Int. J. Oral Maxillofac. Surg.

2002; 31: 439441

doi:10.1054/ijom.2001.0062, available online at http://www.idealibrary.com on

Technical Note
Congenital Craniofacial Deformities

Methylene blue staining and

probing for fistula resection:
application in a case of bilateral
congenital preauricular fistulas

R. Martn-Granizo,
M. C. Perez-Herrero,
A. Sanchez-Cuellar
C/Guzman el Bueno, 70, 4A 28015, Madrid,
Spain

R. Martn-Granizo, M. C. Perez-Herrero, A. Sanchez-Cuellar: Methylene blue

staining and probing for fistula resection: application in a case of bilateral congenital
preauricular fistulas. Int. J. Oral Maxillofac. Surg. 2002; 31: 439441.  2002
Published by Elsevier Science Ltd on behalf of International Association of Oral
and Maxillofacial Surgeons.
Abstract. Preauricular sinus and fistulas are minor developmental anomalies. They
are bilateral in 35% to 50% of cases. We describe the application of a combined
technique in a rare case of bilateral congenital preauricular fistulas. Initial fistula
probing serves as a surgical guide, and further methylene blue infection helps to
avoid leaving viable squamous epithelial remnants.

Periauricular congenital lesions are

grouped as preauricular sinuses and first
branchial cleft anomalies. They share
similar clinical presentations and principles of surgical treatment. Preauricular
sinuses, cysts, and fistulas are congenital
malformations with an incidence ranging from 0.1% to 0.9%, although a
higher incidence of 4% and 10% has been
reported in blacks and orientals1,4,13.
They are bilateral in 35% to 50% of the
cases4,14. First described by H
in 18646, the generally accepted embriogenic theory is their origin from a faulty
or incomplete fusion of the first arch
hillocks, with entrapment of ectodermal
epithelium10. On the other hand, first
branchial cleft anomalies are rare,
accounting for 1% to 8% of all branchial
cleft malformations4. Several surgical
techniques have been described for their
treatment4,1012,14. Among them, the
most popular have been the use of sinus
tract or fistula probing4,12. It is wellknown that incomplete surgical resection
0901-5027/02/040439+03 $35.00/0

of periauricular fistulas and cysts is

the main factor in recurrence14. This
report describes the application of a
combined technique that facilitates
surgical excision in a rare case of bilateral congenital preauricular fistula.
Material and methods
A 43-year-old female presented with a
5-year history of recurrent infections in
her right preauricular area, accompanied
by pain and occasional fever. Her past
medical history was non-contributory,
with no familial history of similar symptoms. On examination, she exhibited
tender swelling of her right preauricular
area with pus exuding through a small
skin orifice at the root of the helix
(Fig. 1). A similar opening was detected
in front of the opposite ear, but without
signs of inflammation (Fig. 1). A presumptive diagnosis of bilateral preauricular sinuses vs first branchial cleft
fistulas was made. Consequently, she

Key words: preauricular fistulas; congenital

fistulas; methilene blue staining; surgical
probing.
Accepted for publication 22 January 2001

was treated with oral antibiotics, and a

MRI was done, which showed bilateral
preauricular sinus tracts from the skin to
the helical cartilage, without involvement of middle ear structures nor of
the external auditory canal. Therefore, a
diagnosis of bilateral preauricular sinus
and fistulas was made. The patient
underwent surgery under general
anesthesia. The operative field was infiltrated with local anesthetic and vasoconstrictor, around and beneath the fistula.
A lacrimal probe was used to gently
canalize the duct tract, and methylene
blue was injected until reflux through the
orifice was verified (Fig. 2). The syringe
was then removed but the probe maintained in place, and an oval incision
including the pit was made. Next, a
sharp clamp was placed, grasping both
fistula and probe (Fig. 3), and dissection
was continued. At this point, the lacrimal probe served as a guide for accurate excision, whereas methylene blue
stained epidermal tissues of the duct

 2002 Published by Elsevier Science Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.

440

Martn-Granizo et al.

Fig. 1. A 43-year-old female with bilateral

congenital fistulas. (Left) View of her right
and, (Right) left side fistulas (Arrows).

Fig. 3. Intraoperative view of the surgical

technique. Fistula tract has been followed and
dissected using the cannula as a guide. Note
the sebaceous cyst at the end of the tract. A
complete resection is mandatory in order to
avoid further recurrence.

Fig. 2. Instillation of methylene blue once

fistula has been cannulated.

helped to completely identify the fistula

and cysts (Fig. 3). Deep structures of the
sinus were attached to the cartilage of
the helix, and therefore a small portion
of the helical rim was resected to prevent
recurrence. Surgical specimen was sent
for histopathologic analysis (Fig. 4), and
surgical wound was closed in a standard
fashion without drainage. Compressive
dressings were used for 24 h. Histology
showed both duct and cyst lined with
stratified squamous epithelium infiltrated by polymorphonuclear leukocytes, with no malignancy. No hairy
structures were found. Follow-up was
uneventful with no signs of recurrence 1
year later.
Discussion
Preauricular sinus and fistula is a minor
developmental anomaly, etiology is
unknown. The most accepted hypothesis

Fig. 4. Macroscopic view of both fistulas and

cysts with the probes still in place, once
surgical excision has been completed.

is an autosomal dominant inheritance

with low penetrance and variable expression, and without sex dierence2,8. Some
authors have reported association of
preauricular sinuses and fistulas with
renal and other anatomic anomalies4,7,8.
E et al.4, reported a familial predisposition to fistula formation in nine of
62 patients (14%). In the present case we
have not found familial antecedents.
Although one third of the patients
remain asymptomatic, fistulas may
present with symptoms such as swelling,
pain, and discharge, as the present case4.
Likewise, concomitant infection of the

tract may lead to abscess that needs

surgical drainage. The most frequently
colonizing species found are Staphylococus epidermidis and aureus4. A case of
basal cell carcinoma developing in a
preauricular fistula has been reported9.
The length of the fistula tracts is variable, and some authors have pointed out
that inflammation of a fistula may lead
to longer tracts4,13.
The goal of surgery is complete excision of the tract, as epithelial remnants
may lead to unexpected recurrences11.
The standard operative technique consists of an elliptical incision around the
sinus opening and subsequent dissection
of the duct tract. Previous infiltration
with vasoconstrictor is mandatory.
Some variations of this technique have
been introduced11,12,14. The opening of
the cystic duct may be closed by a pursestring suture to prevent extrusion of
the cyst contents14. An oval incision
is usually enough4, although inverted
L-shaped
incisions14,
the
supra11
auricular , and preauricular approaches
have been described3. Optical magnification with surgical glasses or the operating microscope is recommended by
many surgeons35,11,12. Probing the
fistula tract may help in precise dissection3,4,11,12. Methylene blue staining
has been used, as it delineates the duct
tract and stains small loculations of the
fistula (Fig. 2)3,11,14. However, ink may
reflux and such a leak may stain the
operative field, thus empairing adequate
vision. Therefore, we have used a clamp
grasping the probe and the fistula duct,
thus avoiding ink and sinus reflux that
may contaminate the wound (Fig. 3).
With this combined technique, the probe
serves as surgical guide and ink as a
test to avoid leaving viable squamous
epithelial remnants.
Recurrence is the most frequent complication of this procedure3,5. According
to P et al., the recurrence rate for
the standard excision was 42%, whereas
the recurrence rate for the supraauricular technique was 5%11. E
et al. reported a recurrence rate of 21%
in 62 cases4. C et al. found a recurrence rate of 19% in 117 patients, and
rates were higher in patients in whom
previous excision had been attempted
(33%), where probing was used (36%),
and in whom local anesthesia was
employed (30%)3.
Although this case report discusses
only a single patient to illustrate the
technique, the authors suggest that the
combination of methylene blue staining
and fistula probing may provide a

Staining and probing for bilateral preauricular fistula resection

suitable method for accurate preauricular fistula resection.
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Address:
Dr Rafael Martn-Granizo
C/Guzman el Bueno, 70, 4A 28015, Madrid,
Spain
Tel.: +34 91 544 05 02
E-mail: rmartinlo@nexo.es