of the external ear. Preauricular
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sinuses are usually found lateral, superior, and posterior to the facial nerve and the parotid gland. In almost all cases, the duct connects to the perichondrium of the auricular cartilage. They can extend into the parotid gland. On gross examination, preauricular sinuses consist of tubular structures of simple or arborized patterns having walls, which may be thin and glistening or white and thickened. They are often full of keratin and are surrounded by dense connective tissue. Microscopically, the duct of the sinus is lined with stratified squamous epithelium and contains many cysts along its tract. The connective tissue surrounding the duct may contain hair follicles, sebaceous and sweat glands, and inflammatory tissue, such as lymphocytes, plasma cells, and polymorphonuclear leukocytes [2]. Although routine radiographic imaging is unnecessary, sonography may readily depict preauricular sinuses and demonstrate their relationship to the superficial temporal artery, the anterior crus of the helix, and the tragus. Ahuja et al [17] reported that the maximum width of the tract was 3 mm, 27% had a branching pattern of the tract, and 40% had an ill-defined, terminal ramifying appearance. The most common pathogens identified on culture were S epidermidis and S aureus. Other pathogens were Streptococcus viridans, Peptococcus species, and Proteus species [2]. Once a patient acquires an infection of the sinus, the subject must receive systemic antibiotics. If an abscess is present, it must be incised and drained, and the exudate should be sent for Gram stain and culture to ensure proper antibiotic coverage. Once infection occurs, the likelihood of recurrent acute exacerbations is high. Therefore, a sinus tract with a history of recurrent infection should be surgically removed. Extirpation of the sinus tract (preauricular fistulectomy) should take place as soon as the infection has been treated with antibiotics and the inflammation has had time to subside. Table 1 Surgical techniques which were reported to reduce the recurrence of the preauricular sinus 1. Preoperative ! To dissect meticulously the sinus tract ! By an experienced surgeon ! Under general anesthesia 2. During operation To identify the whole sinus tract and its branches ! to inject methylene blue dye into the tract ! to use a probe for cannulation ! to use the magnifying glasses or a microscope To identify the temporalis fascia ! to use an extended preauricular incision such as the supraauricular approach ! to ensure complete removal of all epithelial components within superficial temporal vessels, temporalis fascia, and conchal cartilage ! To remove a portion of the auricular cartilage, which is attached to the tract ! To avoid the rupture or spillage of the sinus tract during surgery 3. Perioperative ! To reduce the wound dead space during the closure
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The recurrence rate after surgery is known to be high. Earlier reports suggest a rate between 9% and 42% [15]. However, as many surgical procedures were developed to reduce the recurrence, the recurrence rate was lowered to 3.7–36% [5,7,9]. The reason why our recurrence rate (4.9%) was lower is that several procedures were used together to prevent incomplete removal. In our hospitals, most preauricular fistulectomies were performed under general anesthesia. And whenever possible, it was carried out only when infection or inflammation was absent. Most postoperative recurrences result from incomplete removal of the sinus tract. Therefore, many reports [4,6-9,18] have presented several procedures to prevent incomplete removal (Table 1). First, it is important to meticulously dissect the sinus tract (performed by an experienced surgeon) under general anesthesia. General anesthesia is widely known to withstand the low recurrence rate. In addition, it is crucial to remove the whole sinus tract and abscess. To achieve this, some surgeons cannulate the orifice and inject methylene blue dye into the tract 3 days before surgery under sterile conditions. The opening is then closed with a purse-string suture. This technique distends the sinus tract as well as its ramifications, and helps the surgeon identify the sinus tract in the operation field. Another technique is carried out during surgery, where a probe is used for cannulation of the orifice. Because simple excision without magnification has the highest recurrence rate, some surgeons insist that the use of magnifying glasses or a microscope is mandatory. Other surgical techniques have been studied that use an extended preauricular incision such as the supraauricular approach. The supraauricular approach may incorporate a postauricular extension of the incision to identify the temporalis fascia especially in the revision. It is very important to remove the portion of the auricular cartilage that is attached to the sinus tract. This procedure is known to reduce the incidence of recurrence to 5%. It is also important to avoid the rupture or spillage of the sinus tract during surgery and to reduce the wound dead space during closure of the wound. In cases of postoperative recurrent sinus, several landmarks are used to ensure the complete removal of all epithelial components. Anterior, medial, and posterior dissection landmarks are superficial temporal vessels, temporalis fascia, and conchal cartilage, respectively. The removal of all cystic structures and fibrous tissues within these landmarks reduces the recurrence rate. Most recurrences are known to occur during the early postoperative period, within 1 month of the procedure. However, the period between surgery and recurrence was 9.5 F 91.3 weeks in this study. This result suggests that a long-term follow-up for at least 2–3 months may be needed. Recurrences should be suspected when discharge from the sinus tract opening persists. Although this study showed that surgery under local anesthesia contributed to recurrence, this result was neither carelessly adopted nor broadly interpreted. This study does not conclude that it was only the anesthesia technique that
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influenced recurrence. It is likely that this result was a consequence of the various obstacles to removing the whole sinus tract under local anesthesia. Even if such obstacles were not documented on medical records, we can easily surmise that these factors included the patient’s anxiety, flinching during operation, and restlessness resulting from a lengthy operation, etc. Therefore, surgeons should bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. The main limitation of this study was that recurrent cases were too few to allow a statistical analysis. 4. Conclusion In this study, preauricular sinuses occurred more frequently in women (1.3 times) and in left ears (1.2 times). The most common location of pit was at the anterior margin of the ascending limb of the helix, and the most common indication for surgery was the recurrent acute exacerbations of infection. The recurrence rate was 4.9%. This study showed that surgery under local anesthesia increased the recurrence rate after the procedure. Surgeons should also bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. References [1] Heusinger HK. Fisteln von Noch Nicht Beobachteter Form. Virchows Arch 1864;29:358. [2] Chang PH, Wu CM. An insidious preauricular sinus presenting as an infected postauricular cyst. Int J Clin Pract 2005;59:370 - 2.
[3] Chami RG, Apesos J. Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom. Ann Plast Surg 1989; 23:406 - 11. [4] Joseph VT, Jacobsen AS. Single stage excision of preauricular sinus. Aust N Z J Surg 1995;65:254 - 6. [5] Gur E, Yeung A, Al-Azzawi M, et al. The excised preauricular sinus in 14 years of experience: is there a problem? Plast Reconstr Surg 1998;102:1405 - 8. [6] Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery 2005;137:567 - 70. [7] Currie AR, King WW, Vlantis AC, et al. Pitfalls in the management of preauricular sinuses. Br J Surg 1996;83:1722 - 4. [8] Lam HC, Soo G, Wormald PJ, et al. Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope 2001; 111:317 - 9. [9] Shu MT, Lin HC. Extirpation of ruptured preauricular fistula. Laryngoscope 2001;111:924 - 6. [10] Ewing MR. Congenital sinuses of the external ear. J Laryngol Otol 1946;61:18 - 23. [11] Emery PJ, Salama NY. Congenital pre-auricular sinus. A study of 31 cases seen over a ten year period. Int J Pediatr Otorhinolaryngol 1981; 3:205 - 12. [12] Meggyessy V, Mehes K. Preauricular pits in Hungary: epidemiologic and clinical observations. J Craniofac Genet Dev Biol 1982;2:215 - 8. [13] Tsai FJ, Tsai CH. Birthmarks and congenital skin lesions in Chinese newborns. J Formos Med Assoc 1993;92:838 - 41. [14] Baarsma EA. Surgical treatment of the infected preauricular sinus. Arch Otorhinolaryngol 1979;222:97 - 102. [15] Scheinfeld NS, Silverberg NB, Weinberg JM, et al. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol 2004;21:191 - 6. [16] Zou F, Peng Y, Wang X, et al. A locus for congenital preauricular fistula maps to chromosome 8q11.1-q13.3. J Hum Genet 2003;48:155 - 8. [17] Ahuja AT, Marshall JN, Roebuck DJ, et al. Sonographic appearances of preauricular sinus. Clin Radiol 2000;55:528 - 32. [18] Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol 2003;117: 983 - 4.
The preauricular sinus: factors contributing to recurrence after surgery Sang-Won Yeo, MD, Beom-Cho Jun, MD, Si-Nae Park, MD, Jung-Hak Lee, MD, Chang-Eun Song, MD, Ki-Hong Chang, MD, Dong-Hee Lee, MD4 Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
Abstract
Purpose: The objective of this study was to summarize clinical presentation, treatment, and recurrence of preauricular sinuses. Materials and methods: This retrospective, institutional review board-approved study reviewed the medical records of patients who underwent preauricular fistulectomy between January 1995 and June 2005 at university-based hospitals in South Korea. Only patients who underwent classic preauricular fistulectomy (not incision and drainage) and could be followed up for at least 3 months were included in the study. Results: A total of 191 patients (206 ears) were enrolled. The right and left ears were involved in 79 and 97 patients, respectively. The most common location of the preauricular pit was the anterior margin of the ascending limb of the helix (93.2%). The most common indication for surgery was the recurrent exacerbation of acute infection (58.3%). The recurrence rate after surgery was 4.9%. Surgery under local anesthesia contributed to recurrence after the procedure ( P = .009) and the cases that featured local infiltrative anesthesia had a higher rate of recurrence than the cases that had general anesthesia with an odds ratio of 6.875. Conclusions: Although this study showed that surgery under local anesthesia contributed to recurrence, it did not mean that it was only the anesthesia technique that influenced the recurrence. Surgeons should bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. The main limitation of this study was that recurrent cases were too few to allow a statistical analysis. D 2006 Elsevier Inc. All rights reserved.
Preauricular sinuses are common congenital malformations first described by Heusinger [1] in 1864. Most people with this malformation are asymptomatic. Some patients may present with facial cellulitis or ulcerations located anterior to the ear. Treatment of acute infection or abscess includes antibiotics and adequate drainage, as indicated. Some patients present with chronic intermittent drainage of purulent material from the opening. Once infection occurs, the likelihood of recurrent acute exacerbation is high. At this point, the sinus tract should be surgically removed. Complete removal of the epithelial lining of the sinus is very important.
4 Corresponding author. Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, 65-1 Gumoh-Dong, Uijeongbu City, Gyeonggi-Do, 480-717, South Korea. Tel.: +82 31 820 3564; fax: +82 31 847 0038. E-mail address: [email protected] (D.-H. Lee). 0196-0709/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.03.008
This study surveyed the clinical presentation as well as the factors contributing to the postoperative recurrence of preauricular sinuses in a Korean population. The specific goals of this study were to (1) summarize the clinical presentation and treatment of the preauricular sinuses and (2) evaluate the factors contributing to recurrence after extirpation. 1. Subjects and methods This retrospective, institutional review board-approved study reviewed the medical records of patients who presented with preauricular sinuses and underwent preauricular fistulectomy (excision or extirpation of the sinuses) between January 1995 and June 2005 at the otolaryngology-head and neck surgery department of 3 university-based hospitals: Kangnam St. Mary’s Hospital, St. Mary’s Hospital, and Uijeongbu St. Mary’s
S.-W. Yeo et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 396 – 400
Hospital. This study included only those patients who underwent the classic preauricular fistulectomy (not incision and drainage) and could be followed up for at least 3 months. Each ear involved in bilateral procedures was regarded as a separate operation. 2. Results A total of 191 patients (206 ears) were enrolled in this study, consisting of 84 males and 107 females. Their mean age at the time of surgery was 14.7 years (SD = 13.3 years, range = 0.7 – 66.1 years). The right and left ears were involved in 79 and 97 patients, respectively. Bilateral surgery was needed in 15 patients (7.9%). Postoperative antibiotics were administered intravenously during admission and orally during 5–7 days after discharge. If fistulectomy was performed in an outpatient basis, postoperative antibiotics were administered orally until stitch out. 2.1. Summary of clinical presentation, treatment, and association of preauricular sinuses The pit was located at the anterior margin of the ascending limb of the helix in 192 ears (93.2%). The second most common location of the pit was along the posterior surface of the helicine crus (cymba concha) (8 ears). In 3 cases, the pit was located superior to the ascending limb of the helix. In 2 cases the pit was located in the postauricular area, and in 1 case in the ear lobule (Fig. 1). The most common indication for surgery was recurrent acute exacerbations of infection (120 ears, 58.3%). In 49 ears that were asymptomatic, fistulectomy was performed to remove only the pit. Thirty-seven ears required fistulectomy, because of chronic intermittent drainage of foul-smelling material from the sinus orifice.
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Infectious agents were identified in 23 patients and included methicillin-resistant Staphylococcus aureus (2 patients), methicillin-sensitive S aureus (2 patients), Staphylococcus epidermidis (1 patient), Streptococcus (2 patients), Klebsiella pneumoniae (2 patients), and Citrobacter (1 patient). Thirteen patients had no growth on bacterial cultures. Most surgical procedures were performed when there was no infection or inflammation (137 ears). However, fistulectomy was performed in 43 ears that showed active infection at the time of surgery. In addition, fistulectomy was performed in 26 ears that had intractable discharge and granulation at the time of surgery. Ninety-one ears (44.2%) had a history of incision and drainage for a preauricular abscess or a previously attempted simple excision. The mean number of incision and drainage procedures were 1.0 (SD = 1.3 times, range = 1–10 times) and the mean interval between the last drainage and fistulectomy was 8.0 weeks (SD = 128.2 weeks, range = 1 week – 6.2 years). Fistulectomy was performed for the first time in 190 ears, and as revision in 16 ears. General anesthesia was used in 158 patients and local infiltrative anesthesia in the remainder (35 ears from 33 patients). All patients, except one, were admitted to the hospital for the procedure. Mean hospital stay was 4.8 days (SD = 2.1 days, range = 1–16 days). During the procedure, a portion of the conchal cartilage, which was attached to the sinus tract, was removed in 71 ears. In 100 ears, a silastic drain was inserted to prevent hematoma from occurring and was kept in place for 3.3 days (SD = 1.9 days, range = 1– 10 days). After fistulectomy, a standard compress dressing was used; except for 31 ears, it was kept in place for 2.9 days (SD = 1.7 days, range = 1–10 days). The mean period of follow-up was 26.1 weeks (SD = 36.9 weeks, range = 10 weeks –5.9 years). A wound infection developed in 10 cases; all infections resolved with conservative treatment. Ten (4.9%) of 206 ears that underwent surgical excision had a recurrence; the mean period between the surgery and recurrence was 9.5 weeks (SD = 91.3 weeks, range = 1–288 weeks). 2.2. Factors contributing to recurrence after surgery (preauricular fistulectomy)
Fig. 1. Locations of the preauricular pits (n = 206). The preauricular sinuses are noted (A) at the anterior margin of the ascending limb of the helix, (B) superior to the auricle, (C) along the posterior surface of the helicine crus (cymba concha), (D) at the lobule, and (E) posterior to the auricle.
In this study, the recurrence rate after surgery was 4.9%. To determine the factors contributing to recurrence after surgery, the following factors were considered: (1) the reason for surgery, (2) status of the sinus at the time of surgery, 3) a history of drainage of an abscess before surgery, (4) whether surgery was done under general or local anesthesia, (5) whether the conchal cartilage around the sinus was removed, (6) whether a drain was inserted, and (7) whether a compressive dressing was applied. Chi-square test including Fisher exact test was performed using the SPSS software program (SPSS Inc., Chicago, Il), and P b .05 was considered significant.
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S.-W. Yeo et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 396 – 400
2.2.1. Reasons for surgery: asymptomatic or infectious A total of 157 cases required fistulectomy because of infection, such as chronic intermittent drainage or foulsmelling discharge or recurrent acute exacerbations of the infection. Of these, 7 cases recurred. In 49 ears that were asymptomatic, there were 3 recurrences. There was no significant difference between these 2 groups ( P = .704). 2.2.2. Status of the sinus at the time of surgery: only a pit or infectious state At the time of surgery, there were 137 ears that represented an isolated pit without infection or inflammation. Of these, 6 cases recurred. Sixty-nine ears had an active infection or intractable discharge and granulation at the time of surgery, and in this group 4 cases recurred. There was no significant difference between these 2 groups ( P = .735).
there was no significant difference in the duration when the drain was kept in place between recurred and nonrecurred groups ( P = .398). 2.2.7. Compress or simple dressing The number of cases with a compress dressing was 175, and in 8 cases there was a recurrence. Thirty-one ears received a simple dressing and in this group 2 cases recurred. There was no significant difference in recurrence rates between these groups ( P = .649). In addition, in the group that required a compress dressing, there was no significant difference in the duration when a compress dressing was applied between recurred and nonrecurred groups ( P = .647). 3. Discussion
2.2.3. History of drainage of an abscess before surgery There were 91 ears that had a history of drainage of an abscess before surgery; 2 of these cases recurred. One hundred fifteen ears did not have a history of drainage of an abscess before surgery. Of these, 8 cases recurred. There was no significant difference between these 2 groups ( P = .191). In a group with a history of drainage, there was no significant difference in the frequency of incisional drainage between recurred and nonrecurred groups ( P = .464). In addition, there was no significant difference in the interval between the last drainage and the surgery between recurred and nonrecurred groups ( P = .843). 2.2.4. General or local anesthesia There were 158 ears that underwent general anesthesia for the procedure. In this group, there were 4 recurrences. There were 33 ears that were had the procedure under local infiltrative anesthesia. Of these, 5 cases recurred. There was a significant difference in the rates of recurrence between these 2 groups ( P = .009). In addition, the cases that had local infiltrative anesthesia had a higher rate of recurrence than the cases that had general anesthesia with an odds ratio of 6.875. 2.2.5. Removal of the conchal cartilage around the sinus or not There were 71 cases where the conchal cartilage was removed during surgery; 4 of these cases recurred. In 135 cases the conchal cartilage was not removed; of these, 6 cases recurred. There was no significant difference in the recurrence rates between these 2 groups ( P = .740). 2.2.6. Insertion of a drain or not A drain was inserted during surgery in 100 ears; of these, 6 cases recurred. A total of 106 ears did not have a drain, and of these 4 cases recurred. There was no significant difference in the rates of recurrence between these 2 groups ( P = .529). Moreover, in the group of ears with a drain,
Preauricular sinuses are common congenital malformations first described by Heusinger [1] in 1864. They are frequently noted during routine physical examination as small pits adjacent to the external ear, usually at the anterior margin of the ascending limb of the helix. However, they have also been reported to occur along the lateral or posterior surface of the helicine crus and the superior posterior margin of the helix, the tragus, or the lobule [2,3]. Most investigations [2-6] showed that men and women are equally affected; however, there is also literature that supports a more frequent occurrence in women [7,8]. In addition, these malformations are also more commonly observed in Asian and African ethnic groups when compared to Caucasians [2,7-9]. The rate of incidence has been reported to be 0.1–0.9% in the United States [10] (0.23% in New York [11]), 0.9% in England [10], 0.06% in Scotland [11], 0.47% in Hungary [12], and 1.6–2.5% in Taiwan [13]. In one study [14], the incidence rate was estimated to be 0.25% among Caucasians and 4–10% in some parts of Asia and Africa [4,8,15]. Preauricular sinuses are developmental anomalies and inherited in an incomplete autosomal dominant pattern, with reduced penetrance and variable expression [2]. Recently, a locus was found to map to chromosome 8q11.1-q13.3 [16]. The sinus may be bilateral in 33 –43% of cases, and bilateral sinuses are more likely to be hereditary [4,5,7]. In unilateral cases, both right and left ears are affected, with a slight predominance for the right ear [5,8,15]. Most people with preauricular sinuses are asymptomatic. Some patients present with chronic intermittent drainage of purulent material from the opening. Draining sinuses are prone to infection. Once infected, these sinuses rarely become asymptomatic and often develop recurrent acute exacerbations. Preauricular sinuses are usually narrow; they vary in length (usually they are short) and their orifices are usually minute. They may arborize and follow a tortuous course in the immediate vicinity of the external ear. Preauricular
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sinuses are usually found lateral, superior, and posterior to the facial nerve and the parotid gland. In almost all cases, the duct connects to the perichondrium of the auricular cartilage. They can extend into the parotid gland. On gross examination, preauricular sinuses consist of tubular structures of simple or arborized patterns having walls, which may be thin and glistening or white and thickened. They are often full of keratin and are surrounded by dense connective tissue. Microscopically, the duct of the sinus is lined with stratified squamous epithelium and contains many cysts along its tract. The connective tissue surrounding the duct may contain hair follicles, sebaceous and sweat glands, and inflammatory tissue, such as lymphocytes, plasma cells, and polymorphonuclear leukocytes [2]. Although routine radiographic imaging is unnecessary, sonography may readily depict preauricular sinuses and demonstrate their relationship to the superficial temporal artery, the anterior crus of the helix, and the tragus. Ahuja et al [17] reported that the maximum width of the tract was 3 mm, 27% had a branching pattern of the tract, and 40% had an ill-defined, terminal ramifying appearance. The most common pathogens identified on culture were S epidermidis and S aureus. Other pathogens were Streptococcus viridans, Peptococcus species, and Proteus species [2]. Once a patient acquires an infection of the sinus, the subject must receive systemic antibiotics. If an abscess is present, it must be incised and drained, and the exudate should be sent for Gram stain and culture to ensure proper antibiotic coverage. Once infection occurs, the likelihood of recurrent acute exacerbations is high. Therefore, a sinus tract with a history of recurrent infection should be surgically removed. Extirpation of the sinus tract (preauricular fistulectomy) should take place as soon as the infection has been treated with antibiotics and the inflammation has had time to subside. Table 1 Surgical techniques which were reported to reduce the recurrence of the preauricular sinus 1. Preoperative ! To dissect meticulously the sinus tract ! By an experienced surgeon ! Under general anesthesia 2. During operation To identify the whole sinus tract and its branches ! to inject methylene blue dye into the tract ! to use a probe for cannulation ! to use the magnifying glasses or a microscope To identify the temporalis fascia ! to use an extended preauricular incision such as the supraauricular approach ! to ensure complete removal of all epithelial components within superficial temporal vessels, temporalis fascia, and conchal cartilage ! To remove a portion of the auricular cartilage, which is attached to the tract ! To avoid the rupture or spillage of the sinus tract during surgery 3. Perioperative ! To reduce the wound dead space during the closure
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The recurrence rate after surgery is known to be high. Earlier reports suggest a rate between 9% and 42% [15]. However, as many surgical procedures were developed to reduce the recurrence, the recurrence rate was lowered to 3.7–36% [5,7,9]. The reason why our recurrence rate (4.9%) was lower is that several procedures were used together to prevent incomplete removal. In our hospitals, most preauricular fistulectomies were performed under general anesthesia. And whenever possible, it was carried out only when infection or inflammation was absent. Most postoperative recurrences result from incomplete removal of the sinus tract. Therefore, many reports [4,6-9,18] have presented several procedures to prevent incomplete removal (Table 1). First, it is important to meticulously dissect the sinus tract (performed by an experienced surgeon) under general anesthesia. General anesthesia is widely known to withstand the low recurrence rate. In addition, it is crucial to remove the whole sinus tract and abscess. To achieve this, some surgeons cannulate the orifice and inject methylene blue dye into the tract 3 days before surgery under sterile conditions. The opening is then closed with a purse-string suture. This technique distends the sinus tract as well as its ramifications, and helps the surgeon identify the sinus tract in the operation field. Another technique is carried out during surgery, where a probe is used for cannulation of the orifice. Because simple excision without magnification has the highest recurrence rate, some surgeons insist that the use of magnifying glasses or a microscope is mandatory. Other surgical techniques have been studied that use an extended preauricular incision such as the supraauricular approach. The supraauricular approach may incorporate a postauricular extension of the incision to identify the temporalis fascia especially in the revision. It is very important to remove the portion of the auricular cartilage that is attached to the sinus tract. This procedure is known to reduce the incidence of recurrence to 5%. It is also important to avoid the rupture or spillage of the sinus tract during surgery and to reduce the wound dead space during closure of the wound. In cases of postoperative recurrent sinus, several landmarks are used to ensure the complete removal of all epithelial components. Anterior, medial, and posterior dissection landmarks are superficial temporal vessels, temporalis fascia, and conchal cartilage, respectively. The removal of all cystic structures and fibrous tissues within these landmarks reduces the recurrence rate. Most recurrences are known to occur during the early postoperative period, within 1 month of the procedure. However, the period between surgery and recurrence was 9.5 F 91.3 weeks in this study. This result suggests that a long-term follow-up for at least 2–3 months may be needed. Recurrences should be suspected when discharge from the sinus tract opening persists. Although this study showed that surgery under local anesthesia contributed to recurrence, this result was neither carelessly adopted nor broadly interpreted. This study does not conclude that it was only the anesthesia technique that
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influenced recurrence. It is likely that this result was a consequence of the various obstacles to removing the whole sinus tract under local anesthesia. Even if such obstacles were not documented on medical records, we can easily surmise that these factors included the patient’s anxiety, flinching during operation, and restlessness resulting from a lengthy operation, etc. Therefore, surgeons should bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. The main limitation of this study was that recurrent cases were too few to allow a statistical analysis. 4. Conclusion In this study, preauricular sinuses occurred more frequently in women (1.3 times) and in left ears (1.2 times). The most common location of pit was at the anterior margin of the ascending limb of the helix, and the most common indication for surgery was the recurrent acute exacerbations of infection. The recurrence rate was 4.9%. This study showed that surgery under local anesthesia increased the recurrence rate after the procedure. Surgeons should also bear in mind that complete removal of the epithelial lining provides a lower recurrence rate, especially under local anesthesia. References [1] Heusinger HK. Fisteln von Noch Nicht Beobachteter Form. Virchows Arch 1864;29:358. [2] Chang PH, Wu CM. An insidious preauricular sinus presenting as an infected postauricular cyst. Int J Clin Pract 2005;59:370 - 2.
[3] Chami RG, Apesos J. Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom. Ann Plast Surg 1989; 23:406 - 11. [4] Joseph VT, Jacobsen AS. Single stage excision of preauricular sinus. Aust N Z J Surg 1995;65:254 - 6. [5] Gur E, Yeung A, Al-Azzawi M, et al. The excised preauricular sinus in 14 years of experience: is there a problem? Plast Reconstr Surg 1998;102:1405 - 8. [6] Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery 2005;137:567 - 70. [7] Currie AR, King WW, Vlantis AC, et al. Pitfalls in the management of preauricular sinuses. Br J Surg 1996;83:1722 - 4. [8] Lam HC, Soo G, Wormald PJ, et al. Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope 2001; 111:317 - 9. [9] Shu MT, Lin HC. Extirpation of ruptured preauricular fistula. Laryngoscope 2001;111:924 - 6. [10] Ewing MR. Congenital sinuses of the external ear. J Laryngol Otol 1946;61:18 - 23. [11] Emery PJ, Salama NY. Congenital pre-auricular sinus. A study of 31 cases seen over a ten year period. Int J Pediatr Otorhinolaryngol 1981; 3:205 - 12. [12] Meggyessy V, Mehes K. Preauricular pits in Hungary: epidemiologic and clinical observations. J Craniofac Genet Dev Biol 1982;2:215 - 8. [13] Tsai FJ, Tsai CH. Birthmarks and congenital skin lesions in Chinese newborns. J Formos Med Assoc 1993;92:838 - 41. [14] Baarsma EA. Surgical treatment of the infected preauricular sinus. Arch Otorhinolaryngol 1979;222:97 - 102. [15] Scheinfeld NS, Silverberg NB, Weinberg JM, et al. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol 2004;21:191 - 6. [16] Zou F, Peng Y, Wang X, et al. A locus for congenital preauricular fistula maps to chromosome 8q11.1-q13.3. J Hum Genet 2003;48:155 - 8. [17] Ahuja AT, Marshall JN, Roebuck DJ, et al. Sonographic appearances of preauricular sinus. Clin Radiol 2000;55:528 - 32. [18] Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol 2003;117: 983 - 4.