What is the management for a 2-month-old with an ear pit (preauricular pit)?

Management of Preauricular Sinus in a 2-Month-Old

For a 2-month-old with an asymptomatic preauricular pit, observation and monitoring is the recommended management approach, with surgical intervention reserved only for cases with recurrent infection or drainage.

Understanding Preauricular Sinuses

• Preauricular sinuses (ear pits) are common congenital abnormalities that appear as small openings adjacent to the external ear near the anterior margin of the ascending limb of the helix 1
• They may be unilateral or bilateral (25-50% of cases are bilateral) and can be either inherited (autosomal dominant with reduced penetrance) or sporadic 1
• Most preauricular sinuses are benign and require no intervention unless they become infected 2

Initial Assessment

• Determine if the preauricular sinus is associated with other congenital anomalies, as 3-10% of cases may be features of other conditions or syndromes 1
• Consider auditory testing if there are concerns about hearing, as preauricular sinuses can be associated with hearing impairment in some syndromic cases 1
• Assess for any signs of infection such as redness, swelling, pain, or drainage 1, 3

Management Approach

For Asymptomatic Preauricular Sinuses

• Observation is the recommended approach for asymptomatic preauricular sinuses 2
• No intervention is required for non-infected, non-draining sinuses 1, 2
• Regular follow-up during well-child visits to monitor for any changes or signs of infection 1

For Infected Preauricular Sinuses

• If infection occurs, obtain cultures of any exudate to identify the causative organism (most commonly gram-positive bacteria) 1
• Treat acute infections with appropriate antibiotics based on culture results 1
• For recurrent infections, complete surgical excision is the only definitive cure 1, 2, 3

Surgical Considerations

• Surgery should be performed when the sinus is not actively infected to reduce recurrence rates 4
• Complete excision of the pit and sinus tract provides the only definitive cure 2, 3
• Recurrence rates after surgery range from 9% to 42%, with lower rates when performed by experienced surgeons 1, 4
• Surgical techniques that include excision of cartilage at the base of the tract and use of dye injection to identify the sinus tract have shown lower recurrence rates 4

Special Considerations for Infants

• In a 2-month-old, the primary focus should be on monitoring for infection and providing parent education 1
• Parents should be educated about signs of infection to watch for (redness, swelling, drainage) 1, 3
• If infection occurs in an infant, consultation with a pediatric otolaryngologist is recommended for appropriate management 3

When to Refer to a Specialist

• Refer to a pediatric otolaryngologist if:
  • The sinus becomes infected or begins draining 1, 3
  • There are concerns about associated congenital anomalies 1
  • The child has recurrent infections requiring surgical intervention 3
  • The sinus is associated with hearing concerns or other ear abnormalities 1

Pitfalls to Avoid

• Failure to recognize an infected preauricular sinus may lead to inadequate management and unnecessary procedures 3
• Incomplete excision during surgery significantly increases the risk of recurrence 4
• Attempting surgical drainage without addressing the underlying sinus tract will not provide definitive treatment 3
• Overlooking potential associated conditions, especially in bilateral cases 1