Preauricular Sinuses

Preauricular Sinuses

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Preauricular sinuses are common congenital malformations first described by Heusinger in 1864. Preauricular sinuses are frequently noted on routine physical examination as small dells adjacent to the external ear, usually at the anterior margin of the ascending limb of the helix. However, preauricular sinuses have been reported to occur along the lateral surface of the helicine crus and the superior posterior margin of the helix, the tragus, or the lobule. Anatomically, preauricular sinuses are lateral and superior to the facial nerve and the parotid gland.

Preauricular sinuses are inherited in an incomplete autosomal dominant pattern, with reduced penetrance and variable power of expression. They can arise spontaneously. The sinus may be bilateral in 25-50% of cases, and bilateral sinuses are more likely to be hereditary. [1] In unilateral cases, the left side is more commonly affected.

Also see the related article Preauricular Cysts, Pits, and Fissures.

During embryogenesis, the auricle arises from the first and second branchial arches during the sixth week of gestation. Branchial arches are mesodermal structures covered by ectoderm and lined with endoderm. These arches are separated from each other by ectodermal branchial clefts externally and by endodermal pharyngeal pouches internally. The first and second branchial arches each give rise to 3 hillocks; these structures are called the hillocks of His. Three hillocks arise from the caudal border of the first branchial arch, and 3 arise from the cephalic border of the second branchial arch. These hillocks should unite during the next few weeks of embryogenesis. Preauricular sinuses are thought to occur as a result of incomplete fusion of these hillocks.

Preauricular sinuses are usually narrow, they vary in length (usually they are short), and their orifices are usually minute. They may arborize and follow a tortuous course in the immediate vicinity of the external ear. The preauricular sinuses are usually found lateral, superior, and posterior to the facial nerve and the parotid gland. In almost all cases, the duct connects to the perichondrium of the auricular cartilage. They can extend into the parotid gland.

Congenital periauricular fistulas may be seen as variations of preauricular sinuses. [2]

United States

In one study, the incidence of preauricular sinuses in the United States is estimated to be 0-0.9% and the incidence in New York State is estimated to be 0.23%.

International

In Taiwan, the incidence of preauricular sinuses is estimated to be 1.6-2.5%; in Scotland, 0.06%; and in Hungary, 0.47%. In some parts of Asia and Africa, the incidence of preauricular sinuses is estimated to be 4-10%. One study in Kenya found preauricular sinuses to be the most common congenital oral and craniofacial anomalies, with a rate of 4.3 cases per 1000 persons. [3]

The incidence of preauricular sinuses in whites is 0.0-0.6%, and the incidence of preauricular sinuses in African Americans and Asians is 1-10%.

Both men and women are affected equally by preauricular sinuses.

Preauricular sinuses arise in the antenatal period and are usually present at birth, but they can become apparent later in life.

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].

Kim JR, Kim do H, Kong SK, Gu PM, Hong TU, Kim BJ, et al. Congenital periauricular fistulas: possible variants of the preauricular sinus. Int J Pediatr Otorhinolaryngol. 2014 Nov. 78(11):1843-8. [Medline].

Odhiambo A, Rotich EC, Chindia ML, Macigo FG, Ndavi M, Were F. Craniofacial anomalies amongst births at two hospitals in Nairobi, Kenya. Int J Oral Maxillofac Surg. 2012 May. 41(5):596-603. [Medline].

Wang R, Martinez-Frias ML, Graham JM Jr. Infants of diabetic mothers are at increased risk for the oculo-auriculo-vertebral sequence: A case-based and case-control approach. J Pediatr. 2002 Nov. 141(5):611-7. [Medline].

Saltzmann RM, Lissner GS. Familial absence of lacrimal puncta associated with preauricular sinuses. J Pediatr Ophthalmol Strabismus. 2006 Jul-Aug. 43(4):233-5. [Medline].

Choi SJ, Choung YH, Park K, Bae J, Park HY. The variant type of preauricular sinus: postauricular sinus. Laryngoscope. 2007 Oct. 117(10):1798-802. [Medline].

Leung AK, Robson WL. Association of preauricular sinuses and renal anomalies. Urology. 1992 Sep. 40(3):259-61. [Medline].

Amer I, Falzon A, Choudhury N, Ghufoor K. Branchiootic syndrome–a clinical case report and review of the literature. J Pediatr Surg. 2012 Aug. 47:1604-6. [Medline].

Sampath S, Keats BJ, Lacassie Y. HPPD: A newly recognized autosomal dominant disorder involving hypertelorism,preauricular sinus, punctal pits, and deafness mapping to chromosome 14q31. Am J Med Genet A. 2011 May. 5:976-85. [Medline].

Yilmaz AE, Sarifakioglu E, Aydemir S, Tas T, Orün E, Aydemir H. Preauricular sinus, nephrolithiasis, infantine eczema and natal tooth:a new association. Eur J Dermatol. 2011 Mar-Apr. 2:234-7. [Medline].

Lapeña JF Jr, Jimena GL. Coexisting first and bilateral second branchial fistulas in a child with nonfamilial branchio-otic syndrome. Ear Nose Throat J. 2013 Jul. 92(7):304, 306-9. [Medline].

Jalil J, Basheer F, Shafique M. Branchio-oto-renal syndrome. J Coll Physicians Surg Pak. 2014 May. 24(5):367-8. [Medline].

Martin-Granizo R, Perez-Herrero MC, Sanchez-Cuellar A. Methylene blue staining and probing for fistula resection: application in a case of bilateral congenital preauricular fistulas. Int J Oral Maxillofac Surg. 2002 Aug. 31(4):439-41. [Medline].

McArdle AJ, Shroff R. Question 3 * Is ultrasonography required to rule out congenital anomalies of the kidneys and urinary tract in babies with isolated preauricular tags or sinuses?. Arch Dis Child. 2013 Jan. 98:84-7. [Medline].

Shim HS, Ko YI, Kim MC, Han KT, Lim JS. A simple and reproducible surgical technique for the management of preauricular sinuses. Otolaryngol Head Neck Surg. 2013 Sep. 149(3):399-401. [Medline].

Lam HC, Soo G, Wormald PJ, Van Hasselt CA. Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope. 2001 Feb. 111(2):317-9. [Medline].

Leopardi G, Chiarella G, Conti S, Cassandro E. Surgical treatment of recurring preauricular sinus: supra-auricular approach. Acta Otorhinolaryngol Ital. 2008 Dec. 28(6):302-5. [Medline]. [Full Text].

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].

Chang PH, Wu CM. An insidious preauricular sinus presenting as an infected postauricular cyst. Int J Clin Pract. 2005 Mar. 59(3):370-2. [Medline].

Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery. 2005 May. 137(5):567-70. [Medline].

Yeo SW, Jun BC, Park SN, et al. The preauricular sinus: factors contributing to recurrence after surgery. Am J Otolaryngol. 2006 Nov-Dec. 27(6):396-400. [Medline].

Tang IP, Shashinder S, Kuljit S, Gopala KG. Outcome of patients presenting with preauricular sinus in a tertiary centre–a five year experience. Med J Malaysia. 2007 Mar. 62(1):53-5. [Medline].

Bae SC, Yun SH, Park KH, et al. Preauricular sinus: advantage of the drainless minimal supra-auricular approach. Am J Otolaryngol. 2011 Nov 29. [Medline].

Dickson JM, Riding KH, Ludemann JP. Utility and safety of methylene blue demarcation of preauricular sinuses and branchial sinuses and fistulae in children. J Otolaryngol Head Neck Surg. 2009 Apr. 38(2):302-10. [Medline].

Bajwa H, Kumar S. Radiofrequency thermal ablation versus ‘cold steel’ for supra-auricular excision of preauricular sinus: comparative study. J Laryngol Otol. 2010 Jun 11. 1-4. [Medline].

Dunham B, Guttenberg M, Morrison W, Tom L. The histologic relationship of preauricular sinuses to auricular cartilage. Arch Otolaryngol Head Neck Surg. 2009 Dec. 135(12):1262-5. [Medline].

Gan EC, Anicete R, Tan HK, Balakrishnan A. Preauricular sinuses in the pediatric population: Techniques and recurrence rates. Int J Pediatr Otorhinolaryngol. 2012 Dec 21. [Medline].

Kumar Chowdary KV, Sateesh Chandra N, Karthik Madesh R. Preauricular sinus: a novel approach. Indian J Otolaryngol Head Neck Surg. 2013 Jul. 65(3):234-6. [Medline].

Hills SE, Maddalozzo J. Congenital lesions of epithelial origin. Otolaryngol Clin North Am. 2015 Feb. 48 (1):209-23. [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].

Winkler AA, Stallmeyer MJ, Le TT. Report of a scalp arteriovenous malformation spontaneously hemorrhaging into a preauricular sinus. Ear Nose Throat J. 2009 Feb. 88(2):E17-20. [Medline].

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke’s Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Valerie Nozad, DO Staff Physician, Beth Israel Medical Center, Department of Internal Medicine, University Hospital for the Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Jeffrey Weinberg, MD Director, Clinical Research Center, Department of Dermatology, St Luke’s; Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons

Jeffrey Weinberg, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

Julie C Harper, MD Assistant Program Director, Assistant Professor, Department of Dermatology, University of Alabama at Birmingham

Julie C Harper, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Received honoraria from Stiefel for speaking and teaching; Received honoraria from Allergan for speaking and teaching; Received honoraria from Intendis for speaking and teaching; Received honoraria from Coria for speaking and teaching; Received honoraria from Sanofi-Aventis for speaking and teaching.

Preauricular Sinuses

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