Do you have ear pits or sinuses or know someone who does? Do you want to learn about ear pits or sinuses?

We know that information on the topic can be challenging to find and we would like to help.

This blog post was written by an ear, nose and throat surgeon.

As part of the background for this blog post, we also searched the internet for frequently asked questions and answered them.

The goal of the blog post is to educate you about ear pits and sinuses and also to provide information as well as provide helpful illustrations.

Preauricular pit not infected. CamachoMD
Preauricular pit not infected.

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What is an ear (auricular or preauricular) pit or sinus?

Van Heusinger described ear pits or sinuses in 1864.[1, 2]

The ear pits or sinuses are tracts and can be either just under the skin, or the tracts can extend under the skin for a distance or extend into deeper tissues.

Preauricular pit not infected with an arrow pointing to the pit. CamachoMD
Preauricular pit not infected with an arrow pointing to the pit.

Sometimes these pits can become infected and in a severe infection, an abscess (pus pocket) can form.

When an infection spreads, it can form smaller tracts that extend with finger-like projections.

How common are ear pits or sinuses?

Ear pits or sinuses are present at birth in small percentage of the population as follows:

  • About 1% of the population in the US, Hungary and England[3],
  • About 2.5% in Chinese newborns[4], and
  • About 9.3% in a Nigerian population sample.[5]

What causes ear pits or sinuses?

Around the sixth week of development, when a fetus is forming their ears, there are structures known as the first and second branchial arches that contribute to the ear formation.

An embryo showing the development of the head and neck structures. CamachoMD
An embryo showing the development of the head and neck structures.
The head of a developing embryo. CamachoMD
The head of a developing embryo.

The first branchial arch is comprised of the first 3 Hillocks of His:

  • #1: tragus,
  • #2: root of the helix, and
  • #3: helix.

The second branchial arch is comprised of the second 3 Hillocks of His:

  • #4: antihelix,
  • #5: antitragus, and
  • #6: the lobule.
Embryo with the Hillocks of His shown in the different colors. CamachoMD
Embryo with the Hillocks of His shown in the different colors. First branchial arch: red (1st Hillock), orange (2nd Hillock), and yellow (3rd Hillock). Second branchial arch: green (4th Hillock), blue (5th Hillock), and purple (6th Hillock).

If there is incomplete closure of the ear during the development, then an ear pit or sinus can form.

Hillocks of His labeled on an adult ear. First branchial arch: red (1st Hillock), orange (2nd Hillock), and yellow (3rd Hillock). Second branchial arch: green (4th Hillock), blue (5th Hillock), and purple (6th Hillock). CamachoMD
Hillocks of His labeled on an adult ear. First branchial arch: red (1st Hillock), orange (2nd Hillock), and yellow (3rd Hillock). Second branchial arch: green (4th Hillock), blue (5th Hillock), and purple (6th Hillock).

What are the locations that ear pits or sinuses can be found?

Dr. Ian Aird[2] described the following locations for ear pits:

  • Preauricular,
  • Anterior (marginal) helix,
  • Crural,
  • Posterior helix,
  • Helico-lobular,
  • Central lobular,
  • Postauricular,
  • Inferior triangular fossa,
  • Concha, and
  • Anti-tragus.
Labelling for possible preauricular pit locations. CamachoMD
Labelling for possible preauricular pit locations.

When ear pit or sinuses are infected, what are the treatment options?

If the infection is mild and there is not an abscess yet, then oral antibiotics are typically prescribed.

Preauricular pit with redness at the start of a infection CamachoMD
Preauricular pit with redness at the start of a infection.

If the infection progresses or is already an abscess (has pus and is a more severe infection), then the surgeon will either drain the infection with a needle aspiration or with an incision and drainage depending on the size and severity of the infection.

Preauricular pit infected with abscess below the skin
Preauricular pit infected with abscess below the skin.

The treatment of an acute infection is different from the more definitive treatment, which is to remove the pit and tract.

Generally, surgeons will allow several weeks for an acute infection to clear before performing the more definitive treatment which is to cut out the pit and tract.

How are ear pits or sinuses removed?

Once the infection has cleared for several weeks, the surgeon might then remove ear pit or sinus with the tract.

Incision site for preauricular pit removal, the incision site is outlined in blue. CamachoMD
Incision site for preauricular pit removal, the incision site is outlined in blue.
Incisions have been made on the preauricular pit to remove it. CamachoMD
Incisions have been made on the preauricular pit to remove it.
Preauricular pit being removed. CamachoMD
Preauricular pit being removed.
Preauricular pit incision site closed with sutures (shown in blue). CamachoMD
Preauricular pit incision site closed with sutures (shown in blue).
Preauricular pit incision wound healing after removal of the sutures. CamachoMD
Preauricular pit incision wound healing after removal of the sutures.

Dr. Leopardi and colleagues reviewed the literature and found that the technique described by Dr. Prasad and colleagues combines an easier to perform technique and has a lower risk of recurrence.

Dr. Prasad and colleagues describe a technique in which the incision is made around the ear pit and is carried behind the ear.[6] The temporalis muscle fascia behind the ear is identified, and the tissue superficial to that is removed and lastly a portion of the covering of the ear cartilage is removed and the wound is closed.[6]

One group of surgeons has evaluated a technique that minimizes the size of the skin incision and has reported good outcomes.[7]

Do ear pits or sinuses recur after removal?

There have been differences in recurrence based on technique:

  • 0.9% for removal with microscope guidance[8],
  • 3.7% with the use of a supra-auricular approach[9],
  • 4.3% for methylene blue dye and probe guidance[8], and
  • 32% for simple excision of the sinus[9].

Does someone with an ear pit or sinus need to have it removed if it has never been infected or caused problems?

Generally speaking, many surgeons will recommend not removing an asymptomatic ear pit or sinus.

There are risks to removing an ear pit, such as the risks of anesthesia, bleeding, infection and scar tissue formation.

There is a group of surgeons, however, recommends the excision of asymptomatic congenital ear sinus tracts.[1]

Preauricular pit not infected with an arrow pointing to the pit. CamachoMD
Preauricular pit not infected with an arrow pointing to the pit.

Do all children with ear pits or sinuses need to be examined for kidney abnormalities or hearing impairment?

A study evaluating nearly 14,000 children being seen for routine health checks found 35 children with ear pits and sinuses and found only one patient with kidney abnormalities and one patient with hearing impairment.[10]

The study authors stated they believed it is not necessary to investigate further unless there is an association with a syndrome or there is a family history of kidney abnormalities or hearing impairment.[10]

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.         Chami, R.G. and J. Apesos, Treatment of asymptomatic preauricular sinuses: challenging conventional wisdom. Ann Plast Surg, 1989. 23(5): p. 406-11.

2.         Aird, I., Ear-pit (congenital aural and preauricular fistula). Edinburgh medical journal, 1946. 53(9): p. 498-507.

3.         Tan, T., H. Constantinides, and T.E. Mitchell, The preauricular sinus: A review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol, 2005. 69(11): p. 1469-74.

4.         Tsai, F.J. and C.H. Tsai, Birthmarks and congenital skin lesions in Chinese newborns. J Formos Med Assoc, 1993. 92(9): p. 838-41.

5.         Jimoh, O., Alabi BS, Adebayo SS, Prevalence of Preauricular Sinus among Nigerians. Surgery Journal, 2008. 3: p. 61-63.

6.         Prasad, S., K. Grundfast, and G. Milmoe, Management of congenital preauricular pit and sinus tract in children. Laryngoscope, 1990. 100(3): p. 320-1.

7.         Lee, K.H., et al., Minimization of skin incision at preauricular sinusectomy using a trans pit approach. Int J Pediatr Otorhinolaryngol, 2020. 132: p. 109903.

8.         Gan, E.C., et al., Preauricular sinuses in the pediatric population: techniques and recurrence rates. Int J Pediatr Otorhinolaryngol, 2013. 77(3): p. 372-8.

9.         Lam, H.C., et al., Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope, 2001. 111(2): p. 317-9.

10.       Firat, Y., et al., Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment? Eur Arch Otorhinolaryngol, 2008. 265(9): p. 1057-60.