International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

A modified supra-auricular approach with helix cartilage suture for surgical T

treatment of the preauricular sinus
Kai-Chieh Chana,b, Han-Tse Kuob, Valerie Wai-Yee Hoc, Wen-Yu Chuangb,d,
Zung-Chung Chenb,e,∗,1
a
Division of Otology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taiwan
b
School of Medicine, Chang Gung University, Taoyuan, Taiwan
c
Division of Plastic and Reconstructive Surgery, Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong, China
d
Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan
e
Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: Several surgical techniques and modifications have been described to reduce the high recurrence rate
Preauricular sinus after excision of preauricular sinus (PAS). This study was designed to evaluate the surgical outcomes of PAS
Supra-auricular approach excision using a new modified supra-auricular approach (SAA) and to assess the predisposing factors for re-
Recurrence currence.
Helix cartilage suture
Methods: A total of 175 (158 patients) PAS excision procedures were performed from 2007 to 2016 in a single
institute using this modified SAA with helix cartilage suture to obliterate the dead space. The specimens were
assessed to measure the closest distance between the squamous tract and the excised auricular cartilage (sino-
cartilaginous distance). We also evaluated the surgical outcomes and investigated the predisposing factors for
recurrence, including gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or
local), history of infection, and history of incision and drainage (I&D) for abscess.
Results: Patients were followed up for a median duration of 45 months (range from 6 months to 10 years). There
was a 2.3% (4 ears) recurrence rate and a 1.7% (3 ears) complication rate in our series. The average sino-
cartilaginous distance was 0.44 mm (median distance, 0.3 mm) and this value was less than 0.5 mm in 66% of
cases. Recurrence was not significantly affected by gender, lesion laterality, etiology of surgery, anesthesia
method, or a history of infection or preoperative I&D for abscess.
Conclusions: Surgical PAS excision using the modified SAA with cartilage suture of dead space yielded low
overall recurrence and complication rates in this series. Cosmesis was maintained due to a smaller incision. No
significant predisposing factors for recurrence were identified. Thus, the modified technique described in the
present study can be regarded as a simple, effective and reproducible surgical treatment for PAS.

1. Introduction
The preauricular sinus (PAS) is a congenital tract lined by squamous
epithelium with hyperkeratosis and parakeratosis and was first de-
scribed by Van Heusinger in 1864 [1]. Embryonically, the external ear
is formed from six hillocks of His, which arise from the first and second
branchial arches. Failure of complete fusion of the six hillocks or en-
trapment of ectodermal epithelium during auricular development is
believed to result in the formation of a PAS. The prevalence of PAS is
0.1–0.9% in the United States, 0.9% in England, 1.6%–2.5% in Taiwan,
1.91% in South Korea and 4%–10% in some regions of Africa [2–6].
Although PAS is frequently asymptomatic and does not require
treatment, surgical management is indicated when the PAS becomes
infected. Patients may present with local cellulitis or abscess in the
acute inflammatory stage or chronic intermittent discharge from the
sinus opening. Antibiotics and/or adequate incision and drainage (I&D)
can usually control the infection. Once infection occurs, the risk of re-
current infection is increased. Therefore, the entire sinus tract should be
excised completely to eradicate the disease.
Traditional sinusectomy for PAS had been widely adopted in the

∗
Corresponding author. Craniofacial Research Center, Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial
Hospital & Chang Gung University, Linkou, Taiwan.
E-mail addresses: pchenzc2372@yahoo.com.tw, chenzc@adm.cgmh.org.tw (Z.-C. Chen).
1
Address: Din Hu Rd No. 123, Gweishan, Taoyuan, Taiwan.

https://doi.org/10.1016/j.ijporl.2018.08.041
Received 1 May 2018; Received in revised form 31 August 2018; Accepted 31 August 2018
Available online 05 September 2018
0165-5876/ © 2018 Elsevier B.V. All rights reserved.
K.-C. Chan et al.
past, but a high rate of recurrence (19–40%) had been reported [7,8]. It
is believed that unidentified branching of the sinus, remnants of the
sinus wall, and infection with or without formation of abscesses can
lead to disease recurrence. Thus, various modified surgical techniques
for PAS excision have been proposed to achieve a lower recurrence rate,
such as the supra-auricular approach (SAA) [8,9], inside-out technique
[10] or Fig. 8 excision method [11]. Of these, the SAA introduced by
Prasad et al. has been one of the most favorable and widely used
methods since 1990 [8]. The recurrence rate of the SAA ranges between
0 and 23%, with an average rate of 2.2% [12]. However, the main
drawback of the SAA is the large dead space that results from resecting
the PAS with the surrounding subcutaneous tissue via an extended
supra-auricular and postauricular incision. Postoperative drain inser-
tion and compression dressing are usually required for complete closure
of the dead space. Bae et al. [13] designed a drainless minimal SAA
with meticulous subcutaneous mattress suture to obliterate the dead
space for treatment of PAS, and there was no postoperative recurrence
or other serious complication in their study.
Additionally, recurrence after PAS excision was found to be corre-
lated with certain factors, such as preoperative infection status, pre-
operative I&D [14], or local anesthesia technique [15–18].
Thus, the purposes of the present study were to introduce a modified
SAA surgical technique with helix cartilage suture to minimize the dead
space without drainage or dressing and to survey the surgical results for
PAS. Moreover, we also examined various predisposing factors for re-
currence after the surgery in a 10-year retrospective study period.
2. Materials and methods
A retrospective review of the clinical records of consecutive patients
with PAS who underwent the surgery with the modified SAA between
July 2006 and June 2016 was conducted. The study was approved by
the institutional review board of Chang Gung Memorial Hospital in
Linkou, Taiwan (IRB No.201800424B0). All the PAS cases were of the
classic type, with the sinus opening located at the anterior margin of the
ascending limb of the helix.
Indications for this surgery were cases of PAS with a history of
persistent purulent discharge or recurrent infection or asymptomatic
patients with cosmetic concerns because of an apparent PAS opening.
Each ear involved in the bilateral procedures was regarded as a separate
operation. All patients were followed for at least 6 months post-
operatively, with the longest follow-up being 10 years. Postoperative
complications and recurrence were documented. Preoperative predis-
posing factors were collected, and their association with recurrence was
analyzed. These factors included gender, lesion laterality, etiology
(primary or revised), anesthesia methods (general or local), history of
infection, and history of I&D for abscess. Chi-square test or Fisher's
exact test was performed using SPSS statistical software (SPSS Inc.,
Chicago, IL), and P < 0.05 was considered statistically significant.
2.1. Surgical technique
At our institution, surgical excision of the PAS is usually performed
about one month after the resolution of an acute infection. An acutely
infected PAS is first treated with a course of antibiotics. If an abscess is
present, I&D is performed. All subjects underwent PAS excision by the
senior authors (K.C. Chan & Z.C. Chen) under general anesthesia (GA)
or local anesthesia (LA). The operations were performed under GA for
patients under 12 years old and under LA for most adult and adolescent
patients unless they could not comply. The surgical procedure was
modified from the SAA described by Prasad et al. [8]. Local anesthetic
containing epinephrine was infiltrated subcutaneously at the lesion to
include auriculotemporal nerve block. A vertical elliptical incision was
made around the sinus opening and extended upward to the supra-
auricular region for 5 mm without postauricular extension (Fig. 1). A
lacrimal probe was then used to locate the sinus tract gently to avoid
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International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
Fig. 1. A vertical elliptical incision was made around the sinus opening and
extended upward to the supra-auricular region for 5 mm without postauricular
extension.
the creation of false passages. In the case of revision surgery, probing
was not conducted. After the skin incision, en bloc resection of the PAS
with surrounding subcutaneous tissue between the temporalis fascia
and the helix was performed (Fig. 2), taking care not to injure the su-
perficial temporal vessels. A small portion of helix cartilage adjacent to
the PAS tract was routinely resected (Fig. 3a). After complete excision,
the wound was irrigated copiously with dilute povidone-iodine solution
to prevent surgical site infection. Then, absorbable sutures were used to
suture the distal remnant subcutaneous tissue, temporalis fascia, and
helix cartilage in a vertical mattress manner and in a lateral-to-medial
direction to tightly obliterate the dead space (Fig. 3b). A schematic il-
lustration of the helix cartilage suture technique is shown in Fig. 4.
Finally, a local pressure dressing was applied using adhesive bandage
strips. No drains or mastoid dressing was needed (Fig. 5). The bandage
was removed after 48 h. Postoperative oral antibiotics and analgesics
were prescribed for 1 week.
3. Results
There were 175 ears with PAS (152 patients) in this review. The
study cohort included 59 males and 93 females with a median age of
22.5 years (range: 1–78). A total of 88 right ears, and 87 left ears were
operated on (23 patients had bilateral operations). A total of 162 ears
had no previous PAS surgeries (labeled as primary), while 13 ears had a
history of PAS surgery (labeled as revised). There were 96 and 79 ears
treated under LA and GA, respectively. A total of 161 ears had a history
of preoperative infection, while 14 ears were asymptomatic. A total of
20 ears had undergone I&D for abscess, while 155 cases had not
(Table 1). The median follow-up duration was 45 months (range:
6–120).
The diagnosis of PAS was confirmed histopathologically.
Pathological analysis typically showed that the sinus tracts were in
close proximity to the helix cartilage (Fig. 6). A total of 138 specimens
were retrieved to measure the closest distance between the squamous
tract and the excised auricular cartilage. The average sinocartilaginous
distance was 0.44 mm, ranging from 0.1 to 1.9 mm (median distance,
0.3 mm). In 66% (91 cases) of the specimens, the sinocartilaginous
distance was less than 0.5 mm. There were 4 cases of recurrence among
175 operated ears (2.3%). Two cases presented as epidermoid cyst
formation at 12 months and 14 months postoperatively, one presented
as a postoperative nonhealing wound, and one presented as new
aperture formation with discharge at one month after surgery. Three
patients reported complications (1.7%). Two patients had wound de-
hiscence, and one had wound infection. However, no cases of post-
operative seroma/hematoma, perichondritis or chondritis were identi-
fied in this series. Cosmesis was good without any auricular deformity.
The potential predisposing factors for recurrence after surgery,
K.-C. Chan et al.
including gender, lesion laterality, etiology, anesthesia techniques,
history of preoperative infection, and history of preoperative I&D for
abscess formation, were also analyzed (Table 2). Recurrence occurred
in two ears among 93 female patients (1.9%) and in 2 ears among 59
male patients (2.9%); the difference was not statistically significant.
There were 87 left-sided lesions and 88 right-sided lesions, and 2 cases
from each side experienced recurrence (2.3% and 2.2%, respectively).
No statistically significant difference was noted between these two
groups. Regarding etiology, recurrence occurred in 3 ears among 162
primary cases (1.9%), while recurrence occurred in 1 ear among the 13
ears of revised cases (7.7%). No statistically significant difference be-
tween these two groups was demonstrated. There were 96 and 79
procedures performed under LA and GA, respectively. Three cases of
recurrence were noted in the LA group (3.1%), and 1 case of recurrence
was noted in the GA group (1.3%). No statistically significant difference
was shown. A total of 161 ears had a history of preoperative infection,
among which 4 ears (2.5%) experienced postoperative recurrence.
However, there were no cases of recurrence among the 14 asympto-
matic ears. There was no statistically significant difference between
these two groups. Recurrence was noted in one ear among 20 ears (5%)
that had undergone I&D for abscess. Three cases of recurrence were
noted among the other 155 cases (1.9%) without a history of I&D. No
statistically significant difference was shown between these two groups.
4. Discussion
In this study, utilization of the modified SAA resulted in effective
surgical outcomes, with a 2.3% recurrence rate and a 1.7%
Fig. 3. A small part of the helix cartilage adjacent to the sinus tract was routinely resected (3a). Then, the dead space was closed tightly by absorbable stitches via
suturing of the remnant subcutaneous tissue, temporalis fascia and helix cartilage with the vertical mattress technique in a lateral-to-medial direction (3b).
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International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152
Fig. 2. En bloc resection of the sinus tract with the sur-
rounding subcutaneous tissue between the temporalis fascia
(deep boundary, 2b) and the helix (posterior boundary, 2a)
was performed. Of note, caution is required to avoid injury of
the superficial temporal vessels (anterior boundary). S: sinus
tract, C: helix cartilage, and F: temporalis fascia.
complication rate. According to a systemic review [12], the recurrence
rate of the SAA for PAS excision ranged between 0 and 23%, with an
average recurrence rate of 2.2%. The present surgical result is in ac-
cordance with that report. Because the presence of dead space after the
original SAA is associated with wound complications, we advocated
closing the dead space by suturing the helix cartilage, temporalis fascia
and residual subcutaneous tissue. Therefore, this approach contributed
to a low complication rate in our study. Furthermore, the recurrences in
the study were not related to factors including gender, lesion laterality,
anesthesia technique, history of previous sinus excision, history of I&D
or etiology of PAS surgery. Hence, this modified SAA is indeed a reli-
able, effective and safe surgical technique for PAS excision.
The original SAA procedure involved a wide exposure with supra-
auricular extension of the preauricular incision and the identification of
landmarks, including the temporalis fascia (deep boundary), superficial
temporal vessels (anterior boundary), and the cartilage of the anterior
helix (posterior boundary). These landmarks are important in revision
cases or in the acute infection stage. Entire sinus tracts and surrounding
subcutaneous tissue within these landmarks were excised completely.
In our modified surgical method, a 5-mm skin incision is extended su-
periorly, similar to that described by Bae et al. [13], without further
postauricular extension. This technique helps to minimize the dead
space while still maintaining an adequate view for complete excision of
the sinus tract. This modified SAA approach also offered better aesthetic
results than the original SAA due to a smaller incision [13].
Several authors [15] have reported that there are no significant
differences in recurrence rates between the groups with and without
excision of the perichondrium of helix cartilage. However, Dunham
K.-C. Chan et al. International Journal of Pediatric Otorhinolaryngology 114 (2018) 147–152

Table 1
Patient demographics.
No. (%)

Total ears 175(100.0)

Gender
Male 68(38.9)
Female 107(61.1)
Lesion laterality
Right 87(49.7)
Left 88(50.3)
Anesthesia technique
General anesthesia 79(45.1)
Local anesthesia 96(54.9)
Etiology
Primary 162(92.6)
Revised 13(7.4)
History of infection
Yes 161(92.0)
No 14(8.0)
Preoperative incision & drainage
Yes 20(11.4)
No 155(88.6)

cartilage adjacent to the sinus tract is suggested to ensure thorough

Fig. 4. Schematic illustration of the helix cartilage suture technique. A vertical
mattress suture was placed to obliterate the dead space after excision of the
sinus structure and the adjacent helix cartilage.
et al. [19] indicated that the distance between excised preauricular
epithelial sinus tracts and adjacent auricular cartilage measured <
0.5 mm in > 50% of cases and that the epithelial tract was in con-
tinuity with stromal tissue and histologically indistinguishable from the
perichondrium in nearly all cases. The pathological results of the pre-
sent study are also consistent with this finding. Furthermore, the pre-
sence of multiple protruding pouches associated with the fistula wall
and their firm adhesion to the cartilage make complete removal of the
sinus wall difficult, which is especially true when inflammation is
present. Therefore, resection of a small portion of auricular helix
excision and to reduce recurrence rates [10,11,20]. Methylene blue was
not routinely used to mark the sinus tract, as methylene blue may dif-
fuse into tissues and affect the accurate dissection of all the complicated
branches [16].
Regional auriculotemporal nerve block is important during PAS
surgery, especially under LA, since the preauricular region is innervated
by this nerve. Caution should be taken to avoid injury to the superficial
temporal artery because the auriculotemporal nerve usually presents
within the initial loop of the superficial temporal artery. Previous re-
ports [15–18] have shown that dissection of the PAS under GA has a
lower recurrence rate compared with that under LA, because patients
under GA had better tolerance and allowed a more complete dissection
and excision of the PAS. However, there was no statistically significant
difference between these two groups in this study, although the LA
patients had a higher recurrence rate (3.1%) than the GA patients
(1.3%). We postulated that this finding is due to the effective local
regional auriculotemporal nerve block, allowing the procedures to be
performed smoothly.
The present study found that patients with a history of infection or I
&D of the PAS show a higher rate of recurrence than patients without
these conditions (5% vs.1.9% and 2.5% vs. 0%, respectively), but there
was no statistically significant difference. The debate on whether a
history of PAS infection or I&D for abscess is associated with a high rate
of recurrence has been controversial due to mixed reports in the lit-
erature [14,15,17,21]. Thus, no conclusions can be drawn from the
differing results; it is possible that the overall recurrence rate is low and
that most studies are not adequately powered. The recurrence rate in
the revised group was higher than that in the primary group (7.7% vs.
1.9%); however, these results did not show any statistically significant

Fig. 5. Finally, the surgical wound was closed and locally compressed by adhesive bandage strips (not shown) without drainage or mastoid dressing.

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Fig. 6. The specimen opened along the sinus tract (a). Microphotograph showing small unidentified branches of the sinus tract in close proximity to the cartilage (H&
E stain; original magnification ×200) (b). C: helix cartilage and S: sinus tract.

Table 2
Recurrence rate based on different variations of clinical presentation.
Gender Lesion laterality Etiology Anesthesia technique History of infection Preoperative I&D

Male Female R L Primary Revised GA LA Yes No Yes No

Recurrent ears (No.) 2 2 2 2 3 1 1 3 4 0 1 3

Total ears 68 107 87 88 162 13 79 96 161 14 20 155
Recurrence rate (%) 2.9 1.9 2.3 2.2 1.9 7.7 1.3 3.1 2.5 0.0 5.0 1.9
p-value p = 0.644 p = 0.99 p = 0.175 p = 0.413 p = 0.551 p = 0.388

p < 0.05 indicates a statistically significant difference.

Abbreviations: R: right; L: left; GA: general anesthesia; LA: local anesthesia; and I&D: incision and drainage.

between-group difference. Although it is believed that most cases of
recurrence occur in the early postoperative period within one month of
the surgical procedure, two of the four recurrent cases in our series
developed one year after surgery. This result suggests that a long-term
follow up for at least one year may be necessary. Recurrence should be
highly suspected when there is persistent discharge from the wound or
painful swelling around the surgical site. Additionally, some authors
[10,18] have advocated the use of a microscope or magnifying glasses
to reduce the risk of recurrence, as blood vessels and surgical planes can
be clearly identified intraoperatively without any unintended dis-
turbance of the sinus sac. Because no magnifying tools were used in the
current study, we hypothesized that the application of these tools in the
future will help during dissection, especially in the chronically inflamed
or recurrent cases, hence further lowering the recurrence rate.
There are a few limitations in this study. The retrospective study
design resulted in inadequate data collection and a potential informa-
tion bias. Although the patients were routinely followed for at least 6
months, some cases of recurrence may have occurred after the follow-
up period. Furthermore, the low rate of recurrence might preclude
statistical analysis of factors contributing to recurrence.
5. Conclusion
Based on a histopathological study and clinical observation, surgical
PAS excision with the modified SAA and helix cartilage suture of dead
space in our series yielded a low overall recurrence rate and minimal
complications while maintaining cosmesis due to a small incision. The
recurrence rate was not significantly affected by gender, lesion later-
ality, anesthesia methods, etiology of surgery, or a history of infection
or preoperative I&D for abscess. Thus, our modified technique is a
simple, effective and reproducible surgical treatment for PAS.
Ethical statement
This study was approved by the Institutional Review Board Ethical
Committee of Chang Gung Memorial Hospital.
Financial disclosure statement
The authors have no financial or commercial associations that might
create a conflict of interest with the information presented in this ar-
ticle.
Author contributions
Study conception and design: Dr. Kai-Chieh Chan and Dr. Zung-
Chung Chen.
Acquisition of data: Dr. Han-Tse Kuo
Pathology review and analysis: Dr. Wen-Yu Chuang.
Analysis and interpretation of data: Dr. Han-Tse Kuo and Dr. Kai-
Chieh Chan.
Drafting of manuscript: Dr. Kai-Chieh Chan and Dr. Zung-Chung
Chen.
Critical revision: Dr. Valerie Wai-Yee Ho.
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