Case Report

Infected Preauricular Sinus

Presentator : dr. Muhammad Syafiq Riski

Moderator : dr. Agus Surono, Ph.D., M.Sc., Sp.T.H.T.K.L(K)

Departemen Kesehatan Telinga Hidung Tenggorok – Kepala Leher

Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan
Universitas Gadjah Mada/ RSUP DR.Sardjito Yogyakarta
2018
BACKGROUND United States, it is estimated about 0.1% -
0.9% of cases, in the UK is estimated to be
Preauricular abscess is an abscess
up to 0.9% of cases. In Taiwan, the range is
that is formed due to preauricular sinus that
about 1.6% - 2.5% of cases. In Asia about
are irritated and edema caused by bacterial
4% -6%, and in Africa about 4-10% .3,4
infection. The formation of pus due to
prolonged inflammatory and edema Preauricular sinus or preauricular
processes results in sinus ostium blockage. fistula is a congenital disorder that occur
The symptoms of preauricular abscess mainly in children. The incidence of these
include swelling, pain and discharge. The disorder reaches 0.3% - 0.9% among
discharge that produced by the inflammatory pediatric populations.3 The most frequent
process facilitates the occurrence of manifestation of the preauricular sinus is the
infection. Some patients complain of chronic appearance of a small hole ± 3 mm in
purulent discharge and intermittent from the diameter and generally located in the outer
sinus. Once infected, the sinuses are rarely ears at the anterior helix margin. The disease
asymptomatic, usually becomes frequent was first introduced in 1864 by Van
chronic exacerbations of acute infections, heusinger.4.5 Preauricular sinus often appear
then scarring and resulting of cosmetic skin unilateral on one side of the ear, especially
1,2
damage. the left ear and only 25-50% of cases occur
bilaterally.6
From several literatures, the most
common bacterial colonization includes Preauricular sinus is often associated
salivary streptococci, staphylococcal with other conditions or syndrome in 3% -
pyogenes, gram-positive and gram-negative 10% of cases. The majority are associated
bacilli. Scheinfeld reported that the most with deafness and Branchio-oto-renal
common causes of infected preauricular syndrome (BOR). When a congenital
sinus are Epidermidis Staphylococcus anomaly occurs within this sinus, auditory
(31%), S Aureus (31%), Viridans and renal ultrasonography tests must be
Streptococcus (15%), Peptococcus (15%) considered.7 Preauricular sinus is also
and Proteus (8%).2 inherited. From analysis of genetic studies
has reported a congenital preauricular sinus
The incidence of infected
located on chromosome Bq11.1-q13.3.8
preauricular sinus varies globally. In the
 The formation of the preauricular facial nerve and parotid gland. The sinus can
sinus is closely related to the development also extend into the parotid gland.10,11
of ear embryology. In embryogenesis, the
There are 2 types of preauricular
auricle arises from the first and second
sinus : classic and variant types. The classic
branchial arch during the 6th week of
type is defined as a preauricular sinus which
gestation. The branchial arch is a
is located at the anterior to the Canal
mesodermal structure that separated from
auditory externus (CAE). Meanwhile, the
the other by the external ectodermal
variant type is located in the post-auricle
branchial gap and the endodermal
area and sometimes situated on the
pharyngeal pouch from the inside. The first
ascendant helix side. To distinguish the
and second arch each give an intake of 3
classical and the type of variant, an
hillocks that resemble small hills known as
imaginary line can be created starting from
the hillock of His. The 3 hillocks derived
the tragus cartilage to the posterior boundary
from the first caudal boundary of the first
of the ascendant helix. The variant type
branchial arch will form tragus, crus helix
itself can be classified based on hole
and helix. While 3 hillocks from the border
location, type 1 hole located in crus middle
of the second branchial arcus cephalis will
area, type 2 hole located in superior crus,
form antihelix, scapa and lobulus. All these
and type 3 hole located in cymba conchae.3,4
hillocks should unite in the following weeks.
In abou 8th week, the auricle has identifiable Histologically, the sinus preauricula
structure. If the fusion of the hillocks is depicts a stratified squamous epithelium that
incomplete, it will form a gap that is shows hyperkeratosis and parakeratosis that
potentially becomes of preauricular sinus in covers the sinus opening and filled with
the future. Some theories also mention that materials such as sebaceous or sebocite
the folds located at the ectoderm during glands, sweat glands and hair follicles. The
embryological development can cause surrounding tissue contains lymphocyte and
8,9
preauricular sinus formation. neutrophil cell plasma that are easily
clogged and infected. If there is
The tracts in preauricular sinus are
inflammation, the epithelial layer is often
usually narrow and vary in length (usually
covered by granulation tissue.2
short). The preauricular sinus is usually
found laterally, superior and posterior to the
 In the acute phase of infection,
antibiotic intervention should be
immediately given to eradicated pathogenic
bacteria. If an abscess has occurred, an
incision and abscess drainage is required.
Surgical excision of the sinus and the
following tract is required if the infection is
recurrent or persistent. Surgical excision
aims to ensure complete dissection of the
sinuses. Incomplete dissection is believed to
be the cause of recurrence of the infected
preauricular sinuses. Recurrence rate after
excision is estimated about 0-42% .8,11
CASE REPORT
A 26-years-old female came to the
ENT Department RSUP Dr. Sardjito with a
swollen complaint in front of the left ear.
The complaint happened since 2 weeks ago
accompanied by pain. Swelling enlarged and
spread over the last 4 days and occurred
with fever. From physical examination,
there is a small hole in front of the left ear
following by smelly yellowish liquid.
Complaints of the nose and throat are
refused. From previous medical history, the
patient has experienced the same problem
but recovered with medical treatment from
Primary Health Care.
From the examination found that the
general condition were looked moderate
pain and compos mentis. The vital signs
were : Blood Pressure : 120/80 mmHg,
Heart Rate: 90x / minute, Respiration : 22x /
minute, Temperature: 37 'C and Pain scale :
5. On the physical examination, there was
red swelling in front of the left ear also
small hole ± 3 mm diameter was found in
front of the ascenden pars of helix sinistra
accompanied by yellowish pussy and smelly
on the swollen area. From palpation, a
swollen area was palpable in anterior part of
auricle sinistra, containing exudate pus with
warm texture and tighten surface
accompanied by tenderness at the swollen
area. From otoscopic examination, tympanic
membrane was intact with cone of light (+).
Physical examination of the right ear was
found within normal limits. Examination of
anterior and posterior rhinoscopy within
normal limits. Oropharynx examination
within normal limits. Indirect laryngoscopy
examination within normal limits. Neck
examination within normal limit and there
was no enlargement of lymph nodes.
The patient was diagnosed as an
infected preauricular sinus. On May 18,
puncture aspiration was done and
mucoserous liquid was collected then to be
analyzed in microbiology laboratory. The
patient was hospitalized on June 22. On June
25, sinusectomy was succesfully performed.
For after operative treatment, fluid therapy
RL 1500 ml / 24 hours was given, also
ceftriaxone 1 g / 12 hours injection, 500 mg/
tranexamat acid and ketorolac 30 mg / 12
hours of injections. The patient was treated
for 2 days with the same therapy followed
by wound care. On June 26 patient was
allowed to go home given oral cefixim 2 x
200 mg and kalium diclofenac 2 x 50 mg.
Patient then educated how to take care her
wound and how to keep ear clean. The
problem to be raised in this case is
recurrence.
DISCUSSION
A 26-years-old female is diagnosed
as a preauricular abscess. The incidence of
preauricular sinus itself spread globally
around the world. Asia and Africa have a
higher incidence than Europe and America
(4-10%). Adegbiji et al12 in his study
explains the prevalence in Nigerians and
found that the incidence increases at 1-45
years and most often vulnerable at aged 1-18
years. Men were more commonly affected
than women with a ratio of 1.3: 1.0. The left
ear was more commonly affected than the
right ear and affected both ear to just 7%.
Choi SJ et al14 reported the incidence of
variant type preauricular sinus was only
10.9% compared with classical type
preauricular sinus.
Diagnosis is made clinically, either
symptomatic or asymptomatic. Clinical
signs with the discovery of a spot or small
hole in the auricle. From the physical
examination, there is a small hole ± 3 mm
diameter in the left anterior auricle. In the
case of asymptomatic preauricular sinus
does not require therapy.5 However, once
infection occurs, it will result in pain,
swelling and abscess formation. Therapy in
the acute or abscess-developed phase is
adequate drainage.15 Pus results from
drainage should be cultured to allow
appropriate sensitive antibiotic treatment.4
When symptoms are frequent and persistent,
sinus excision is the choice.4,6,9
In the case report was found that
patient had recurrent swelling in the left ear
and this one is her third times. But the last
one continues to expand without any
improvement despite taking oral medication
and antibiotics from Primary Health Care. If
an abscess is already present, sinus incision
and drainage are strongly recommended. On
the other hand, sinus incision and drainage
will alter the architecture of the sinus that
play an important role in increasing
recurrence rates. Surgical excision aims to
ensure complete dissection of the sinus. under general anesthesia. According to a
Incomplete dissection is believed to be the study conducted by Kumar et al14, factors
cause of recurrence of the preauricular sinus. that decreased the recurrence rate of
The recurrence rate after excision is preauricular sinus infections are: 1. Sinus
estimated to be 0-42% .4,6,9 dissection by experienced head and neck
surgeon under general anesthesia, 2. Use of
A Sinusectomy had done to this
longitudinal sinus incisions, 3. Removal of
patient. A sinusectomy is standard technique
cell and epithelial tissue up to the temporal
for preauricular sinus excision in which
fascia to clear all epithelial components, 4.
elicitation is exposed at the sinus opening
Avoid sinus rupture, 5. Closure of dead
and followed by dissection of the sinus tract
space. Goel et al15 added in his study that the
in subcutaneous tissue under visual or
variation of factors that improve the success
palpatory guidance. To identify sinus tract
of surgery are good surgical techniques, free
can be done with several methods such as
infection period and the use of general
using a lacrimal probe or using
9
anesthesia. Hassan et al16 reported that
intraoperative methylene blue injection. It
surgery with local infiltrative anesthesia
is very important to close the dead space gap
increased the recurrence rate compared with
after excision of preauricular sinus to
general anesthesia. Nevertheless, some of
prevent recurrence.15
the postoperative recurrence will exist and
A preauricular sinus with a history of the recurrence rate after excision is
previous infection or an active infection estimated to be 0-42% .8,11 Therefore, the
during definitive surgery increases the risk importance of explaining to the patient and
of recurrence.3 The risk of recurrence can family the relapse of the disease.
even occur postoperative through wound
infection.13 RESUME
A 26-years-old female reportedly
In these patients, recurrence of
came to the ENT Department RSUP Dr.
infected preauricular sinus is increased and
Sardjito with a swollen complaint in front of
persistent, characterized by a failing
the left ear. The complaint happened since
conservative medical treatment and an
two weeks ago accompanied by pain. The
enlarged swelling, so it is decided to initiate
swelling enlarged and spread over the last 4
sinus excision through sinusectomy surgery
days, occurred with fever. There is a small Biomedical Science : IJBS, 9(4),
hole in front of the left ear following by 260–263.
smelly yellowish liquid that came out from
4. Bozan N, Sakin YF, Gözen A,
the hole. The are no complaints of the nose
Bozkuş F. The Preauricular Sinus /
and throat. Patient didn’t experience facial
Cyst: A Case Report. 2016;
paralysis. From the previous medical
23(4): 352-35
history, the patient has experienced the same
problems, approximately about three times 5. Kumar Chowdary, K. V. S., Sateesh
but recovered with medical treatment from Chandra, N., & Karthik Madesh, R.
Primary Health Care. This patient is 2013. Preauricular Sinus: A Novel
diagnosed as an infected preauricular sinus. Approach. Indian Journal of
Sinusectomy and puncture aspiration has Otolaryngology and Head & Neck
been performed. Surgery, 65(3), 234–236.
http://doi.org/10.1007/s12070-012-
REFERENCE
0520-y
1. Ghanie abla. Terapi Operatif Fistula
6. S. Indira Devi, S. Muneeruddin
nd
Preaurikula Kongenital. 2 Ent –
Ahmed, T. Shankar, Manish Guptha,
Head & Neck Surgery Conference an
K. V. N. Durga Prasad. “Pre
3rd Annual Otology Meeting.
Auricular Sinus: A Clinical Analysis
Jakarta;2008.
of 62 Cases and Review of its Micro
2. Scheinfeld, NS. Preauricular sinuses. Surgical Management”. Journal of
Medscape. 2013, Available from: Evolution of Medical and Dental
https://emedicine.medscape.com/arti Sciences 2014; Vol. 3, Issue 62,
cle/1118768-overview. November 17; Page: 13697-13704,
DOI : 10.14260/jemds/2015/3830
3. Adegbiji, W. A., Alabi, B. S.,
Olajuyin, O. A., & Nwawolo, C. C. 7. El-Anwar M, Elaassar,
2013. Presentation of Preauricular Ahmedshaker. 2016. Supra-auricular
Sinus and Preauricular Sinus versus Sinusectomy Approaches for
Abscess in Southwest Preauricular Sinuses. International
Nigeria. International Journal of
 Archives of Otorhinolaryngology. Otorhinolaryngology Head and Neck
DOI: 10.1055/s-0036-1583305 Surgery Departement Medical
Faculty of Andalas University / Dr.
8. Gupta R, Agrawal A, Poorey VK.
M. Djamil Hospital.
Preauricular Sinus: A
Clinicopathological Study. Int J Res 13. Yudhanto D. Penatalaksanaan Sinus
Med Sci 2015;3:3274-7. Preaurikular Kongenital. Jurnal
Kedokteran Unram 2017,6 (1): 1-7
9. Yoo, H., Park, D. H., Lee, I. J., &
ISSN 2301-5977, e-ISSN 2527-7154
Park, M. C. 2015. A Surgical
Technique for Congenital 14. Choi SJ, Choung YH, Park K, Bae J,
Preauricular Sinus. Archives of Park HY. The Variant Type of
Craniofacial Surgery, 16(2), 63–66. preauricular Sinus: Postauricular
http://doi.org/10.7181/acfs.2015.16.2 Sinus. The Laryngoscope 2007;117:
.63 1798-1802

10. Huang WJ, Chu CH, Wang MC, Kuo 15. Leopardi G, Chiarella G, Conti S,
CL, Shiao AS. Decision making in Cassandro. Surgical treatment of
the choice of surgical management recurring preauricular sinus: supra-
for preauricular sinuses with auricular approach. Acta
different severities. Otolaryngology– Otorhinolaryngologica Italica 2008:
Head and Neck Surgery. 28: 302-5.
2013;148(6):959–964.
16. Hassan ME, Samir A. Pre-auricular
11. Shim HS, Kim DJ, Kim MC, Lim JS, sinus: Comparative Study of Two
Han KT. Early one-stage surgical surgical Techniques. Annals of
treatment of infected preauricular Pediatric Surgery 2007;3(3,4): 139-
sinus. European Archives of 43.
OtoRhinoLaryngology.2013;270(12)
17. Dunham B, Guttenberg M, Morrison
:3127–3131
W, Tom L. The Histologic
12. Munilson J, Huriyati E, Triana W. Relationship of Preauricular Sinuses
2013. Management of Infected to Auricular cartilage. Arch
Preauricular Sinus.
otolaryngol Head Neck Surg 2009;
135(12): 1262-5