What is the recommended treatment for a preauricular pit infection in a child?

Treatment of Preauricular Pit Infection in Children

For an infected preauricular pit in a child, treat with oral antibiotics and consider fine-needle aspiration if an abscess is present, while avoiding incision and drainage, then proceed to complete surgical excision once the infection has resolved.

Acute Infection Management

Initial Treatment Approach

• Start oral antibiotics immediately for all infected preauricular sinuses to control the acute infection 1, 2.
• The specific antibiotic choice should cover typical skin flora including Staphylococcus aureus and Streptococcus species 2.

Abscess Management (Critical Decision Point)

• If an abscess is present, perform fine-needle aspiration rather than incision and drainage 1, 2.
• This is a crucial distinction: incision and drainage is associated with an 18.5% recurrence rate after eventual surgical excision, compared to only 3.3% recurrence with fine-needle aspiration or antibiotics alone (absolute difference 15.2%) 1.
• The higher recurrence rate with incision and drainage likely results from scarring and distortion of tissue planes, making complete surgical excision more difficult 1.

When Conservative Management Fails

• If infection cannot be controlled with antibiotics and aspiration, surgical excision while actively infected may be necessary, though this is rare 2.
• One study reported only 1 of 28 infected cases required excision during active infection 2.

Definitive Surgical Management

Timing of Surgery

• Delay definitive surgical excision until the infection has completely resolved 1, 3, 2.
• This approach minimizes recurrence risk and allows for better tissue plane identification 3, 2.

Surgical Technique Considerations

• Complete excision of the pit and entire sinus tract is the only definitive cure 3, 4.
• Excise a piece of auricular cartilage at the base of the tract, as this reduces recurrence from 18.52% to 4.5% 5.
• Use methylene blue dye injection with or without probing to identify the full extent of the tract, which reduces recurrence to 0-2% compared to 21.95% when no tract identification method is used 5.
• For chronic abscesses, curettage of the subcutaneous abscess cavity without resecting the abscess wall or overlying skin provides good cosmetic results 2.

Common Pitfalls to Avoid

Critical Errors in Management

• Never perform incision and drainage as the primary drainage procedure - this significantly increases recurrence risk after definitive surgery 1.
• Failure to recognize the presence of a preauricular sinus when infection presents in the preauricular cheek area leads to inadequate treatment and unnecessary repeat procedures 3.
• Incomplete excision of the sinus tract is the primary cause of recurrence 4, 5.

Recognition Issues

• Infected preauricular sinuses may present with infection erupting away from the visible pit, particularly affecting the preauricular cheek skin 3.
• Always examine for a preauricular pit when evaluating any preauricular soft tissue infection in children 3.

Expected Outcomes

• Overall recurrence rates after proper surgical excision range from 9-12% 1, 5.
• Recurrence is higher (15.79%) when surgery is performed during active infection versus when infection is absent (8.22%), though this difference was not statistically significant 5.
• With optimal surgical technique (cartilage excision and dye injection), recurrence rates can be reduced to 0-4.5% 5.
• Median follow-up in contemporary series shows no recurrence when proper technique is employed 3.