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Preauricular pits and sinuses are congenital nerve at risk, and incompletely excising
anomalies located in or just in front of the the sinus tract. See chapter: Resecting
ascending limb of the helix (Figure 1). branchial cysts, fistulae and sinuses.
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Histopathology field. The frontal branch of the facial nerve
crosses superficially over the zygomatic
Excised sinuses are lined by stratified arch and is at risk of injury only if the
squamous epithelium surrounded by con- surgeon strays anteriorly during the resec-
nective tissue with evidence of chronic in- tion.
flammation. The tract may be of variable
length, have a tortuous course, and exhibit
extensive branching.
Surgical anatomy
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Figure 9: Auricular cartilage superimpos- Figure 10: The temporalis fascia consti-
ed on the ear tutes the deep dissection plane; note the
superficial temporal fat pad anteriorly
Temporalis fascia (Figure 10)
probing the tract with a lacrimal probe, al-
The temporalis fascia forms the deepest though a lacrimal probe may cause a false
plane of the dissection. The frontal branch tract and cannot identify small branches.
of the facial nerve traverses the superficial
temporal fat pad some distance anteriorly The author uses neither technique and does
(Figure 10). not attempt to identify the actual sinus
tract.
Preoperative investigations
Steps taken to reduce recurrence include:
CT or MRI imaging is not indicated unless
a sinus is atypically located, or a branchial • Operate under optimal conditions
cleft remnant is suspected. o Wait for infection to settle
o General anaesthesia without muscle
Surgical principles paralysis (to detect stimulation of
facial nerve)
Recurrence rates following simple sinusec- • Completely excise the sinus tract with
tomy (elliptical incision around sinus and the surrounding tissue
dissection of tract in subcutaneous tissues) o Wide exposure: supra-auricular ex-
of up to 40% have been reported. tension of preauricular incision
o Do not attempt to identify and ex-
Some advocate injecting methylene blue cise only the sinus tract, but widely
into the cyst or sinus but dye often conta-
minates the surgical field. Others favour
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resect all the subcutaneous tissue
between temporalis fascia and helix
o Posterior boundary: auricular carti-
lage
o Anteromedial boundary: parotid
fascia
o Deep boundary: temporalis fascia
o Excise neighbouring perichondrium
and/or cartilage of the helix
Surgical steps
Figure 14: Slither of helical cartilage Figure 16: Surgical defect following exci-
being excised at apex of sinus tract sion of slither of cartilage at the apex of
preauricular sinus
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The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
johannes.fagan@uct.ac.za is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
S ST C License
References