International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

A modified supra-auricular approach with helix cartilage suture for surgical T

treatment of the preauricular sinus
Kai-Chieh Chana,b, Han-Tse Kuob, Valerie Wai-Yee Hoc, Wen-Yu Chuangb,d,
Zung-Chung Chenb,e,∗,1
a
Division of Otology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taiwan
b
School of Medicine, Chang Gung University, Taoyuan, Taiwan
c
Division of Plastic and Reconstructive Surgery, Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong, China
d
Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan
e
Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: Several surgical techniques and modifications have been described to reduce the high recurrence rate
Preauricular sinus after excision of preauricular sinus (PAS). This study was designed to evaluate the surgical outcomes of PAS
Supra-auricular approach excision using a new modified supra-auricular approach (SAA) and to assess the predisposing factors for re-
Recurrence currence.
Helix cartilage suture
Methods: A total of 175 (158 patients) PAS excision procedures were performed from 2007 to 2016 in a single
institute using this modified SAA with helix cartilage suture to obliterate the dead space. The specimens were
assessed to measure the closest distance between the squamous tract and the excised auricular cartilage (sino-
cartilaginous distance). We also evaluated the surgical outcomes and investigated the predisposing factors for
recurrence, including gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or
local), history of infection, and history of incision and drainage (I&D) for abscess.
Results: Patients were followed up for a median duration of 45 months (range from 6 months to 10 years). There
was a 2.3% (4 ears) recurrence rate and a 1.7% (3 ears) complication rate in our series. The average sino-
cartilaginous distance was 0.44 mm (median distance, 0.3 mm) and this value was less than 0.5 mm in 66% of
cases. Recurrence was not significantly affected by gender, lesion laterality, etiology of surgery, anesthesia
method, or a history of infection or preoperative I&D for abscess.
Conclusions: Surgical PAS excision using the modified SAA with cartilage suture of dead space yielded low
overall recurrence and complication rates in this series. Cosmesis was maintained due to a smaller incision. No
significant predisposing factors for recurrence were identified. Thus, the modified technique described in the
present study can be regarded as a simple, effective and reproducible surgical treatment for PAS.

1. Introduction 1.91% in South Korea and 4%–10% in some regions of Africa [2–6].
Although PAS is frequently asymptomatic and does not require
The preauricular sinus (PAS) is a congenital tract lined by squamous treatment, surgical management is indicated when the PAS becomes
epithelium with hyperkeratosis and parakeratosis and was first de- infected. Patients may present with local cellulitis or abscess in the
scribed by Van Heusinger in 1864 [1]. Embryonically, the external ear acute inflammatory stage or chronic intermittent discharge from the
is formed from six hillocks of His, which arise from the first and second sinus opening. Antibiotics and/or adequate incision and drainage (I&D)
branchial arches. Failure of complete fusion of the six hillocks or en- can usually control the infection. Once infection occurs, the risk of re-
trapment of ectodermal epithelium during auricular development is current infection is increased. Therefore, the entire sinus tract should be
believed to result in the formation of a PAS. The prevalence of PAS is excised completely to eradicate the disease.
0.1–0.9% in the United States, 0.9% in England, 1.6%–2.5% in Taiwan, Traditional sinusectomy for PAS had been widely adopted in the

∗
Corresponding author. Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial
Hospital & Chang Gung University, Linkou, Taiwan.
E-mail addresses: [email protected], [email protected] (Z.-C. Chen).
1
Address: Din Hu Rd No. 123, Gweishan, Taoyuan, Taiwan.

https://doi.org/10.1016/j.ijporl.2018.08.041
Received 1 May 2018; Received in revised form 31 August 2018; Accepted 31 August 2018
Available online 05 September 2018
0165-5876/ © 2018 Elsevier B.V. All rights reserved.
K.-C. Chan et al. International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152

past, but a high rate of recurrence (19–40%) had been reported [7,8]. It
is believed that unidentified branching of the sinus, remnants of the
sinus wall, and infection with or without formation of abscesses can
lead to disease recurrence. Thus, various modified surgical techniques
for PAS excision have been proposed to achieve a lower recurrence rate,
such as the supra-auricular approach (SAA) [8,9], inside-out technique
[10] or Fig. 8 excision method [11]. Of these, the SAA introduced by
Prasad et al. has been one of the most favorable and widely used
methods since 1990 [8]. The recurrence rate of the SAA ranges between
0 and 23%, with an average rate of 2.2% [12]. However, the main
drawback of the SAA is the large dead space that results from resecting
the PAS with the surrounding subcutaneous tissue via an extended
supra-auricular and postauricular incision. Postoperative drain inser-
tion and compression dressing are usually required for complete closure
of the dead space. Bae et al. [13] designed a drainless minimal SAA
with meticulous subcutaneous mattress suture to obliterate the dead Fig. 1. A vertical elliptical incision was made around the sinus opening and
space for treatment of PAS, and there was no postoperative recurrence extended upward to the supra-auricular region for 5 mm without postauricular
extension.
or other serious complication in their study.
Additionally, recurrence after PAS excision was found to be corre-
lated with certain factors, such as preoperative infection status, pre- the creation of false passages. In the case of revision surgery, probing
operative I&D [14], or local anesthesia technique [15–18]. was not conducted. After the skin incision, en bloc resection of the PAS
Thus, the purposes of the present study were to introduce a modified with surrounding subcutaneous tissue between the temporalis fascia
SAA surgical technique with helix cartilage suture to minimize the dead and the helix was performed (Fig. 2), taking care not to injure the su-
space without drainage or dressing and to survey the surgical results for perficial temporal vessels. A small portion of helix cartilage adjacent to
PAS. Moreover, we also examined various predisposing factors for re- the PAS tract was routinely resected (Fig. 3a). After complete excision,
currence after the surgery in a 10-year retrospective study period. the wound was irrigated copiously with dilute povidone-iodine solution
to prevent surgical site infection. Then, absorbable sutures were used to
2. Materials and methods suture the distal remnant subcutaneous tissue, temporalis fascia, and
helix cartilage in a vertical mattress manner and in a lateral-to-medial
A retrospective review of the clinical records of consecutive patients direction to tightly obliterate the dead space (Fig. 3b). A schematic il-
with PAS who underwent the surgery with the modified SAA between lustration of the helix cartilage suture technique is shown in Fig. 4.
July 2006 and June 2016 was conducted. The study was approved by Finally, a local pressure dressing was applied using adhesive bandage
the institutional review board of Chang Gung Memorial Hospital in strips. No drains or mastoid dressing was needed (Fig. 5). The bandage
Linkou, Taiwan (IRB No.201800424B0). All the PAS cases were of the was removed after 48 h. Postoperative oral antibiotics and analgesics
classic type, with the sinus opening located at the anterior margin of the were prescribed for 1 week.
ascending limb of the helix.
Indications for this surgery were cases of PAS with a history of 3. Results
persistent purulent discharge or recurrent infection or asymptomatic
patients with cosmetic concerns because of an apparent PAS opening. There were 175 ears with PAS (152 patients) in this review. The
Each ear involved in the bilateral procedures was regarded as a separate study cohort included 59 males and 93 females with a median age of
operation. All patients were followed for at least 6 months post- 22.5 years (range: 1–78). A total of 88 right ears, and 87 left ears were
operatively, with the longest follow-up being 10 years. Postoperative operated on (23 patients had bilateral operations). A total of 162 ears
complications and recurrence were documented. Preoperative predis- had no previous PAS surgeries (labeled as primary), while 13 ears had a
posing factors were collected, and their association with recurrence was history of PAS surgery (labeled as revised). There were 96 and 79 ears
analyzed. These factors included gender, lesion laterality, etiology treated under LA and GA, respectively. A total of 161 ears had a history
(primary or revised), anesthesia methods (general or local), history of of preoperative infection, while 14 ears were asymptomatic. A total of
infection, and history of I&D for abscess. Chi-square test or Fisher's 20 ears had undergone I&D for abscess, while 155 cases had not
exact test was performed using SPSS statistical software (SPSS Inc., (Table 1). The median follow-up duration was 45 months (range:
Chicago, IL), and P < 0.05 was considered statistically significant. 6–120).
The diagnosis of PAS was confirmed histopathologically.
2.1. Surgical technique Pathological analysis typically showed that the sinus tracts were in
close proximity to the helix cartilage (Fig. 6). A total of 138 specimens
At our institution, surgical excision of the PAS is usually performed were retrieved to measure the closest distance between the squamous
about one month after the resolution of an acute infection. An acutely tract and the excised auricular cartilage. The average sinocartilaginous
infected PAS is first treated with a course of antibiotics. If an abscess is distance was 0.44 mm, ranging from 0.1 to 1.9 mm (median distance,
present, I&D is performed. All subjects underwent PAS excision by the 0.3 mm). In 66% (91 cases) of the specimens, the sinocartilaginous
senior authors (K.C. Chan & Z.C. Chen) under general anesthesia (GA) distance was less than 0.5 mm. There were 4 cases of recurrence among
or local anesthesia (LA). The operations were performed under GA for 175 operated ears (2.3%). Two cases presented as epidermoid cyst
patients under 12 years old and under LA for most adult and adolescent formation at 12 months and 14 months postoperatively, one presented
patients unless they could not comply. The surgical procedure was as a postoperative nonhealing wound, and one presented as new
modified from the SAA described by Prasad et al. [8]. Local anesthetic aperture formation with discharge at one month after surgery. Three
containing epinephrine was infiltrated subcutaneously at the lesion to patients reported complications (1.7%). Two patients had wound de-
include auriculotemporal nerve block. A vertical elliptical incision was hiscence, and one had wound infection. However, no cases of post-
made around the sinus opening and extended upward to the supra- operative seroma/hematoma, perichondritis or chondritis were identi-
auricular region for 5 mm without postauricular extension (Fig. 1). A fied in this series. Cosmesis was good without any auricular deformity.
lacrimal probe was then used to locate the sinus tract gently to avoid The potential predisposing factors for recurrence after surgery,

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Fig. 2. En bloc resection of the sinus tract with the sur-

rounding subcutaneous tissue between the temporalis fascia
(deep boundary, 2b) and the helix (posterior boundary, 2a)
was performed. Of note, caution is required to avoid injury of
the superficial temporal vessels (anterior boundary). S: sinus
tract, C: helix cartilage, and F: temporalis fascia.

including gender, lesion laterality, etiology, anesthesia techniques, complication rate. According to a systemic review [12], the recurrence
history of preoperative infection, and history of preoperative I&D for rate of the SAA for PAS excision ranged between 0 and 23%, with an
abscess formation, were also analyzed (Table 2). Recurrence occurred average recurrence rate of 2.2%. The present surgical result is in ac-
in two ears among 93 female patients (1.9%) and in 2 ears among 59 cordance with that report. Because the presence of dead space after the
male patients (2.9%); the difference was not statistically significant. original SAA is associated with wound complications, we advocated
There were 87 left-sided lesions and 88 right-sided lesions, and 2 cases closing the dead space by suturing the helix cartilage, temporalis fascia
from each side experienced recurrence (2.3% and 2.2%, respectively). and residual subcutaneous tissue. Therefore, this approach contributed
No statistically significant difference was noted between these two to a low complication rate in our study. Furthermore, the recurrences in
groups. Regarding etiology, recurrence occurred in 3 ears among 162 the study were not related to factors including gender, lesion laterality,
primary cases (1.9%), while recurrence occurred in 1 ear among the 13 anesthesia technique, history of previous sinus excision, history of I&D
ears of revised cases (7.7%). No statistically significant difference be- or etiology of PAS surgery. Hence, this modified SAA is indeed a reli-
tween these two groups was demonstrated. There were 96 and 79 able, effective and safe surgical technique for PAS excision.
procedures performed under LA and GA, respectively. Three cases of The original SAA procedure involved a wide exposure with supra-
recurrence were noted in the LA group (3.1%), and 1 case of recurrence auricular extension of the preauricular incision and the identification of
was noted in the GA group (1.3%). No statistically significant difference landmarks, including the temporalis fascia (deep boundary), superficial
was shown. A total of 161 ears had a history of preoperative infection, temporal vessels (anterior boundary), and the cartilage of the anterior
among which 4 ears (2.5%) experienced postoperative recurrence. helix (posterior boundary). These landmarks are important in revision
However, there were no cases of recurrence among the 14 asympto- cases or in the acute infection stage. Entire sinus tracts and surrounding
matic ears. There was no statistically significant difference between subcutaneous tissue within these landmarks were excised completely.
these two groups. Recurrence was noted in one ear among 20 ears (5%) In our modified surgical method, a 5-mm skin incision is extended su-
that had undergone I&D for abscess. Three cases of recurrence were periorly, similar to that described by Bae et al. [13], without further
noted among the other 155 cases (1.9%) without a history of I&D. No postauricular extension. This technique helps to minimize the dead
statistically significant difference was shown between these two groups. space while still maintaining an adequate view for complete excision of
the sinus tract. This modified SAA approach also offered better aesthetic
results than the original SAA due to a smaller incision [13].
4. Discussion Several authors [15] have reported that there are no significant
differences in recurrence rates between the groups with and without
In this study, utilization of the modified SAA resulted in effective excision of the perichondrium of helix cartilage. However, Dunham
surgical outcomes, with a 2.3% recurrence rate and a 1.7%

Fig. 3. A small part of the helix cartilage adjacent to the sinus tract was routinely resected (3a). Then, the dead space was closed tightly by absorbable stitches via
suturing of the remnant subcutaneous tissue, temporalis fascia and helix cartilage with the vertical mattress technique in a lateral-to-medial direction (3b).

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Table 1
Patient demographics.
No. (%)

Total ears 175(100.0)

Gender
Male 68(38.9)
Female 107(61.1)
Lesion laterality
Right 87(49.7)
Left 88(50.3)
Anesthesia technique
General anesthesia 79(45.1)
Local anesthesia 96(54.9)
Etiology
Primary 162(92.6)
Revised 13(7.4)
History of infection
Yes 161(92.0)
No 14(8.0)
Preoperative incision & drainage
Yes 20(11.4)
No 155(88.6)

cartilage adjacent to the sinus tract is suggested to ensure thorough

excision and to reduce recurrence rates [10,11,20]. Methylene blue was
not routinely used to mark the sinus tract, as methylene blue may dif-
fuse into tissues and affect the accurate dissection of all the complicated
branches [16].
Regional auriculotemporal nerve block is important during PAS
surgery, especially under LA, since the preauricular region is innervated
by this nerve. Caution should be taken to avoid injury to the superficial
temporal artery because the auriculotemporal nerve usually presents
within the initial loop of the superficial temporal artery. Previous re-
ports [15–18] have shown that dissection of the PAS under GA has a
lower recurrence rate compared with that under LA, because patients
under GA had better tolerance and allowed a more complete dissection
and excision of the PAS. However, there was no statistically significant
difference between these two groups in this study, although the LA
patients had a higher recurrence rate (3.1%) than the GA patients
Fig. 4. Schematic illustration of the helix cartilage suture technique. A vertical (1.3%). We postulated that this finding is due to the effective local
mattress suture was placed to obliterate the dead space after excision of the regional auriculotemporal nerve block, allowing the procedures to be
sinus structure and the adjacent helix cartilage.
performed smoothly.
The present study found that patients with a history of infection or I
et al. [19] indicated that the distance between excised preauricular &D of the PAS show a higher rate of recurrence than patients without
epithelial sinus tracts and adjacent auricular cartilage measured < these conditions (5% vs.1.9% and 2.5% vs. 0%, respectively), but there
0.5 mm in > 50% of cases and that the epithelial tract was in con- was no statistically significant difference. The debate on whether a
tinuity with stromal tissue and histologically indistinguishable from the history of PAS infection or I&D for abscess is associated with a high rate
perichondrium in nearly all cases. The pathological results of the pre- of recurrence has been controversial due to mixed reports in the lit-
sent study are also consistent with this finding. Furthermore, the pre- erature [14,15,17,21]. Thus, no conclusions can be drawn from the
sence of multiple protruding pouches associated with the fistula wall differing results; it is possible that the overall recurrence rate is low and
and their firm adhesion to the cartilage make complete removal of the that most studies are not adequately powered. The recurrence rate in
sinus wall difficult, which is especially true when inflammation is the revised group was higher than that in the primary group (7.7% vs.
present. Therefore, resection of a small portion of auricular helix 1.9%); however, these results did not show any statistically significant

Fig. 5. Finally, the surgical wound was closed and locally compressed by adhesive bandage strips (not shown) without drainage or mastoid dressing.

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Fig. 6. The specimen opened along the sinus tract (a). Microphotograph showing small unidentified branches of the sinus tract in close proximity to the cartilage (H&
E stain; original magnification ×200) (b). C: helix cartilage and S: sinus tract.

Table 2
Recurrence rate based on different variations of clinical presentation.
Gender Lesion laterality Etiology Anesthesia technique History of infection Preoperative I&D

Male Female R L Primary Revised GA LA Yes No Yes No

Recurrent ears (No.) 2 2 2 2 3 1 1 3 4 0 1 3

Total ears 68 107 87 88 162 13 79 96 161 14 20 155
Recurrence rate (%) 2.9 1.9 2.3 2.2 1.9 7.7 1.3 3.1 2.5 0.0 5.0 1.9
p-value p = 0.644 p = 0.99 p = 0.175 p = 0.413 p = 0.551 p = 0.388

p < 0.05 indicates a statistically significant difference.

Abbreviations: R: right; L: left; GA: general anesthesia; LA: local anesthesia; and I&D: incision and drainage.

between-group difference. Although it is believed that most cases of Financial disclosure statement
recurrence occur in the early postoperative period within one month of
the surgical procedure, two of the four recurrent cases in our series The authors have no financial or commercial associations that might
developed one year after surgery. This result suggests that a long-term create a conflict of interest with the information presented in this ar-
follow up for at least one year may be necessary. Recurrence should be ticle.
highly suspected when there is persistent discharge from the wound or
painful swelling around the surgical site. Additionally, some authors Author contributions
[10,18] have advocated the use of a microscope or magnifying glasses
to reduce the risk of recurrence, as blood vessels and surgical planes can Study conception and design: Dr. Kai-Chieh Chan and Dr. Zung-
be clearly identified intraoperatively without any unintended dis- Chung Chen.
turbance of the sinus sac. Because no magnifying tools were used in the Acquisition of data: Dr. Han-Tse Kuo
current study, we hypothesized that the application of these tools in the Pathology review and analysis: Dr. Wen-Yu Chuang.
future will help during dissection, especially in the chronically inflamed Analysis and interpretation of data: Dr. Han-Tse Kuo and Dr. Kai-
or recurrent cases, hence further lowering the recurrence rate. Chieh Chan.
There are a few limitations in this study. The retrospective study Drafting of manuscript: Dr. Kai-Chieh Chan and Dr. Zung-Chung
design resulted in inadequate data collection and a potential informa- Chen.
tion bias. Although the patients were routinely followed for at least 6 Critical revision: Dr. Valerie Wai-Yee Ho.
months, some cases of recurrence may have occurred after the follow-
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