Surgical techniques

A new surgical technique for treatment

of preauricular sinus
Robert J. Baatenburg de Jong, MD, PhD, Leiden, The Netherlands

Background. The objectives of this paper are to describe the shortcomings of current techniques for
treatment of preauricular sinus (PAS) and to introduce a new surgical technique. PAS is a common
congenital abnormality. Usually these lesions are asymptomatic. However, some patients complain of
discharge and/or (recurrent) infections, and require excision. Surgical treatment of PAS is characterized
by high recurrence rates. This paper describes a single institution’s experience with the operative
management of PAS and introduces a new technique.
Methods. Data on PAS procedures were collected from a retrospective review of patients’ charts and
interviews by questionnaire of all patients treated operatively for PAS in the Leiden University Medical
Centre from 1984 to 2003.
Results. Thirty-nine patients (21 male, 18 female) with PAS underwent 40 procedures for PAS. These
procedures included 17 classic operations (in 16 patients) and the ‘‘inside-out technique’’ in 23
patients. In the patient group treated ‘‘classically,’’ 2 patients developed a recurrence; one underwent
successful reoperation; the other patient has been lost to follow-up. Another patient developed wound
breakdown postoperatively, resulting in an ugly scar. Two patients had postoperative infections requiring
treatment. Neither recurrences nor complications requiring treatment occurred in the group who
underwent the inside-out technique.
Conclusions. The inside-out technique provides an easy solution for patients with PAS. However, further
study on a larger patient group is necessary. (Surgery 2005;137:567-70.)

From the Department of Otolaryngology and Head and Neck Surgery, Leiden University Medical Centre

PREAURICULAR SINUS (PAS) is a common congenital
abnormality described by Van Heusinger in 1864.1
This abnormality also has been described as a
preauricular pit, preauricular fistula, preauricular
tract, and preauricular cyst. The sinus is usually
located anterior to the anterior limb of the
ascending helix. In rare patients, the opening is
found at the superoposterior edge of the helix or
the tragus, or even in the lobule.2 Subcutaneously,
there is a simple sac or multiple epithelium-lined
tracts. A connection to the external auditory canal
of the tympanic cavity has not been described in
patients with isolated PAS.3 In more than 50% of
the patients, the sinus is unilateral2 and asymp-
Accepted for publication January 30, 2005.
Reprint requests: Robert J. Baatenburg de Jong, MD, PhD,
Professor and Vice-Chairman, Department of Otolaryngology
and Head and Neck Surgery, Leiden University Medical Centre,
PO Box 9600, 2300RC Leiden, The Netherlands. E-mail:
r.j.baatenburg_de_jong@lumc.nl.
0039-6060/$ - see front matter
Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.surg.2005.01.009
tomatic. Preauricular abnormalities are believed to
result from a failure of fusion of the primitive
tubercles from which the pinna is formed.4 An
incomplete, dominant, autosomal gene of variable
penetrance transmits the malformation.5 Recently,
a locus was found to map to chromosome 8q11.1-
q13.3.6 The incidence of PAS varies from 0.9%
(whites) and 5% (blacks) to even 10% (Asians).7
Males and females are affected equally.
Treatment is usually recommended in case of
recurrent infections or bothersome discharge.
Various surgical techniques have been described,
including simple excision with or without the use
of probes or methylene blue instillation, and the
supra-auricular approach. These techniques will be
referred to as the classic approach in the following
discussion. The multitude of techniques described
in literature is a testimony to their inadequacies
and shortcomings.8 Recurrence rates have been
reported to be as high as 42%.5,9
METHODS AND RESULTS
In the 1970s, a modified surgical technique was
introduced by Jensma from the Sophia’s Children

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568 Baatenburg de Jong Surgery
May 2005

Figure. Inside-out technique. A, A small skin island around the sinus is made. B, Stay sutures allow trac-
tion to facilitate dissection of the tract(s). C, The sinus is opened with sharp scissors. D, Under magnified
vision, the glistening lining (‘‘inside’’) and the outer wall of the tract (‘‘out’’) are dissected free of the
surrounding tissue.

Hospital in Rotterdam, but never published in the
literature. We adapted his technique and named it
the inside-out technique. In this paper, the results of
this technique will be compared with classic
techniques.
Technique. The use of magnifying glasses or a
microscope is mandatory. The surroundings of the
sinus are infiltrated with xylocaine 2%/epineph-
rine 1:100.000 (1-2 cm from the sinus) to reduce
bleeding. A vertical elliptical incision encompass-
ing the sinus is made (Fig, A). The skin island to be
resected is made as small as possible. Stay sutures
are placed at both ends of the skin island (superior
and inferior) (Fig, B). Subsequently, the sinus is
opened with sharp scissors (Fig, C). The sinus can
now be viewed and followed from both the outside
(as in classic procedures) and from the inside (Fig,
D). Each subsequent tract is opened and followed
in a similar way until every dead end is identified.
A fine lacrimal duct probe may be used to establish
the directions of small tracts. Usually one of the
tracts is closely adherent to the perichondrium of
the root of the helix and/or tragus. This piece of
perichondrium (and related cartilage) is resected
in continuity with the specimen. The medial
(deep) limit of the dissection is always the tempo-
ralis fascia. The wound bed is checked for rem-
nants of the sinus, but until now residual disease
has not been identified. After hemostasis, the
wound is closed in one layer, without a drain.
The wound is dressed with sterile skin closure
strips.
Surgery
Volume 137, Number 5
Patients and data collection. This study is retro-
spective and data were collected from the patients’
files. Since follow-up appeared to be short in
general, a simple questionnaire containing the
following questions also was distributed:
1. After surgery, did you ever have complaints in the
operated region?
2. If so, what were these complaints?
3. Did you ever need additional treatment?
From 1984 to 2003, 39 patients (21 male, 18
female) with PAS underwent 40 procedures in the
Department of Otolaryngology and Head and Neck
Surgery. These 40 procedures included 17 classic
operations (in 16 patients) and the inside-out
technique in 23 patients. Two patients in the classic
group and 8 patients in the inside-out group had
undergone prior attempts to remove the lesion.
Age ranged from 2 to 71 years (average, 21.4
years). One patient had branchio-oto-renal syn-
drome, with renal anomalies and missing stapes
and incus. All but 1 patient had recurrent infec-
tions before the procedure; 2 patients in the classic
group and 9 patients in the inside-out group had
undergone incision and drainage of an abscess
previously. Before 1991, a variety of surgical pro-
cedures were performed, such as simple sinectomy,
use of methylene blue staining, lacrimal duct
probes, and so forth. After 1991, the author
treated most of the patients (23), who all under-
went the inside-out technique.
Follow-up ranged from 1 to 25 months; 35 of 39
questionnaires were returned and were evaluable.
From the group who underwent classic surgery,
the patient with branchio-oto-renal syndrome
recurred. A wide re-resection appeared curative.
Another patient who continued to have discharge
because of residual disease was lost to follow-up.
One patient developed wound breakdown post-
operatively, resulting in an ugly scar. Two patients
had postoperative infections requiring treatment.
Another patient experiences local infection every 2
to 3 years.
In the patients who underwent the inside-out
technique, neither recurrences nor perioperative
complications requiring treatment occurred. One
patient stated that she experiences occasional pain
in a cold environment, and another patient is
treated by a dermatologist for skin problems in the
preauricular region.
DISCUSSION
The diagnosis of PAS is usually clear cut: only a
sebaceous cyst has to be excluded. Misdiagnosis is
therefore not the reason for the recurrence rates,
Baatenburg de Jong 569
which are remarkably high. Unfamiliarity with the
disease and/or limited experience with the
required surgical techniques probably influence
recurrence rates unfavorably: Although the inci-
dence of PAS is quite high, the number of patients
who require excision is limited. The experience of
individual surgeons is further limited by the fact
that treatment is performed by plastic surgeons,
and ENT, head and neck, and maxillofacial sur-
geons. In addition, PAS excision is generally con-
sidered a minor procedure and may be performed
by less-experienced surgeons or residents. It seems
advisable to limit the referral of patients to one
dedicated surgeon per institution.
Simple excision without magnification has the
highest recurrence rate and is not recommended.
The other techniques (use of probes and/or dye,
the supra-auricular approach) are characterized by
fewer recurrences.5 With the use of probes, how-
ever, minor tracts may escape attention and some-
times fausses routes occur.9,10 The instillation of
methylene blue makes sense theoretically; how-
ever, in daily practice it often results in diffuse
staining of the surgical field and the overlooking of
small tracts.9 In addition, when tracts are filled
with debris, the dye cannot fill the tract.
Another reason for surgical failure may be
insufficient magnification during an operation.
Excision of a simple, unilocular lesion may some-
times be performed successfully with the naked
eye, but, when multiple tracts are involved, mag-
nification is indispensable. Even with magnifica-
tion, minor tracts may escape attention, making a
recurrence inevitable.5
The supra-auricular technique is based on iden-
tification of the temporalis fascia (medial border
of the dissection), and the cartilage of the helix
and auditory canal (posterior border of the dissec-
tion). Subsequently, an en bloc resection of the
sinus is performed. Reported recurrence rates are
less than 5%.9,11 Most authors obtain better results,
irrespective of the technique they use, when they
include a part of cartilage (root of the helix/
tragus/auditory canal) in the resection.5,7,9
The dissection with the inside-out technique is
facilitated by the fact that the different aspect of
the lining of the tract helps to identify even the
smallest tracts, especially while one is working with
magnification. Because of the small incision and
the subcutaneous dissection, a primary closure is
accomplished easily.
Recurrence rates are influenced by the surgical
technique, by the number and severity of infec-
tions, and by previous surgery.12 In patients with
isolated PAS, there is no reason to explore for
570 Baatenburg de Jong
connections to the auditory canal or tympanic
cavity. A true fistula communicating with the tym-
panic cavity is extremely rare and is described only
when associated with branchiogenic anomalies.
Since this is a small retrospective study, it does
not allow a statistical comparison between tech-
niques and has limitations, but recurrences and
complications, albeit minor, were only observed
in the patients who underwent a classic approach.
Of course, other circumstances may have changed
over the years, which contributed to the better
outcome in the recent years that the inside-out
technique was used.
I would like to thank Dr H. Jensma for developing
the original technique, and Dr A. P. M. Langeveld and
Dr J. C. Jansen for critical readings of the manuscript.
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