Mouse   over   the   picture   on   your   left   to   take   a closer look.. How   many   preauricular   sinus   or   sinuses   do you see ? (Don’t   cheat   -   Answer   is   at   the   bottom   of   the page)
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EDUCATION Preauricular  Sinus
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Introduction Preauricular   sinus,   a   common   congenital   malformation,   is   a   tract   or   'tunnel'   that has   an   opening   on   the   skin   but   has   a   longer   blind-ended   portion   underneath the   skin.   It   has   an   epithelial   inner   lining   (i.e   the   inner   coating   of   the   tract)   that   is continuous   with   the   skin   opening,   therefore   predisposing   it   to   infection.   It   is frequently   noted   on   routine   physical   examination   as   small   pit(s)   -   more   than one   may   exist-      adjacent   to   the   external   ear,   usually   at   the   front   part   of   the   ear pinna.   Other   locations   are   possible   but   much   rarer.   They   are   usually   present   at birth, but they usually become more apparent later in life.   The   sinus   may   occur   on   both   ears   (bilateral)   in   25-50%   of   cases,   and   bilateral sinuses   are   more   likely   to   be   hereditary   (Scheinfeld).   In   one-sided   (unilateral) cases,   it   is   commoner   on   the   left   side.   Both   men   and   women   are   equally affected in terms of frequency of cases. Causes This   condition   is   different   from   preauricular   cyst   or   tags   although   they   generally arise   as   a   result   of   the   branchial   arch   malformations.   Infants   of   diabetic   mothers are   at   increased   risk   for   the   oculo-auriculo-vertebral   sequence,   which   includes   preauricular   sinuses   ( Wang   R ).   Some   cases   of   preauricular   sinuses are   associated   with   some   congenital   facial   deformity   syndromes,   like   Treacher   Collins   syndrome,   branchio-oto-renal   (BOR)   syndrome   and   many other rare ones. Effects Preauricular   sinus   itself   does   not   directly   cause   or   lead   to   any   life-threatening   conditions.   In   a   lot   of patients,   it   remains   there   without   causing   symptoms   ( so   much   so   that   the   patients   themselves   and/or   the people around don't even realise it is there ! ) However,   in   a   fraction   of   patients,   there   is   significant   morbidity   associated   with   preauricular   sinus(es). This includes   recurrent   infection   at   the   site,   infection/inflammation   spreading   to   the   face   (facial   cellulitis)   and ulceration   with   subsequent   scarring.   Infection   may   also   take   the   form   of   chronic   intermittent   drainage   of pus-like   yellowish   material   from   the   opening.   It   may   discharge   for   a   few   weeks   before   it   subsides   to   recur again   some   time   later.   Draining   sinuses   are   usually   prone   to   infection.   This   may   lead   to   redness   over   the opening   and   sometimes   forming   painful   swelling   over   the   opening.   Some   may   resort   to   see   their   family physicians   or   their   ENT   doctors   where   antibiotics   prescription   is   usually   given   out.   Occasionally   the swelling   progresses   to   form   small   abscesses.   Large   abscesses   can   also   develop   as   a   result   of   local infection,   sometimes   requiring   surgical   drainage   of   the   abscess.   The   scarring   itself,   with   or   without surgical intervention, can be disfiguring in chronic or severe cases. What to do ? While   asymptomatic   ones   are   best   left   alone,   those   infected   ones   are   indicated   for   surgical   removal.   Once infection   has   occurred   (even   once!),   the   likelihood   of   subsequent   recurrent   acute   exacerbations   is   high. The best solution is to have the entire sinus tract surgically removed as the definitive treatment. Surgery   should   be   performed   once   any   infection   has   been   optimally   treated   with   antibiotics   and   the   inflammation has   had   time   to   subside.      Be   warned   that   an   actively   infected   during   the   definitive   surgery   may   have   a   higher tendency   of   recurrence.   One   should   suspect   incomplete   removal   of   the   sinus   tract   or   recurrence   if   discharge from   the   sinus   tract   opening   persists   or   recurs.   Most   recurrences   occur   early   within   the   first   few   months.     A   prior incomplete   attempt   to remove   the   tract   and/or   preceeding   surgical   drainage   for   any   abscess   as   a   result   of   the   local   infection   can   also make   the   subsequent   definitive   surgical   removal   of   the   sinus   tract   difficult   due   to   scarring   changes,   hence   the   higher   recurrence   rate   in   the   future.     Therefore early treatment of infected tract is advisable for better clinical outcome. The importance of a complete removal of the preauricular sinus tract cannot be overemphasized to prevent recurrence. References 1 . Scheinfeld   NS,   Silverberg   NB,   Weinberg   JM,   Nozad   V.   The   preauricular   sinus:   a   review   of   its   clinical   presentation,   treatment,   and associations. Pediatr Dermatol. May-Jun 2004;21(3):191-6. 2 . Wang   R,   Martinez-Frias   ML,   Graham   JM   Jr.   Infants   of   diabetic   mothers   are   at   increased   risk   for   the   oculo-auriculo-vertebral   sequence:   A case-based and case-control approach. J Pediatr. Nov 2002;141(5):611-7
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© Vincent Tan ENT The external ear canal Ear drum (normal) © Vincent Tan ENT (source of unlabelled diagram: Netter Atlas of Anatomy)  © Vincent Tan ENT The external ear canal (EAC) Ear drum (normal) ear pinna The normal external ear tragus external ear meatus © Vincent Tan ENT The normal ear cross section. Notice the outer skin of the EAC is thicker and has glands (red asterisk) while the inner part is thinner with no glands. The normal ear drum as seen on a microscope or endoscope *
How many times have you actually taken a closer look at other’s or even your own ear (medical term = ear pinna) ? Have you ever noticed small slits or pit(s) in front of the usual opening (medical term = external ear meatus ) to the canal  ?
(Mouse over to zoom in)
© Vincent Tan ENT
Left figure: Preauricular tag (red arrow). Right figure:  Preauricular cyst (blue arrow) © Vincent Tan ENT
So, answer = 2 preauricular sinuses
Preauricular sinus no.1
Just a mole on the skin
Preauricular sinus no.2
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D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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