The surgical management

of congenital
sinus

Patrick
E.N.T. Depurmmt.

pre-auricular

Chapman

St. Peter:$ Hqml,

Chertur,: Sunw

KTlh OP_ 11;. K ,

(Received January 2 1 st. 198 I )

(Accepted July 27th. I98 I )

Summary
The gross anatomy of pre-auricular
sinuses is discussed and illustrated. Previously
described
methods to aid complete
excision are discussed
and a new surgical
approach which facilitates the total excision of a pre-auricular
sinus is recorded.
Knowledge
of the sometimes extensive nature of a pre-auricular
sinus with both
pre-auricular
and post-auricular
tracts is necessary to obtain complete excision. The
technique described allows extensive subcutaneous
exposure of the sinus, excision of
skin where necessary and also primary closure.

Introduction
The aetiology, incidence and sites of the cutaneous
orifices of congenital
preauricular sinuses are well described [ 1,2]. It is usually stated that complete excision is
the correct management
of a pre-auricular
sinus although little is written about the
gross anatomy of the sinuses. This paper describes the anatomy of pre-auricular
sinuses and discusses some techniques
used to facilitate complete excision of the
sinus which include pre-operative
X-ray sinography
[ 171, peroperative
injection of
the sinus with methylene blue [9] and the use of the operating microscope [ 11. It was
found that these techniques were either unnecessary or unsatisfactory
and a new and
simple technique of ensuring complete excision of the sinus is described.
Material
The paper is based on the experience drawn from a personal series of 6 patients
treated during a period of two years. Two patients underwent
bilateral operations
and there were no recurrences
in a follow-up period of two years or more. The
chnical histories of each case are summarized
in Table I.
01~5-5X7h/X2,/(X)00-0000/$02.75

C 1982 Elsevier Biomedical

Press

F
F
M
M
M
F

2
3
4
5
6

Sex

HISTORIES

Patient

CLINICAL

TABLE

36
17
26
12
8
26

Age

OF THE 6 PATIENS

right
both
left
right
both
left

Ear

STUDY

3 months
3 years
some years
3 years
since birth
5 years

Duration
of symptoms

OF THE PRESENT

extensive
extensive
extensive
extensive
extensive
extensive

Extent
of sinus

incised
none
previous
none
none
none

Previous
surgery

excision

27
42
41
29
40
24

months
months
months
months
months
months

Follow-up
period

The symptoms experienced were those of intermittent purulent discharge from the
sinus frequently associated with a tender painful pre-auricular swelling. One patient
had undergone incision and drainage of a pre-auricular abscess prior to referral.
Patient 3 in Table1 had undergone an operation by another surgeon one year
previously who had used the methylene blue dye injection technique to assist sinus
localization. At the revision operation it was clear that the previous surgery had only
partially resected the pre-auricular sinus and 4 tracts of the sinus remained in situ.
No complications of the procedure were experienced in the cases reported.

Anatomy

Auricular sinuses and pre-auricular sinuses usually occur alone and they are
infrequently associated with accessory auricular tags and abnormalities of the pinna.
The possible sites for the cutaneous orifice of auricular sinuses have been reported
by Congdon [2] but a majority open in the pre-auricular region as indicated in Fig. 1.
Auricular and juxta-auricular sinuses are of variable size [2] but in all the patients
reported here the pre-auricular sinus consisted of a sinus sac with a number of
tracts projecting from it extending in anterior and posterior directions. (Fig. 2) In the
two bilateral operations there was a close correlation between the shape and extent
of the sinuses on the two sides. Sinus tracts extending anteriorly were common; an
important finding in all the ears that underwent operation was that of a relatively

Fig. I. Illustrates a typical pm-auricular

sinus. The continuous line i indicates the incision used and the
arrow indicates an elipse surrounding
the common site for a cutaneous orifice of the sinus.
Fig. 2. Illustrates the tracts radiating from the sinus body. I. a commonly
2, tract connected
to the antihelix; 3. tract connected
to the external
radiating anteriorly. The arrow indicates the sinus body.

found post-auricular
extension:
cartilagenous
meatus: 4. tracts

large tract running posteriorly towards the mastoid process. Fig. 3 illustrates an
abscess of such a tract in a patient that had a congenital auricular tag, a congenital
auricular sinus and a normal middle ear cleft. In 4 of the ears there was a tract
running posteriorly and medially where in 3 patients the tract connected with the
anterior cartilagenous wall of the external auditory meatus and in the fourth patient
the tract opened into the lumen of the external auditory meatus. In 4 of the ears
there was also a connection to the cartilage of the antihelix.
The sinus and its tracts lie in the subplatysmal plane immediately superficial to
temporalis fascia lying in close relationship with the
the parotid gland and

Fig. 3. Illustrates an abscess in a sinus tract which lies over the mastoid
cutaneous orifice of the auricular pit.

process.

The arrow indicates

the

superficial temporal artery. Tracts of the sinus may lie close to the facial nerve in
two regions. The trunk of the facial nerve may be damaged whilst resecting a tract
which runs posteriorly and medially to its connection with the cartilagenous external
auditory meatus. Branches of the facial nerve may be damaged whilst resecting tracts
which run anteriorly and extend beyond the border of the parotid gland.
Embryologically the ear develops from 6 primary ear tubercles, 3 being on each of
the first and second branchial arches. The tragus and part of the helix originate from
those tubercles on the first arch whilst the rest of the pinna is derived from the
tubercles of the second arch. Opinions vary [2,14] on the embryological development
of an auricular sinus but the intertubercular hypothesis of His [7] is the most
acceptable description of the development to date. The sinus is described as
developing from a groove between 2 of the 6 primary ear tubercles and results from
incomplete fusion of the tubercles in the early stages of development.

Surgical Procedure

The operation is performed under general anaesthesia and a strip of scalp is

shaved in the temporal region to facilitate performing the incision illustrated in
Fig. 1. The incision commences in the temporal region, runs caudally in front of the
pinna excising the cutaneous orifice of the pre-auricular sinus extending to a level in
front of the ear lobule. Exposure of the sinus is achieved by dissecting down to
temporalis fascia superiorly, and extending this plane of dissection in an inferior
direction until the upper border of the sinus sac is exposed. The deep surface of the
sinus is dissected from from the temporalis fascia and the parotid gland (Fig. 4).

Fig. 4. Illustrates the upper border

being dissected on the deep surface

of the pre-auricular
from above.

sinus lying on temporalis

fascia

and the sinus

20

Commencing superiorly each tract of the sinus may then be individually followed to
its termination and the sinus fully excised. The superficial temporal artery will need
to be dissected free and preserved or be ligated. Haemastasis is obtained, the skin
flap replaced and the skin is closed in layers using a redivac suction drain.
If it was necessary to excise a significant amount of facial skin with the sinus,
primary skin closure is possible as skin mobilisation occurs during the anterior
dissection of the sinus tracts and this may be extended if necessary, as in rhytidectomy, to allow primary closure. Haematoma formation is the most significant
postoperative problem. No complications occurred in the small series reported but
the proximity of the facial nerve is discussed later.

Discussion

Pre-auricular sinuses are inherited as an incompletely dominant autosomal gene

with variable penetrance. [3,4,14] The association between pre-auricular sinuses and
other abnormalities is well reported [4,6,8,10,1 l] and the author has treated a patient
with Marfans syndrome situs inversus and bilateral pre-auricular sinuses.
Commonly pre-auricular sinuses occur unassociated with other abnormalities.
Some pre-auricular sinuses remain asymptomatic throughout life and these may
represent the smaller pits sometimes described [2]. All the sinuses excised as reported
in this paper had been symptomatic and were large requiring an extensive dissection.
Any infection was treated and sterilized pre-operatively.
The method of excision described gives good cosmetic results with an incision
planned to excise the cutaneous sinus orifice but is otherwise similar to that used for
rhytidectomy although it is not usually necessary to extend the incision below the
lobule of the ear. The great advantage of the procedure described is the excellent
exposure obtained. The key to the dissection is the cephalic approach to the sinus
permitting dissection on deep and superficial surfaces of the sinus both anterior and
posterior to the pinna, thus demonstrating the sinus and the sinus tracts radiating
from the sinus. The reported incidence of recurrence occurring after resecting
pre-auricular sinuses is high [ 12,13,15,16] and probably results from using a limited
pre-auricular incision which does not extend sufficiently into the temporal region to
permit demonstration of the superior border of the sinus with its uppermost anterior
and posterior tracts from above. In consequence either the anterior or posterior
border of the sinus sac is first dissected free and a number of sinus tracts will be
divided from the main body of the sinus before the deep surface of the sinus is
exposed thus leaving sinus remnants in situ which give rise to recurrence as had
occurred in Case 3 reported in this paper.
It is felt that the technique of methylene blue injection [9] to demonstrate the
anatomy of the sinus to be resected may be satisfactory for an uncomplicated sinus,
but once infection has occurred it is likely that adhesions will develop and filling of
the sinus may then be incomplete. For this reason it is felt to be an unreliable
technique to ensure total excision of a pre-auricular sinus. Whilst performing the
operative technique described in this paper it has not been necessary to use the

operating microscope, although if, in the sites previously described, proximity of the
facial nerve is feared use of the operating microscope may be helpful.
Wide skin excision followed by grafting or healing by secondary intention
has
sometimes been necessary in the treatment of recurrent pre-auricular
sinuses [ 161 as
has the use of sclerosing material [5]. It is felt that the approach described in this
paper will obviate the necessity for such techniques.
The primary pathology of a
pre-auricular
sinus lies in a subcutaneous
plane and an extensive subcutaneous
dissection is facilitated by this approach. Furthermore,
if skin excision is necessary
primary closure of the wound may be obtained as in rhytidectomy.

Acknowledgments
I am indebted to Mr. Robert Pracey, with whom this technique was developed at
the Royal National Throat Nose and Ear Hospital, for permitting
me to report on
his patients. I am also grateful to Miss G. Short for her line drawings, to St. Marys
Hospital Praed Street, London, W.2. for photographic
prints and to Miss Wooding
for typing the manuscript.

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