Nasal septal abscess: Treatment, symptoms, advice

and help
About nasal septal abscess
Nasal septal abscess is a serious pus-forming, bacterial infection within the nasal septum. The nasal septum is a normal
tissue that runs through the middle of the nose separating both the nostrils. An abscess is a term used for pus-filled
pocket of localized infection.

Nasal septal abscess: Incidence, age and sex

The exact incidence of nasal septal abscess is not known; it is usually seen in individuals with nose trauma. It may
affect an individual at any age.

Signs and symptoms of nasal septal abscess: Diagnosis

An individual with nasal septal abscess generally gives a history of trauma or nasal surgery. Presence of an abscess
within nasal septum is manifested by increasing nasal blockage, pain and redness over nasal bridge or nasal tip. As the
nasal blockage progresses, it leads to difficulty in breathing. Fever, headache and malaise are also seen in an individual
with nasal septal abscess.
The condition can be diagnosed on basis of symptoms, physical examination and meticulous inspection of the nasal
cavity by a health care provider. Blood test usually reveals an elevated white blood cell count which signifies the
presence of bacterial infection. The pus sample (which may be taken during the surgical incision and drainage
procedure) may be cultured for establishing the presence of bacterial growth.

Causes and prevention of nasal septal abscess

The most common cause of nasal septal abscess is trauma to the nose which results in bleeding within the nasal
septum. The blood then pools within the nasal septum resulting in haematoma. This haematoma over a period of time
gets infected with bacteria eventually resulting in pus collection (abscess). The most common bacteria implicated in
such cases are Staphylococcus aureus. Other risk factors for development of nasal septal abscess include blood
clotting disorder like haemophilia, chronic sinusitis, dental infections and nasal surgery.
Adequate and timely management of any nasal trauma or chronic nasal infections may help in preventing the
development of nasal septal abscess.

Nasal septal abscess: Complications

The complications of nasal septal abscess include permanent damage of the nasal septum resulting in physical
deformity of nose.

Nasal septal abscess: Treatment

The main line of treatment for nasal septal abscess includes surgical management which involves incision of abscess
and subsequent drainage of the pus. Intravenous antibiotic medication is required before the advent of this minor
surgery. The antibiotic medication is then continued orally for an extended period of time, after the pus has been
surgically drained. In cases, where the nose has been physically deformed, reconstructive surgical repair may be
needed.

A peritonsillar abscess forms in the tissues of the throat next to one of the tonsils. An abscess is a
collection of pus that forms near an area of infected skin or other soft tissue.
The abscess can cause pain, swelling, and, if severe, blockage of the throat. If the throat is blocked,
swallowing, speaking, and even breathing become difficult.
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When an infection of the tonsils (known as tonsillitis) spreads and causes infection in the soft
tissues, a peritonsillar abscess may result.
Peritonsillar abscess is relatively common in adults but rare in infants and young children.
Causes of a Peritonsillar Abscess
A peritonsillar abscess is most often a complication of tonsillitis. The bacteria involved are similar to
those that cause strep throat.
Streptococcal bacteria most commonly cause an infection in the soft tissue around the tonsils (usually
just on one side). The tissue is then invaded by anaerobes (bacteria that can live without oxygen),
which enter through nearby glands.
Dental infection (such as the gum infections periodontitis and gingivitis) may be a risk factor. Other
risk factors include:

Chronic tonsillitis

Infectious mononucleosis

Smoking

Chronic lymphocytic leukemia (CLL)

Stones or calcium deposits in the tonsils (tonsilloliths)

Symptoms of a Peritonsillar Abscess

The first symptom of a peritonsillar abscess is usually a sore throat. A period without fever or other
symptoms may follow as the abscess develops. It is not unusual for a delay of 2 to 5 days between
the start of symptoms and abscess formation.

The mouth and throat may show a swollen area of inflammation -- typically on one side.

The uvula (the small finger of tissue that hangs down in the middle of the throat) may be
shoved away from the swollen side of the mouth.

Lymph glands in the neck may be enlarged and tender.

Other signs and symptoms may be observed:

Painful swallowing

Fever and chills

Spasm in the muscles of the jaw (trismus) and neck (torticollis)

Ear pain on the same side as the abscess

A muffled voice, often described as a "hot potato" voice (sounds as if you have a
mouthful of hot potato when you talk)
Difficulty swallowing saliva
When to Seek Medical Care for a Peritonsillar Abscess
Discuss any sore throat with fever or other symptoms with your doctor by phone or with an office visit
to see if you have a peritonsillar abscess.
If you have a sore throat and trouble swallowing, trouble breathing, difficulty speaking, drooling, or any
other signs of potential airway obstruction, you should seek emergency transportation to a hospital's
ER.
Exams and Tests for a Peritonsillar Abscess
A peritonsillar abscess is usually diagnosed based on history and a physical exam. A peritonsillar
abscess is easy to diagnose when it is large enough to see. The doctor will look into your mouth using
a light and, possibly, a tongue depressor. Swelling and redness on one side of the throat near the
tonsil suggests an abscess. The doctor may also gently push on the area with a gloved finger to see if
there is pus from infection inside.

Lab tests and X-rays are not used often. Sometimes an X-ray or an ultrasound will be
performed, typically to make sure other upper airway illnesses are not present. These conditions
may include the following:

Epiglottitis, an inflammation of the epiglottis (the flap of tissue that prevents food from
entering the windpipe)

Retropharyngeal abscess, a pocket of pus that forms beneath the soft tissue in the
back of the throat (like a peritonsillar abscess but in a different location)

Peritonsillar cellulitis, an infection of the soft tissue itself (a peritonsillar abscess forms
beneath the surface of the tissue)

Your doctor may test you for mononucleosis, a virus. Some experts suggest that mono is
associated with up to 20% of peritonsillar abscesses.

Your doctor also may send pus from the abscess to the lab so the exact bacteria can be
identified. Even so, identifying the bacteria rarely changes treatment.
Peritonsillar Abscess Treatment and Care at Home
There is no home treatment for peritonsillar abscess. Call your doctor for an immediate appointment
to check your symptoms.

Medical Treatment for a Peritonsillar Abscess

If you have a peritonsillar abscess, the doctor's primary concern will be your breathing and airway. If
your life is in danger because your throat is blocked, the first step may be to insert a needle in the pus
pocket and drain away enough fluid so you can breathe comfortably.
If your life is not in immediate danger, the doctor will make every effort to keep the procedure as
painless as possible. You will receive a local anesthetic (like at the dentist) injected into the skin over
the abscess and, if necessary, pain medicine and sedation through an IV inserted in your arm. The
doctor will use suction to help you avoid swallowing pus and blood.

The doctor has several options for treating you:

Needle aspiration involves slowly putting a needle into the abscess and withdrawing
the pus into a syringe.

Incision and drainage involves using a scalpel to make a small cut in the abscess so
pus can drain.

Acute tonsillectomy (having a surgeon remove your tonsils) may be needed if, for
some reason, you cannot tolerate a drainage procedure, or if you have a history of frequent tonsillitis.

You will receive an antibiotic. The first dose may be given through an IV. Penicillin is the best
drug for this type of infection, but if you are allergic, tell the doctor so another antibiotic can be used
(other choices may be erythromycin or clindamycin).

If you are healthy and the abscess drains well, you can go home. If you are very ill, cannot
swallow, or have complicating medical problems (such as diabetes), you may be admitted to the
hospital. Young children, who often need general anesthesia for drainage, frequently require a
hospital stay for observation.
Follow-Up for a Peritonsillar Abscess
Arrange follow-up with your doctor or an ear-nose-throat specialist (otolaryngologist) after treatment
for a peritonsillar abscess. Also:

If the abscess starts to return, you may need a different antibiotic or further drainage.
If you develop excessive bleeding or have trouble breathing or swallowing, seek medical
attention immediately.

Prevention of a Peritonsillar Abscess

There is no reliable method for preventing a peritonsillar abscess other than limiting risks: Do not
smoke, maintain good dental hygiene, and promptly treat oral infections.

If you develop a peritonsillar abscess, you may possibly prevent peritonsillar cellulitis by
taking an antibiotic. However, you should be closely monitored for abscess formation and may even
be hospitalized.

If you are likely to form an abscess (for example, if you have tonsillitis frequently), talk with
your doctor about whether you should have your tonsils removed.

As with any prescription, you must finish the full course of the antibiotic even if you feel better
after a few days.
Outlook for a Peritonsillar Abscess
People with an uncomplicated, well-treated peritonsillar abscess usually recover fully. If you don't
have chronic tonsillitis (in which your tonsils regularly become inflamed), the chance of the abscess
returning is only 10%, and removing your tonsils is usually not necessary.
Most complications occur in people with diabetes, in people whose immune systems are weakened
(such as those with AIDS, transplant recipients on immune-suppressing drugs, or cancer patients), or
in those who don't recognize the seriousness of the illness and do not seek medical attention.
Major complications of a peritonsillar abscess include:

Airway blockage

Bleeding from erosion of the abscess into a major blood vessel

Dehydration from difficulty swallowing

Infection in the tissues beneath the breastbone

Pneumonia

Meningitis

Sepsis (bacteria in the bloodstream)

ABSES PERITONSIL
Diposkan oleh Taufik Abidin
oleh: Taufik Abidin

PENDAHULUAN
Abses peritonsiler dapat terjadi pada umur 10-60 tahun, namun paling sering terjadi
pada umur 20-40 tahun. Pada anak-anak jarang terjadi kecuali pada mereka yang menurun
sistem immunnya, tapi infeksi bisa menyebabkan obstruksi jalan napas yang signifikan pada
anak-anak. Infeksi ini memiliki proporsi yang sama antara laki-laki dan perempuan. Bukti
menunjukkan bahwa tonsilitis kronik atau percobaan multipel penggunaan antibiotik oral
untuk tonsilitis akut merupakan predisposisi pada orang untuk berkembangnya abses
peritonsiler. Di Amerika insiden tersebut kadang-kadang berkisar 30 kasus per 100.000 orang
per tahun, dipertimbangkan hampir 45.000 kasus setiap tahun4.

Abses leher dalam terbentuk dalam ruang potensial diantara fasia leher dalam sebagai
akibat dari penjalaran infeksi dari berbagai sumber, seperti gigi, mulut, tenggorok, sinus
paranasal, telinga tengah dan leher tergantung ruang mana yang terlibat. Gejala dan tanda
klinik dapat berupa nyeri dan pembengkakan. Abses peritonsiler (Quinsy) merupakan salah
satu dari Abses leher dalam dimana selain itu abses leher dalam dapat juga abses retrofaring,
abses parafaring, abses submanidibula dan angina ludovici (Ludwig Angina) 3.
Abses peritonsiler adalah penyakit infeksi yang paling sering terjadi pada bagian
kepala dan leher. Gabungan dari bakteri aerobic dan anaerobic di daerah peritonsilar. Tempat
yang bisa berpotensi terjadinya abses adalah adalah didaerah pillar tonsil anteroposterior,
fossa piriform inferior, dan palatum superior4.
Abses peritonsil terbentuk oleh karena penyebaran organisme bakteri penginfeksi
tenggorokan kesalah satu ruangan aereolar yang longgar disekitar faring menyebabkan
pembentukan abses, dimana infeksi telah menembus kapsul tonsil tetapi tetap dalam batas
otot konstriktor faring5.
Peritonsillar abscess (PTA) merupakan kumpulan/timbunan (accumulation) pus (nanah) yang
terlokalisir/terbatas (localized) pada jaringan peritonsillar yang terbentuk sebagai hasil dari
suppurative tonsillitis.
ETIOLOGI
Abses peritonsil terjadi sebagai akibat komplikasi tonsilitis akut atau infeksi yang
bersumber dari kelenjar mucus Weber di kutub atas tonsil. Biasanya kuman penyebabnya
sama dengan kuman penyebab tonsilitis. Biasanya unilateral dan lebih sering pada anak-anak
yang lebih tua dan dewasa muda2.
Abses peritonsiler disebabkan oleh organisme yang bersifat aerob maupun yang
bersifat anaerob. Organisme aerob yang paling sering menyebabkan abses peritonsiler
adalah Streptococcus pyogenes(Group A Beta-hemolitik streptoccus), Staphylococcus aureus,
danHaemophilus
influenzae. Sedangkan
organisme
anaerob
yang
berperan
adalah Fusobacterium. Prevotella, Porphyromonas, Fusobacterium,dan Peptostreptococcus
spp. Untuk kebanyakan abses peritonsiler diduga disebabkan karena kombinasi antara
organisme aerobik dan anaerobik6.
PATOLOGI
Patofisiologi PTA belum diketahui sepenuhnya. Namun, teori yang paling banyak
diterima adalah kemajuan (progression) episode tonsillitis eksudatif pertama menjadi
peritonsillitis dan kemudian terjadi pembentukan abses yang sebenarnya (frank abscess
formation).
Daerah superior dan lateral fosa tonsilaris merupakan jaringan ikat longgar, oleh
karena itu infiltrasi supurasi ke ruang potensial peritonsil tersering menempati daerah ini,

sehingga tampak palatum mole membengkak. Abses peritonsil juga dapat terbentuk di bagian
inferior, namun jarang.
Pada stadium permulaan, (stadium infiltrat), selain pembengkakan tampak juga
permukaan yang hiperemis. Bila proses berlanjut, daerah tersebut lebih lunak dan berwarna
kekuning-kuningan. Tonsil terdorong ke tengah, depan, dan bawah, uvula bengkak dan
terdorong ke sisi kontra lateral.
Bila proses terus berlanjut, peradangan jaringan di sekitarnya akan menyebabkan
iritasi pada m.pterigoid interna, sehingga timbul trismus. Abses dapat pecah spontan,
sehingga dapat terjadi aspirasi ke paru.
Selain itu, PTA terbukti dapat timbul de novo tanpa ada riwayat tonsillitis kronis atau
berulang (recurrent) sebelumnya. PTA dapat juga merupakan suatu gambaran (presentation)
dari infeksi virus Epstein-Barr (yaitu: mononucleosis).
GEJALA KLINIS DAN DIAGNOSIS
Selain gejala dan tanda tonsilitis akut, terdapat juga odinofagia (nyeru menelan) yang
hebat, biasanya pada sisi yang sama juga dan nyeri telinga (otalgia), muntah (regurgitasi),
mulut berbau (foetor ex ore), banyak ludah (hipersalivasi), suara sengau (rinolalia), dan
kadang-kadang sukar membuka mulut (trismus), serta pembengkakan kelenjar submandibula
dengan nyeri tekan.
Bila ada nyeri di leher (neck pain) dan atau terbatasnya gerakan leher (limitation in
neck mobility), maka ini dikarenakan lymphadenopathy dan peradangan otot tengkuk
(cervical muscle inflammation)1.
Prosedur diagnosis dengan melakukan Aspirasi jarum (needle aspiration). Tempat
aspiration dibius / dianestesi menggunakan lidocaine dengan epinephrine dan jarum besar
(berukuran 1618) yang biasa menempel pada syringe berukuran 10cc. Aspirasi material
yang bernanah (purulent) merupakan tanda khas, dan material dapat dikirim untuk dibiakkan.

Pada penderita PTA perlu dilakukan pemeriksaan7:

1. Hitung darah lengkap (complete blood count), pengukuran kadar elektrolit (electrolyte
level measurement), dan kultur darah (blood cultures).
2. Tes Monospot (antibodi heterophile) perlu dilakukan pada pasien dengan tonsillitis
dan bilateral cervical lymphadenopathy. Jika hasilnya positif, penderita memerlukan
evaluasi/penilaian hepatosplenomegaly. Liver function tests perlu dilakukan pada
penderita dengan hepatomegaly.
3. Throat culture atau throat swab and culture: diperlukan untuk identifikasi
organisme yang infeksius. Hasilnya dapat digunakan untuk pemilihan antibiotik yang
tepat dan efektif, untuk mencegah timbulnya resistensi antibiotik.
4. Plain radiographs: pandangan jaringan lunak lateral (Lateral soft tissue views) dari
nasopharynx dan oropharynx dapat membantu dokter dalam menyingkirkan diagnosis
abses retropharyngeal.
5. Computerized tomography (CT scan): biasanya tampak kumpulan cairan hypodense
di apex tonsil yang terinfeksi (the affected tonsil), dengan peripheral rim
enhancement.
6. Ultrasound, contohnya: intraoral ultrasonography.
KOMPLIKASI
Komplikasi yang mungkin terjadi ialah2:
1. Abses pecah spontan, mengakibatkan perdarahanm aspirasi paru, atau piema.
2. Penjalaran infeksi dan abses ke daerah parafaring, sehingga terjadi abses parafaring.
Kemudian dapat terjadi penjalaran ke mediastinum menimbulkan mediastinitis.
3. Bila terjadi penjalaran ke daerah intracranial, dapat mengakibatkan thrombus sinus
kavernosus, meningitis, dan abses otak.
Sejumlah komplikasi klinis lainnya dapat terjadi jika diagnosis PTA diabaikan.
Beratnya komplikasi tergantung dari kecepatan progression penyakit. Untuk itulah diperlukan
penanganan dan intervensi sejak dini.
DIAGNOSIS BANDING
Infiltrat peritonsil, tumor, abses retrofaring, abses parafaring, aneurisma arteri karotis
interna, infeksi mastoid, mononucleosis, infeksi kelenjar liur, infeksi gigi, dan adenitis
tonsil2,8,9.
TERAPI
Pada stadium infiltrasi, diberikan antibiotika dosis tinggi dan obat simtomatik. Juga
perlu kumur-kumur dengan air hangat dan kompres dingin pada leher. Antibiotik yang
diberikan ialah penisilin 600.000-1.200.000 unit atau ampisilin/amoksisilin 3-4 x 250-500 mg
atau sefalosporin 3-4 x 250-500 mg, metronidazol 3-4 x 250-500 mg2.

Bila telah terbentuk abses, dilakukan pungsi pada daerah abses, kemudian diinsisi
untuk mengeluarkan nanah. Tempat insisi ialah di daerah yang paling menonjol dan lunak,
atau pada pertengahan garis yang menghubungkan dasar uvula dengan geraham atas terakhir.
Intraoral incision dan drainase dilakukan dengan mengiris mukosa overlying abses, biasanya
diletakkan di lipatan supratonsillar. Drainase atau aspirate yang sukses menyebabkan
perbaikan segera gejala-gejala pasien.
Bila terdapat trismus, maka untuk mengatasi nyeri, diberikan analgesia lokal di
ganglion sfenopalatum.
Kemudian pasien dinjurkan untuk operasi tonsilektomi a chaud. Bila tonsilektomi
dilakukan 3-4 hari setelah drainase abses disebut tonsilektomi a tiede, dan bila tonsilektomi
4-6 minggu sesudah drainase abses disebut tonsilektomi a froid. Pada umumnya
tonsilektomi dilakukan sesudah infeksi tenang, yaitu 2-3 minggu sesudah drainase abses2.
Tonsilektomi merupakan indikasi absolut pada orang yang menderita abses
peritonsilaris berulang atau abses yang meluas pada ruang jaringan sekitarnya. Abses
peritonsil mempunyai kecenderungan besar untuk kambuh. Sampai saat ini belum ada
kesepakatan kapan tonsilektomi dilakukan pada abses peritonsil. Sebagian penulis
menganjurkan tonsilektomi 68 minggu kemudian mengingat kemungkinan terjadi
perdarahan atau sepsis, sedangkan sebagian lagi menganjurkan tonsilektomi segera10.

Penggunaan steroids masih kontroversial. Penelitian terbaru yang dilakukan Ozbek

mengungkapkan bahwa penambahan dosis tunggal intravenous dexamethasone pada
antibiotik parenteral telah terbukti secara signifikan mengurangi waktu opname di rumah
sakit (hours hospitalized), nyeri tenggorokan (throat pain), demam, dan trismus dibandingkan
dengan kelompok yang hanya diberi antibiotik parenteral.
PROGNOSIS
Abses peritonsoler hampir selalu berulang bila tidak diikuti dengan tonsilektomi.,
maka difunda sampai 6 minggu berikutnya. Pada saat tersebut peradangan telah mereda,
biasanya terdapat jeringan fibrosa dan granulasi pada saat oprasi.
DAFTAR PUSTAKA
1. Adams, G.L. 1997. Penyakit-Penyakit Nasofaring Dan Orofaring. Dalam: Boies, Buku
Ajar Penyakit THT, hal.333. EGC,Jakarta.
2. Fachruddin, darnila. 2006. Abses Leher Dalam. Dalam: Buku Ajar Ilmu Kesehatan,
Telinga-Hidung-Tenggorokan, hal. 185. Balai Penerbit FKUI, Jakarta.

3. Soepardi,E.A, Iskandar, H.N, Abses Peritonsiler, Buku Ajar Ilmu Kesehatan Telinga,
Hidung dan Tenggorokan, Jakarta: FKUl, 2000; 185-89.
4. Mehta, Ninfa. MD. Peritonsillar Abscess. Available from. www.emedicine.com. Accessed
at Juli 2007.
5. Adrianto, Petrus. 1986. Penyakit Telinga, Hidung dan Tenggorokan, 296, 308-09.
EGC, Jakarta.
6. Bailey, Byron J, MD. Tonsillitis, Tonsillectomy, and Adenoidectomy. In : Head and Neck
Surgey-Otolaryngology 2nd Edition. Lippincott_Raven Publisher. Philadelphia. P :1224,
1233-34.
7. Anurogo,

Dito.

2008. Tips

Praktis

Mengenali

Abses

Peritonsil.

Accessed:

http://www.kabarindonesia.com/berita.php?pil=3&dn=20080125161248.
8. Preston,

M.

2008. Peritonsillar

Abscess

(Quinsy).

accessed:

http://www.patient.co.uk/showdoc/40000961/.
9. STEYER, T. E. 2002. Peritonsillar Abscess: Diagnosis and Treatment. accessed:
http://www.aafp.org/afp/20020101/93.html.
10. Hatmansjah. Tonsilektomi. Cermin Dunia Kedokteran Vol. 89, 1993. Fakultas
Kedokteran Universitas Indonesia, hal : 19-21.

Background
Preauricular cysts, pits (as shown below), fissures, and sinuses are benign congenital malformations
of the preauricular soft tissues first described by Van Heusinger in 1864. Preauricular pits or fissures
are located near the front of the ear and mark the entrance to a sinus tract that may travel under the
skin near the ear cartilage. These tracts are lined with squamous epithelium and may sequester to
produce epithelial-lined subcutaneous cysts or may become infected, leading to cellulitis or abscess.

Close-up image of preauricular pit. Image courtesy of Ed Porubsky, MD.

Preauricular tags, as shown below, are epithelial mounds or pedunculated skin that arise near the
front of the ear around the tragus. They have no bony, cartilaginous, or cystic components and do not
communicate to the ear canal or middle ear.

Preauricular ear tag. Image courtesy of Jack Yu, MD.

Simple preauricular cysts should not be confused with first branchial cleft cysts. Branchial cleft
anomalies are closely associated with the external auditory canal, tympanic membrane, angle of the
mandible, and/or facial nerve. Misinterpreting a first brachial abnormality for a simple sinus tract may
place the unsuspecting physician at risk for damaging the facial nerve, incompletely excising the
lesion, or both.
Patients identified with preauricular pits or cysts should be examined for other congenital anomalies.

Epidemiology
Frequency
Malformations of the external ear are not uncommon. Generally, they occur in 1 of every 12,500
births. Incidence of spontaneous formation of ear pits in the nonsyndromic population ranges from
0.3-0.9%.
These conditions affect males and females equally and have no race predilection.

Etiology
Embryology and branchial arch development
The auricle forms during the sixth week of gestation. The first and second branchial arches give rise
to a series of 6 mesenchymal proliferations known as the hillocks of His, which fuse to form the
definitive auricle. The first arch gives rise to the first 3 hillocks, which form the tragus, helical crus, and
the helix. The second arch gives rise to the second 3 hillocks, which form the antihelix, scapha, and
the lobule.
Defective or incomplete hillock fusion during auricular development is postulated as the source of the
preauricular sinus. Another theory suggests that localized folding of ectoderm during auricular
development is the cause of preauricular sinus formation. The first 3 hillocks are most often linked to
supernumerary hillocks, leading to preauricular tag formation.

Genetics
Correct sequential gene activation is required for normal ear and facial development. Interrupting the
gene activation sequence in laboratory animals disrupts ear development.
Genetic linkage analysis studies have suggested that congenital preauricular sinus localizes to
chromosome 8q11.1-q13.3.[1]
The inner neurological hearing apparatus, cochlea, and auditory nerve form in conjunction with the
outer ear structures during the early developmental stages. External deformities may be associated
with an inner neurological deformity and, hence, suggest a possible deafness.

Associated syndromes
Syndromic expression of pits, tags, and fissures occurs at much higher frequencies in certain
craniofacial dysmorphisms. Minor anomalies of the head and neck may aid the clinician in developing
a presumptive diagnosis during the initial examination. Additional ear anomalies include helical fold
abnormalities, asymmetry, posterior angulation, small size, absent tragus, and narrow external
auditory meatus. Some syndromes with characteristic ear anomalies are as follows:

Branchiootorenal syndrome (BOR) - Preauricular sinus

Beckwith-Wiedemann syndrome - Preauricular sinus with asymmetric earlobes
Mandibulofacial dysostosis - Auricular pits/fistulas
Oculoauriculovertebral dysplasia - Preauricular tags (see the image below)

Multiple tags in a child with oculoauriculovertebral dysplasia. Note the hemifacial

atrophy, retrognathia, and lower set ear. Image courtesy of Jack Yu, MD.

Chromosome arm 11q duplication syndrome - Preauricular tags or pits

Chromosome arm 4p deletion syndrome - Preauricular dimples or skin tags
Chromosome arm 5p deletion syndrome - Preauricular tags

Pathophysiology
Preauricular sinuses may be asymptomatic for life. An infection arises when the opening of the pit
seals bacteria within the sinus tract along with desquamated skin. Early signs and symptoms of
swelling, pain, and erythema should prompt the practitioner to begin antibiotic therapy directed at
common skin bacterial organisms. Surgical drainage may be indicated if there is recurrent drainage
from a preauricular pit,[2] obvious abscess formation occurs or swelling progresses despite antibiotic
therapy. Toxic-appearing and immunocompromised patients may require observation, intravenous
antibiotic therapy, and surgical drainage. Complete surgical removal is the treatment of choice for
recurrent infection and drainage problems.
Ear tags alone pose no threat to any structure and are usually merely a cosmetic deformity. They are
usually excised in young patients by qualified surgeons who treat head and neck
abnormalities. General anesthesia is typically required. Recurrence rates are low.
Smaller, narrowly based tags are tied at their bases with thread or suture in infants during office visits.
Simple excision at the base may be performed using topical EMLA cream. Larger, broad-based,
multiple, or complex tags may require elliptical excision and plastic closure, which requires general
anesthesia.

Presentation

Clinical presentation of various ear anomalies may be summarized as follows:

Noninfected pits - Pinpoint hole in front of the ear or above tragus, as shown below
Nondraining

Lacks swelling

Uninfected preauricular pit. Image courtesy

of Ed Porubsky, MD.

o
o
o
o
o
o
o

Infected pits - Cellulitis and abscess

Red, swollen
Draining purulent material
Granulation around pit
Tender
Previous surgical scar with underlying swelling
Cysts - Slowly enlarging preauricular mass
Usually nontender if uninfected
Associated pit usually adjacent to cyst, as shown below

Infected preauricular cyst with swelling and erythema toward the cartilage of
the ear.

o
o
o
o
o

Tags - Fleshy knobs of skin in front of the ear

Nontender
Nondraining
Color similar to surrounding skin
Appears to be attached on the surface of the cheek, pinna, tragus, or lobe
No rapid growth

Differential diagnoses

Preauricular swelling/infection
Parotid swelling/mass/tumor
First branchial cleft cyst
Duplication of ear canal
Trauma
Cellulitis from otitis externa
Trauma
Body piercing
Previous surgical site

Indications
Most patients with preauricular pits in the typical location are asymptomatic and require no surgical
intervention. Needle aspiration is indicated for abscess that fails to respond to antibiotics. Incision and
drainage complicates later excision and should be reserved for abscess that recurs after needle
aspiration.
Complete excision of the cyst or sinus tract may be undertaken in cases of recurrent infection.
Ear tags are removed for cosmetic reasons.

Relevant Anatomy
A preauricular pit may mark the entrance to a sinus tract, which can vary in length, follow a tortuous
course, and branch extensively. Preauricular sinuses and cysts have a component of close
association with the auricular perichondrium. For this reason, some argue that complete removal of a
sinus tract or cyst should also include a portion of the auricular perichondrium at the base of the
lesion.
Preauricular sinuses or cysts are found lateral and superior to the facial nerve and parotid gland,
whereas first branchial cleft malformations are found in close association with these structures, as
well as with the external auditory canal.
Excision of complex or broad-based tags requires the knowledge of relaxed skin lines and wound
tension in the region of the face and ear.

Contraindications
An infected cyst or tract may be considered a relative contraindication to excision of a sinus tract or
cyst. Antibiotics and, occasionally, steroids should be considered to control any residual inflammation
prior to surgery.