Preauricular Sinus Surgery: Treatment and Management
Surgical Indication
Complete surgical excision is the only definitive treatment for symptomatic preauricular sinuses with recurrent or persistent infection, and should be performed electively after acute infection has resolved. 1, 2, 3
When Surgery is Indicated
- Operate for: Recurrent infections, persistent drainage, or history of abscess formation requiring drainage 1, 3
- Do not operate for: Asymptomatic preauricular pits discovered incidentally—these require no intervention 3, 4
- Timing is critical: Defer definitive excision until all acute infection has completely resolved, as operating during active infection increases recurrence rates from 8.22% to 15.79% 1
Optimal Surgical Technique to Minimize Recurrence
The surgical approach must include complete tract visualization, cartilage excision at the base, and wide local excision—not simple sinectomy—to achieve acceptable recurrence rates. 1, 3
Critical Technical Elements
Tract identification: Use methylene blue dye injection combined with simultaneous probing—this combination achieved 0% recurrence in one series, compared to 21.95% recurrence when no tract identification method was used 1
Dye injection alone: Achieved 2% recurrence rate 1
Probing with cannula alone: Associated with 10.87% recurrence rate 1
No identification method: Resulted in 21.95% recurrence rate 1
Cartilage excision: Always excise a piece of auricular cartilage at the base of the tract—failure to do so increases recurrence from 4.5% to 18.52% 1
Surgical exposure: Employ wide local excision with adequate exposure of all branching tracts, not simple sinectomy 3, 4
Consider magnification: Use surgical loupes or microscopy to identify all tract branches 3
"Inside-out technique": This approach (opening and following tracts from inside as well as outside) has shown zero recurrences in some series 5, 3
Preoperative Assessment
- Screen for associated anomalies: Check for renal abnormalities and other congenital malformations, particularly in pediatric patients—consider renal ultrasound in selected cases 3
- Document infection history: Prior abscess drainage increases recurrence risk to 16.7% versus 8.16% without prior abscess 1
Management of Acute Infection
- Acute phase treatment: Administer appropriate antibiotics and perform incision and drainage if abscess is present 3
- Delay definitive surgery: Wait until infection completely resolves before performing definitive excision 1, 3
Common Pitfalls to Avoid
- Inadequate tract identification: Failure to recognize the full extent of branching tracts leads to incomplete excision and recurrence—this is the most common cause of treatment failure 2, 3
- Operating during active infection: Increases recurrence risk by approximately 2-fold 1
- Simple sinectomy: This limited approach has higher recurrence rates compared to wide local excision 3
- Misdiagnosis: Infected sinuses may present as preauricular cheek infections away from the pit opening—failure to identify the sinus leads to repeated inadequate drainage procedures 2
- Omitting cartilage excision: This technical oversight quadruples the recurrence rate 1
Expected Outcomes
- Overall recurrence rate: Approximately 9% with standard techniques 1
- Optimized technique recurrence: Can be reduced to 0-2% with meticulous technique including dye injection, probing, and cartilage excision 1, 5
- Complications: Wound breakdown, infection, and scarring occur in a small percentage of cases 1