Excision of a Preauricular Cyst

Patient was consented in the preoperative area and brought back to the operating room and placed under general anesthesia. Facial nerve monitoring was used for this procedure due to the proximity of the lesion to the facial nerve.

The patient’s left preauricular area was prepped and draped in the standard fashion. A 2 cm incision was made just posterior to the lesion with a 15 blade scalpel. Dissection was carried with a sharp hemostat down the level of the parotid fascia. The facial nerve was not encountered during this dissection. A 1 cm cystic structure was found adherent to the overlying dermis. An elliptical incision was then made over the mass and it was removed with the adherent overlying skin. The specimen was sent for pathological analysis. The wound was then irrigated. Wound was closed in 3 layers. First, the deep layer was closed with 5-0 PDS in interrupted fashion, followed by 5-0 monocryl in running subcuticular fashion, followed by Dermabond. The patient was returned to the care of anesthesia where she was awoken, extubated, and transported to PACU in stable condition. The patient tolerated the procedure well and was discharged the same day.

The pathology report showed that the mass was an epidermal inclusion cyst.

Identifiable mass bothersome to the patient/family
Recurrent infection requiring many rounds of systemic antibiotic therapy
Enlarging or painful mass leading to impingement or invasion of surrounding structures (i.e. cranial nerve 7, parotid gland, mandibular joint range of motion, et cetera)
Excision is diagnostic as well as therapeutic

Patients who do not respond well to anesthesia (i.e. malignant hyperthermia) - may consider in-office excision of cyst under local anesthesia
Patients with active infection who require anti-inflammatory medications or antibiotics

15 blade scalpel
5-0 Monocryl Suture
5-0 PDS suture
Adson tissue forceps with teeth
Bovie or Bipolar Cautery
DeBakey forceps
dermabond
Facial Nerve Monitoring System
Hemostats
iris scissors
Lidocaine
Marking pen
needle driver
Needles and Syringes
Sterile Saline
Suction
suture scissors

Patient was placed in the supine position and administered general anesthesia.
Sterile technique - drapes, betadine prep, etc.
Facial nerve monitoring system
Lidocaine for local anesthesia with epinephrine for hemostasis
Needles and syringes required for injection of local anesthetic
Sterile saline for irrigation
Suction set-up
Marking pen
Scalpel (15 blade)
DeBakey forceps
Bovie or Bipolar cautery
Iris scissors
Hemostats
Needle driver
Adson tissue forceps with teeth
Suture scissors
5-0 PDS suture
5-0 monocryl suture
Dermabond

Thorough history and physical examination
Thorough cranial nerve examination
Personal or family history of bleeding disorders
History of prior surgery
Family history or patient history of prior issues with anesthesia
Consideration of imaging (i.e. CT or ultrasound imaging of mass)
Consideration of fine needle aspiration of mass
May require pre-operative risk stratification prior to surgery if multiple medical comorbidities
Hold anticoagulation or anti-platelet medications prior to surgery
Consider obtaining pre-operative blood work such as PT, INR, PTT, BMP, and CBC

Parotid Fascia
Facial nerve anatomy

Complications/Risks
Bleeding
Infection
Violation of cyst capsule
Recurrence of lesion post-operatively
Injury to branches of the facial nerve

None

1. Zuber, T. (2019). Minimal Excision Technique for Epidermoid (Sebaceous) Cysts. [online] Aafp.org. Available at: https://www.aafp.org/afp/2002/0401/p1409.html [Accessed 29 Jul. 2019].

2. Weir CB, St.Hilaire NJ. Epidermal Inclusion Cyst. [Updated 2019 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532310/

3. Flint P, Cummings C. Cummings Otolaryngology. Philadelphia, Pa: Elsevier, Saunders; 2015:286-290.