Preauricular Cysts, Pits, and Fissures
Preauricular cysts, pits (as shown below), fissures, and sinuses are benign congenital malformations of the preauricular soft tissues first described by Van Heusinger in 1864. Preauricular pits or fissures are located near the front of the ear and mark the entrance to a sinus tract that may travel under the skin near the ear cartilage. These tracts are lined with squamous epithelium and may sequester to produce epithelial-lined subcutaneous cysts or may become infected, leading to cellulitis or abscess.
Preauricular tags, as shown below, are epithelial mounds or pedunculated skin that arise near the front of the ear around the tragus. They have no bony, cartilaginous, or cystic components and do not communicate to the ear canal or middle ear.
Simple preauricular cysts should not be confused with first branchial cleft cysts. Branchial cleft anomalies are closely associated with the external auditory canal, tympanic membrane, angle of the mandible, and/or facial nerve. Misinterpreting a first brachial abnormality for a simple sinus tract may place the unsuspecting physician at risk for damaging the facial nerve, incompletely excising the lesion, or both.
Patients identified with preauricular pits or cysts should be examined for other congenital anomalies.
With regard to laboratory studies, culture samples may be obtained during drainage procedures.
Imaging is not indicated for routine preauricular cysts and sinuses. However, it is indicated in patients who present with pits or fistulas located in atypical regions, those with cartilage duplication around the external auditory canal that extends into the parotid, and those with recurrent parotid swelling. Patients who have preauricular cysts or pits and a branchial cleft cyst should undergo renal ultrasonography to rule out branchio-oto-renal syndrome.
Antibiotics (eg, cephalexin [Keflex], amoxicillin and clavulanate potassium [Augmentin], erythromycin) are indicated in patients with cellulitis from infected preauricular pits.
Incision and drainage procedures may be required for patients with abscess formation. Staphylococcus aureus is the most common bacteria found in these infections, followed by Proteus, Streptococcus, and Peptococcus species.
The authors discourage standard incision and drainage in the setting of abscess formation within a preauricular sinus tract or cyst. A potential alternative to incision and drainage is the use of a blunt-ended lacrimal probe inserted into the preauricular pit in order to open the abscess cavity. However, acute inflammation usually makes this option technically difficult and painful. Aspiration with a 21-gauge needle reliably provides at least temporary relief, eases pain, and provides purulent material for culture and sensitivity. Needle aspiration may need to be repeated if an abscess reaccumulates, but this procedure reliably leads to a better cosmetic result than incision and drainage.
Complete surgical excision of a preauricular sinus tract or cyst is indicated in the setting of recurrent or persistent infection. The operation is typically performed when the acute infection has subsided. Recurrence rates following excision range from 0-42%. Factors that reportedly reduce the risk of recurrence include complete excision of the sinus and tract with associated perichondrium, dissection down to temporalis fascia, closure of dead space, and avoidance of sinus rupture.
Malformations of the external ear are not uncommon. Generally, they occur in 1 of every 12,500 births. Incidence of spontaneous formation of ear pits in the nonsyndromic population ranges from 0.3-0.9%. (These conditions affect males and females equally and have no race predilection.)
A Korean study that assessed data from 23,533 individuals found the incidence of unilateral and bilateral preauricular sinuses to be 1.3% and 0.3%, respectively. The adjusted odds ratio for having bilateral sinuses was higher in children of a parent with bilateral sinuses, but the same was not true for unilateral sinuses. No association was found between preauricular sinuses and hearing impairment. 
Another Korean study, by Lee et al, estimated the overall prevalence of preauricular sinuses in South Korea to be 1.91%, with these occurring unilaterally in 79.08% of cases. The study, which involved a survey of 56,592 individuals, found the prevalence to be highest in females. 
The auricle forms during the sixth week of gestation. The first and second branchial arches give rise to a series of 6 mesenchymal proliferations known as the hillocks of His, which fuse to form the definitive auricle. The first arch gives rise to the first 3 hillocks, which form the tragus, helical crus, and the helix. The second arch gives rise to the second 3 hillocks, which form the antihelix, scapha, and the lobule.
Defective or incomplete hillock fusion during auricular development is postulated as the source of the preauricular sinus. Another theory suggests that localized folding of ectoderm during auricular development is the cause of preauricular sinus formation. The first 3 hillocks are most often linked to supernumerary hillocks, leading to preauricular tag formation.
Correct sequential gene activation is required for normal ear and facial development. Interrupting the gene activation sequence in laboratory animals disrupts ear development.
Genetic linkage analysis studies have suggested that congenital preauricular sinus localizes to chromosome 8q11.1-q13.3. 
The inner neurological hearing apparatus, cochlea, and auditory nerve form in conjunction with the outer ear structures during the early developmental stages. External deformities may be associated with an inner neurological deformity and, hence, suggest a possible deafness.
Syndromic expression of pits, tags, and fissures occurs at much higher frequencies in certain craniofacial dysmorphisms. Minor anomalies of the head and neck may aid the clinician in developing a presumptive diagnosis during the initial examination. Additional ear anomalies include helical fold abnormalities, asymmetry, posterior angulation, small size, absent tragus, and narrow external auditory meatus. Some syndromes with characteristic ear anomalies are as follows:
Branchiootorenal syndrome (BOR) – Preauricular sinus
Beckwith-Wiedemann syndrome – Preauricular sinus with asymmetric earlobes
Mandibulofacial dysostosis – Auricular pits/fistulas
Oculoauriculovertebral dysplasia – Preauricular tags (see the image below)
Chromosome arm 11q duplication syndrome – Preauricular tags or pits
Chromosome arm 4p deletion syndrome – Preauricular dimples or skin tags
Chromosome arm 5p deletion syndrome – Preauricular tags
A study by Beleza-Meireles et al of clinical phenotypes in 51 patients with oculoauriculovertebral dysplasia found ear abnormalities in 47 (92%) of them (unilateral: 24 patients; bilateral: 23 patients). 
A study by Andersen et al suggested that the occurrence of birth defects in the face and neck region, including preauricular cysts, may be linked to the use of propylthiouracil in early pregnancy to treat maternal hyperthyroidism. In a review of records from more than 1.6 million children born in Denmark between 1996 and 2008, the investigators concluded that in terms of having a birth defect in the head or neck region—specifically, a preauricular or branchial sinus, fistula, or cyst—children exposed to propylthiouracil had a hazard ratio (HR) of 4.92. These same children also had an HR of 2.73 for a urinary system birth defect (single renal cyst, hydronephrosis). Possible propylthiouracil-related birth defects were found in a total of 14 children, including three whose mothers were initially given methimazole/carbimazole but were switched to propylthiouracil in early pregnancy. 
Preauricular sinuses may be asymptomatic for life. An infection arises in cases of preauricular sinus when the opening of the pit seals bacteria within the sinus tract along with desquamated skin. Early signs and symptoms of swelling, pain, and erythema should prompt the practitioner to begin antibiotic therapy directed at common skin bacterial organisms. Surgical drainage may be indicated if there is recurrent drainage from a preauricular pit,  obvious abscess formation occurs or swelling progresses despite antibiotic therapy. Toxic-appearing and immunocompromised patients may require observation, intravenous antibiotic therapy, and surgical drainage. Complete surgical removal is the treatment of choice for recurrent infection and drainage problems. The aforementioned Korean study did not find preauricular sinuses to be associated with hearing impairment. 
Ear tags alone pose no threat to any structure and are usually merely a cosmetic deformity. They are usually excised in young patients by qualified surgeons who treat head and neck abnormalities. General anesthesia is typically required. Recurrence rates are low.
Smaller, narrowly based tags are tied at their bases with thread or suture in infants during office visits. Simple excision at the base may be performed using topical EMLA cream. Larger, broad-based, multiple, or complex tags may require elliptical excision and plastic closure, which requires general anesthesia.
Clinical presentation of various ear anomalies may be summarized as follows:
Noninfected pits – Pinpoint hole in front of the ear or above tragus, as shown below
Infected pits – Cellulitis and abscess
Draining purulent material
Granulation around pit
Previous surgical scar with underlying swelling
Cysts – Slowly enlarging preauricular mass
Usually nontender if uninfected
Associated pit usually adjacent to cyst, as shown below
Tags – Fleshy knobs of skin in front of the ear
Color similar to surrounding skin
Appears to be attached on the surface of the cheek, pinna, tragus, or lobe
No rapid growth
See the list below:
First branchial cleft cyst
Duplication of ear canal
Cellulitis from otitis externa
Previous surgical site
Most patients with preauricular pits in the typical location are asymptomatic and require no surgical intervention. Needle aspiration is indicated for abscess that fails to respond to antibiotics. Incision and drainage complicates later excision and should be reserved for abscess that recurs after needle aspiration.
Complete excision of the cyst or sinus tract may be undertaken in cases of recurrent infection.
Ear tags are removed for cosmetic reasons.
A preauricular pit may mark the entrance to a sinus tract, which can vary in length, follow a tortuous course, and branch extensively. Preauricular sinuses and cysts have a component of close association with the auricular perichondrium. For this reason, some argue that complete removal of a sinus tract or cyst should also include a portion of the auricular perichondrium at the base of the lesion.
Preauricular sinuses or cysts are found lateral and superior to the facial nerve and parotid gland, whereas first branchial cleft malformations are found in close association with these structures, as well as with the external auditory canal.
Excision of complex or broad-based tags requires the knowledge of relaxed skin lines and wound tension in the region of the face and ear.
An infected cyst or tract may be considered a relative contraindication to excision of a sinus tract or cyst. Antibiotics and, occasionally, steroids should be considered to control any residual inflammation prior to surgery.
An SY, Choi HG, Lee JS, Kim JH, Yoo SW, Park B. Analysis of incidence and genetic predisposition of preauricular sinus. Int J Pediatr Otorhinolaryngol. 2014 Dec. 78 (12):2255-7. [Medline].
Lee KY, Woo SY, Kim SW, Yang JE, Cho YS. The prevalence of preauricular sinus and associated factors in a nationwide population-based survey of South Korea. Otol Neurotol. 2014 Dec. 35 (10):1835-8. [Medline].
Zou F, Peng Y, Wang X, et al. A locus for congenital preauricular fistula maps to chromosome 8q11.1-q13.3. J Hum Genet. 2003. 48(3):155-8. [Medline].
Beleza-Meireles A, Hart R, Clayton-Smith J, et al. Oculo-auriculo-vertebral spectrum: Clinical and molecular analysis of 51 patients. Eur J Med Genet. 2015 Sep. 58 (9):455-65. [Medline].
Andersen SL, Olsen J, Wu CS, et al. Severity of Birth Defects After Propylthiouracil Exposure in Early Pregnancy. Thyroid. 2014 Jun 25. [Medline].
Scheinfeld NS, Silverberg NB, Weinberg JM, Nozad V. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol. 2004 May-Jun. 21(3):191-6. [Medline].
Wu GT, Devine C, Xu A, Geelan-Hansen K, Anne S. Is routine audiometric testing necessary for children with isolated preauricular lesions?. Int J Pediatr Otorhinolaryngol. 2017 Feb. 93:68-70. [Medline].
Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol. 2003 Dec. 117(12):983-4. [Medline].
Firat Y, Sireci S, Yakinci C, et al. Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment?. Eur Arch Otorhinolaryngol. 2008 Sep. 265(9):1057-60. [Medline].
Tan T, Constantinides H, Mitchell TE. The preauricular sinus: A review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol. 2005 Nov. 69(11):1469-74. [Medline].
Rataiczak H, Lavin J, Levy M, Bedwell J, Preciado D, Reilly BK. Association of Recurrence of Infected Congenital Preauricular Cysts Following Incision and Drainage vs Fine-Needle Aspiration or Antibiotic Treatment: A Retrospective Review of Treatment Options. JAMA Otolaryngol Head Neck Surg. 2017 Feb 1. 143 (2):131-4. [Medline].
Choo OS, Kim T, Jang JH, Choung YH. The clinical efficacy of early intervention for infected preauricular sinus. Int J Pediatr Otorhinolaryngol. 2017 Apr. 95:45-50. [Medline].
Samuel T Ostrower, MD Staff Physician, Department of Otorhinolaryngology, Albert Einstein College of Medicine
Samuel T Ostrower, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
John P Bent, III, MD Professor, Director of Pediatric Otolaryngology, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Albert Einstein School of Medicine; Director, Airway Clinic, Cochlear Implant Program, Children’s Hospital at Montefiore
John P Bent, III, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Neurotology Society, American Otological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, The Triological Society
Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Michael J Biavati, MD, FACS, FAAP Clinical Assistant Professor of Otolaryngology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Private Practice, ENT Care for Kids, Dallas, TX
Michael J Biavati, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, American Academy of Pediatrics, American Cleft Palate-Craniofacial Association, American College of Surgeons, The Triological Society, Texas Medical Association
Disclosure: Nothing to disclose.
Mitchell B Austin, MD Director, Associate Professor, Department of Pediatrics, Division of Otolaryngology, Children’s Medical Center, Medical College of Georgia
Mitchell B Austin, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American College of Surgeons
Disclosure: Nothing to disclose.
Preauricular Cysts, Pits, and Fissures
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