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Main Article

PREAURICULAR SINUS: OPERATING MICROSCOPE IMPROVES OUTCOME

Krishna K. Kumar, V. B. Narayanamurthy*, V. Sumathi, R. Vijay

ABSTRACT: A retrospective review of preauricular sinuses operated in Sundaram Medical Foundation, a 140-bedded tertiary care hospital during the period 1995 to 2000 is presented. Patients were operated six to eight weeks after control of infection. Magnification with an operating microscope was always used. A team of ENT and Plastic surgeons was involved in all the cases. Involvement of a Plastic and Reconstructive surgeon permitted primary closure after surgery without any drains, individualised incisions in every patient, and early discharge from hospital. A follow up of all operated patients for a period of 18 months revealed good results without any recurrence. Key Words: Preauricular sinus, microscope, plastic surgeon, primary closure

INTRODUCTION Patients with preauricular sinuses present to the clinician with persistent discharge, recurrent infections or recurrence after surgery. Surgery has always been regarded as the treatment of choice. Ancillary methods, adopted to improve success rates, include probing and methylene blue injection, diathermy cauterization and excision followed by secondary healing. The objective of this study is to analyze our methods and results with preauricular sinus excisions. Background Lau JT (1983) have shown that preoperative injection of methylene blue into the tract followed by purse-string closure of the orifice, 3 days prior to surgery, together with addition of a posterior drain, improves outcome. If complete excision of the gland and duct is done, the recurrence rate should be substantially reduced. Joseph V T and Jacobsen A S (1995) have reported recurrences due to incomplete excision of the gland. Lam H C and colleagues (2001) have shown that the supraauricular approach for excision of a preauricular sinus has a statistically lower recurrence rate in comparison with sinectomy. Surgery done in the presence of infection results in higher recurrence. Gur E and co-workers (1998) have reported a recurrence of 8.22% without any infection as compared to 15.79% in patients with active infection present at surgery. Use of blunt

probing and injection of methylene blue dye simultaneously to delineate the sinus ramifications have resulted in no postoperative recurrence as reported by Gur E and co-workers (1998). Currie A R and colleagues (1996) have shown that previous history of excision, the use of a probe to delineate the sinus and operating under local anaesthesia all increase the chances of recurrence. Postoperative wound asepsis is also mandatory to facilitate good healing without recurrence. Currie A R and colleagues (1996) have reported higher recurrence in patients who developed postoperative wound sepsis. Results are always better in primary preauricular sinus excisions. Ellie M and co-workers (1998) have reported a recurrence rate of 14% in first operations and 42% in patients operated for a recurrence. MATERIALS AND METHODS The hospital medical records of all nine patients operated for a preauricular sinus in our hospital during the period 1995 to 2000 were studied. Details of the patients are given in [Table 1]. Method Infection is controlled and a period of 6 weeks allowed before surgery is undertaken. [Table 1] gives the details of the antibiotics used. Co-amoxiclav is the preferred antibiotic but Ciprofloxacin was used in patients with proven sensitivity patterns. General anaesthesia was used in all cases. The team

Department of Otorhinolaryngology and *Plastic surgery, Sundaram Medical Foundation, IV Avenue, Shanthi Colony, Anna Nagar, Chennai-600040, India
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 1, January-March 2006

Preauricular sinus

Table 1: Patient profile S. No. Age 1 2 3 4 20 68 29 9 Sex F M F F Presentation Discharge Discharge and pain Discharge Swelling and Discharge, Unilateral/ bilateral Right Left Left Left Left Bilateral Right Left Right Primary/ recurrent Primary Primary Primary Primary Primary Primary Recurrent Primary Primary Antibiotics Co-Amoxiclav Co-Amoxiclav Co-Amoxiclav Co-Amoxiclav Co-Amoxiclav Ciprofloxacin Ciprofloxacin Co-Amoxiclav Cloxacillin Follow up 18 months 18 months 18 months 24 months 24 months 24 months 24 months 36 months 36 months

Multiple tract sinus 5 8 M Discharge 6 16 M Bilateral discharge L > R,

Multiple tract sinus 7 15 F Discharge and pain 8 9 5 5 F M Discharge and swelling Swelling and discharge

of ENT and Plastic surgeons jointly operated all cases. Gentle probing with a blunt ended malleable probe is done first to delineate the extent and presence of multiple ramifications. [Figure 1] Local infiltration of 2% lignocaine and adrenaline around the delineated area is done. An elliptical incision including the sinus opening was used. A zigzag incision was used where multiple openings were present, to give maximum exposure. Magnification with an operating microscope, bipolar dissecting forceps and local infiltration of adrenaline provides a bloodless field. All ramifications could be meticulously dissected and excised in Toto [Figure 1]. As meticulous haemostasis is always attained, no drain is used and primary closure is done. RESULTS Nine patients were operated, of which 5 were females. Seven of them were less than 21 years, one of them was 68 years

old. Sinuses were more common on the left[5] than on the right,[3] one of them was bilateral with more discharge on the left side. Eight of our patients were primary preauricular sinus excisions while 1 had undergone a previous sinus incision and drainage outside. Sinus tracts were single in 7 patients and multiple in 2. All patients were followed up for a minimum period of 18 months, the longest being 36 months. None of the operated patients have had a postoperative recurrence to date. DISCUSSION A preauricular sinus is a congenital anomaly. It may be an inclusion dermoid resulting from epithelium trapped between the developing auricular tubercles or it may be a remnant of first branchial groove epithelium, which has failed to resorb. Recurrence in preauricular sinus excision is due to incomplete excision of the sinus tract and presence of residual viable squamous epithelium. Recurrence can manifest in the form of persistence of sepsis, resurgence of swelling, repeated sinus discharge or recurrence of a preauricular mass. However, in our series, we have had extremely gratifying results without a single recurrence in any of the nine patients operated so far. General anaesthesia is preferred to ensure patient co-operation. Magnification with an operating microscope enables precise dissection without any epithelial breach. Copious local infiltration with adrenaline facilitates a bloodless field for the surgeon, making dissection more easy and fruitful. Blunt metal probing to delineate the sinus ramifications, should be gentle and meticulous to avoid the creation of new false passages. Bipolar diathermy cauterization and use of diathermy

Figure 1: Preauricular sinus: Initial step of gentle probing with a blunt ended malleable probe

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 1, January-March 2006

Preauricular sinus

dissection ensures a clean bloodless field. Involvement of an experienced plastic and reconstructive surgeon, with a sound knowledge of wound healing and meticulous planning preoperatively and preoperatively, helps minimise the scar. REFERENCES
1. 2. 3. Lau JT. Towards better delineation and complete excision of Preauricular sinus. Aust N Z J Surg 1983;53:2679. Joseph VT, Jacobsen AS. Single stage excision of Preauricular sinus. Aust N Z J Surg 1995;65:2546. Lam HC, Soo G, Wormald PJ, Van Hasselt CA. Excision of the Preauricular sinus: a comparison of two surgical techniques. Laryngoscope 2001;111:3179. 4. Gur E, Yeung A, AlAzawwi M, Thomson H. The excised preauricular sinus in 14 years: Is there a problem? Plastic Reconstr Surg

1998;102:14058. 5. 6. Currie AR, King WW, Vlantis AC, Li AK. Pitfalls in the management of Preauricular sinuses. Br J Surg 1996;83:17224. Ellie M, Lakswaki R, Anglebe C, Altrogge C. Clinical evaluation and surgical management of congenital Preauricular fistulas. J Oral Maxillofac Surg 1998;56:82730.

Address for Correspondance Dr. K. Krishna Kumar, Department of Otolaryngology, Sundaram Medical Foundation, IV Avenue, Shanthi Colony, Anna nagar, Chennai 600 040, India E-mail: drkumark@yahoo.com

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 1, January-March 2006