Standard Treatment Algorithm for Preauricular Pit
Asymptomatic preauricular pits require no intervention; infected pits should be treated with antibiotics and fine-needle aspiration (NOT incision and drainage), followed by complete surgical excision only after infection has fully resolved. 1, 2, 3
Initial Assessment
When evaluating a preauricular pit, determine:
- Infection status: Look for erythema, swelling, purulent drainage, or abscess formation in the preauricular cheek skin 4
- Bilateral involvement: 25-50% of cases are bilateral, which increases likelihood of hereditary pattern 2
- Associated anomalies: Screen for deafness, renal abnormalities, or features of branchio-oto-renal (BOR) syndrome, as 3-10% of preauricular sinuses are syndromic 5, 2
If other congenital anomalies coexist, obtain auditory testing and renal ultrasound. 2
Management Based on Clinical Presentation
Asymptomatic Pits
- No treatment required 1, 2
- The vast majority are benign and require no intervention 1
- Counsel patients/families about signs of infection 2
Acute Infection (First Episode)
Critical: Avoid incision and drainage at all costs. 3
- Culture the exudate before starting antibiotics 2
- Administer appropriate antibiotics targeting gram-positive bacteria (most common pathogens) 2
- Consider fine-needle aspiration for abscess drainage rather than incision and drainage 3
- Evidence shows incision and drainage leads to 18.5% recurrence rate versus only 3.3% recurrence with antibiotics or fine-needle aspiration alone (absolute difference 15.2%) 3
Recurrent Infection
Complete surgical excision is the only definitive cure and is clearly indicated. 1, 2, 4
- Surgery must be performed after infection has completely resolved, not during active infection 4
- Excision must include the entire sinus tract and associated subcutaneous cyst network 1
Surgical Technique Principles
When excision is indicated:
- Wide exposure is essential to prevent recurrence 1
- Make an elliptical incision around the sinus opening, extending to identify the plane of the temporalis fascia 6
- Excise all soft tissue between the temporalis fascia plane and the skin anterior to the sinus, including a piece of adjoining helical cartilage 6
- The sinus tract is closely related to helical cartilage and must be completely removed 6
- Meticulous technique by an experienced head and neck surgeon minimizes recurrence risk 2
Common Pitfalls to Avoid
- Never perform incision and drainage for infected preauricular sinuses—this creates a 15% higher recurrence rate and may lead to chronic fistulae 3
- Never perform incomplete excision—failure to recognize the full extent of the sinus tract (which may erupt away from the pit opening into preauricular cheek skin) leads to inadequate treatment and unnecessary repeat procedures 4
- Never operate during active infection—this significantly increases recurrence rates (9-42% overall) 2, 4
- Inexperienced clinicians often fail to identify the preauricular pit as the source when infection presents in the preauricular cheek, leading to inappropriate drainage procedures 4