Four cases of preauricular fistula based on systematic review resulted

new algorithm
Dini Widiarni Widodo, Hemastia Manuhara Harba’i
*
Otorhinolaryngology Head and Neck Surgery Department,
Cipto Mangunkusumo Hospital – Universitas Indonesia

ABSTRACT

Background: Preauricular Fistula is a congenital malformation condition of tractus which

was basely built by squamous epithelials, firstly initiated in front of ear auricles. It is caused
by an imperfect fusion of the first arch tuberculum to other tuberculums. Diagnosis is based
upon anamnesis and physical examination where a small hole in front of ear auricles is
found. Therapy is given whenever the symptomsoccur. An infection will create a swollen
area in front of ear auricles with pain and suppuration. A tractus extirpation is done best when
the acute infection is already subdued. Purpose: To evaluate a surgery technique with the
lowest complication and recurrence rate. Methods: Reviewing 26 surgical cases treated
between January 2015 to April 2017 in Cipto Mangunkusumo General Hospital. From
these26 cases the author will report 4 cases. Results: There were four cases with closure
operations i.e. primary closure only, primary closure with supra auricular approach, repeated
case with supra auricular approach and wide undermining. Conclusion: The supra auricular
approach can be the better surgical technique for fistula preauricular.

Keywords: preauricular fistula, infection, fistulectomy

ABSTRAK
Pendahuluan: Fistel preaurikula suatu kongenital malformasi dimana tidak menyatunya
tuberkulum arkus pertama ke tuberkulum-tuberkulum lainnya. Diagnosis ditegakkan
berdasarkan anamnesis dan pemeriksaan fisik. Pada pemeriksaan tampak lubang kecil di
depan daun telinga. Pengobatan dilakukan bila dijumpai adanya gejala. Bila terjadi infeksi
biasanya menyebabkan daerah di depan daun telinga bengkak dan sakit serta bernanah.
Ekstirpasi yang sempurna dari traktus dilakukan setelah infeksi akut sudah reda. Tujuan:
Mengevaluasi teknik bedah dengan tingkat komplikasi dan kambuh terendah. Metode:
Penelitian ini 26 kasus antara Januari 2015 dan April 2017 di Rumah Sakit Umum Cipto
Mangunkusumo. Namun penulisan dalam kasus ini akan melaporkan 4 kasus. Hasil: Ada
empat kasus dengan operasi penutupan primer, operasi pendekatan supra aurikula, kasus
berulang dengan pendekatan supra aurikula dan undermining luas. Kesimpulan:
Pendekatan auricular supra bisa menjadi teknik lebih baik untuk fistula preauricular.
Kata kunci: fistel preaurikula, infeksi, fistulektomi.

Corresponding Author: Dini Widiarni Widodo, MD ORL PhD, Rhinology Consultant,

Otorhinolaryngology Head and Neck Surgery Department, Cipto Mangunkusumo Hospital –
Universitas Indonesia, Pangeran Diponegoro Street no.71, Senen, Central Jakarta 10430,
Indonesia. Cellph. +62816807230. Email: [email protected]

INTRODUCTION

Preauricular fistula was first introduced by

Van Heusinger in 1864. The disorder is Picture 1
inherited in autosomal dominant Ear development stage
incomplete, 25-50% occurs bilaterally. (1) Tragus (2) Krus helix(3) Helix (4)
The literature mentions that in Asia the Antihelix (5) Antitragus
incidence reaches 1-10%. There is no (6) Lobule2

significant difference between the

incidence of preauricular fistula in men SIGN AND SYMPTOM

and women.1

PATHOPHYSIOLOGY

There is a theory explaining the formation

of preauricular fistula. The theory says it
occurred from an imperfect fusion of 6
hillocks auricle resulting in fistula
preauricula.
Usually asymptomatic, preauricular Baatenburg de Jong4 introduced a
infection patients frequently seek technique which is a modified technique of
treatment due to infection. Preauricular wide local excision. The procedure of this
fistula appears in the form of small
depressions or pits which are usually
located in the anterior border of the
ascending helix. The preauricular fistula is
generally narrow, variety in length, but the
orificium is usually short and small,
protected and forked/bifurcated around the technique was introduced as an "inside-
outer ear. The length of the fistula tract out". This method used a microscope.
varies between 3 to 22 mm. Methylene Followed sinus track from the outside
blue can predict the length of the (such as the classic technique) and inside.
tract.Fistulography -as another method- is Branch - a branch that is open tract
performed by injected the contrast liquid followed until edges are identified and
through the sinus cavities. Usually found excised. Baatenburg de Jong reported 0%
on latero-superior and posterior of the recurrence rate with this inside-out
facial nerve and parotid gland. Fistula tract technique.4
is located close to the facial nerve, at the Picture 2
time of removal of the fistula tract to the Inside-out technique. 4
anterior and that extends to the border of A: Creating an elliptical incision around
the parotid gland can cause trauma to the the mouth of the fistula. B: Creating
facial nerve. In some cases, the channel is stitches around the mouth of the fistula as
associated with perichondrium ear a handle for easy dissection of the fistula
cartilage. tract. C: Opening fistula channel with
sharp scissors. D: Using a magnifying
TREATMENT
glass, a wall that has been stained with
In the acute phase of preauricular sinus
methylene blue ("inside") and the outer
infection, adequate antibiotics against
wall of the fistula tract is freed from the
pathogens should be given, and drainage
surrounding tissues.
should be done. Coatesworthet
al3.describes techniques using preauricular Other techniques with radical techniques
abscess drainage lacrimal probe. supra-auricular approach is known as wide
local excision. On the approach may
involve post supra auricle with an elliptical significant tension could be felt when the
incision around the sinus orifice. surgeon attempted to approximate the
wound margins. This incision is similar to
Incomplete excision would result in
a facelift incision. This procedure was
recurrence of preauricular fistula. There
done by inserting the silicon drain into the
was no up to proven effective operation
posterior side. The subcutaneous tissue
techniques can be lifted completely fistula
was repaired with skin suture.
preauricula. Recurrence rate is quite high
If the auricular cartilage was exposed
at 20%.
during the excision of the preauricular
sinus and the tissue defect was wide, the
closure was performed bya posterior
auricular transposition flap. The flap was
transferred to the defect by a rotation of up
to 120° on the subcutaneous pedicle. 5,6

METHODS

This study reviewed 26 surgical cases

treated between January 2015 and April
2017 in Cipto Mangunkusumo General
Hospital. The 26 cases involved the first
excision of symptomatic congenital pre-
auricular sinuses. Patients ages ranged
from was 7 months to 60 years, with
median age was 15 years old and there
Picture 3
were 9 male and 17 female patients in the
Reconstruction algorithm of post-
group. But from these26 cases the author
preauricular sinus excision5,6
will report 4 cases.

The closure operations were classified into In each case, the patient was given general
3 categories: those involving primary anesthesia, and an otolaryngologist
closure only, those involving primary injected methylene blue dye into the open
closure with wide undermining, and those fistula to determine if the tract was
involving auricular flap repairs.5,6 connected to the sinus. The operations
Primary closure with wide undermining. If were primary closure only.
the resected area was sufficiently large,
Of the 26 cases examined, primary closure the fistula tract An elliptical incision was
were performed. In 26 cases involving made around the fistula, followed by a
primary closure, the repair was performed sharp dissection along the fistula tract. The
using simple suturing. fistula was located on the anterior cartilage
helix and medical borders with temporal
There were 3 patients who underwent a
fascia and contain of pustule The whole
conservative treatment using antibiotic
tract and sinuses can be removed intact.
before surgery . From all 26 cases there
Drain was inserted and suturing wounds
was no recurrency after the surgery.
was done.

Case # 1

A woman aged 18 years complaining of

recurrent ulcers in front of the left earlobe,
often occured in the same spot since 3
years ago. Patient admitted there was a Picture 6
small hole in front of her left ear since Post operation case # 1
birth, sometimes there was a discharge
from the hole. Patient has been to the Case # 2
clinic, had antibiotic orally but there but A male patient, 44 years old came with a
there was no improvement. hole in front of the ear present since birth.
There was a history of itching and
discharge from that hole a few years ago.

Picture 4
Case #1

Picture 7
Case # 2
Picture 5 Preauricular fistula in anterior helix. There
Case #1 patient with methylene blue were no signs of edema, hyperemia, and
insertion secretions from the fistula.

Fistulectomi surgery. Before the incision,

methylene blue solution was injected into
 Picture 8
Retroauricular fistula case # 2

The patient underwent supra auricular

approach. Methylene blue was injected
into the fistula tract so that the blue tract
can be shown clearly. Then the drain can
be shown clearly. Then the drain was
inserted.

Picture 11
Surgery picture case #

CASE #4

Picture 9 Patient was 3 years old baby girl with a

Surgery picture case # 2 hole in front of the right ear since birth.
There was a family history.
The patient underwent a surgical therapy
of simple fistulectomy and primary
closure.

Picture 10
Post operative case # 2

Case # 3
A man aged 25 years complained of
recurrent infections in a hole in front of Picture 12
left ear. He got several surgery before. . After surgery picture case # 4
On ENT examination, there was a scar in
front of the left ear. He underwent
supraauricular flap fistulectomy
 question,the result is one journal with title
A Systematic Review on the Surgical
Outcome of Preauricular Sinus Excision
Techniques. On this journal they said that
supra-auricular approach could be the
preferable technique for preauricular sinus
Picture 13 removal .7
Post operative case #4
LITERATURE ANALYSIS
EVIDENCE BASED ANALYSIS
What question Yes
Patient: Patient with preauricula fistula
(PICO) did the Domain : Pre-
(adults and children )
systematic auricular sinus
Intervention: Supra auricular approach
review address? patients (adults
Comparison:simple fistulectomy
+children)
Outcome: Lowest complication and
Determinant :
recurrence rate
Preauricula sinus

CLINICAL QUESTION removal techniques

Is it unlikely Yes,they conducted a

Does the supra auricular approach for
that important, systematic search in
preauricular fistula removal give result of
relevant studies the PubMed and
the lowest complication and recurrence
were missed? Embase databases on
rate in children and adults, compared with
March 20, 2015
the eclips incision techniques?
(Appendix 1). Both
LITERATURE RESEARCH METHOD title and abstract and
full-text screening
Literature research through Pubmed,
were based on
Wiley and Proquest with keywords of
predefined inclusion
“Preauricular fistula AND surgical
and exclusion criteria
treatment” revealed 10 literatures (in
and performed by
Pubmed), 1 literature (in Wiley) and 1
two independent
literature (in Proquest). The selection
authors.
based through 2012-2017 publication
Were the Yes
dates, English language, and free full text.
criterias used to 1.Clear description
Selection again through the clinical
 select articles of preauricular sinus Pooled recurrence rates
for inclusion removal technique showed that sinectomy
appropriate? 2.Adults and children resulted in signifi- cantly (P
with preauricular 5 .04) more recurrence 5.5%
sinus 3.Studies (95% confidence interval
assessing [CI] 3.6–8.3%) than SAA
postoperative 2.2% (95% CI 0.7–7.0).
residual and Sinectomy using the
recurrence ratios microscope resulted in the
4.Studies reporting lowest sinectomy recurrence
on complication risks rates (1.9%). SAA in

Were the Yes, combination with a Penrose

included studies 1) clear description drain resulted in 0%

sufficiently valid of applied surgical recurrence in revision cases.

for the type of technique(s), 2) a Drain use resulted in the

question asked? minimum follow-up lowest SAA recurrence

of 1 year, and 3) rates; however, drain

complete description application was not advised

of baseline due to higher complication

characteristics. rates (frequent wound

Were the results Yes, From infection [P 5 .003] and
similar from Directness of more [P 5 .002] and longer
study to study? Evidence [P 5 .001] compression
dressing use).

Are this journal important?

How are the Fourteen high directness of

Can I apply this valid, important evidence
results evidence studies were
about prognosis to my patient?
presented? included. Reported
complication rates were Were all Therefore, presented
similar: sinectomy [0– patient evidence has a high clinical
31.4%] and supra-auricular important applicability and can be
approach (SAA) [0–18.2%]. outcomes directly implemented in
 considered? current clinical practice. The reconstruction technique suggested in
this paper has the advantage of being
applicable to various excision methods,
and should be considered when repeat
surgery is necessary. This is especially true
DISCUSSION
when postsurgical wound dehiscence
Fistula preauricula was diagnosed by becomes chronic and a flap of healthy
history and physical examination. Obtained tissue is required to cover the scar.
a history. Patient was complaining of Furthermore, because the posterior
frequent discharge accompanied by the auricular area has a rich vascular supply,
smell of froma small hole in the front of flaps from this area adhere well to other
the left ear. From a physical examination tissue, leading to higher success rates.9
looks foundscar a hole in front of the left
ear frony of the ear.

All defects created after sinus excision are

generally closed with simple repair of the
conventional, and this frequently causes
wound dehiscence due to the tension
caused by the suture. Hospital-stays are
longer and the risks of secondary infection
are increased when such patients are
treated by continued dressing changes and
delayed revision surgery. The wound
infection may worsen, with the
development of chondritis, because the
area is adjacent to the cartilage. This
complication can be reduced by
determining the best approach to the New Algorithm
treatment: simple suture, primary repair
with wide undermining, or the use of a However, for young and short hair patient,

posterior auricular flap, depending on the the surgeon should try to minimize the size

degree of tension and the depth of the of the scar. Therefore, primary repair after

defect.8,9 wide undermining was chosen over closure

with a local flap. This method needs for an
additional skin incision to decrease skin 5. Chang PH, Wu CM. An insidious
tension when approximating the margins preauricular sinus presenting as an

of the wound, resulting in more aesthetic infected postauricular cyst. Int J ClinPract

outcomes.Full of appointed of the bag and 2005;59:370-2

ducts do in case of persistent or recurrent 6. Lee JM, et all. Reconstruction Techniques

for Tissue Defects Formed after
infections that interfere with the activity.
Preauricular Sinus Excision. Arch Plast
Supra auricular techniques is
Surg. 2014 Jan; 41(1): 45–49.
advicedadviced in attempted a technique to
7. Bruijnzeel H, et all. A Systematic Review
reduce recurrence rate.
on the Surgical Outcome of Preauricular
Sinus Excision Techniques.
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