para>A very small minority of patients with preauricular sinuses have branchiootorenal syndrome. Clinicians should inquire regarding hearing loss, renal abnormalities, and/or multiple branchial cleft anomalies. If any are present, could consider renal ultrasound to rule out structural abnormalities of the renal system.
Diagnostic Procedures/Other
Sinus tract can be assessed with methylene blue staining and probing, although it is rarely performed (1)[C].
TREATMENT
GENERAL MEASURES
If an abscess is present, empiric antibiotics with efficacy against the most common organisms infecting this site may be considered. Needle drainage for small abscesses should be obtained prior to beginning a course of antibiotics. Incision and drainage of a large abscess may lead to a more complicated surgical intervention requiring complete removal of the sinus tract.
MEDICATION
First Line
- Clindamycin
- 300 to 450 mg PO 3 times daily for 7 to 10 days
- Pediatric dose: 40 mg/kg/day orally divided in 3 to 4 doses; maximum daily dose 600 mg to 1.8 g
- Trimethoprim-sulfamethoxazole (TMP-SMX)
- 1 double-strength tablet orally 2 times daily for 7 to 10 days
- Pediatric dose: 8 to 12 mg/kg/day of trimethoprim and 40 to 60 mg/kg/day of sulfamethoxazole divided in 2 doses; maximum daily dose 320 mg of trimethoprim, 1.6 g of sulfamethoxazole
- Doxycycline 100 mg 2 times per day for 7 to 10 days
- As skin flora are the most common organisms causing preauricular abscess, antibiotic selection is based on treatment of Staphylococcus spp. and Streptococcus spp. Empiric antibiotic therapy should have in vitro activity against community-acquired methicillin-resistant Staphylococcus aureus (MRSA), which has become more common. Clindamycin, TMP-SMX, or doxycycline is recommended for oral therapy (2)[A].
Pediatric Considerations
Doxycycline is an inappropriate antibiotic choice in children <8 years of age due to significant risks for tooth discoloration and enamel hypoplasia (3)[A].
- Analgesia
- Over-the-counter pain medication is usually adequate for pain relief.
- Acetaminophen, ibuprofen, naproxen
ISSUES FOR REFERRAL
Patient should be referred to head and neck surgeon for complete excision of preauricular sinus if it has previously been infected or if it frequently drains purulent, or white, cheese-like material.
SURGERY/OTHER PROCEDURES
- Traditionally, complete excision of the preauricular sinus is recommended once abscess and surrounding infection has resolved.
- One recent study on immediate one stage surgical repair in acutely infected preauricular sinuses showed good surgical outcomes (4)[B].
- To avoid recurrence, surgery should involve removal of the sinus and the cyst present beneath the skin. Removal of involved cartilage at the root of the helix has also been described (5)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inpatient management usually not necessary
- Condition can be managed outpatient with oral antibiotics and incision and drainage if needed.
- Sepsis requires inpatient workup and treatment.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
1 week follow-up after initial presentation. Review cultures and sensitivities if applicable.
DIET
No dietary restrictions needed
PATIENT EDUCATION
Prevent recurrences by always keeping area clean.
PROGNOSIS
- Uncomplicated course in most patients
- Rarely can progress to sepsis
- Recurrence rates are as high as 9 " 42% after surgery.
COMPLICATIONS
- Recurrent abscesses (9 " 42%)
- Sepsis (very rare)
Pediatric Considerations
Infants with preauricular pits and tags have a significantly higher prevalence of hearing impairment compared to infants without pits or tags (6)[B].
REFERENCES
11 Gan EC, Anicete R, Tan HK, et al. Preauricular sinuses in the pediatric population: techniques and recurrence rates. Int J Pediatr Otorhinolaryngol. 2013;77(3):372 " 378.22 Singer AJ, Talan DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med. 2014;370(11):1039 " 1047.33 Gulati RK. Doxycycline in children? " the unanswered question. Pediatr Dermatol. 2010;27(4):419.44 Shim HS, Kim DJ, Kim MC, et al. Early one-stage surgical treatment of infected preauricular sinus. Eur Arch Otorhinolaryngol. 2013;270(12):3127 " 3131.55 Bae SC, Yun SH, Park KH, et al. Preauricular sinus: advantage of the drainless minimal supra-auricular approach. Am J Otolaryngol. 2012;33(4):427 " 431.66 Dancel R, Price D, Kaufmann L. Evaluation of newborns with preauricular skin lesions. Am Fam Physician. 2012;85(10):993 " 998.
ADDITIONAL READING
- Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery. 2005;137(5):567 " 570.
- Bellini C, Piaggio G, Massocco D, et al. Branchio-oto-renal syndrome: a report on nine family groups. Am J Kidney Dis. 2001;37(3):505 " 509.
- Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol. 2003;117(12):983 " 984.
- Ellies M, Laskawi R, Arglebe C, et al. Clinical evaluation and surgical management of congenital preauricular fistulas. J Oral Maxillofac Surg. 1998;56(7):827 " 830.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18 " e55.
- Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope. 1990;100(3):320 " 321.
- Scheinfeld NS, Silverberg NB, Weinberg JM, et al. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol. 2004;21(3):191 " 196.
CODES
ICD10
- Q18.1 Preauricular sinus and cyst
- L02.811 Cutaneous abscess of head [any part, except face]
ICD9
- 744.46 Preauricular sinus or fistula
- 682.8 Cellulitis and abscess of other specified sites
SNOMED
- Preauricular sinus (disorder)
- Abscess of preauricular sinus (disorder)
CLINICAL PEARLS
- Can be easily misdiagnosed as an infected sebaceous cyst
- Mainstay of treatment is oral antibiotic therapy and possible needle drainage.
- Incision and drainage should be reserved for complicated cases and may result in a more difficult definitive surgical excision.
- Patient should be referred to a head and neck surgeon for complete excision of preauricular sinus.