Abstract
Objectives
We performed this study to introduce our minimal supra-auricular approach for the surgical management of a preauricular sinus (PAS) and to evaluate the advantages of this drainless technique.
Study design
This was a retrospective study.
Setting
The study was done in a tertiary referral center.
Methods
We enrolled 94 patients (101 ears) with a PAS who underwent surgical treatment via a minimal supra-auricular approach performed by one surgeon between April 1999 and May 2010. After removing the specimen, meticulous subcutaneous suturing and no drain were used in 83 patients (89 ears) and a postoperative drain was inserted in 11 patients (12 ears). Surgical outcomes of this technique were compared between the groups with and without postoperative drain insertion.
Results
With a good surgical view and meticulous subcutaneous mattress sutures in our minimal supra-auricular approach for PAS excision, there was no postoperative recurrence or other serious complication. In the drain group, previous operation history was more frequent ( P = .010), and the rate of preoperative infection was higher than in the drainless group ( P = .018). Postoperatively, a compression dressing was required more frequently ( P = .002) and for longer in the drain group ( P = .001). The rate of immediate postoperative wound infection was higher in the drain group ( P = .003).
Conclusion
Our drainless minimal supra-auricular approach for the surgical removal of a PAS has advantage in terms of good surgical results of no recurrence and is more comfortable for patients because of the reduced need for a compression dressing. We suggest that this technique is effective and safe for PAS excision.
1
Introduction
The preauricular sinus (PAS) is a benign congenital lesion of the preauricular soft tissues. It is a common clinical malformation, and the diagnosis is usually simple. The treatment of a PAS is also simple. If the PAS becomes symptomatic, surgical excision is necessary. However, using the standard sinusectomy technique for PAS, the recurrence rate of PAS is as high as 42% .
In 1990, Prasad et al first reported a supra-auricular approach for PAS removal, which had a lower recurrence rate of 5%. In 2001, Lam et al reported that the standard technique and supra-auricular approach had recurrence rates of 32% and 3.7%, respectively. However, the classical supra-auricular approach may lead to a relatively large dead space after resecting the PAS, requiring postoperative drain insertion and a compression dressing.
Thus, we designed a modified approach to minimize the incision, called the minimal supra-auricular approach , for PAS removal, to produce a minimum dead space and a good surgical view, and to eliminate the need for a postoperative drain. In this study, we evaluated the results of this surgical technique.
2
Materials and methods
2.1
Patients
We enrolled 94 patients (101 ears) who presented with a symptomatic PAS and underwent surgical treatment via the minimal supra-auricular approach performed by the same surgeon between April 1999 and May 2010. The medical and operative records were reviewed. The SPSS software (version 15; SPSS, Chicago, IL) was used for all statistical analyses. The recurrence rate, pre- and postoperative infection rates, duration of the compression dressing, preoperative incision and drainage history, and number of internal pits or branches of the PAS were analyzed statistically using the χ 2 and Mann-Whitney U tests. P < .05 was deemed to indicate statistical significance.
This study was approved by the institutional review board of Seoul St Mary’s Hospital (KC11RISE0244).
2.2
Surgical techniques
Patients afraid of the procedure (n = 30, 34 ears) and children younger than 7 years (n = 18, 20 ears) underwent the surgery under general anesthesia. The other patients (n = 46, 47 ears) underwent the surgery under local anesthesia. An elliptical incision was made around the sinus orifice and extended upward to the supra-auricular area by 5 to 7 mm. Methylene blue was instilled into orifice to mark the branches of the sinus tract. After making the skin incision, the dissection was continued along the sinus tract and superficial to the temporalis fascia medially and to the perichondrium of the anterior helical cartilage posteriorly. The sinus tract and surrounding subcutaneous tissues were excised completely with direct vision of the dye-stained sinus tissue, and a small portion of the anterior helical cartilage that was nearly attached to sinus tract was also removed using a cold knife. After removing the sinus tract, we opened the tract along its longitudinal axis and confirmed the presence of a complete blind pouch of the sinus by inserting a lacrimal probe into each branch or pit of the sinus tract, the so-called blind sac confirmation procedure. If there was an opening in the sinus tract, we reexplored the original site in the operative field and removed more soft tissue. However, most of the sinuses in this study were excised completely initially, without leaving any remnant tissue, as evaluated by dye staining and the blind sac confirmation procedure. The wound bed was irrigated profusely with warm saline, and hemostasis was achieved using bipolar cautery. In the drainless group, the wound was closed with meticulous absorbable subcutaneous sutures in an inferior-to-superior direction, which better ensured complete removal of the dead space. For tight wound closure, a mattress suture technique involving the subcutaneous tissue, fascia of temporalis muscle, and subcutaneous tissue was used. A simple wound dressing was applied to the drainless group in most cases ( Fig. 1 ). In 8 cases of preoperative infection that were unable to be controlled within 2 to 3 weeks of antibiotics and local treatment, we performed the same procedure. In drainless group, patients who had very big PASs or active wound inflammation and granulation tissue required a compression dressing. In the drain group, a Penrose drain was inserted in the wound, and a compression dressing using an elastic bandage was applied until the drain remained.
2
Materials and methods
2.1
Patients
We enrolled 94 patients (101 ears) who presented with a symptomatic PAS and underwent surgical treatment via the minimal supra-auricular approach performed by the same surgeon between April 1999 and May 2010. The medical and operative records were reviewed. The SPSS software (version 15; SPSS, Chicago, IL) was used for all statistical analyses. The recurrence rate, pre- and postoperative infection rates, duration of the compression dressing, preoperative incision and drainage history, and number of internal pits or branches of the PAS were analyzed statistically using the χ 2 and Mann-Whitney U tests. P < .05 was deemed to indicate statistical significance.
This study was approved by the institutional review board of Seoul St Mary’s Hospital (KC11RISE0244).
2.2
Surgical techniques
Patients afraid of the procedure (n = 30, 34 ears) and children younger than 7 years (n = 18, 20 ears) underwent the surgery under general anesthesia. The other patients (n = 46, 47 ears) underwent the surgery under local anesthesia. An elliptical incision was made around the sinus orifice and extended upward to the supra-auricular area by 5 to 7 mm. Methylene blue was instilled into orifice to mark the branches of the sinus tract. After making the skin incision, the dissection was continued along the sinus tract and superficial to the temporalis fascia medially and to the perichondrium of the anterior helical cartilage posteriorly. The sinus tract and surrounding subcutaneous tissues were excised completely with direct vision of the dye-stained sinus tissue, and a small portion of the anterior helical cartilage that was nearly attached to sinus tract was also removed using a cold knife. After removing the sinus tract, we opened the tract along its longitudinal axis and confirmed the presence of a complete blind pouch of the sinus by inserting a lacrimal probe into each branch or pit of the sinus tract, the so-called blind sac confirmation procedure. If there was an opening in the sinus tract, we reexplored the original site in the operative field and removed more soft tissue. However, most of the sinuses in this study were excised completely initially, without leaving any remnant tissue, as evaluated by dye staining and the blind sac confirmation procedure. The wound bed was irrigated profusely with warm saline, and hemostasis was achieved using bipolar cautery. In the drainless group, the wound was closed with meticulous absorbable subcutaneous sutures in an inferior-to-superior direction, which better ensured complete removal of the dead space. For tight wound closure, a mattress suture technique involving the subcutaneous tissue, fascia of temporalis muscle, and subcutaneous tissue was used. A simple wound dressing was applied to the drainless group in most cases ( Fig. 1 ). In 8 cases of preoperative infection that were unable to be controlled within 2 to 3 weeks of antibiotics and local treatment, we performed the same procedure. In drainless group, patients who had very big PASs or active wound inflammation and granulation tissue required a compression dressing. In the drain group, a Penrose drain was inserted in the wound, and a compression dressing using an elastic bandage was applied until the drain remained.
