Management of Recurrent Congenital Preauricular Fistula: A Case Report

Congenital preauricular fistula is a malformation of the six auditory hillocks during the development of the auricle when an imperfect fusion of the first arch tuberculum to other tuberculums occurs and generates a tract. The difficulty in the surgical treatment for preauricular fistulas is the high recurrence rate. Surgical techniques were developed and modified to reduce the recurrence rate. This study aimed to describe a recurrent preauricular fistula and its treatment. A 7-year-old patient came to the otorhinolaryngology clinic with complaints of recurrent swelling and discharge on the left preauricular region. Initially, there was only a small hole at the base of the left ear since birth. A thick white discharge appeared and disappeared for 3 months. The lesion was itchy, and the patient frequently scratched it so that the area around the hole became red, swollen, and painful. The patient had undergone surgery for the same complaint in 2016 with a simple fistulectomy. Oral antibiotics were given and planned for fistulectomy under general anesthesia. Evaluation until 3 months postoperatively showed good surgical wounds and non-recurrent infections. In conclusion, the supra-auricula approach had a significantly lower recurrence rate than the sinusectomy approach, and was recommended to make it the standard primary procedure for preauricular sinus excision besides its use in recurrent cases.


Introduction
Congenital preauricular sinus is a common congenital malformation of the preauricular soft tissue. This fistula is an incomplete autosomal dominant hereditary disorder that is often found in groups of children as a result of fuse and closure failure from the bulges (hillocks) in the first and second branchial arches, which normally form the auricle during 6 weeks of gestation. The fistula is frequently found on lateral surfaces of the helical arcus and posterosuperior edge of the helix, tragus, or lobule. [1][2][3] The incidence of preauricular fistula in Indonesia is also quite large. A study mentioned the incidence of cases in 7 years as many as 30 cases of preauricular fistula. 4 From several studies, it was reported that bilateral lesions were found in 25%-50% of cases, and unilateral lesions were > 50%. [5][6][7] Preauricular fistula is a common case in children. Usually, the abnormality is discovered during a physical examination or after a complication so that the patient comes for treatment.
Diagnosis of a preauricular fistula can be confirmed by finding a fistula orifice around the ear that is present from birth. Surgical techniques with a supra-auricular incision approach to expand the operating field and excision of part of the exposed helical cartilage can

A B S T R A C T
Congenital preauricular fistula is a malformation of the six auditory hillocks during the development of the auricle when an imperfect fusion of the first arch tuberculum to other tuberculums occurs and generates a tract. The difficulty in the surgical treatment for preauricular fistulas is the high recurrence rate. Surgical techniques were developed and modified to reduce the recurrence rate. This study aimed to describe a recurrent preauricular fistula and its treatment. A 7-year-old patient came to the otorhinolaryngology clinic with complaints of recurrent swelling and discharge on the left preauricular region. Initially, there was only a small hole at the base of the left ear since birth. A thick white discharge appeared and disappeared for 3 months. The lesion was itchy, and the patient frequently scratched it so that the area around the hole became red, swollen, and painful. The patient had undergone surgery for the same complaint in 2016 with a simple fistulectomy. Oral antibiotics were given and plan ned for fistulectomy under general anesthesia. Evaluation until 3 months postoperatively showed good surgical wounds and non-recurrent infections.
In conclusion, the supra-auricula approach had a significantly lower recurrence rate than the sinusectomy approach, and was recommended to make it the standard primary procedure for preauricular sinus excision besides its use in recurrent cases.

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aspiration when there is an abscess. Patients usually come with obstruction and infection of the fistula orifice. If there are no complaints, surgery is not necessary. 8,9 Complete fistula removal should be done when there are recurrent abscesses and chronic secretion because it will cause a recurrence of infection. The recurrence rate in patients with the standard technique was 32%, while the supraauricular approach was only 3.7%. 4,5 This study aimed to describe how to properly diagnose and manage recurrence cases of preauricular fistula.

Discussion
The preauricular fistula is usually found in children. Abnormalities are usually discovered during physical examination or when they seek health care Other studies have recommended using methylene blue or gentle probing to accurately delineate the tract.
However, this approach did not guarantee complete tract removal. The reported recurrence was quite high, about 20%. [8][9][10] In in a simple fistulectomy group. [11][12][13][14] Patient with infected preauricular fistula was given antibiotics first until the infection was relieved, then followed by fistulectomy surgery. The surgical technique was a supra-auricular approach incision, using methylene blue to trace the tract from the fistula so that it could be completely excised. Part of the helical cartilage was excised to prevent a recurrence.
The supra-auricular approach had a significantly lower recurrence rate than tract fistulectomy approaches. Thus, it is a good option as a standard procedure for preauricular fistula excision. 13-17

Conclusion
Supra-auricula approach had a significantly lower recurrence rate than the sinusectomy approach and was recommended to make it the standard primary procedure for preauricular sinus excision besides its use in recurrent cases.