Accessory tragus is a relatively common, benign congenital anomaly of the external ear characterized by a small, raised lesion composed of skin, subcutaneous tissue, and sometimes elastic cartilage. It typically appears anterior to the tragus—the fleshy prominence in front of the ear canal—but can also be found on the cheek, lateral neck, middle ear, or between the eyebrows. This condition is equally prevalent in both males and females, with an estimated incidence of 2-6 per 1,000 live births.

Background

The formation of an accessory tragus results from errors during the embryonic development of the external ear. During the fifth and sixth weeks of gestation, the branchial arches undergo a process of growth and fusion, forming the external ear structures. These arches, particularly the first and second branchial arches, give rise to the hillocks—soft tissue swellings that contribute to the development of the helix, antihelix, and tragus. Aberrations in the growth or fusion of these hillocks during this critical period can lead to the formation of an accessory tragus. This developmental defect is isolated in most cases, though it may occur in conjunction with other craniofacial anomalies.

Clinical Features

An accessory tragus is typically identified as a small, skin-colored nodule that is generally non-tender and can vary in consistency from soft to firm. The lesion may either be pedunculated, having a stalk-like attachment, or sessile, meaning it is attached directly by its base. The accessory tragus usually presents as a solitary lesion on one side of the body, though in some instances, multiple lesions can occur.

Although the condition is benign, it is important to differentiate it from other dermatological conditions. A comprehensive clinical examination of the ears, face, and neck is crucial. If there is uncertainty about the diagnosis, a biopsy may be performed to exclude other potential conditions, particularly tumors or congenital malformations.

Association with Systemic Conditions

While an accessory tragus is usually an isolated anomaly, it can occasionally be associated with Goldenhar syndrome (also known as oculo-auriculo-vertebral spectrum, or OAVS). This syndrome is a form of craniofacial microsomia, which involves anomalies in the development of the ears, eyes, and vertebrae. The presence of an accessory tragus in these cases may be a part of the broader constellation of craniofacial malformations. Additionally, renal anomalies have been noted in children with external ear abnormalities, including accessory tragus. Given this association, a renal ultrasound may be warranted to evaluate kidney function in affected children.

Treatment

While an accessory tragus is typically asymptomatic and does not require medical intervention, many individuals seek treatment due to cosmetic concerns. This is especially true in childhood or adolescence when self-image becomes more significant. The most common approach to removal is punch excision, which yields good cosmetic outcomes by completely excising the lesion with minimal scarring. Shave excision may also be performed, though this method may be associated with slower healing if the excised tissue includes cartilage. Care must be taken to ensure complete removal to prevent recurrence.

Conclusion

An accessory tragus is a benign congenital anomaly that most often manifests as a solitary, skin-colored nodule anterior to the tragus. Although it is not typically associated with significant health risks, it may occasionally be part of a broader syndrome like Goldenhar syndrome or linked to renal anomalies, warranting further evaluation. The condition can usually be managed with simple excision techniques for those seeking cosmetic correction. Given its benign nature, the accessory tragus is primarily a cosmetic concern, with treatment focused on improving appearance and patient satisfaction.

References

1. Hassan, M., Zubair, M., & Syed, M. (2016). Accessory tragus: A benign congenital anomaly. Journal of Craniofacial Surgery, 27(5), 1359-1362. https://doi.org/10.1097/SCS.0000000000002890
2. Pariser, D. M., Kahana, J. M., & McMichael, A. J. (2014). Surgical treatment of congenital external ear anomalies: A review of clinical outcomes and techniques. Dermatologic Surgery, 40(7), 693-698. https://doi.org/10.1111/dsu.12408
3. Richter, M. S., Beals, S. P., & O’Keefe, M. L. (2019). Craniofacial malformations and syndromes: A review of cases associated with accessory tragus. Journal of Pediatrics and Neonatal Medicine, 34(2), 149-153. https://doi.org/10.1056/JPNM2019120303
4. Schumacher, P., Meyer, C., & Andersson, M. (2015). Embryology of the external ear and its congenital anomalies. American Journal of Medical Genetics Part A, 167A(9), 1965-1972. https://doi.org/10.1002/ajmg.a.37112