Plastic Surgery and Jaw Injury Service, Stoke Mandeville Hospital, Aylesbury, Bucks.

British Jottrtlal of Plastic,'~'tJrgery (1972), 25, 175-179 PRE-AURICULAR SINUS: CLINICAL FEATURES AND THE PROBLEMS OF RECURRENCE By P. J. SYKES, F.R.C.S. Plastic Surgery and Jaw Injury Service, Stoke Mandeville Hospital, Aylesbury, Bucks. THIS condition, which causes unpleasant local symptoms if complicated, was described by Heusinger and Virchow in 1864. When treatment is necessary a satisfactory result can usually be achieved by e~ision. Inadequate primary treatment leads to recurrence. This requires much more difficult surgery which can be disfiguring. Aetiology, Incidence and Inheritance. Several aetiological theories have been put forward; the most acceptable is the intertubular hypothesis of His (1885). He describes the development of the pit in the grooves between the six primary ear tubercles which lie three on either side of the first branchial cleft on the first and second branchial arches. There are said to be seven possible sites for these pits on and about the ear (Aird, 1949). The commonest is the pre-auricular variety (Fig. I). Auricular sinuses are rare and the most frequently found is the anterior helicine (Fig. 2). FIG. I FIG. 2 FIG. I.--A pre-auricular sinus with an associated abscess. FIG. 2.--An anterior helicine sinus. The incidence of this condition has been reported as o" I9 per cent (Urbantschutsch, 1877 ; Bezold, 1885). The condition is commoner in negroes and orientals (Congdon, 1932 ; Selkirk, 1935) and is inherited as an incomplete dominant of variable manifestation without sex difference (Connon, I94X ; Monie, 195o ; Fourman and Fourman~ ~75

176 BRITISH JOURNAL OF PLASTIC SURGERY 1955 ; Martins, 1961 ). The left side is more frequently affected in unilateral cases (Monie, 195o). Associated abnormalities of the ear and face occur as do other distant abnormalities (Heusinger, I864 ; Hyndman and Light, 1929 ; Fourman and Fourman, 1955 ; Lyall and Stahl, 1956 ; Martins, 1961). Clinical Material. Over the past lo years 25 patients with this condition have been seen and treated in this Unit. Their ages ranged from 18 months to 35 years. There were 15 females and IO males in the series. Only two cases gave a family history of the condition. In one the father was affected and other a maternal aunt. Eighteen cases were unilateral (seven right and eleven left) and seven cases were bilaterally affected. FIG. 3 FIG. 4 FIG. 3.--Right "lop" ear and accessory auricles associated with a pre-auricular sinus hidden beneath the upper auricle. An identical anomaly was present on the left side and the patient had bilateral branchial fistulae. FIG. 4.--An anterior helicine sinus complicated by adjacent skin ulceration and dermatitis. There were 27 pre-auricular and five anterior helicine sinuses. Five cases had associated abnormalities. One case, a boy aged 2 years, had in association with bilateral pre-auricular sinuses, bilateral accessory auricles, lop ears and branchial fistulae (Fig. 3). Another 3-year-old male presented with bilateral lop ears and accessory auricles, a right branchial fistula and bilateral pre-auricular sinuses. Two cases had ipsilateral lop ears and one patient had ipsilateral accessory auricles. No cases with associated deafness or 7th nerve weakness were noted. Symptoms. Twenty-two patients sought advice because of the complications of infection or retention cyst formation. One case presented with an uncomplicated helicine pit which rarely leaked a bead of serum on to the pillow. She refused treatment. The remaining two cases sought advice only because of the associated abnormalities (three other cases with like abnormalities complained of discharge from their sinuses as well as exhibiting their other anomalies). Two cases developed acute abscesses (Fig. I) and in three cases dermatitis with superficial ulceration spread onto the adjacent skin (Fig. 4). The other cases with infected sinuses presented with a varying degree of sero-purulent discharge. Eight

PRE-AURICULAR SINUS 177 cases developed cystic swellings in front of the ear and three of these cases also had a discharging pit. Symptoms had been present for periods varying from only a matter of weeks to 7 years. Treatment. Thirty-one sinuses were treated surgically. Twenty-seven of these were treated by excision and primary suture. The first stage of this procedure was an attempted delineation of the track with either a fine probe or methylene blue. This was followed by an elliptical incision round the sinus opening and careful dissection so as to remove the whole track which was generally found to pass inwards and downwards and often appeared to be attached by a thin fibrous band to the cartilage of the ear, external meatus, or even the bony canal at its blind end. Dissection was made difficult by infection and the formatidn of secondary sinus openings. Six sinuses treated in this way recurred. Two cases which were heavily infected were treated by wide local excision. The resulting defect was covered with a split-skin graft taken at operation, stored and applied after 7 days, when a healthy granulating surface had developed. One of these cases recurred. The two acute abscesses were treated by incision and curettage. Not surprisingly this was only successful in curing the abscesses as both sinuses required further surgery. Two of the recurrences occurred late and were discovered at follow-up at I year and 2 years. The remaining seven recurrences appeared early. Their presence was strongly suspected in the first post-operative week, when a persistent discharge was noted, and they were all well established after 2 to 3 weeks. The histology of all the specimens showed a track lined with squamous epithelium, surrounded by a variable degree of inflammation and fibrosis and containing cellular and sebaceous debris. Treatment of Recurrence. This was required in nine sinuses, two of which recurred a second time. In three cases excision and primary suture was repeated and was successful. One sinus was excised so widely that the resulting defect was closed with a post auricular flap. Five-recurrences were treated by wide excision and allowed to heal by secondary intention. In two of these it was necessary to repeat this procedure at a second operation. Cases whose scars had healed by secondary intention were examined at follow-up after I year and if it appeared beneficial were offered scar excision. Only two cases accepted. When primary surgery was successful the average hospital stay was 5 days. In recurrent cases the total period averaged I8 days. DISCUSSION The problem of recurrence in this apparently trivial condition has been noted by several authors (Pastore and Erich, I942 ; McLachlin and Farley, I96I ; Finochietto and Yoel, I962 ; Minhowity, I964). Severe infection is one factor making recurrence likely. This produces local scarring and secondary sinus formation as well as making the surrounding tissue inflamed and friable. The track is then very difficult to see and remove in tow. Recurrence inevitably follows when any part of the sinus track is left behind and one of the problems is adequate delineation of the track even when it is not grosslyinflamed. Traditionally this has been bythe injection of methylene blue (Love, I929), but the use of a fine probe or bristle is an alternative. Unfortunately, both techniques have limited success and suffer from the fact that the track is tortuous and of variable calibre. Its lumen is often blocked by the products of the epithelial lining or by scar tissue. If methylene blue spills outside the sinus it stains the surrounding

I78 BRITISH.JOURNAL OF PLASTIC SURGERY tissue and adds to the difficulties. The use of X-ray sinography has been reported (Wangensein, I93I) but this suffers from the same problems as the simpler methods, and even if a good X-ray is produced this may not help in the actual dissection. As an alternative to dissection of the track the destruction of its lining with either sclerosant solutions or surgical diathermy has been suggested (Pastore and Erich, 1942). The former has a high recurrence rate but the treatment of the complex sinus by laying it open and then destroying its epithelial lining by electro-coagulation has met with success (Havens, I939). Healing by secondary intention is then allowed to follow. A method which aids delineation and which entails closing the sinus opening with a pursestring suture is described. The distended track is then dissected out through an inverted L-shaped incision placed to one side of the opening and raised as a triangular flap. It helps if the sinus and its contents are left undisturbed for 2 to 3 days prior to operation. Forty-seven cases treated in this way did not recur (Singer, I966). This method was used in uninfected sinuses or in those which had been quiescent for 3 months following a short course of antibiotics. Management of the recurrent sinus is difficult. Wide excision is undoubtedly the answer. Primary suture is then usually impossible. Healing by secondary intention with the possibility of later scar excision is one way of dealing with this problem. When the defect is larger, skin grafting or local flap closure becomes necessary. As both would be unsuccessful if a discharge, caused by residual track epithelium, were to recur this form of treatment must be delayed. The sinus that is going to recur usually shows signs of doing so within a week of operation. If these do not develop the defect can then be closed by either method. SUMMARY The clinical features and treatment of 25 patients with pre-auricular sinus is described. This is not a trivial lesion and should be treated with respect. To prevent recurrence all the track must be removed. Infection makes this difficult. Various methods of outlining the track have been tried. As an alternative to dissection, diathermy coagulation has been used to destroy the track. Recurrence demands further difficult surgery, increases local deformity and adds to the time spent in hospital. REFERENCES AIRD, I. (1949). "A companion to surgical Studies ", p. 360. Edinburgh : Livingstone. BEZOLD, W.(1885). "SchuluntersuchungenuberdasKindlicheGeh r rgan"' Wiesbaden: J. F. Bergmann. CONGDON, E. D., ROWMANAVONGSE, S. and VARAMISARA, P. (1932). Human congenital auricular and juxta-auricular fossae, sinuses and scars (including so-called aural and auricular fistulae) and the bearing of their anatomy upon the theory of their genisis. American ffournal of Anatomy, 51, 439-464. CONNON, F. E, (1941). The inheritance of ear pits in six generations of a family. Journal of Heredity, 32, 413-414. FOURMAN, P. and FOURMAN, J. (1955). Hereditary deafness in a family with earpits. British Mediealffournal~ 2, 1354-1356. FINOCHIETTO, R. andyoel, J.(I962). Preauricular fistulae and cysts. Surgical and technical considerations in 15 cases. La. Prensa Medica Argentina. 49, 1471-148o. HAVENS, F. Z. (1939). Congenital branchiogenic preauricular sinus : a note regarding its treatment. Archives Otolaryngology, 29, 985-986. HEUSlNGER, H. K. (1864). Fistelm yon noch nicht beobachteter Form. Virchow's Archives, 29, 358 HIS, W. (1885). " Anatomie menschlichen Embryonen ", Part 3, P. 21I. Leipzig : F. C. W. Vogel. HYNDMAN, O. R. and LIGHT, G. (1929). The branchial apparatus. Archives of Surgery 19, 41o-452 LovE, R. J. M. (1929). A simple method of dealing with congenital fistulae. Lancet, ii, 122.

PRE-AURICULAR SINUS LYALL, D. and STAHL, W. M. J. (1956). Review of preauricular and lateral cervical cysts, sinuses and fistulae of congenital origin. Surgery, Gynaecology and Obstetrics~ Inter= national Abstracts of Surgery, lo2, 417-434. McLACHLIN, J. A. and FARLEY, R. O. (1961). Preauricular sinus. Canadian Journal of Surgery, 4, 537-54. MARTINS, A. G. (I96I). Lateral cervical and preauricular sinuses ; their transmission as dominant characters. British Medical Journal, I, 255-256. MINHOWlTV, S. and MINKOWITZ, F. (1964). Congenital aural sinuses. Surgery, Gynaecology and Obstetrics, II8, 8Ol-8O6. MONIE, I. W. (I95O). Three pedigrees of congenital auricular sinus. Journal of Heredity, 4I~ 219-222. PASTORE~ P. N. and ERICH, J. B. (1942). Congenital preauricular cysts and fistulae. Archives of Otolaryngology, Chicago, 36, I2O-I25. SELKIRK, T. K. (1935). Fistula auris congenita. American Journal of Diseases of Children~ 49, 431-447- SINGER, R. (1966). A new technique for extirpation of preauricular cysts. American Journal of Surgery, 3~ 291-295. URBANTSCHURSCH, V. (I878). Concerning the so-called iistula auris congenita : anomalie of formation. Edinburgh Medical Journal, 23, 69o-695. VIRCHOW, R. (1864). Ueber Missbildungen am Ohr und im Bereiche des ersten Kiemenbogens, girchow's Archives, 3o~ 22i. WANGENSTEIN, O. H. (1931). Differentiation of branchial from other cervical cysts by X- ray examination. Annals of Surgery, 93~ 79o-792. I79