Accessory tragus is a fairly common, benign congenital anomaly of the external ear that presents as a small elevation of the skin that is made up of skin, subcutaneous fat, and/or elastic cartilage. It is located most commonly just anterior to the tragus, which is the fleshy prominence in front of the opening of the ear. They can also occur on the cheek, lateral part of the neck, in the middle ear, or between the eyebrows. Accessory tragus is present in males and females equally with a prevalence of approximately 2-6/1000 live births.
The formation of an accessory tragus is due to errors during embryogenesis. During the fifth and sixth week of intrauterine life, there are soft tissue swellings on the surface of the embryo called hillocks, which are derived from the first and second branchial arch. These hillocks grow and fuse to become the three parts of the ear: helix, antihelix, and the tragus. Any aberration during this process can result in an accessory tragus.
Patients may present with a small, skin colored nodule that is usually non-tender and can be either soft or firm. The accessory tragus can be pedunculated (have a stalk-like structure) or sessile (directly attached by the base). They are usually just on one side and more commonly appear as a solitary lesion, although there may be multiple.
A thorough examination of the ears, face, and neck should be performed. If there is any doubt, a biopsy may be performed to confirm the diagnosis of an accessory tragus and to rule out other skin conditions.
Although an accessory tragus is a benign finding, it is important to note that it may appear as part of Goldenhar syndrome (also known as oculo-auriculo-vertebral spectrum), a type of craniofacial microsomia. Furthermore, children with external ear anomalies have a slight increased risk of renal anomalies so a thorough history and referral to a nephrologist for a renal ultrasound may be warranted.
Patients may be uncomfortable with the appearance of an accessory tragus. Many patients seek treatment especially during childhood and adulthood for cosmetic purposes. A punch excision is successful in removing the accessory tragus with cosmetically appealing results. A shave excision can also be performed, although there may be slow healing if a fragment of excised cartilage is exposed.
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