You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > EXTERNAL EAR DISEASES Preauricular Cysts, Pits, and FissuresArticle Last Updated: Aug 31, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Samuel T Ostrower, MD, Staff Physician, Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine Samuel T Ostrower is a member of the following medical societies: Alpha Omega Alpha and American Academy of Otolaryngology-Head and Neck Surgery Coauthor(s): John P Bent lll, MD, Assistant Professor, Director of Medical Student Education, Departments of Otolaryngology - Head and Neck Surgery and Pediatrics, Albert Einstein School of Medicine; Director, Airway Clinic, Children's Hospital at Montefiore; Mitchell Austin, MD, FACS, Director, Department of Pediatrics, Division of Otolaryngology, Associate Professor, Children's Medical Center, Medical College of Georgia Editors: Michael J Biavati, MD, Clinical Assistant Professor, Department of Otolaryngology, University of Texas Southwestern; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, School of Human Development, Chief of Medical Services at Callier Center for Communicative Disorders, University of Texas at Dallas; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: preauricular tags, epithelial mounds, pedunculated skin, preauricular sinus pit, sinus tracts, subcutaneous cysts, branchiootorenal syndrome, BOR syndrome, Beckwith-Wiedemann syndrome, mandibulofacial dysostosis, oculoauriculovertebral dysplasia, chromosome arm 11q duplication syndrome, chromosome arm 4p deletion syndrome, chromosome arm 5p deletion syndrome, preauricular cysts, pits, and fissures INTRODUCTIONSection 2 of 12
  Preauricular cysts, pits, fissures, and sinuses are benign congenital malformations of the preauricular soft tissues first described by Van Heusinger in 1864. Preauricular pits or fissures are located near the front of the ear and mark the entrance to a sinus tract that may travel under the skin near the ear cartilage. These tracts are lined with squamous epithelium and may sequester to produce epithelial-lined subcutaneous cysts or may become infected, leading to cellulitis or abscess. Preauricular tags are epithelial mounds or pedunculated skin that arise near the front of the ear around the tragus. They have no bony, cartilaginous, or cystic components and do not communicate to the ear canal or middle ear. Simple preauricular cysts should not be confused with first branchial cleft cysts. Branchial cleft anomalies are closely associated with the external auditory canal, tympanic membrane, angle of the mandible, and/or facial nerve. Misinterpreting a first brachial abnormality for a simple sinus tract may place the unsuspecting physician at risk for damaging the facial nerve, incompletely excising the lesion, or both. Patients identified with preauricular pits or cysts should be examined for other congenital anomalies. FrequencyMalformations of the external ear are not uncommon. Generally, they occur in 1 of every 12,500 births. Incidence of spontaneous formation of ear pits in the nonsyndromic population ranges from 0.3-0.9%. These conditions affect males and females equally and have no race predilection. EtiologyEmbryology and branchial arch development The auricle forms during the sixth week of gestation. The first and second branchial arches give rise to a series of 6 mesenchymal proliferations known as the hillocks of His, which fuse to form the definitive auricle. The first arch gives rise to the first 3 hillocks, which form the tragus, helical crus, and the helix. The second arch gives rise to the second 3 hillocks, which form the antihelix, scapha, and the lobule. Defective or incomplete hillock fusion during auricular development is postulated as the source of the preauricular sinus. Another theory suggests that localized folding of ectoderm during auricular development is the cause of preauricular sinus formation. The first 3 hillocks are most often linked to supernumerary hillocks, leading to preauricular tag formation. Genetics Correct sequential gene activation is required for normal ear and facial development. Interrupting the gene activation sequence in laboratory animals disrupts ear development. Genetic linkage analysis studies have suggested that congenital preauricular sinus localizes to chromosome 8q11.1-q13.3. The inner neurological hearing apparatus, cochlea, and auditory nerve form in conjunction with the outer ear structures during the early developmental stages. External deformities may be associated with an inner neurological deformity and, hence, suggest a possible deafness. Associated syndromes Syndromic expression of pits, tags, and fissures occurs at much higher frequencies in certain craniofacial dysmorphisms. Minor anomalies of the head and neck may aid the clinician in developing a presumptive diagnosis during the initial examination. Additional ear anomalies include helical fold abnormalities, asymmetry, posterior angulation, small size, absent tragus, and narrow external auditory meatus. Some syndromes with characteristic ear anomalies are as follows:
PathophysiologyPreauricular sinuses may be asymptomatic for life. An infection arises when the opening of the pit seals bacteria within the sinus tract along with desquamated skin. Early signs and symptoms of swelling, pain, and erythema should prompt the practitioner to begin antibiotic therapy directed at common skin bacterial organisms. Surgical drainage may be indicated if obvious abscess formation occurs or swelling progresses despite antibiotic therapy. Toxic-appearing and immunocompromised patients may require observation, intravenous antibiotic therapy, and surgical drainage. Complete surgical removal is the treatment of choice for recurrent infection and drainage problems. Ear tags alone pose no threat to any structure and are usually merely a cosmetic deformity. They are usually excised in young patients by qualified surgeons who treat head and neck abnormalities. General anesthesia is typically required. Recurrence rates are low. Smaller, narrowly based tags are tied at their bases with thread or suture in infants during office visits. Simple excision at the base may be performed using topical EMLA cream. Larger, broad-based, multiple, or complex tags may require elliptical excision and plastic closure, which requires general anesthesia. ClinicalClinical presentation of various ear anomalies may be summarized as follows:
Differential Diagnoses Preauricular swelling/infection Parotid swelling/mass/tumor First branchial cleft cyst Duplication of ear canal Trauma Cellulitis from otitis externa Trauma Body piercing Previous surgical site INDICATIONSSection 3 of 12
Most patients with preauricular pits in the typical location are asymptomatic and require no surgical intervention. Needle aspiration is indicated for abscess that fails to respond to antibiotics. Incision and drainage complicates later excision and should be reserved for abscess that recurs after needle aspiration. Complete excision of the cyst or sinus tract may be undertaken in cases of recurrent infection. Ear tags are removed for cosmetic reasons. RELEVANT ANATOMYSection 4 of 12
A preauricular pit may mark the entrance to a sinus tract, which can vary in length, follow a tortuous course, and branch extensively. Preauricular sinuses and cysts have a component of close association with the auricular perichondrium. For this reason, some argue that complete removal of a sinus tract or cyst should also include a portion of the auricular perichondrium at the base of the lesion. Preauricular sinuses or cysts are found lateral and superior to the facial nerve and parotid gland, whereas first branchial cleft malformations are found in close association with these structures, as well as with the external auditory canal. Excision of complex or broad-based tags requires the knowledge of relaxed skin lines and wound tension in the region of the face and ear. CONTRAINDICATIONSSection 5 of 12
An infected cyst or tract may be considered a relative contraindication to excision of a sinus tract or cyst. Antibiotics and, occasionally, steroids should be considered to control any residual inflammation prior to surgery. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Diagnostic Procedures
Histologic FindingsFindings associated with ear pits include diffuse interstitial dermatitis, abundant foreign body reaction, and ruptured follicular cyst, epidermal cyst, and epidermal sinus tract. TREATMENTSection 7 of 12
Medical therapyConsultations with the following specialists may be beneficial:
Antibiotics (eg, cephalexin [Keflex], amoxicillin and clavulanate potassium [Augmentin], erythromycin) are indicated in patients with cellulitis from infected preauricular pits. Incision and drainage procedures may be required for patients with abscess formation. Staphylococcus aureus is the most common bacteria found in these infections followed by Proteus, Streptococcus, and Peptococcus species. Surgical therapySinuses, cysts, and pits The authors discourage standard incision and drainage in the setting of abscess formation within a preauricular sinus tract or cyst. A potential alternative to incision and drainage is the use of a blunt-ended lacrimal probe inserted into the preauricular pit in order to open the abscess cavity. However, acute inflammation usually makes this option both technically difficult and painful. Aspiration with a 21-gauge needle reliably provides at least temporary relief, eases pain, and provides purulent material for culture and sensitivity. Needle aspiration may need to be repeated if an abscess reaccumulates, but reliably leads to a better cosmetic result than incision and drainage. Complete surgical excision of a preauricular sinus tract or cyst is indicated in the setting of recurrent or persistent infection. The operation is typically performed when the acute infection has subsided. Recurrence rates following excision range from 0-42%. Factors that reportedly reduce the risk of recurrence include complete excision of the sinus and tract with associated perichondrium, dissection down to temporalis fascia, closure of dead space, and avoidance of sinus rupture. Inflammation always exists to varying degrees around the cyst wall in the surgical field. Using auricular cartilage as a posterior boundary and the preparotid fascia as a medial boundary helps to assure complete excision when edema and fibrosis obscure the cyst wall. Some authorities recommend methylene blue injection into the cyst to caution against cyst wall violation, but the dye invariably leaks out of the tract into the surgical field, offsetting its benefit. The authors favor the use of a lacrimal probe during the procedure to help define the cyst's periphery. Tags An elliptical incision is made around tag at the base, and the skin is closed primarily. Preoperative detailsThe infectious process should be optimally controlled prior to excision of the tract or cysts. Intraoperative detailsAlthough several techniques for excision have been described, the following is a standard approach:
Postoperative detailsPassive drain should be removed on the first postoperative day. Keep the wound dry for 3 days. Watch for bleeding, erythema, and fever. Patients should report any of these unusual symptoms. Purulent drainage is uncommon. Children usually resume normal activities by the following day. Follow-upA follow-up visit should occur 7-14 days after surgery for wound evaluation. COMPLICATIONSSection 8 of 12
Bleeding and infection are the most common complications. Incomplete control of bleeding with failure to close the wound sufficiently may allow bacteria to flourish under the skin, causing infection and wound breakdown. A seroma may form but typically responds to simple needle drainage or observation. A thick scar may form in wounds closed with too much tension. Scar formation is associated with skin of moderate or high melanin content. Keloid formation is also possible. Incomplete removal of a sinus tract may lead to recurrence. OUTCOME AND PROGNOSISSection 9 of 12
The prognosis is excellent if the tract, fissure, and/or cyst is completely removed. Cosmesis is dependent on surgical knowledge and the scar-forming attributes of the patient. Previously infected cysts and tracts may cause deeper tissue damage that requires rotational and or advancement flap procedures for improved cosmetic outcome. FUTURE AND CONTROVERSIESSection 10 of 12
Routine renal ultrasonography has been advocated as a result of several studies that suggest a higher incidence of renal anomalies among patients with ear anomalies, and specifically those with preauricular pits. Cost-effectiveness data to support this practice, however, is lacking, and routine renal ultrasonography has yet to become the standard of care in the workup of patients with isolated preauricular pits. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Preauricular Cysts, Pits, and Fissures excerpt Article Last Updated: Aug 31, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
