Preauricular Pit/Cyst Excision

This video demonstrates the excision of a preauricular pit/cyst in a pediatric patient.

John Maddalozzo, MD
Sarah Maurrasse, MD
Johanna Wickemeyer, MD
Sneha Giri, MD

Division of Pediatric Otolaryngology-Head & Neck Surgery
Ann & Robert H. Lurie Children’s Hospital of Chicago

A crescent shaped incision is marked out around the pit that follows the contour of the helix. It should extend to the tragal cartilage inferiorly to allow greater exposure of the helical rim. This is incised with a 15 blade scalpel while retracting the ear laterally. Next, a scissor is used to bluntly dissect onto the cartilage of the helical root. It is important to spread all the way down to the cartilage during this step. The tissue on either side of the incision is divided and dissection of the lesion begins. Care is taken to include the sinus tract in the dissection. If needed, a lacrimal probe can be used to identify its exact location. Circumferential dissection continues around the lesion. Scissors are used to bluntly dissect and then cut the remaining tissue bridges. Sometimes it is necessary to reflect the helical rim posteriorly to better expose the temporal and parotid fascia. The terminal branches of the temporal artery and vein can be encountered during dissection. If the lesion tracts down to the helical cartilage, a small portion can be resected superiorly. This decreases the likelihood of recurrence. The borders of the dissection are the helical and tragal cartilages, and the fascia of the temporalis muscle and parotid. Once the lesion is completely removed, the wound bed is irrigated. The helical cartilage is sutured to the underlying fascia. The dermis is reapproximated with interrupted deep dermal vicryl sutures. The epidermis can be closed with a running monocryl suture or with dermabond.
-Recurrent infections -Cosmetic deformity
Relative contraindications include: -Acute infection -Comorbidities that increase anesthetic risk
-Mark out crescent shaped incision around the preauricular pit along the helical rim -Inject with vasoconstriction agent -Prep and drape in standard sterile fashion The procedure can be performed under local or general anesthesia, but in pediatric patients, general anesthesia is preferred
Preoperative workup includes a detailed history and physical exam. The history of present illness should address the presence of the following symptoms: hearing impairment, pain, ear drainage, fever, growth/progression of lesion, history of previous infections. The physical exam should include a careful exam of both ears for swelling, pain, warmth, erythema, fluctuance, or pus in and/or around the pit. Ears should also be examined for asymmetry or hearing loss which can indicate syndromes such as Beckwith-Wiedemann or branchio-oto-renal syndrome. Referral to appropriate specialists should be performed for patients who appear syndromic. Imaging with CT or MRI is generally recommended when pits appear in conjunction with other external ear abnormalities or have an atypical location, such as below the external auditory canal.
-Tragal cartilage -Helical cartilage -Root of the helix -Temporal fascia -Parotid fascia -Temporal artery/vein
The advantages of preauricular pit excision compared to antibiotic treatment or infection include reduced incidence of infections and improved cosmesis. Disadvantages include procedural risks of bleeding, infection, and damage to surrounding structures of the ear and post-op scarring and pain.
Possible complications of preauricular pit excision include bleeding, infection, damage to surrounding structures of the ear, scarring, and pain. There is also a risk of incomplete excision which can lead to further infections and necessitate additional procedures. Recurrence rates after primary surgery are approximately 5%.
Thank you to Vidal Maurrasse for providing the voice-over material.
Yeo SW, Jun BC, Park SN, Lee JH, Song CE, Chang KH, Lee DH. The preauricular sinus: factors contributing to recurrence after surgery. Am J Otolaryngol. 2006 Nov-Dec;27(6): 396-400.

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