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18]

Original Article

Preauricular Sinus: A Comparative Study between Different

Surgical Approaches
Ahmed Shaker ElAassar, Mohammad Abd‑El Hady, Sherif M. Askar, Hazem Said Amer, Mohammad Waheed El‑Anwar
Department of Otorhinolaryngology, Head and Neck Surgery, Zagazig University, Zagazig, Egypt

Abstract
Background: The preauricular sinus is a congenital abnormality of the external ear that is usually asymptomatic. However, if recurrent
infection, persistent discharge or abscess formation occurs, complete surgical excision of the sinus is required. Objective: The objective
of the study is to compare the long‑term results of the preauricular sinus excision by simple sinectomy, microscopic‑assisted sinectomy,
and supra‑auricular approach. Patients and Methods: Patients who had symptomatic preauricular sinus scheduled for surgical excision
were randomly categorized into three groups: Group A (sinectomy) for whom preauricular sinus was excised by simple sinectomy using
methylene blue; Group B (microscopic‑assisted sinectomy) treated by simple sinectomy using the microscopic to follow, dissect out and excise
the sinus tract(s); and Group C (supra‑auricular approach) treated by the supra‑auricular approach. Results: Excisions of 68 preauricular
sinuses were carried out in 58 patients. The mean follow‑up period was 19.7 months with a range of 9–30 months. The overall recurrence
rate was 13.4% (9 cases). The timing of recurrence ranged from 3 to 6 months (3–12 months). The simple sinectomy technique had the
highest recurrence rate (28%). The recurrence rate of the microscopic‑assisted technique was 15% while the supra‑auricular approach had
the lowest recurrence rate (3.4%). Conclusion: The supra‑auricular approach offers the most favorable outcome for the management of
the preauricular sinus.

Keywords: Microscopic‑assisted sinectomy, preauricular sinus, simple sinectomy, supra‑auricular approach

Introduction Patients and Methods

Heusinger (1864) was the first to describe the preauricular sinus
as a common congenital ear abnormality.[1] Males and females
are equally affected.[2] Over 50% of cases are unilateral, on the
right side, and most often sporadic. Bilateral cases are more
likely to be inherited in a pattern of incomplete autosomal
dominance with reduced (around 85%) penetrance.[3]
Preauricular sinus is usually asymptomatic requiring no
treatment. However, when infected, these sinuses become
painful, swollen, and discharging.[4‑6]
The ultimate goal of treatment is complete excision of the sinus
sac or fistula.[7] Several surgical techniques were described.
Unfortunately, recurrence still occurs after excision.[8]
The current study aimed to compare the long‑term results
of the preauricular sinus excision by simple sinectomy,
microscopic‑assisted sinectomy, and supra‑auricular
approach.
This prospective study was carried out in Otorhinolaryngology,
Head and Neck Surgery Department over a period from
November 2013 to December 2016. The Institutional Review
Board approval had been taken from the institute before
starting this research. Patients with symptomatic preauricular
sinus scheduled for surgical excision were included in the
current study. Revision cases were excluded from the study.
A thorough history and head and neck examination was
performed for all patients. Surgeries were conducted in an
infection‑free interval and under general anesthesia. Written
consent was obtained from each patient according to the policy
of the hospital.
Address for correspondence: Dr. Ahmed Shaker ElAassar,
2 El‑Gergawy St., Mesaha, Dokki, Giza, Egypt.
E‑mail: ahmadshaker12@hotmail.com

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DOI: How to cite this article: ElAassar AS, Abd-El Hady M, Askar SM,
10.4103/indianjotol.INDIANJOTOL_69_17 Amer HS, El-Anwar MW. Preauricular sinus: A comparative study between
different surgical approaches. Indian J Otol 2017;23:193-6.

© 2017 Indian Journal of Otology | Published by Wolters Kluwer - Medknow 193

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ElAassar, et al.: Preauricular sinus: A comparative study
Surgical technique
The preauricular area was infiltrated with Xylocaine 2% with
epinephrine 1:100.000 to reduce intraoperative bleeding.
Patients were randomly categorized into three groups as
follows:  (1) Group A  (sinectomy): Preauricular sinus was
excised by simple sinectomy using methylene blue.[9] The
preauricular sinus was first filled with methylene blue.
Then, a vertical elliptical skin incision was made around
the sinus orifice followed by naked eye dissection of the
sinus tract and excision of the entire length of the sinuses.
(2) Group B (microscopic‑assisted sinectomy):[10] After vertical
elliptical incision around the orifice of the preauricular sinus,
the operating microscope (Ziess, 200 mm wave length) was
used to follow, dissect out, and excise the sinus tract(s).
(3) Group  C  (supra‑auricular approach):[11] Treated by the
supra‑auricular approach on which a vertical elliptical incision
was made around the orifice of the sinus. Then, the incision
was extended supra‑auricularly. Dissection was carried out to
identify the temporalis fascia that was the medial limit of the
dissection and continues over the cartilage of the anterior helix
that was regarded as the posterior margin of dissection. Tissue
superficial to the temporalis fascia was removed together with
the preauricular sinus [Figure 1].
In all cases of the three groups, the related perichondrium
(± cartilage) of the helix at the base of the sinus was dissected
and removed with the specimen to ensure complete removal of
the epithelial lining. Finally, the wound was closed in layers.
All patients were discharged on the same day of surgery. One
week postoperatively, the stitches were removed. Then, the
patients were followed up once every 2 weeks for 1 month,
monthly for 6 months, and then once every 3 months later.
Statistical analysis
The statistical analysis and comparison were performed
utilizing SPSS 14.0 statistical software for Windows (SPSS
Inc., Chicago, IL, USA). The significance level was set at
P < 0.05.
a b
c d
Figure 1: (a) Preauricular sinus. (b) Mark for the incision and injection.
(c) Complete dissection. (d) The operative field after excision
194
Results
Sixty‑six patients were operated for symptomatic preauricular
sinus (22 in each group). From them, 58 patients (92%) were
available to follow‑up postoperatively and included in this
study: 35 males (60.3%) and 23 females (39.2%). Their ages
ranged from 7 to 17 years with a mean of 11.4 years. The right
side was involved in 27 cases, the left side was involved in
22 cases, and bilateral involvement was detected in 9 cases,
so 67 operations were performed [Table 1].
The mean follow‑up period was 19.7  months  (range
9–36  months). Serious intraoperative or postoperative
complications, such as bleeding, wound dehiscence, or facial
nerve injury, were not reported. One case (5.6%) from Group
A had postoperative wound infection and another case (5%)
from Group B. Both cases cured after 5  days of systemic
antibiotics and daily dressing. The criteria of recurrence were
local inflammation, subcutaneous mass, or persistent draining
sinus after initial healing.
The overall recurrence rate was 13.4% (9 cases). The timing of
recurrence ranged from 3 to 6 months. In a simple sinectomy
group, 5 of 18 cases (28%) recurred and 3 of 20 cases (15%)
of microscopic‑assisted sinectomy group recurred. Both
sinectomy groups had recurrent rate  (12/38  cases, 21%).
In supra‑auricular approach group, only one case out of
29  cases  (3.4%) recurred. Hence, supra‑auricular approach
expresses significantly less recurrence rate than sinectomy
approaches (χ2 = 4.384, P = 0.036). However, there was no
significant difference between the recurrence rate after standard
sinectomy and the microscopic‑assisted technique ( χ2 = 0.931,
P = 0.3346) [Table 2].
Discussion
Incomplete excision of the preauricular sinus tract(s) and
the presence of residual viable squamous epithelium might
be considered the main cause of recurrence after excision of
preauricular sinus.[12] Furthermore, tortuous tract course, the
high variability, and number of its ramifications which are
difficult for the surgeon to follow[13,14] and infectious episodes,
possibly with abscess, increase the incidence of recurrence.[15]
Table 1: Patient data
Number of patients (%)
Number of patients 58
Number of preauricular sinus 67
Male/female 35 (60.3)/23 (39.7)
Side of preauricular sinus
Left 22 (38)
Right 27 (46.5)
Bilateral 9 (15.5)
Age at surgery (years)
Mean 11.4
Range 7‑17
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ElAassar, et al.: Preauricular sinus: A comparative study
Table 2: Postoperative recurrence rate
Surgical technique Total number of
sinuses: 67, n (%)
Simple sinectomy with methylene blue 18 (27)
Microscopic‑assisted technique 20 (30)
Sinectomy approach and its modifications 38 (57)
Supra‑auricular approach 29 (43)
S: Significant, NS: Nonsignificant
Several tools and methods were introduced for proper tract(s)
identification such as methylene blue staining, tract(s)
probing, microscope, or magnifying glasses.[9,10] However, the
recurrence rate remains significant.
The supra‑auricular approach, described by Prasad et al. in
1990, was based on the theory that a preauricular fistula is
almost found in subcutaneous tissues between the temporalis
fascia and perichondrium of the helical cartilage. The
supra‑auricular approach is assumed to have a lower recurrence
risk.[11]
The concept of supra‑auricular approach depends on
identification of the temporalis fascia and the cartilage of the
helix and auditory canal followed by an en bloc resection of
the sinus, removing all involved subcutaneous tissue between
the temporalis fascia and the helix.[16] Hence, identification
of the entire sinus tract and its branches is not necessary.[13,17]
In the current study, the supra‑auricular approach had the
lowest recurrence rate (3.4%). These results are in agreement
with   Prasad et al.[11]  (5% recurrence) and Lam et  al.[13]
(3.7% recurrence rate) on using the supra‑auricular approach
for excision of preauricular sinus and also agree with the
systematic review done by El‑Anwar and El‑Aassar[7] who
found that the recurrence rate was 4/333  (1.2%) with the
supra‑auricular approach after reviewing nine researches using
this technique. Another systematic review done by Bruijnzeel
et  al. reported 2.2% recurrence rate after supra‑auricular
approach.[18]
The supra‑auricular approach allows the surgeon to excise
the peri‑preauricular sinus soft tissue in toto encapsulating
the sinus itself and avoids the need for dissecting out every
ramification. The excision of a portion of cartilage at the base
of the sinus tract prevents the incomplete removal of the closely
adherent epithelial lining. These factors may explain the lower
observed recurrence rate of this approach.[13]
In the current study, simple sinectomy with methylene blue
technique had a high recurrence rate (28%). These results are
comparable to Lam et al.[13] and Currie et al.[19] who reported a
recurrence rate of 32% and 19%, respectively, using the simple
sinectomy technique.
Theoretically, the instillation of methylene blue makes sense;
however, in daily practice, it often results in diffuse staining
of the surgical field and the overlooking of small tracts. In
addition, when tracts are filled with debris, the dye cannot fill
Indian Journal of Otology  ¦  Volume 23  ¦  Issue 3  ¦  July-September 2017
Total number of recurrent P
cases: 9 (13.4%), n (%)
5 (28) Between simple sinectomy and 0.3346 NS
3 (15) microscopic‑assisted technique ( χ2=0.931)
8 (21) Between sinectomy approaches 0.036 S
1 (3.4) and Supra‑auricular approach (χ2=4.384)
the tract. Furthermore, surgical failure may be due to insufficient
magnification during the operation. Excision of a simple,
unilocular lesion may sometimes be performed successfully
with the naked eye, but, when multiple tracts are involved,
magnification is indispensable.[10] These factors could explain
the high recurrence rate of the simple sinectomy technique.
In this study, the microscopic‑assisted technique has a
15% recurrence rate. These results are in accordance with
Ellies et al.[20] who reported a recurrence rate of 21%. With
the microscopic‑assisted technique, there is no need to
use the methylene blue to delineate the tract of the sinus
because the methylene blue does not stain the epithelium
itself. Hence, the epithelium remnant can easily be identified
with the operating microscope. [21] However, even with
magnification, minor tracts may escape attention, making a
recurrence inevitable.[1] Furthermore, it takes a longer time in
dissection, especially when bilateral sinuses have been excised
at one sitting.
Supra‑auricular approach is simple, effective technique, with
negligible recurrence and with no need for extra assisting tool
(microscope, probe, or magnifying loop). Hence, it is better to
be used regularly as standard procedure for preauricular sinus
excision, especially that it showed no significant complications
and less postoperative scar formation.[15] Furthermore, it is the
ideal technique particularly for recurrent cases or cases doing
sinectomy after abscess incision and drainage. Thus, it would
be helpful for surgeons to be familiar with this approach.
Conclusion
Supra‑auricular approach had significantly lower recurrence
rate than tract sinectomy approaches, so it is recommended to
make it the standard primary procedure for preauricular sinus
excision besides its use in recurrent cases. Thus, it would be
helpful for surgeons to be familiar with this approach.
Financial support and sponsorship
This research is not funded by any resource except the authors
themselves.
Conflicts of interest
There are no conflicts of interest.
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