What is the best course of treatment for a patient with a preauricular pit infection?

Treatment of Preauricular Pit Infection

For an infected preauricular pit, treat with oral antibiotics (fluoroquinolones or alternatives covering Staphylococcus and Pseudomonas) and avoid incision and drainage, as I&D significantly increases recurrence rates after definitive surgical excision.

Initial Management of Acute Infection

Antibiotic Selection

• First-line therapy: Fluoroquinolones (ciprofloxacin or levofloxacin) provide excellent coverage for the most common pathogens in preauricular infections, including Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pyogenes 1
• Alternative regimens: Clindamycin, ceftazidime, or cefepime may be used depending on severity and local resistance patterns 1
• MRSA consideration: If MRSA is suspected or confirmed, linezolid has demonstrated efficacy in preauricular infections 2
• Atypical organisms: In recurrent or treatment-resistant cases, consider mycobacterial infection and test for acid-fast bacilli, particularly in endemic areas 3

Critical Management Decision: Avoid Incision and Drainage

The single most important treatment principle is to avoid incision and drainage (I&D) during acute infection. 4

• I&D of infected preauricular cysts results in an 18.5% recurrence rate after eventual surgical excision 4
• Conservative management with antibiotics or fine-needle aspiration results in only a 3.3% recurrence rate (absolute difference of 15.2%) 4
• If drainage is absolutely necessary for a large abscess, fine-needle aspiration is strongly preferred over I&D 4

Definitive Treatment: Surgical Excision

Timing of Surgery

• Perform complete surgical excision only after infection has completely resolved 5, 4
• Presence of active infection at surgery increases recurrence to 15.79% versus 8.22% when no infection is present 6
• Previous abscess drainage (I&D) increases surgical recurrence to 16.7% versus 8.16% without prior drainage 6

Surgical Technique to Minimize Recurrence

Key technical factors that reduce recurrence: 6

• Excise auricular cartilage at the base of the tract: Failure to excise cartilage results in 18.52% recurrence versus 4.5% when cartilage is excised (p=0.006) 6
• Use methylene blue dye injection: Dye injection alone reduces recurrence to 2% 6
• Optimal visualization: Combined dye injection plus probing results in 0% recurrence versus 21.95% when no tract identification method is used 6
• Complete excision: Wide exposure and removal of the entire pit and subcutaneous cyst network is essential for cure 5

Treatment Algorithm

1. Acute infection present: Start oral fluoroquinolone (or alternative based on severity/resistance patterns) 1
2. Large abscess requiring drainage: Use fine-needle aspiration only, never I&D 4
3. Recurrent or resistant infection: Consider mycobacterial infection, obtain AFB testing 3
4. After infection resolves: Schedule elective complete surgical excision 5, 3
5. At surgery: Use methylene blue injection, probe the tract, excise cartilage at the base, ensure complete removal of all cyst networks 6

Common Pitfalls to Avoid

• Never perform I&D for infected preauricular pits—this dramatically increases recurrence after definitive surgery 4
• Do not operate during active infection—wait for complete resolution to minimize recurrence 6
• Do not skip cartilage excision—this is statistically significant for preventing recurrence 6
• Do not rely on probing alone—use methylene blue dye injection for optimal tract visualization 6
• Do not assume bacterial etiology in recurrent cases—test for mycobacteria in treatment-resistant infections 3