Preauricular Cysts, Pits, and Fissures

Background
Preauricular cysts, pits (as shown below), 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.

IMAGE(http://thehealthscience.com/thsattachs/921929/111917372683971.jpg)
Close-up image of preauricular pit. Image courtesy of Ed Porubsky, MD. Preauricular tags, as shown below, 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.

IMAGE(http://thehealthscience.com/thsattachs/921929/111917372683972.jpg)
Preauricular ear tag. Image courtesy of Jack Yu, MD. 

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.
Epidemiology
Frequency
Malformations 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.
Etiology
Embryology 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.[1] 
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:

  • Branchiootorenal syndrome (BOR) - Preauricular sinus
  • Beckwith-Wiedemann syndrome - Preauricular sinus with asymmetric earlobes
  • Mandibulofacial dysostosis - Auricular pits/fistulas
  • Oculoauriculovertebral dysplasia - Preauricular tags (see the image below)
    IMAGE(http://thehealthscience.com/thsattachs/921929/111917372783973.jpg)
    Multiple tags in a child with oculoauriculovertebral dysplasia. Note the hemifacial atrophy, retrognathia, and lower set ear. Image courtesy of Jack Yu, MD.
  • Chromosome arm 11q duplication syndrome - Preauricular tags or pits
  • Chromosome arm 4p deletion syndrome - Preauricular dimples or skin tags
  • Chromosome arm 5p deletion syndrome - Preauricular tags

Pathophysiology
Preauricular 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 there is recurrent drainage from a preauricular pit,[2] 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.
Presentation
Clinical presentation of various ear anomalies may be summarized as follows:

  • Noninfected pits - Pinpoint hole in front of the ear or above tragus, as shown below
    • Nondraining
    • Lacks swelling
      IMAGE(http://thehealthscience.com/thsattachs/921929/111917372783974.jpg)
      Uninfected preauricular pit. Image courtesy of Ed Porubsky, MD.
  • Infected pits - Cellulitis and abscess
    • Red, swollen
    • Draining purulent material
    • Granulation around pit
    • Tender
    • Previous surgical scar with underlying swelling
  • Cysts - Slowly enlarging preauricular mass
    • Usually nontender if uninfected
    • Associated pit usually adjacent to cyst, as shown below
      IMAGE(http://thehealthscience.com/thsattachs/921929/111917372783975.jpg)
      Infected preauricular cyst with swelling and erythema toward the cartilage of the ear.
  • Tags - Fleshy knobs of skin in front of the ear
    • Nontender
    • Nondraining
    • Color similar to surrounding skin
    • Appears to be attached on the surface of the cheek, pinna, tragus, or lobe
    • No rapid growth

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

Indications
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 Anatomy
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.
Contraindications
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.

Laboratory Studies

Culture samples may be obtained during drainage procedures.
Imaging Studies
Imaging is not indicated for routine preauricular cysts and sinuses.
Imaging is indicated in patients who present with pits or fistulas located in atypical regions, those with cartilage duplication around the external auditory canal that extends into the parotid, or those with recurrent parotid swelling. Sedation may be necessary in uncooperative or frightened children.
CT scans with contrast offer better bone definition, while MRI with contrast shows superior soft tissue delineation.
Ultrasound imaging may help the physician differentiate cysts, abscesses, and solid masses in this region, but it may not allow for complete analysis of the finer detail in small tracts and deeper fistulae.
Patients who have preauricular cysts or pits and a branchial cleft cyst should undergo a renal ultrasound to rule out branchio-oto-renal syndrome.
Other Tests
Audiogram is not indicated in isolated preauricular cysts, pits or tags.
Diagnostic Procedures
Needle aspiration may be performed in patients with infected lesions that have not responded to oral antibiotic therapy.
Histologic Findings
Findings associated with ear pits include diffuse interstitial dermatitis, abundant foreign body reaction, and ruptured follicular cyst, epidermal cyst, and epidermal sinus tract.

Medical Therapy
Consultations with the following specialists may be beneficial:

  • Otolaryngologist
  • Audiologist: Although most neonates are screened in the United States, confirming normal hearing in any infant who presents with external ear deformities is prudent. No definitive studies, however, have demonstrated that isolated preauricular pits necessitate hearing assessment.
  • Craniofacial teams: Consult these teams in the presence of multiple organ system abnormalities and for children thought to have syndromic features.

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 Therapy
Sinuses, 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 needle aspiration reliably leads to a better cosmetic result than incision and drainage.
Complete surgical excision, as shown below, 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.

IMAGE(http://thehealthscience.com/thsattachs/921929/111917372883976.jpg)
Preauricular sinus tract, cyst, and granulation removed. 

The skin was closed with slight undermining and no tension. Sutures are removed 7-10 days later. 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 Details
The infectious process should be optimally controlled prior to excision of the tract or cysts.
Intraoperative Details
Although several techniques for excision have been described, the following is a standard approach:

  • The pit is excised with a rim of normal tissue.
  • Dissection onto temporalis fascia allows identification of normal tissue plane
  • A probe may be placed to follow the tract down to the base.
  • Blue dye may be used to document the extent of the tract.
  • A rim of auricular cartilage may be taken near the base of the tract to reduce recurrence.
  • Avoid violating the skin of the auricle.
  • Try to preserve skin that overlies the cyst, even if it looks nonviable.
  • If greater exposure is required, the incision may be extended into the postauricular groove.
  • Bipolar cautery and blunt dissection facilitate tissue plane preservation.
  • The wound is irrigated and closed with absorbable sutures.
  • A small rubber band drain may be used and is removed the next day.
  • A flexible dressing may be applied over the ear and around the head. The dressing is removed the next day.

Postoperative Details
Passive 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-up
A follow-up visit should occur 7-14 days after surgery for wound evaluation.
Complications
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, as shown below, is also possible.

IMAGE(http://thehealthscience.com/thsattachs/921929/111917372883977.jpg)
Keloid scar formed several months after removal of preauricular sinus tract. Intralesional steroids and close observation are indicated. Incomplete removal of a sinus tract may lead to recurrence.
Outcome and Prognosis
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 Controversies
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.

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1.Preauricular ear tag. Image courtesy of Jack Yu, MD.
2.Multiple tags in a child with oculoauriculovertebral dysplasia. Note the hemifacial atrophy, retrognathia, and lower set ear. Image courtesy of Jack Yu, MD.
3.Uninfected preauricular pit. Image courtesy of Ed Porubsky, MD.
4.Close-up image of preauricular pit. Image courtesy of Ed Porubsky, MD.
5.Infected preauricular cyst with swelling and erythema toward the cartilage of the ear.
6.A preauricular sinus tract is probed with a blunt needle, and methylene blue dye is injected. Note the region in front of the pit, where previous abscess formation, spontaneous drainage, and residual scarring and granulation have occurred. This circumstance requires a more complex procedure. Removal of the entire sinus tract and the granulation disease is essential. Image courtesy of Ed Porubsky, MD.
7.Preauricular sinus tract, cyst, and granulation removed. The skin was closed with slight undermining and no tension. Sutures are removed 7-10 days later.
8.Keloid scar formed several months after removal of preauricular sinus tract. Intralesional steroids and close observation are indicated.

References
[*]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(3):155-8. .
[*]Scheinfeld NS, Silverberg NB, Weinberg JM, Nozad V. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol. May-Jun 2004;21(3):191-6. .
[*]Aronsohn RS, Batsakis JG, Rice DH, Work WP. Anomalies of the first branchial cleft. Arch Otolaryngol. Dec 1976;102(12):737-40. .
[*]Baarsma EA. Surgical treatment of the infected preauricular sinus. Arch Otorhinolaryngol. 1979;222(2):97-102. .
[*]Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol. Dec 2003;117(12):983-4. .
[*]Currie AR, King WW, Vlantis AC, Li AK. Pitfalls in the management of preauricular sinuses. Br J Surg. Dec 1996;83(12):1722-4. .
[*]Figueroa AA, Friede H. Craniovertebral malformations in hemifacial microsomia. J Craniofac Genet Dev Biol Suppl. 1985;1:167-78. .
[*]Firat Y, Sireci S, Yakinci C, et al. Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment?. Eur Arch Otorhinolaryngol. Sep 2008;265(9):1057-60. .
[*]Gur E, Yeung A, Al-Azzawi M, Thomson H. The excised preauricular sinus in 14 years of experience: is there a problem?. Plast Reconstr Surg. Oct 1998;102(5):1405-8. .
[*]Mallo M. Retinoic acid disturbs mouse middle ear development in a stage-dependent fashion. Dev Biol. Apr 1 1997;184(1):175-86. .
[*]Mandell DL. Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am. Dec 2000;33(6):1309-32. .
[*]O'Rahilly R. The timing and sequence of events in the development of the human eye and ear during the embryonic period proper. Anat Embryol (Berl). 1983;168(1):87-99. .
[*]Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope. Mar 1990;100(3):320-1. .
[*]Rothschild MA, ed. Syndromic and Other Congenital Anomalies of the Head and Neck. Otolaryngol Clin North Am. Dec 2000;33(6).
[*]Smith RJ, Coppage KB, Ankerstjerne JK, et al. Localization of the gene for branchiootorenal syndrome to chromosome 8q. Genomics. Dec 1992;14(4):841-4. .
[*]Tan T, Constantinides H, Mitchell TE. The preauricular sinus: A review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol. Nov 2005;69(11):1469-74. .

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