Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

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
Holly Rataiczak, DO; Jennifer Lavin, MD; Michelle Levy, PA; Joshua Bedwell, MD; Diego Preciado, MD;
Brian K. Reilly, MD

IMPORTANCE Treatment modalities for preauricular sinus tract infections vary. Effort should
be taken to decrease methods that lead to increased recurrence after surgical excision.

OBJECTIVE To determine whether incision and drainage (I & D) of infected congenital

preauricular cysts is associated with increased rate of recurrence when compared with
fine-needle aspiration or antibiotic treatment.

DESIGN, SETTING, AND PARTICIPANTS This was a 9-year (2006-2014) retrospective cohort
study undertaken at a tertiary care pediatric hospital. Children treated for preauricular sinus
tract infections were identified using the procedure code for excision of preauricular pit, cyst,
or sinus tract.

MAIN OUTCOMES AND MEASURES Postexcision recurrence.

RESULTS Sixty-nine children ranging in age from 4 months to 17 years (mean age, 5.9 years)
underwent excision of a preauricular cyst. Thirty-seven of 69 patients (54%) were female.
Fifty-seven of 69 (83%) had a preoperative history of infection; the remainder had chronic
drainage. Of children with preoperative infection, 27 were initially treated with incision and
drainage (I & D), 12 were treated with fine-needle aspiration only, and 18 received antibiotic
therapy alone. Overall, the recurrence rate was 8 in 69 (11.6%). Among the 27 patients with a
preoperative history of infection treated with I & D, 5 lesions (18.5%) recurred, and among
those who only received preoperative antibiotic therapy or fine-needle aspiration 1 in 30
lesions (3.3%) recurred (absolute difference of 15.2%; 95% CI, −1.7% to 33.6%).

CONCLUSIONS AND RELEVANCE Among infants and children undergoing excision of

preauricular cysts, a history of infection was not associated with a higher recurrence rate.
There was, however, evidence to suggest that a higher rate of recurrence exists among
children who had a preoperative history of infection treated with I & D. Our results suggest a
more conservative treatment of infected preauricular pit and/or sinus.

Author Affiliations: Department of

Otolaryngology, Walter Reed National
Military Medical Center, National
Capital Consortium, Washington, DC
(Rataiczak); Division of
Otolaryngology, Children's National
Medical Center; Sheikh Zayed
Institute for Pediatric Surgical
Innovation, Children's National
Medical Center, Washington, DC
(Lavin, Levy, Bedwell, Preciado,
Reilly).
Corresponding Author: Holly
Rataiczak, DO, Walter Reed National
Military Medical Center, 8901
JAMA Otolaryngol Head Neck Surg. 2017;143(2):131-134. doi:10.1001/jamaoto.2016.2988 Wisconsin Ave, Bethesda, MD 20889
Published online October 27, 2016. (rataichm@gmail.com).

(Reprinted) 131

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 Research Original Investigation
P
reauricular pits (PAPs) are commonly encountered con-
genital malformations that are often seen on examina-
tion but may not have clinical significance. Preauricu-
lar pits can arise sporadically or are inherited in an incomplete
autosomal dominant fashion, with reduced penetrance and
variable expressivity.1 The incidence of PAPs varies in the lit-
erature, depending on the patient population, and has been
reported to be 0.23% in studies in New York, 0.47% in studies
in Hungary,2 and 1.9% in studies in South Korea.2,3 Preauricu-
lar pits are more common among people of African and Asian
descent.4 They are theorized to be the result of an incom-
plete embryonic fusion of the 6 Hillocks of His.
Preauricular pit sinus tracts typically present as indolent
pinpoint depressions, located along the anterior margin of the
ascending limb of the helix.1 Preauricular pits may also ex-
tend superior to the auricle, along the cymba concha, at the
lobule, or posterior to the auricle.5 Occasionally, PAPs can be-
come infected, manifesting as facial cellulitis or a localized ab-
scess, and require antibiotic therapy and, at times, incision and
drainage (I & D).
Surgical treatment ideally consists of complete excision of
the PAP sinus tract, preferably when the tissue is not actively
infected. Surgical methods and PAP recurrence rates follow-
ing sinus tract excision have been documented, but the im-
pact of recurrence after I & D remains unclear.5,6 Incision and
drainage procedures are typically avoided in acute infections
because I & D may increase risk of recurrence after definitive
tract removal. Results from studies investigating whether pre-
excision I & D is associated with increased postexcision recur-
rence rates, however, have been mixed.5,6 Hence, further in-
vestigation is warranted.
The purpose of this study is to investigate whether I & D
performed prior to a staged excision is associated with in-
creased rate of recurrence of PAPs. Our hypothesis is that I &
D of an infected preauricular cyst is not associated with an in-
creased rate of recurrence, compared with fine-needle aspi-
ration or antibiotic treatment alone.
Methods
After obtaining approval from the Children’s National Medi-
cal Center’s institutional review board, we undertook a 9-year
retrospective review (January 1, 2006, to December 31, 2014)
of all children with PAPs. Study patients were identified using
the Current Procedural Terminology (CPT) procedure code for
excision of PAP, cyst, or sinus tract. Each medical record was
individually reviewed. The data extracted included sex, age
at surgery, preoperative antibiotic treatment, preoperative fine-
needle aspiration, preoperative I & D, time from surgery to re-
currence, size of specimen, intraoperative rupture, size of ex-
cised tract, and final pathology reports. All cysts were excised
using the same technique: lacrimal probes guided a wide ex-
cision of surrounding soft tissue along with a small section of
cartilage. Recurrence was defined as a persistent preauricu-
lar mass or drainage from the area. We excluded children who
did not have a cyst confirmed by pathology reports. Statisti-
cal analysis was completed using the 2-sided Fisher exact test
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Comparison of Treatment Options for Congenital Preauricular Cysts
Key Points
Question Is incision and drainage of infected congenital
preauricular cysts associated with increased rate of recurrence
when compared with fine-needle aspiration (FNA) or antibiotic
treatment?
Finding In a cohort study of children with a history of
preoperative infection, an increase in recurrence was found in
patients undergoing preoperative incision and drainage when
compared with patients treated with FNA or antibiotics alone.
Meaning These results guide the practitioner toward more
conservative treatment modalities, such as oral antibiotics or FNA,
and avoidance of incision and drainage for initial management.
Figure 1. Diagram of Study Populations, Treatment Modalities, and
Recurrence Rates
Excision of PAP
Indications
57 History of 12 With chronic
infection drainage
27 Treated 12 Treated 18 Treated with 2 With
with I&D with FNA antibiotics recurrence
5 With 0 With 1 With
recurrence recurrence recurrence
FNA indicates fine-needle aspiration; I & D, incision and drainage; PAP,
preauricular pit.
to compare the rates of recurrence with or without preopera-
tive infection and with or without I & D, and a Kaplan-Meier
curve examining percentages of recurrence-free patients. Re-
sults were deemed to be significant if P < .05.
Results
Demographics
A review of CPT codes yielded 69 patients who underwent ex-
cision during the study period, with pathology report–
confirmed anomalies. The average age of the patients was 5.9
years (range, 4 months to 17 years), and 37 of 69 of patients
(54%) were female. Fifty-seven of the patients (83%) had a his-
tory of infection prior to the scheduled surgical excision, and
12 patients had chronic drainage as the indication for surgery
(17%). Of the 57 patients with preoperative infection, 27 were
treated with I & D, 12 underwent fine-needle aspiration, and
18 were treated medically with antibiotics. See Figure 1.
Recurrence Rates
The recurrence rate in our study was found to be 8 in 69 (11.6%).
In patients with a preoperative history of infection treated with
I & D, 5 of 27 lesions (18.5%) recurred, and among those who
only received preoperative antibiotic therapy or fine-needle
jamaotolaryngology.com
 Comparison of Treatment Options for Congenital Preauricular Cysts
aspiration 1 of 30 lesions (3.3%) recurred (absolute difference
of 15.2%; 95% CI, −1.7% to 33.6%). There was a 15.2% differ-
ence in recurrence between patients treated with I & D and
those who received preoperative antibiotic therapy or fine-
needle aspiration, and this difference could be as great as
34.0%. The data are also compatible with a slight (2%) de-
crease in recurrence among those treatment without I & D. A
multivariate analysis comparing age, sex, presence of preop-
erative infection, and size of the specimen did not yield any
other significant parameters influencing recurrence. Kaplan-
Meier analysis displays a fairly steep curve showing rapid re-
currence among those who had I & D compared with those who
had no I & D (Figure 2).
Discussion
In our study, we retrospectively compared postoperative pit
recurrence rates in patients undergoing preoperative I & D with
those undergoing antibiotic treatment or fine-needle aspira-
tion. In patients who had a preoperative history of infection
that required I & D prior to definitive removal, 5 of 27 (18.5%)
lesions recurred. The data are inconclusive regarding the re-
lationship between type of treatment for preoperative infec-
tion and recurrence but do suggest that recurrence is greater
for those who undergo I & D.
This finding is supported by Tang et al,4 who compiled a
retrospective analysis of 71 patients over 5 years at a single ter-
tiary care facility. They found an overall recurrence rate of
14.1%. Among the 12 patients who underwent drainage for an
abscess before the definitive surgery, 4 (33.3%) experienced
recurrence. Among the 39 patients who did not have an ab-
scess, only 6 (15.3%) experienced recurrence, with an abso-
lute difference of 18% (95% CI, −9% to 50%). Furthermore,
among the 13 sinuses that were actively infected at the time
of definitive surgery, 4 lesions (30.7%) recurred, while among
the 38 noninfected sinus tracts, only 6 recurred (15.7%), for an
absolute difference of 15% (95% CI, −11% to 47%). Tang et al4
surmised that complete excision of the sinus tract is more dif-
ficult owing to the fibrotic and edematous changes associ-
ated with postinfection inflammation and scarring.5 Similar
findings were reported in a study by Gur et al,6 who exam-
ined 165 patients over the course of 14 years. In patients who
underwent surgical drainage of an abscess before sinus tract
excision, 16.7% recurred, whereas in the patients who did not
have incision prior to the procedure only 8.16% recurred
(P = .25; odds ratio, 2.25). The result of Gur et al,6 however,
failed to reach statistical significance; the authors attributed
the statistical insignificance to small sample size. As in the
study by Tang et al,4 the article hypothesizes that changes from
I & D distort the normal tissue structure and make definitive
sinus tract surgery more complex, leading to higher recur-
rence rates.6
Indeed, histological studies show that there is a branching
pattern to the preauricular cyst. In 2009, Dunham et al7 exam-
ined the relationship between the epithelial tract of excised PAPs
and the adjacent auricular cartilage. They7 stated that the epi-
thelial tracts commonly arborize with narrow, tortuous paths,
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Original Investigation Research
Figure 2. Kaplan-Meier Analysis Showing Patients Without Incision and
Drainage Prior to Surgical Removal and Rate of Recurrence-Free Period
100
Recurrence-Free Rate, %
80
60
Previous I & D
No previous I & D
40
20
0
0 20 40 60 80 100
Recurrence-Free Period, wk
No. at risk
Previous I & D 26 4 3 0 0 0
No previous I & D 42 3 2 1 1 0
and their findings suggest they are found less than 5 mm from
the cartilage in 50% of the specimens.
Similarly, in 2012, a study by Gan et al8 demonstrated that
PAP epithelialization does not merely occur along a single tract.
Gan et al8 divided PAPs into 2 excision groups: 114 partici-
pants were placed into an excision under microscope group and
94 participants into a methylene blue dye and probe group.
Surgical excision with microscope guidance had significantly
lower recurrence rate (0.9%) compared with surgical exci-
sion with methylene blue dye and probe guidance (4.3%), with
an odds ratio of 28.4 (95% CI, 1.22-659.99). The lower recur-
rence rate was attributed to clear identification of the PAP and
magnified surgical planes.9
Finally, Lam et al9 also found that preauricular cysts are
multibranched. They compared wide local excision of PAPs
with simple fistulectomy. Finding that wide local excision leads
to lower recurrence rates, the authors stated that preauricu-
lar sinuses are multibranched and ramifying within the soft
tissue and can be difficult to identify as a result of the inflam-
mation from previous abscess formation.
Yeo et al10 studied factors contributing to recurrence after
surgery among 191 patients with preauricular sinus tract
infections in South Korea. The overall recurrence rate was 4.9%.
In contrast to our findings and proposed hypothesis, they found
an absolute difference in recurrence rate of only 5% (95% CI,
−2.5% to 12%) between patients with a history of drainage com-
pared with those who did not have drainage. They found that
recurrence increased only if the procedure was performed un-
der local anesthesia, which was attributed to the tortuous course
and pattern of arborizations frequently associated with PAP
tracts and the difficulty of effective dissection on conscious
patients.10 Another article, by Huang et al,11 stratified PAP op-
erative procedures into 3 groups based on degree of inflamma-
tion. In group 1, PAPs with mild inflammation, lesions were
excised with a simple sinusotomy; group 2, lesions with mod-
erate inflammation were excised with a local wide excision; and
in group 3 they was removed in a “figure 8” method. Their over-
all recurrence rate was 7.34% (8 of 109). Of the 34 sinuses drained
for an abscess, 5 (14.7%) had recurrence, while 3 of the 65 (4.6%)
that did not have previous I & D recurred for an absolute differ-
ence of 10.1% (95% CI, −3% to 28%). This rate is similar to ours.
133
 Research Original Investigation Comparison of Treatment Options for Congenital Preauricular Cysts

They found presence of preoperative I & D was not significant.
This could be related to their method of a figure 8 excision,
which was composed of 2 wedge resections down to the tem-
poralis fascia for an extended fistulectomy. This widened ap-
proach could capture fragmented tracts after I & D.
Similar to PAPs, other congenital malformations have been
associated with postoperative recurrence. The relationship of
malformation recurrence in the setting of preoperative I & D has
also been investigated in these other lesions. In a study by Simon
and Magit,12 no significant relationship between preoperative I &
D of thyroglossal duct cysts and cyst recurrence was found. Their
study,12 however, found that the rate of recurrence among the
49 patients with infection was 20%, the rate of recurrence among
the 71 without infection was 4% for an absolute difference of
16% (95% CI, 3%-31%). The difference between these findings and
our findings in PAPs could be attributed to the multibranched,
arborized nature of the PAP in contrast to the thyroglossal duct
cyst, which forms along a single tract.12
Unlike other studies, our study included patients who un-
derwent preoperative fine-needle aspiration in our analysis.
No difference in recurrence rate was noted between patients
undergoing fine-needle aspiration and I & D or between pa-
tients undergoing fine-needle aspiration and those treated with
antibiotics alone. It is likely, however, that this lack of rela-
tionship is due to small population size, so further investiga-
tion is warranted. In our analysis we compared patients un-
dergoing I & D with patients undergoing either fine-needle
aspiration or antibiotic therapy. The decision to combine fine-
needle aspiration and antibiotic groups into 1 group is justi-
fied because fine-needle aspiration is less likely to disrupt the
sinus tract when compared with I & D.
The genetic pattern of dominant inheritance may often
prompt the parent or guardian to avoid interventions that may
not seem to be urgent or necessary. In addition, the progres-
sion of the infection in the PAP may be very rapid and treat-
ment can become complex if the patient is in pain and or has
extensive swelling, abscess formation, and expansion of the
fluid collection on the anterior aspect of the face.
Limitations
Thus, this study has the following limitations: because
patients were not randomized, the decision to proceed with
I & D, fine-needle aspiration, or antibiotic therapy may cre-
ate a source of bias. The retrospective nature of the study
limits the variables available for analysis. In addition, this
study has a small sample size, which could reduce the likeli-
hood that a statistically significant result reflects a true
effect. Severity of infection is one confounding variable that
might require drainage prior to definitive excision. Most
treatment modalities prior to operative incision and drain-
age in our review were managed by primary care and emer-
gency medicine physicians. At this time, treatment guide-
lines are not available to influence clinical decision making.
It is the aim of future endeavors to establish such treatment
protocols. As demonstrated in our study, attempts should
be made to treat the PAP with antibiotics and fine-needle
aspiration.
Conclusions
Preoperative I & D of the infected PAP or sinus, is associated
with increased incidence of recurrence after surgical exci-
sion. The absence of a history of infection enhances the chances
that the excision of the PAP will be complete and a long-term
success. Our results guide the practitioner toward more con-
servative treatment modalities, such as oral antibiotics or fine-
needle aspiration, and avoidance of I & D treatments.

ARTICLE INFORMATION
Accepted for Publication: August 7, 2016.
Published Online: October 27, 2016.
doi:10.1001/jamaoto.2016.2988
Author Contributions: Dr Rataiczak had full access
to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Reilly.
Acquisition, analysis, or interpretation of data:
Rataiczak, Lavin, Levy, Preciado, Reilly.
Drafting of the manuscript: Rataiczak, Lavin.
Critical revision of the manuscript for important
intellectual content: Rataiczak, Lavin, Levy,
Preciado, Reilly.
Statistical analysis: Rataiczak, Lavin, Levy, Preciado.
Administrative, technical, or material support:
Rataiczak, Reilly.
Study supervision: Lavin, Preciado, Reilly.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and
none were reported.
Previous Presentation: This study was presented
at Combined Otalaryngology Spring Meetings/
American Society of Pediatric Otolaryngology; April
24, 2015; Boston, Massachusetts.
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