Tragal Pointer as a Surgical Landmark
The tragal pointer is a critical anatomical landmark used to locate the facial nerve trunk during parotidectomy and other head and neck surgical procedures, positioned approximately 1 cm deep and slightly inferior to the cartilaginous projection of the tragus. 1
Anatomical Definition and Location
The tragal pointer refers to the cartilaginous projection of the tragus—the small, flat, triangular prominence situated anteriorly to the external auditory canal entrance. 2 This structure serves as a reliable external landmark for identifying deeper anatomical structures that cannot be directly visualized from the surface. 1
Primary Clinical Applications
Facial Nerve Identification
- The tragal pointer is most commonly used during parotidectomy to locate the facial nerve trunk, which typically lies approximately 1 cm deep and slightly inferior to this landmark. 1
- This relationship provides surgeons with a consistent reference point to avoid iatrogenic facial nerve injury during parotid gland surgery. 1
Other Surgical Procedures
The tragal pointer serves as a landmark in multiple head and neck procedures: 1
- Internal fixation of subcondylar and condylar fractures
- Mandibular osteotomy procedures
- Temporomandibular joint arthroplasty
- Percutaneous nerve blocks of trigeminal nerve branches
- Pterygopalatine ganglion blocks
- Maxillary artery identification
Surgical Considerations and Pitfalls
Tragal Cartilage Harvesting
- When tragal cartilage is harvested for reconstructive purposes (such as tympanoplasty), patients should be counseled preoperatively that this may affect their ability to wear in-ear headphones postoperatively. 3
- In one study, 10 of 12 patients (83%) who had tragal cartilage harvested experienced problems with in-ear earphones post-operatively, compared to only 1 of 12 (8%) in the control group (p<0.05). 3
- Problems included pain and devices falling out due to loss of the cartilaginous support structure. 3
Syndromic Associations
- Accessory tragus or tragal abnormalities may signal underlying craniofacial syndromes, particularly Goldenhar syndrome (oculoauriculovertebral dysplasia). 4
- Accessory tragus is a constant feature of Goldenhar syndrome and represents a first branchial arch anomaly. 4
- These lesions contain cartilage and should not be treated with simple shave excision like skin tags, as this may expose cartilage and cause complications. 4
Additional Clinical Context
While the tragal pointer's primary significance lies in surgical navigation, the tragus itself has other clinical applications. Tragal pumping—pressing on the tragus to increase external auditory canal pressure—has been shown to facilitate ototopical medication delivery through tympanostomy tubes into the middle ear cavity. 5