Congenital preauricular fistulas are formed during the development of the embryonic first gill slit and are more common clinically, manifesting as a small hole in front of the foot of the ear wheel that can wait to be observed if it is not inflamed. Preauricular fistula infections are most likely to occur in childhood and can be erythematous, painful, ulcerated, and scarred, often requiring surgical treatment. For those with recurrent infections, the most reliable means of preventing recurrence is still complete surgical excision. The traditional view is that preauricular fistulas need to be removed after the infection is fully controlled and the skin color returns to normal, and that surgery during the inflammatory phase can easily lead to recurrence of the residual tube. However, once infected, the fistula is stretched, squeezed, deformed and blocked due to inflammatory granulation or scar formation, and secretions are not easily discharged, causing the infection to persist and the inflammatory granulation to continue to grow, requiring repeated scratching and medication changes, which can take up to several months. Is it possible to operate on an infected preauricular fistula? We believe that it is appropriate to remove the preauricular fistula during the infection period. According to our treatment experience: the local abscess formation in pediatric preauricular fistula infection should be controlled after the inflammation is removed by surgery as soon as possible, otherwise the local inflammation is prolonged, the skin becomes thin, necrotic defects, and local scar tissue, which also has a negative impact on re-operation. From clinical observation, in the early stage of inflammation or after the initial control of inflammation, after careful operation and appropriate expansion of the scope of surgery and other treatments, it is still possible to achieve more desirable surgical results. In the early stage of inflammation or after the initial control of inflammation, when the abscess has been drained by incision, the swelling has subsided, the scope is limited and the boundary is relatively clear, even though there is still pus, but because the inflammation is limited, the surgery can remove the disease, thus allowing the inflammation to be controlled and healed. Surgery can be cured, thus reducing the pain and economic burden of the child.3 Surgery after abscess incision and drainage, when there is less local secretion and only inflammatory granulation tissue or scar is left, can reduce the risk of complications. Timing of surgery Surgery is possible during the infection period, but the appropriate timing of surgery must be chosen. The best time to operate for congenital preauricular fistula co-infection is when pus drainage is basically clean, soft tissue inflammation around the fistula is relatively limited, and the patient has no significant systemic reaction. At this time, intraoperative bleeding is low, the anatomic level is clearer, and the residual fistula can be carefully searched for under the microscope, and any remaining fistula epithelium, scales, and sebaceous material can be completely excised together. Surgical techniques Incisions: The current trend in surgery is minimally invasive, and although preauricular fistula surgery is a minor operation, our surgical incisions are critical in considering the surgical results and also the postoperative aesthetics, especially in children. Our incisions are all shuttle-shaped, with the fistula removed as completely as possible along the edge of the fistula (along with some of the cartilage of the ear chakra), and the infected fistula is removed subcutaneously to remove the foci of infection and surrounding inflammatory granulation tissue and to protect the integrity of the skin as much as possible. If necessary, a double incision is made, a shuttle incision is made around the infected focus and the fistula respectively, the skin and subcutaneous tissue are incised and the tissue is separated along the peri-fistula up to the blind end. Use of the microscope: the fistula and normal tissue can be clearly distinguished under the microscope. It is particularly important to use the microscope to distinguish between the fistula and inflammatory tissue in patients undergoing surgery in the infected phase because the fistula capsule lumen is open due to preoperative incision and drug exchange, and the fine branches of the fistula complicating the infected focus have been blocked by inflammatory necrotic granulation and fibrous proliferation, resulting in the inability to inject stain into the fine branches. The usual treatment for debridement is followed: repeated irrigation with hydrogen peroxide, antibiotic saline, and saline, and irrigation of the operative cavity with amikacin or metronidazole. Complete excision of the fistula and the affected auricular cartilage and granulation and scar tissue within the infected focus is performed. Because of the large amount of skin and subcutaneous tissue loss after local fistula, scar and granulation tissue removal, dead cavities are easily left behind, increasing the chance of infection. Skin with deep tissue together with transverse mattress suture, the operation is simple and reliable, ensuring the incision I healing, leaving only linear scar after healing, in line with the requirements of cosmetic surgery, and avoiding skin edge involution and dead cavity formation. After the operation, pressure bandages should be applied and anti-infection treatment should be continued. Is there a high recurrence rate of surgery during the infected period? The clinical term “recurrence” refers to the recurrence of fistula, especially branch fistulae, after abscess drainage or fistula removal. The recurrence of postoperative infection depends mainly on the complete removal of the fistula and the affected auricular cartilage and the granulation and scar tissue within the infected site. Therefore, thorough removal of the fistula and leaving no residual tube is the key to preventing recurrence of fistula infection. Effective postoperative compression bandaging and systemic anti-infective therapy are also key to the recovery of surgical patients in the early stages of inflammation or after initial control of inflammation. Early surgical removal of the congenital preauricular fistula with intensive systemic anti-infection therapy shortens the treatment time and saves the cost of treatment, and surgical skill and proficiency is the key to healing the preauricular fistula and reducing recurrence.