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  Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 5  |  Page : 789-791  

Pseudocyst of auricle—An uncommon condition and novel approach for management


Department of Dermatology, GMERS Medical College and Hospital, Sola, Ahmedabad, Gujarat, India

Date of Submission22-Oct-2019
Date of Decision09-Jun-2020
Date of Acceptance08-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Krina B Patel
GMERS Medical College and Hospital, Sola, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_532_19

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   Abstract 


Pseudocyst of the auricle is a rare benign condition due to the accumulation of intracartilaginous fluid. Various treatment modalities are suggested in literature; the goal being the preservation of architecture of the pinna and prevention of recurrence. We report two cases: An 11-year-old boy treated conventionally with surgical management with the development of mild deformity and an 18-year old male treated with novel nonsurgical modality with the excellent cosmetic result. Here we emphasize the importance of such a simple routine procedure, which can be done on an OPD basis with a better cosmetic outcome.

Keywords: Auricular pseudocyst, dental mold, lactic dehydrogenase level


How to cite this article:
Agrawal PU, Patel KB, Chauhan VF, Nagani SM. Pseudocyst of auricle—An uncommon condition and novel approach for management. Indian Dermatol Online J 2020;11:789-91

How to cite this URL:
Agrawal PU, Patel KB, Chauhan VF, Nagani SM. Pseudocyst of auricle—An uncommon condition and novel approach for management. Indian Dermatol Online J [serial online] 2020 [cited 2020 Oct 26];11:789-91. Available from: https://www.idoj.in/text.asp?2020/11/5/789/295585




   Introduction Top


A pseudocyst of the auricle is a rare benign cystic swelling resulting from the accumulation of intercartilaginous fluid.[1] The term “pseudo” comes from the histopathological finding of a lack of epithelial lining around the cyst. The condition can involve the antihelix, cymba concha, scaphoid, and triangular fossa.[2],[3] Auricular pseudocyst generally has a unilateral presentation affecting males in the mean age group of 35–40 years. Various terms for this condition are endochondral pseudocyst, cystic chondromalacia, intracartilaginous auricular seroma cyst, and benign idiopathic cystic chondromalacia.[4] The etiology of this condition is unknown, but different hypotheses suggest the role of chronic low-grade trauma and congenital embryonic dysplasia of the auricular cartilage as the predisposing factors. Inflammatory cells and granulation tissue observed on histology may be contributing factors for the separation and dilatation of embryogenic intracartilage spaces.[4] A recent analysis of the cytokine profile of the fluid indicates markedly elevated levels of interleukins (IL-6), which is believed to stimulate chondrocyte proliferation.[5]

Diagnosis is based on clinical characteristics and no evidence of infection. Confirmation can be done by measuring fluid lactic acid dehydrogenase (LDH) levels, which rises due to damage to chondrocytes.[2],[4] The differential diagnosis includes cellulitis, relapsing polychondritis, chondrodermatitis helicis, and subperichondrial hematoma secondary to trauma.[4]

Various treatment modalities are suggested by various authors. Resection of the anterior cartilaginous leaflet of pseudocysts with repositioning of the overlying skin flap (deroofing technique) followed by buttoning is seen to produce the best results in the literature.[3] But this technique may lead to deformity of the ear, and also it is expensive. Simple aspiration though cost-effective may lead to recurrence. Hence, a unique technique using dental wax mold has been tried in one of our patients with an excellent result.


   Case History Top


Case 1

An 11 year old male presented with recurrent painless swellings on the right external ear probably due to wearing of a bicycle helmet. Clinical diagnosis based on history and examination was pseudocyst, which was confirmed by cyst fluid LDH levels 1490 U/mL (reference range: 60–103 U/mL). His other routine investigations were normal, and the child was otherwise healthy. He was treated with aspiration of fluid from cyst several times with recurrence after each aspiration within a few days. Conservative management with an aspiration of fluid combined with pressure dressing with button also did not lead to long-term remission. The patient was treated with surgical excision of pseudocyst by an ENT surgeon under general anesthesia, which required prolonged healing time of 3 weeks and led to mild deformity of the cartilage [Figure 1]a and [Figure 1]b.
Figure 1: (a) Case 1 at the time of presentation. (b) Mild external ear deformity after healing

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Case 2

An 18-year-old male presented to skin OPD with slightly tender fluid-filled swelling on the left auricle. Clinical diagnosis based on history and examination was pseudocyst. It was confirmed by measuring fluid LDH levels, which was 1200 U/mL. His other routine investigations were normal. We treated the patient with an aspiration of fluid followed by pressure dressing with dental wax molded to the patient's ear shape and size to avoid refilling of the pseudocyst. The bandage was done by elastocrape bandage. Rebandage was done after 3 days, and it was kept along with the mold for 7 days. The patient was not given oral or intralesional steroid. The regular follow-up of the patient was done for 4 months. There was no recurrence and no deformity or scarring [Figure 2]a, [Figure 2]b, [Figure 2]c.
Figure 2: (a) Case 2 at the time of presentation. (b) Dental wax set on the ear after aspiration of fluid. (c) 1 week posttreatment

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   Discussion Top


The first report of pseudocyst of the pinna of 12 patients was by a German physician Arthur Hartmann in 1846.[3] It was reported in English-language literature much later in 1966, by Engel in Chinese men.[1] Hansen reported a series of 6 patients of the intracartilaginous cyst and termed them pseudocyst.[6]

Histologically, pseudocyst is characterized by an intracartilaginous cavity lacking in the epithelial lining and contains thinned cartilage and hyalinizing degeneration along the internal border of the cystic space and granulation tissue.[3],[4]

Our cases were not confirmed histologically but were confirmed by measuring fluid LDH levels. LDH 4 and LDH 5; major components of human auricular cartilage may be released due to repeated minor trauma from the degenerated auricular cartilage.[4] The site of involvement in both our cases was helix, cymba concha, and triangular fossa. Both of them had a unilateral presentation. Pseudocysts present unilaterally that too right side as reported by many authors, but there are reports of bilateral presentation typically in children.[7],[8] The volume of aspirates ranges between 0.5 and 10 mL,[7] and we found it between 3 and 5 mL. The size of lesions in our cases ranged between 3 and 5 cm.

In both of our cases, trauma due to wearing of the helmet was likely to cause the pseudocyst of auricle. The ultimate aim of treatment is successful drainage of the fluid without any damage to the cartilage preserving its anatomy and avoiding recurrence.

Various treatment modalities are described in the literature so far e.g., conservative management with aspiration and pressure dressing with or without intralesional or oral corticosteroids, intralesional minocycline;[8] surgical curettage and fibrin sealant; deroofing of cyst followed by buttoning; punch biopsy and application of a bolster;[9] drainage tube inserted into the pseudocyst using a guide needle; and a piece of cartilage removed posteriorly and corrugated drain kept in place have all been shown to be effective. However, many of these techniques may result in alteration of the normal anatomy of the cartilage, which may be cosmetically not acceptable to the patient or have chances of recurrence.

There are few cases reported in Indian literature, most of them from ENT surgeons.[10],[11] Only a few case reports without management have been reported in the Indian dermatology literature.[12] Most of the cases presenting to dermatologists might be referred to other specialties because of recurrence associated with conservative management. In our patient, we used a simple heated dental wax molded to the shape of the ear, placed on the scaphoid fossa after draining the fluid and kept in place by an elastocrape bandage. The patient did not show any deformity or scarring and no recurrence at the end of 4 months. This procedure can be combined with intralesional steroids after aspiration if needed.

This is a simple and inexpensive technique, which can be of great help in saving the patient from the surgical procedure. We recommend this innovative technique for all cases of pseudocyst of auricle presenting to dermatologists.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Engel D. Pseudocyst of the auricle in Chinese. Arch Otolaryngol 1966;83:197-202.  Back to cited text no. 1
    
2.
Cameron K. Dermatoses of external ear. In: Christopher G, Jonathan B, Tanya B, Robert C, Daniel C, editors. Rook's Textbook of Dermatology. 9th ed. vol 3. New York: John Wiley and Sons Inc; 2016. p. 108:10-11.  Back to cited text no. 2
    
3.
Khan NA, Ul Islam M, Ur Rehman A, Ahmad S. Pseudocyst of pinna and its treatment with surgical deroofing: An experience at tertiary hospitals. J Surg Tech Case Rep 2013;5:72-7.  Back to cited text no. 3
    
4.
Ramadass T, Ayyaswamy G. Pseudocyst of auricle-etiopathogenesis, treatment update and literature review. Indian J Otolaryngol Head Neck Surg 2006;58:156-9.  Back to cited text no. 4
    
5.
Yamamoto T, Yokoyama A, Umeda T. Cytokine profile of bilateral psuedocyst of the auricle. Acta Derm Venereol 1996;76:92-3.  Back to cited text no. 5
    
6.
Hansen JE. Pseudocyst of the auricle in Caucasians. Arch Otolaryngol 1967;85:1-13.  Back to cited text no. 6
    
7.
Cohen PR, Grossmen ME. Pseudocyst of the auricle. Case report and world literature review. Otolaryngol Head Neck Surg 1990;116:1202-4.  Back to cited text no. 7
    
8.
Supiyaphun P, Decha W. Auricular pseudocysts: A treatment with the Chulalongkorn University vacuum device. Otolaryngol Head Neck Surg 2001;124:213-6.  Back to cited text no. 8
    
9.
Hegde R, Bhargava S, Bhargava KB. Pseudocyst of the auricle: A new method of treatment. J Laryngol Otol 1996;110:767-9.  Back to cited text no. 9
    
10.
Babu AR, Bharathi MB, Joshi P. Pseudocyst of auricle-our experience with a simple treatment technique. Int J Cont Med Res 2017;4:681-3.  Back to cited text no. 10
    
11.
Dabholkar Y, Chawathey S, Velankar H. A novel modality of treatment for pseudocyst of auricle. Indian J Otol 2018;24:20-2.  Back to cited text no. 11
  [Full text]  
12.
Kaur S, Thami G P, Bhalla M. Pseudocyst of the auricle. Indian J Dermatol Venereol Leprol 2003;69(Suppl S1):85-6  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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