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 DOI: 10.1177/0194599813497185

2013 149: 399 originally published online 15 July 2013Otolaryngology -- Head and Neck SurgeryHyung-Sup Shim, Young-Il Ko, Min-Cheol Kim, Ki-Taik Han and Jin-Soo Lim

A Simple and Reproducible Surgical Technique for the Management of Preauricular Sinuses  

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Clinical Techniques and Technology—General Otolaryngology

A Simple and Reproducible SurgicalTechnique for the Management ofPreauricular Sinuses

Otolaryngology–Head and Neck Surgery149(3) 399–401� American Academy ofOtolaryngology—Head and NeckSurgery Foundation 2013Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0194599813497185http://otojournal.org

Hyung-Sup Shim, MD1, Young-Il Ko, MD2, Min-Cheol Kim, MD2,Ki-Taik Han, MD, PhD2, and Jin-Soo Lim, MD, PhD2

No sponsorships or competing interest have been disclosed for this article.

Abstract

Preauricular sinus is a relatively common congenital anomalythat mainly exists on the anterior aspect of the anterior limbof the ascending helix. Although many surgical techniques havebeen developed, extirpation of the sinus is not easy because ofthe ramifications of the sinus, remnants of the sinus wall, andinfection with or without formation of abscesses, which can alllead to disease recurrence. In our institution, we have surgi-cally treated a total of 141 cases of congenital preauricularsinuses. Instead of using the conventional lacrimal probe andmethylene blue method, we used a gentian violet–soakedCottonoid, which has antibacterial effects against the mainpathogen responsible for causing infection of the preauricularsinus. Results have been very favorable, with a zero recurrencerate. We present here a simple and reproducible surgical tech-nique using a gentian violet–soaked Cottonoid that even begin-ning surgeons can easily follow.

Keywords

preauricular sinus, surgical technique, gentian violet,Cottonoid

Received April 9, 2013; revised May 31, 2013; accepted June 19, 2013.

Preauricular sinus is a relatively common congenital

anomaly located mainly on the anterior aspect of the

anterior limb of the ascending helix. It is usually

composed of a single tract with its end attached to the ear

cartilage, possibly with many epithelium-lined tracts branch-

ing at its end point.

More than half of all cases of preauricular sinuses present

as unilateral and asymptomatic, but those with signs of

infection, wound discharge, or abscess formation necessitate

appropriate treatment. Many surgical methods for treating

these complications have been reported to date.

We present here an operative technique using a gentian

violet (G-V) solution–soaked Cottonoid (Johnson &

Johnson, New Brunswick, New Jersey) that was used to

treat more than 100 patients with good postoperative results

and no recurrences.

MethodsPatients

The authors have performed surgical treatment for a total of

141 cases of congenital preauricular sinuses in 113 patients

from January 1, 2007, through December 31, 2012, at St

Vincent’s Hospital. Patients who had received preoperative anti-

biotics because of an infected sinus or who had underwent an

incision-and-drainage procedure were excluded from the study.

All medical records were retrospectively reviewed through elec-

tronic medical records, and the study was approved by the

Institutional Review Board of St Vincent’s Hospital.

Technique

Patients were preoperatively examined to determine whether

they had a simple sinus opening or an accompanying

abscess cavity with thinning of the adjacent skin.

In the case of a simple and uncomplicated sinus opening,

the direction, depth, and base of the tract, along with its

attachment to the ear cartilage, were examined using a lacri-

mal probe under the aid of loupe magnification. A

Cottonoid strip with a radiopaque label was then soaked

with G-V solution (3%; Kuk-Jeon Pharmacy, Seoul, Korea)

and was inserted into the sinus tract through the preauricular

skin opening (Figures 1 and 2).

When the sinus opening was in its usual location on the

anterior portion of the ascending helix, a 4- to 5-cm-long

strip proved to be sufficient for fully dilating the tract. A 1-

to 2-cm-long elliptical incision line that included the sinus

opening was made, and then we inserted the strip with cau-

tion to avoid causing injury to the tract and adjusted the

length by halting on sensing resistance to the insertion. The

wall of the tract, which was distended and stained with the

G-V solution, was well visualized and easily distinguished

1Department of Plastic and Reconstructive Surgery, Uijeongbu St Mary’s

Hospital, The Catholic University of Korea, Uijeongbu, Korea2Department of Plastic and Reconstructive Surgery, St Vincent’s Hospital,

The Catholic University of Korea, Paldal-Gu, Suwon, Gyeonggi-Do, Korea

Corresponding Author:

Jin-Soo Lim, MD, PhD, Department of Plastic and Reconstructive Surgery,

St Vincent’s Hospital, The Catholic University of Korea, 93-6 Ji-Dong,

Paldal-Gu, Suwon, Gyeonggi-Do 442-723, Korea.

Email: prsdrlim@yahoo.com

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from adjacent normal tissue, facilitating the operative pro-

cess. Dissection was performed to the end point of the tract,

and its attachment to the ear cartilage was visualized. After

examining for possible branching of the sinus tract, the tract

was excised en bloc along with part of the ear cartilage.

After meticulous bleeding control, the subcutaneous layer

was repaired layer by layer using absorbable sutures, and the

skin was closed with minimal undermining of the skin flap.

In the case of a combined abscess formation, an additional

2 to 4 cm of extended elliptical line was designed to include

the thinned (or ruptured) skin overlying the abscess. A small

amount of G-V solution was then primarily injected through

the thinned skin to stain the abscess wall before the dissec-

tion. Care was taken not to injure the stained abscess wall

during the en bloc excision of the sinus tract and the commu-

nicating abscess cavity, as well as the adjacent unhealthy

granulation and infected tissue. The skin and subcutaneous

layer was repaired in a similar fashion as mentioned above.

Results

Postoperative complications included 2 cases of wound

infection, 1 case of wound disruption, and 3 cases of skin

defects due to necrosis of the skin margin. All of these

complications occurred within 5 postoperative days, and all

completely healed within 2 weeks after the surgery. No

other acute complications such as hematoma or seroma

were observed, and no signs of recurrence such as recurrent

infections or chronic wound problems were evident over 1

to 3 years of follow-up.

Discussion

Many surgical methods of treating preauricular sinus have

been reported to date. The traditional method of using a

lacrimal probe has been widely accepted,1 but the relatively

high postoperative recurrence rate has prompted the devel-

opment of other approaches such as the inside-out tech-

nique2 and the supra-auricular approach.3 All of these

surgical options aim for a zero recurrence rate, and although

these procedures do not require great expertise in the field

to perform, a simpler and effective technique still would be

useful for beginning surgeons in treating preauricular sinus.

We have therefore used a relatively simple and reprodu-

cible technique as described above. Packing a G-V

solution–soaked Cottonoid into the sinus tract offers many

advantages, including the expansion of the sinus tract up to

3 to 4 mm in diameter, allowing its easy visualization

(Figure 3). In addition, by staining the tract’s narrow end

point, any possible branches, and the abscess wall, a total

excision of the lesion is feasible (Figure 4), lowering the

recurrence rate to zero. The G-V solution itself has an anti-

bacterial effect against Staphylococcus species,4 which is

the main bacteria involved in sinus infections; thus, using

the agent intraoperatively may aid in controlling infections.

In addition, the radiopaque label of the strip enables the sur-

geon to confirm its complete removal through postoperative

radiographs should such concern arise.

As long as the tract is not ruptured from packing in too

much strip and the surrounding unhealthy granulation and

infected tissue is sufficiently removed, using a G-V–soaked

Cottonoid to extirpate preauricular sinuses may be an effec-

tive and easy method with a zero postoperative recurrence

rate that can be performed even by beginning surgeons.

Figure 1. A Cottonoid strip with a radiopaque label (left) andinsertion of the gentian violet–soaked Cottonoid through theopening of the preauricular sinus (right).

Figure 2. After dilation of the sinus opening with a surgical dilator (left), a gentian violet (G-V)–soaked Cottonoid is inserted through theopening while holding the edge of the sinus (middle). This maneuver enables dilation of the whole sinus tract, eases its dissection, andallows visualization of the G-V–stained minor ramifications (right).

400 Otolaryngology–Head and Neck Surgery 149(3)

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Author Contributions

Hyung-Sup Shim, acquisition of data, drafting the article, final

approval; Young-Il Ko, acquisition of data, drafting the article;

Min-Cheol Kim, interpretation of data, revising the article; Ki-Taik

Han, interpretation of data, revising the article; Jin-Soo Lim, con-

ception, design, revising the article, final approval.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

References

1. Martın-Granizo R, Perez-Herrero MC, Sanchez-Cuellar A.

Methylene blue staining and probing for fistula resection: appli-

cation in a case of bilateral congenital preauricular fistulas. Int

J Oral Maxillofac Surg. 2002;31:439-441.

2. Baatenburg de Jong R. A new surgical technique for treatment

of preauricular sinus. Surgery. 2005;137:567-570.

3. Lam HC, Soo G, Wormald PJ, Van Hasselt CA. Excision of the

preauricular sinus: a comparison of two surgical techniques.

Laryngoscope. 2001;111:317-3179.

4. Saji M, Taguchi S, Uchiyama K, Osono E, Hayama N, Ohkuni

H. Efficacy of gentian violet in the eradication of methicillin-

resistant Staphylococcus aureus from skin lesions. J Hosp

Infect. 1995;31:225-228.

Figure 3. Visualization of the sinus wall, enabled by the dilatationand staining of the structure.

Figure 4. En bloc excision of the sinus tract and accompanyingabscess. Note the communication between the sinus tract and theabscess.

Shim et al 401

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