Preauricular Pit and Epidermal Cyst: A Brief Clinical and Histopathological Comparison Benjamin A Maertins, M.D.

Department of Pathology Creighton University Medical Center Omaha, NE, USA Deba P Sarma, M.D. Department of Pathology Creighton University Medical Center Omaha, NE, USA Key words: Preauricular pit, preauricular sinus, epidermal cyst Source of financial support: None Table of Contents Abstract Preauricular pit Epidermal cyst Comment Abstract Preauricular pits are congenital epidermal cysts around the ear whereas the epidermal cysts are acquired dermal cysts occurring in all locations. A brief clinical and microscopic review of these two conditions is presented. Preauricular pit Preauricular pits are small, subtle indentations located anterior to the helix and superior to the tragus of the ear. These embryonic remnants are bilateral in up to 50% of cases and are most commonly found in Asian children.

Children with preauricular pits are at five times the risk for permanent hearing impairment. Preauricular pits may be the first indication of branchio-oto-renal syndrome, an autosomal dominant syndrome characterized by sensorineural hearing loss, preauricular pits, branchial cysts, malformed ears, and renal anomalies, including renal dysplasia and bifid renal pelvises. Unless preauricular pits become repeatedly infected or continuously discharge squamous material, surgery is not required [1]. However, when surgery is indicated, excision of the pit, the squamous-lined cyst, and the cartilage at the root of the helix en bloc is necessary to avoid recurrence [2]. Microscopically (Figure 1), the preauricular pits are lined by normal squamous epithelium of the skin with all the adnexal structures, such as hair follicles, sebaceous glands and sweat glands. The wall of the pit may show cartilage of the ear. The lumen may contain keratinous material and inflammatory exudates. Figure 1. Preauricular pit.

Epidermal cyst Epidermal cysts are the most common type of cutaneous cysts. Often, epidermal cysts are referred to erroneously as sebaceous cysts when in fact

there is no sebaceous component in the lesion. They present as elevated, firm, round, freely movable and slow growing intradermal cystic tumors which stop growing after they reach 1 to 5 cm in diameter [3]. Often found in hair-bearing areas on the scalp, neck, face and trunk, they can occasionally be found on the palms and soles. Most of the epidermal cysts derive from the infundibular part of the hair follicle. The epidermal cysts of the palms and soles originate from implantation of the epidermal squamous cells into the dermis. These cysts can be truly called epidermal inclusion cysts and trauma may be a factor causing the implantation of the epidermal cells. Typically, a patient will have only one to two cysts, however, in rare instances, such as in Gardners syndrome, the patient may develop numerous epidermal cysts [3]. Microscopically (Figure 2), the epidermal cyst is located in the dermis and is lined by epidermis composed of keratinizing normal squamous cells with a granular layer. The lumen of the cyst contains flaky keratin arranged in laminated layers. As opposed to the preauricular cyst, adnexal structures are not present in the cyst wall. If a cyst ruptures (Figure 3), its keratinous contents are released into the dermis resulting in a foreign-body reaction with numerous multinucleated giant cells and chronic inflammation. Figure 2. Epidermal cyst.

Figure 3. Ruptured epidermal cyst.

Comment When clinically comparing preauricular pits with epidermal cysts, one can look at the location. Preauricular pits are found superior to the tragus and anterior to the helix whereas epidermal cysts are typically located in hair bearing areas of the face, neck, scalp and trunk. In addition to location, these cysts can be differentiated based on gross appearance. Preauricular pits are typically not raised and have a central pit whereas epidermal inclusion cysts are raised, firm, freely movable masses which occasionally have a central punctum. The preauricular pits may become infected and epidermal cysts can rupture. The preauricular pits may be present in the branchio-oto-renal syndrome and numerous epidermal cysts may be found in Gardners syndrome. Microscopically, both of these squamous epithelial lined lesions are located in the dermis. The lining of the preauricular pits is composed of skin with normal adnexae whereas the epidermal cysts are lined by keratinizing epidermal cells with no adnexal structures.

Correspondence Deba P Sarma, M.D. Department of Pathology Creighton University Medical Center Omaha, NE, USA debasarma@creighton.edu References:
1. Scheinfeld NS, Silverberg NB, Weinberg JM. The preauricular sinus:

a review of its clinical presentation, treatment and associations. Pediatric Dermatology 2004; 21(3): 191-196.
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preauricular pit and sinus tract in children. Laryngoscope 1990; 100(3):320-321.

3. Lever FW, Schaumburg-Lever G. Histopathology of the Skin. 9th Ed.

Philadelphia. PA: J.B. Lippincott; 2005: 814.