Preauricular Sinus (Pit)
A preauricular sinus, sometimes called a preauricular pit or simply an ear pit, is a small opening in the skin just in front of the ear. Most people who have one were born with it. Many never have any problem from it at all. A smaller number develop recurrent infections, and it is usually those patients who eventually come to consider surgery.
I see patients of all ages with preauricular sinuses in my NHS and private practice in Oxford. The most common reason for referral is recurrent infection, but I also see patients seeking advice on whether surgery is the right option for them. This page covers what a preauricular sinus actually is, when it does and doesn't need treating, and what the surgery involves.
What is a preauricular sinus?
A preauricular sinus is a small opening on the skin in front of the ear, almost always at the upper edge where the helix (the curved outer rim of the ear) meets the face. It is the visible end of a small tract or channel that runs beneath the skin towards the cartilage of the ear. The tract can be short and simple, or longer and branched.
Preauricular sinuses develop before birth, during the formation of the outer ear in the womb. They arise when two parts of the developing ear fail to fuse together completely, leaving behind a small lined channel that opens onto the skin. Once formed, the sinus is permanent.
The opening itself is often very small and easy to miss, and patients sometimes only become aware of it once it starts to cause trouble. Many parents notice it shortly after birth; others only see it years later. Around one in three to one in two cases are on both sides.
Preauricular sinuses are reasonably common. In UK and European populations, they affect roughly 1 in 100 to 1 in 1,000 people, with higher prevalence in some Asian and African populations.
Very rarely, a preauricular sinus can be associated with other underlying conditions affecting the ear or kidneys (such as branchio-oto-renal syndrome). In adults presenting for the first time with a preauricular sinus, these associated conditions, if present, will almost always already have been identified earlier in life.
What problems can they cause?
In most people, a preauricular sinus causes no symptoms at all and may never need any treatment. It just sits there as a small dimple in the skin, sometimes with a tiny amount of clear or slightly cloudy fluid that occasionally appears at the opening.
In a smaller number of people, the sinus becomes infected. Because the tract is a blind-ended channel lined with skin, debris and bacteria can accumulate within it and trigger inflammation. When this happens, the typical features are:
Redness and swelling around the opening of the sinus
Discomfort or pain
Discharge of pus from the opening, sometimes with a smell
Occasionally a more substantial swelling (an abscess) that needs to be drained
An early infection often settles with a course of antibiotics. If the infection doesn't settle on antibiotics alone, or if a pocket of pus (an abscess) has formed, it needs to be drained. This is usually done either with a fine needle to aspirate the pus, or by making a small incision in the skin to let it out, depending on the size and position of the collection. Drainage usually relieves the symptoms quickly and is done in clinic. Many people have only one episode of infection in their lifetime. The reason this matters for management is that once the sinus has been infected once, the chance of it happening again is higher, and patients who go on to develop recurrent infections are the group for whom surgical removal is usually recommended.
When does it need treating?
The honest answer is: only when it is genuinely causing trouble.
A preauricular sinus that has never been infected and is not causing any symptoms does not need to be removed. Operating on a problem that isn't currently a problem doesn't usually make sense, and the cosmetic appearance of the sinus opening itself is generally not a strong reason for surgery either.
Surgery is usually considered when:
The sinus has been infected on more than one occasion
An infection has not fully cleared with antibiotics
An abscess has formed
The discharge from the sinus is persistent and bothersome
For most patients, the decision to operate is built up over time rather than made at a single appointment. A first infection treated with antibiotics is often the start of a conversation about what to do if it happens again.
Timing: why we wait for the infection to settle
Surgery for a preauricular sinus should not be done during an active infection. The reasons are practical:
Inflamed, infected tissue is harder to dissect cleanly, which makes complete removal of the tract more difficult.
The risk of wound complications and further infection is higher.
Most importantly, the chance of leaving some of the tract behind, which then causes the problem to come back, is significantly increased.
The right approach is to settle the infection first, with antibiotics if needed, and to drain any abscess if one is present. Once the ear has been quiet for a few weeks, the operation can be planned electively. For patients with recurrent infections, the surgery is usually scheduled during a settled period between episodes, ideally when there has been at least a few weeks without inflammation.
What does the surgery involve?
The operation is called excision of a preauricular sinus. The aim is to remove the entire tract and any branches it has, so that nothing is left behind that could cause the problem to come back.
I offer the supra-auricular approach. This removes the sinus together with a small block of the adjacent tissue, including a small piece of the ear cartilage where the tract typically ends. Removing it as a single piece, rather than trying to follow the tract along its length, gives a much more reliable clearance of the whole sinus and any branches it has. The chance of the sinus coming back after this approach is around 1 to 5%, considerably lower than after the older "simple sinusectomy" technique, which has recurrence rates reported anywhere from 8% to over 30%. The scar is sited within the natural skin folds in front of and above the ear, and in most patients heals very well and is well hidden once mature.
For larger or more complex sinuses where the tract extends further than usual, there is a very small risk to the small branches of the facial nerve, which run near the operating area. In these cases I use a facial nerve monitor throughout the operation, which alerts me immediately if the nerve is being approached. With this in place, facial nerve injury is rare.
The skin is closed with fine sutures, usually dissolvable.
The operation is a day case. Most patients come into hospital in the morning and go home the same day, usually within a few hours of the procedure finishing.
The surgery is performed under general anaesthetic. The operation itself usually takes around 30 to 45 minutes, though this varies depending on how branched the tract turns out to be.
Aftercare
Recovery is generally straightforward.
Some discomfort and tenderness around the wound for a few days, easily controlled with paracetamol.
A small dressing over the wound for 7 days.
Sutures are usually dissolvable and do not need to be removed.
The wound should be kept clean and dry for 7 days, then can be gently washed with normal hair and face washing.
Most patients are back to normal day-to-day activities within a few days. Children can usually return to school within a week. More vigorous physical activity and contact sports should be avoided for around two weeks while the wound settles.
I will see you back in clinic a few weeks after the operation to check the wound has healed properly and to review the long-term outcome.
What are the risks?
For a small procedure, the risks are correspondingly modest, but they are worth knowing about.
Recurrence of the sinus. This is the main risk specific to this operation. With the supra-auricular approach, it is uncommon (around 1 to 5%) but not zero. If it does happen, further surgery to remove the residual tract is possible.
Wound infection in the early weeks. Uncommon and usually treatable with a short course of antibiotics.
A small scar in front of the ear. This is unavoidable but usually settles well and is often nearly invisible once mature.
Bleeding or bruising around the wound. Minor and self-limiting in nearly all cases.
Damage to the small branches of the facial nerve. Very rare with this operation because the dissection is mostly superficial to where the nerve runs. In larger or more complex sinuses where the tract extends further, the risk is slightly higher, and I use a facial nerve monitor throughout the operation in those cases to minimise it. With this in place, facial nerve injury is rare.
General anaesthetic risks. Generally very low in fit, healthy patients and discussed separately by the anaesthetist on the day.
When should you come and see me?
Come and see me if:
Your preauricular sinus has been infected more than once
You have ongoing discharge, swelling, or discomfort from the sinus
You have had an abscess that needed draining
You are considering surgery and would like to discuss whether it is the right option for you
I will examine the ear, take a history of how the sinus has behaved, and discuss the realistic options and outcomes specific to your situation. Where surgery is appropriate, I will go through what is involved in detail, answer any questions, and arrange the procedure when the timing is right.
If you would like to be seen urgently, please contact my secretary and I will do my best to accommodate.
Helpful resources
Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice. If you or your child has a preauricular sinus that is causing problems, please get in touch to book an appointment so I can assess the situation properly and give you advice specific to your circumstances.