Preauricular Pits

What are preauricular pits?

Preauricular pits are also known as preauricular cysts, fissures, or sinuses. A pit is essentially a sinus tract traveling under the skin that doesn’t belong there; it’s marked by a tiny opening to the tract, right in front of the ear and above the ear canal. In atypical cases, the opening appears below the ear canal, closer to the lobe.

A pit’s tract running underneath the skin can be either short or long and convoluted, with extensive branching. It’s more common for only one ear to have a preauricular pit.

Preauricular pits are congenital, meaning children are born with this malformation when ear development goes awry early in gestation. However, the malformation is not associated with hearing impairments, and only rarely associated with a genetic syndrome involving other problems. A baby born with a preauricular pit will be examined for other abnormalities to rule out these syndromes.

The main problem with preauricular pits, if they appear in an otherwise healthy child, is that they can lead to benign cysts or infections, including small pus-filled masses known as abscesses. When a child gets repeat infections, a surgeon may recommend complete removal of the pit. Otherwise, if the pit poses no chronic problems, it may be left alone.

Preauricular pits are different from preauricular tags, which are fleshy knobs of skin in front of the ears without an attached sinus tract. Tags pose only a cosmetic problem and not a risk of infection like pits do.   

On the other hand, preauricular pits are less serious than—and must be differentiated from – a branchial cleft cyst. A branchial cleft cyst, which may appear as a small opening, skin tag, or dimpling on the side of the neck can become infected and drain fluid.  All such malformations of the outer ear, when taken together, occur in less than 1 percent of otherwise healthy babies. They are considered a common congenital defect, even if the occurrence rate sounds low. Boys and girls are equally affected by outer ear malformations. And although these malformations don’t necessarily run in the family, when both ears are affected, a family history is more likely.

Causes

The visible part of the ear is called the auricle. It forms during the sixth week of gestation. When auricular development encounters fusion problems, a preauricular pit forms.

Signs and symptoms

Children with a preauricular pit don’t always have the same set of symptoms. Some also have a syndrome associated with their pit. The most common symptoms of a pit by itself and in conjunction with a syndrome include:

  • A visible tiny opening in front of one or both ears.
  • An opening that appears as more of a dimpling.
  • Swelling, pain, fever, redness or pus in and around the pit, signaling an infection, such as cellulitis or an abscess.
  • A slow-growing painless lump right next to the opening, signaling a cyst. A cyst also raises the risk of infection.

Associated syndromes

  • Asymmetric earlobes and an abnormally large tongue in addition to pits in front of the ears can be a sign of Beckwith-Wiedemann syndrome. This syndrome is associated with abdominal abnormalities and kidney and liver cancers. 
  • Holes or pits in the side of the neck, pits and/or tags in front of the ear, hearing loss, and kidney abnormalities can all be a sign of branchio-oto-renal syndrome.

Testing and diagnosis

A preauricular pit may go unnoticed at birth. Whether you or your primary care provider first notices the tiny hole, the next step is to see an otolaryngologist. An otolaryngologist can perform the proper evaluation of the pit and any associated risks. During the course of the evaluation, the otolaryngologist may:

  • Rule out various genetic syndromes that cause abnormalities of the face and head; some syndromes cause more severe abnormalities with the ear, including folded or asymmetrical ears, and hearing loss as well. Sometimes, these additional abnormalities can be very mild and hardly noticeable, but a specialist’s careful eye can recognize them.
  • Examine your child’s pits and look for signs of cysts or infection.
  • Perform imaging, such as a CT scan or MRI with contrast, in cases where the pit is in an atypical location, such as below the external auditory canal (closer to the lobe); this can be signaled by frequent swelling. Imaging is also generally recommended when pits appear with other outer-ear abnormalities.
  • Perform imaging to help the doctor differentiate cysts and abscesses
  • Perform an ultrasound of the kidneys if your child has preauricular pits and a branchial cleft cyst, to rule out branchio-oto-renal syndrome
  • Perform an audiogram if the pits are associated with other outer-ear deformities. Pits by themselves don’t usually require a hearing test. In addition, most newborns in the U.S. undergo auditory screening at birth. Confirmation of normal hearing is recommended for children with ear deformities in addition to pits.
  • Refer your child to appropriate specialists if he has organ system abnormalities or other syndromic features.

Treatment

An otolaryngologist is the best type of specialist to recommend and perform treatment for a preauricular pit since treatment can vary according to a complex set of factors. In addition, if the sinus tract ultimately requires surgical removal, the tract might be lengthy and convoluted and best left to the most experienced hands. Possible treatment approaches include:

  • Leaving a pit alone if it doesn’t become infected.
  • Prescribing your child oral antibiotics if the pit shows the earliest signs of infection, including redness and swelling.
  • Performing needle aspiration on a difficult infection known as an abscess, if it fails to respond to antibiotics. The doctor may “culture,” or examine, the bacteria extracted from the pus.
  • Performing incision and drainage if the abscess fails to respond to needle aspiration.
  • Surgically removing the entire tract if the pit is prone to recurrent infections. The procedure is done under general anesthesia and may take up to an hour; it can be done in an outpatient facility. A surgeon will usually postpone surgery until after an infection and residual inflammation are cleared up. Pits behind the external auditory canal require two incisions to remove the tract completely.

Outlook

A child with a preauricular pit by itself is usually otherwise healthy. Often, people hardly notice a pit or, if it’s close enough to the ear, may mistake it for an ear piercing. A pit can be left alone unless it poses a risk of recurrent infection or cysts. In that case, surgery can successfully remove the entire pit and your child will have no further problems associated with it.

Follow-up care

If your child has been treated for an infection in his preauricular pit, he will be followed closely. Repeat infections will require surgery.

If your child does have surgery to remove his pit, he can usually go to an outpatient facility for this procedure and be sent home the same day. The doctor and nurse will recommend wound care for the bandaged area, prescribe antibiotics, and schedule a follow-up appointment. Sutures will dissolve on their own. Your child will need to keep his head elevated at night for about a week and avoid showering until the bandage is removed. He can usually return to school within the week but will have to avoid strenuous activity for several weeks.

Why choose CHOP

Because a preauricular pit can pose a risk of serious infection or may be associated with other abnormalities, it’s important for your child to be in the hands of a highly experienced specialist. Proper treatment of an infected pit is crucial not only to eliminate the infection but to avoid damaging the pit in case surgery is needed later. In addition, the surgery itself requires highly specialized training and experience to remove the complete tract, which often has extensive and deep branching. The otolaryngology team at CHOP has the expert training and experience to properly diagnose, manage, and treat a preauricular pit.