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ORIGINAL ARTICLE

A W . N.Z. J . Sur<q. (1995) 65. 254-256

SINGLE STAGE EXCISION OF PREAURICULAR SINUS


V. T. JOSEPH AND A. S. JACOBSEN Department of Paediatric Surgery, Singapore General Hospital, Singapore, Republic. of Singapore
A total of 44 patients with preauricular sinus underwent one-stage surgical treatment. There were 32 unilateral and 12 bilateral cases giving a total of 56 sinuses. Of these 16 were infected at the time of presentation. Based on the observation that preauricular sinus represents the duct of a preauricular gland which is closely adherent to the fibrocartilage of the ear, the authors propose a method for the complete cure of this lesion by excising the whole gland and duct together. This technique was used in all cases including 16 patients with infected sinuses. There were three recurrences, two of which were due to incomplete excision of the gland. The third case was found to have a fistula leading to an atretic external auditory canal. All other patients have shown no evidence of recurrence on follow up of six months or longer. Our experience has shown that preauricular sinus can be effectively treated at any stage by a simple surgical technique based on a clear understanding of the underlying anatomy of the lesion.

Key words: branchial arch, preauricular, sinus.

INTRODUCTION Congenital preauricular sinus is generally regarded as an innocuous condition and hence receives little or no attention. However, when infection occurs it becomes very troublesome with chronic discharge, repeated abscess formation and considerablescarring leading to an unsightly appearance (Fig. 1). Various methods of treatment have been advocated but the results have not always been satisfactory. We present our experience with a single-stage technique that we have developed and used in both infected and non-infected patients. PATIENTS AND METHODS
From 1 January 1981 to 31 December 1990,44 patients with congenital preauricular sinus were treated in the Departments of Surgery and Paediatric Surgery, Singapore General Hospital using the described technique. Details of the clinical profile of the cases are given in Table 1. Patients with bilateral sinuses were offered the option of bilateral excision even in the absence of symptoms. All patients were followed up for at least 6 months with two outpatient clinic reviews. At the end of this period, those who had a satisfactory result could be discharged with instructions to return to the clinic if any subsequent problems arose. Recurrence was diagnosed if symptoms and signs of inflammation and infection occurred following initial excision, or if persistent discharge was present with failure of wound healing.

and with the aid of the operating loupe, the track was carefully separated from the surrounding tissues. Towards its termination it will be found to be closely adherent to the fibro-cartilage of the ear from which it was separated by sharp scissor dissection without excising or damaging the cartilage. In non-infected cases, the sinus track will be found

Surgical technique Under general anaesthesia, an elliptical incision was made around the sinus and extended inferiorly for about 1 cm. The incision was deepened and the edges retracted with skin hooks. The ellipse of skin with the sinus opening was grasped with toothed forceps and, by applying traction, the sinus track can be easily identified. Using sharp dissection
Correspondence: Dr V. T. Joseph, Department of Paediatric Surgery, Singapore General Hospital, Outram Road, Singapore 03 16, Republic of Singapore. Accepted for publication I September 1994.

Fig. 1. Infected preauricular sinus, typical site of abscess formation.

Table 1. Clinical characteristics


No. patients Unilateral Bilateral Discharge (intermittent) Infected Recurrent (previous surgery) Declined surgery No. sinuses (%) 32 (57) 24 (43) 35 (63) 16 (29) 6(11)
4 (7)

32 12 35 16 6
4

EXCISION OF PREAURICULAR SINUS

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Table 2. Recurrence following surgery


Case
1

Clinical features Non-infected, recurrent sinus Previous surgery for infection Infected sinus Bilateral sinus, infected left side with previous drainage

Cause of recurrence Incomplete excision Incomplete excision Persistent fistula to atretic external auditory canal

Treatment/result Complete excision/cured Complete excision/cured Complete excision of fistula tract/cured

with infected sinuses. In patients with skin loss due to infection the wound can still be closed using limited local mobilization of adjacent skin. Patients are discharged on the same or following day.

RESULTS
There were 44 patients with 56 sinuses. The age at operation ranged from 6 months to 15 years with a mean age of 4.4 years. There were 24 males and 20 females. In total, 52 sinuses were operated on. Of the 12 patients with bilateral sinuses, five had bilateral primary excision, three had staged bilateral excision, and four had only one side operated on. All patients had experienced discharge from the sinuses and 16 sinuses (28%) were infected at the time of surgery. Six patients had previous incision and drainage of infected sinuses with non-resolution of symptoms. There were three recurrences (5%)of 52 sinuses which were excised. Two of these were due to incomplete excision where, during dissection, a strip of epithelium had been left behind (Table 2). The third case had been treated elsewhere previously and at the time of re-exploration was found to have a fistula leading to an atretic external auditory canal. This probably represents a more complex first pouch and cleft abnormality. All three patients were successfully treated after re-exploration. Postoperative cosmetic results were excellent in all 44 cases.

DISCUSSION
The incidence of preauricular sinus varies in different races, being most common among orientals where figures of 4-6% have been reported. The embryology of the preauricular sinus is related to the incomplete fusion of the three nodules originating from the first branchial arch forming the tragus and the helix.*The sinus extends for a variable distance anteriorly and inferiorly and ends in a multiloculated, ramifying, cystic glandular structure. This gland may have developed from accumulation of secretions from the epithelial-lined sinus, and it is always firmly adherent to the fibro-cartilage of the ear. Although most patients are generally unconcerned about asymptomatic sinuses, we advocate surgical excision in all cases because of the potential risk of infection and the resultant difficulty of complete removal of the tracks following repeated ~ e p s i sThe key to successful .~ treatment is the complete removal of the sinus track with its epithelial ramifications. In non-infected cases this can be easily done by dissecting the sinus tract under magnification. Traction on the sinus opening enables the tract to be clearly defined and is an important aid in separating it from the ear cartilage to which it is closely adherent. The use of methylene blue and lacrimal probes to aid in the dissection is unne~essary.~ have also found that an extended incision We

Fig. 2. Excision of sinus tract and infected cystic spaces. The tract is seen adherent to fibrocartilageof the ear from which it has been shaved off.

to terminate in a globular mass consisting of cyst-like spaces filled with sebaceous material. During dissection if this cheese-like material is seen escaping in the wound it indicates that the wall has been breached. It is then essential to look carefully for the epithelial lining and continue dissection in an outer plane to ensure that all epithelium is completely removed so as to avoid recurrence. In infected sinuses the track from the external opening up to the portion which is densely adherent to the ear cartilage can still be identified and dissected (Fig. 2). Beyond that the cyst-like spaces are replaced by abscess, granulation tissue and surrounding fibrosis. All unhealthy tissue is removed using a combination of sharp dissection,just outside the surrounding fibrous layer, and curettage. Haemostasis is carefully secured and primary closure of the wound is carried out without drains. Antibiotics are not routinely used except in patients

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ramifies into many offshoots ending in a mass of infected, granulation tissue.* In our technique the sinus track is dissected and shaved off from the ear cartilage to prevent recurrence. Following this step the infected mass can be removed by dissecting along the fibrous tissue that surrounds it. We have not found it necessary to use skin grafts to close the defect. Our method of single stage excision of preauricular sinuses gives satisfactory results with a very acceptable cosmetic appearance (Fig. 3). Recurrence rates of 3-1096 have been Our rate of 5 % compares favourably, especially as in the three cases which recurred there were technical problems in the excision procedure. All three patients were completely cured by a repeat operation. In our experience the method of treatment described has been favourably accepted by our patients. The operation is done during a single short hospital stay, reducing hospital and patient costs, and no special postoperative treatment or precautions are required.

REFERENCES
1 Congdon ED, Rowmanavongse S , Varamisara P. Human congenital auricular and juxta-auricular fossae, sinuses and scars (including so-called aural and auricular fistulae) and the bearing of their anatomy upon the theory of their genesis. Am. J. Anat. 1932; 51: 439-64. 2. Ladd WE, Gross RE. Congenital branchiogenic anomalies. Am. J. Surg. 1938; 39: 234-48. 3. Havens FZ. Congenital branchiogenic preauricular sinus: A note regarding its treatment. Arch. Otolaryngol. 1939; 29: 985-6. 4. Chami RG, Apesos J. Treatment of asymptomatic preauricular sinuses: Challenging conventional wisdom. Ann. Plasr. Surg. 1989; 23: 406- 1 1. 5. Lau JTK. Towards better delineation and complete excision of preauricular sinus. Aust. N.Z. J. Surg. 1983; 53: 267-9. 6. Prasad S , Grundfast K, Milmoe G.Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990; 100: 320-1. 7. Raman R. Excision of preauricular sinus. Arch. Otolaryngol. HeadNeckSurg. 1990; 116: 1452. 8. Pastore PN, Erich JB. Congenital preauricular cysts and fistulas. Arch. 0101. 1942; 36: 120-5. 9. Sykes PJ. Preauricular sinus: Clinical features and the problems of recurrence. Br. J. Plastic Surg. 1972; 25: 175-9.

Fig. 3. Good cosmetic result at 6 weeks after excision of infected sinus.

with a supra-auricular approach is not required to identify the sinus tracks even after repeated episodes of infection.( The use of magnification has been found to be helpful in clearly identifying the diseased tissue. We routinely carry out our dissection with the operating loupe. In infected sinuses the track leading up to the ear cartilage is still present and can be dissected in the same way as for non-infected cases. The difference is that beyond this point the track