What is
Excision Pre-auricular Cyst?
Preauricular cysts, pits, fissures, and
sinuses are benign congenital malformations
of the preauricular soft tissues.
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.
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.
Back to Top
Effects
of Excision Pre-auricular Cyst
The prognosis is excellent if the tract,
fissure, and/or cyst is completely removed.
Back to Top
Candidates
for Excision Pre-auricular Cyst
Patients with preauricular sinuses present to the clinician
with persistent discharge, recurrent
infections or recurrence after surgery.
Malformations of the external ear are not uncommon. These
conditions affect males and females equally
and have no race predilection.
Back to Top
Your
Consultation
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.
Back to Top
The Excision Pre-auricular Cyst
Procedure
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.
Back to Top
Recovery
A small rubber band drain may be used and is removed the next
day. flexible dressing may be applied over
the ear and around the head. The dressing is
removed the next day.
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. A
follow-up visit should occur 7-14 days after
surgery for wound evaluation.
Back to Top
Risks
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.
Back to Top
Frequently Asked
Questions
Q: What is a Pre-auricular sinus/pit?
A:
Preauricular sinuses are common congenital
malformations that usually occur at the
anterior margin of the ascending limb of the
helix.
Q: What happens during the procedure?
A:
Although several techniques for excision
have been described, the following is a
standard approach:
-
The pit is excised with a rim of normal tissue.
-
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.
Q: What are the indications of preauricular cysts/pits?
A:
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.
Q: What are the risks and complications
involved in this procedure?
A:
Previously infected cysts and tracts may
cause deeper tissue damage that requires
rotational and or advancement flap
procedures for improved cosmetic outcome.
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.
Back to Top |
