What is the management approach for a pediatric preauricular pit?

Management of Pediatric Preauricular Pits

The majority of preauricular pits are benign and require no intervention unless they become infected or develop recurrent infections, in which case complete surgical excision is the only definitive cure.

Clinical Presentation and Diagnosis

• Preauricular pits (also called preauricular sinuses or ear pits) are common congenital abnormalities
• They appear as small openings adjacent to the external ear, typically near the anterior margin of the ascending limb of the helix 1
• Characteristics:
  • More frequently found on the right side
  • Bilateral in 25-50% of cases (increasing likelihood of inheritance) 1
  • Can be inherited (autosomal dominant with reduced penetrance) or sporadic

Assessment

When evaluating a child with a preauricular pit:

1. Examine for infection signs:

   • Erythema, swelling, pain, or discharge from the pit
   • Postauricular infected cysts (may indicate an insidious preauricular sinus) 2

2. Check for associated conditions:

   • Preauricular pits are features of other conditions in 3-10% of cases 1
   • Associated with deafness and branchio-oto-renal (BOR) syndrome
   • Consider auditory testing and renal ultrasound if other congenital anomalies are present 1

Management Algorithm

1. Asymptomatic Preauricular Pits

• Recommendation: Observation only
• No intervention required for asymptomatic pits 3, 1
• Educate parents about signs of infection to monitor

2. Infected Preauricular Pits

• Acute infection management:

  • Culture exudate from the sinus 1
  • Treat with appropriate antibiotics (typically targeting gram-positive bacteria) 1
  • Consider topical non-ototoxic fluoroquinolone drops if drainage is present 4
  • Avoid ototoxic topical preparations to prevent hearing loss and balance disturbance 4

• For abscess formation:

  • Incision and drainage may be necessary
  • Note: Drainage alone has higher recurrence rates (16.7%) compared to complete excision 5

3. Recurrent Infections

• Recommendation: Complete surgical excision of the pit and sinus tract 3, 1, 6
• This is the only definitive cure for recurrent infections

Surgical Considerations

When surgical excision is indicated:

1. Timing:

   • Ideally performed when infection has resolved
   • Operating during active infection increases recurrence rate (15.79% vs 8.22%) 5

2. Technique for optimal outcomes:

   • Wide exposure of the lesion 3
   • Excision of auricular cartilage at the base of the tract (reduces recurrence from 18.52% to 4.5%) 5
   • Use of methylene blue dye injection and probing to identify the entire sinus tract (reduces recurrence to 0%) 5
   • Complete removal of all sinus tracts to prevent recurrence 6

3. Postoperative care:

   • Keep the surgical site clean and dry
   • Monitor for signs of infection
   • Follow-up to ensure complete healing

Important Considerations

• Recurrence rates after surgery range from 9% to 42%, with an average of 9.09% 1, 5
• Misdiagnosis risk: Failure to recognize a preauricular sinus, particularly when infection erupts away from the sinus opening, may lead to inadequate management and unnecessary procedures 6
• Surgical expertise: Meticulous excision by an experienced head and neck surgeon minimizes recurrence risk 1

Follow-up

• Regular follow-up after surgical excision to monitor for recurrence
• If other congenital anomalies are present, appropriate specialist referrals should be made
• Consider auditory testing if there are concerns about associated hearing issues 1