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http://oto.sagepub.com/content/149/3/399The online version of this article can be found at:
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: [email protected]
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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
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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-
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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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