Are You Confident of the Diagnosis?
An auricular pseudocyst generally arises over the period of a few weeks without history of preceding trauma. Patients are otherwise healthy. The affected area is usually asymptomatic.
Characteristic features on physical examination
Examination reveals a fluctuant noninflammatory swelling, usually at the anterior aspect of the ear. Most cases are unilateral, but bilateral involvement has been noted. Common areas involved include the scapha and triangular fossa. May drain fluid similar in color and texture to olive oil.
Expected results of diagnostic studies
The diagnosis is usually clinical. Histopathology shows cystic cavity within the cartilage lacking true epithelial lining, accompanying cartilaginous degeneration and fibrosis (Figure 1).
Differential diagnosis includes:
Chondrodermatitis nodularis helicis – usually painful, involves the helix and antihelix most commonly
Hematoma – history of surgery or trauma
Relapsing polychondritis – progressive, other cartilaginous structure affected
Traumatic perichondritis – history of trauma
Dermoid cyst – present from birth
Hidrocystoma – usually on eyelids, pathology will distinguish
Who is at Risk for Developing this Disease?
Age of onset most commonly in the 3rd decade, with males affected more than females. Patients with atopic dermatitis may have an increased risk.
What is the Cause of the Disease?
Etiology is unknown, but the following two theories have been noted:
Repetitive minor trauma (regular use of headphones, helmets, etc). Support exists for this theory because patients with atopic dermatitis tend to have an earlier age of onset and bilateral involvement which could be secondary to rubbing.
Embryologic abnormality resulting in a potential space within the auricular cartilage that reopens
Systemic Implications and Complications
Pseudocyst of the auricle is a benign condition, and no systemic workup is necessary. If left untreated, patients are at risk for permanent ear deformity.
Treatment options are summarized in Table I.
|Excision of anterior segment of cartilage following by compression as noted above||Lower risk of recurrence than simple aspiration||More technically demanding; floppy ear|
|Punch biopsy (2-3mm) at inferior border of cyst for drainage followed by application of a bolster dressing (dental roll, metal clip, ear cast of polyethylene) for 2 weeks||Lower risk of recurrence than simple aspiration||Recurrence with resulting ear deformity, perichondritis|
|Intralesional steroids (5mg/mL concentration) with or without accompanying drainage/bolster||Lower risk of recurrence than simple aspiration||Ear deformity, atrophy, and skin color change|
|Use of intralesional sclerosing agent such as intralesional minocycline 1mg/mL or fibrin glue||Lower risk of recurrence than simple aspiration||Adverse reaction to sclerosing agent|
|Aspiration||Easy to perform||Higher risk of recurrence and subsequent permanent ear deformity|
|Observation (reports of spontaneous regression)||No risk of perichondritis or other adverse effect from intervention||Permanent ear deformity if left untreated|
Optimal Therapeutic Approach for this Disease
The goal of treatment is to eliminate the cyst and restore normal architecture of the ear. Recommended treatments are generally surgical in nature and cited in case reports. Recurrences are problematic but can be minimized by using a combination approach. Recommended initial treatment includes excision of the anterior segment of cartilage followed by compression for a period of 10 days to 2 weeks (employing one of the various bolstering methods described above). Compression can be obtained with supplies readily available in the clinic.
Steps in excision include local anesthesia, incising then undermining skin above the pseudocyst, removing the anterior segment of cartilage and resuturing the skin in place with the posterior segment of cartilage remaining intact. Aspiration with accompanying compression is another effective approach. Excision is more invasive, and the risk of perichondritis is higher than aspiration plus compression, but the results are often longer lasting.
Intralesional steroids and sclerosing agents also act to obliterate the cystic cavity, but carry the risk of ear deformity, atrophy and skin color change. Sclerosants may not be readily available in the clinic. Simple aspiration has an unacceptably high level of recurrence, and observation may result in permanent ear deformity if the pseudocyst does not spontaneously resolve.
The patient should understand this is a benign condition. The reason to treat is to avoid potentially permanent ear deformity. Recurrence rates are not well characterized in the literature with different interventions.
Unusual Clinical Scenarios to Consider in Patient Management
A few case reports detail pseudocyst of the auricle occurring in patients with lymphoma (secondary to intense itching).
What is the Evidence?
Schulte, KW, Neumann, NJ, Ruzicka, T. “Surgical pearl: the close-fitting ear cover cast—a non-invasive treatment for pseudocyst of the ear”. J Am Acad Dermatol. vol. 44. 2001. pp. 285-7. (This article describes a nonsurgical approach to pseudocyst relying on compression to obliterate the fluid-filled space.)
Ming, LC, Hong, GY, Shuen, CS, Lim, L. “Pseudocyst of the auricle: a histologic perspective”. Laryngoscope. vol. 114. 2004. pp. 1281-4. (All 16 specimens revealed an intracartilaginous cyst devoid of epithelial lining and a perivascular mononuclear infiltrates of lymphocytes evident in the connective tissue layer just superficial to the anterior segment of the cartilage. There were no true cysts)
Ng, W, Kikuchi, Y, Chen, X, Hira, K, Ogawa, H, Ikeda, S. “Pseudocysts of the auricle in a young adult with facial and ear atopic dermatitis”. J Am Acad Dermatol. vol. 56. 2007. pp. 858-61. (Pseudocyst are not true cysts in that they lack epithelial lining.)
Paul, AY, Pak, HS, Welsh, ML, Toner, CB, Yeager, J. “Pseudocyst of the auricle: diagnosis and management with a punch biopsy”. J Am Acad Dermatol. vol. 45. 2001. pp. S230-2. (Drainage of a pseudocyst, particularly if performed inferiorly allowing gravity-assisted drainage, may solve the problem.)
Kim, TY, Kim, DH, Yoon, MS. “Treatment of recurrent auricular pseudocyst with intralesional steroid injection and clip compression dressing”. Dermatol Surg. vol. 35. 2009. pp. 245-7. (It is not clear if steroid injection offers benefit beyond compression.)
Li, LJ, Elenitsas, R, Bondi, E. “Noninflammatory fluctuant swelling of the ear”. Arch Dermatol. vol. 137. 2001. pp. 657-62. (A case report of a pseudocyst of the auricle developing days after an insect bite reaction.)
Abbas, O, Ghosn, S, Ghani Kibbi, A, Salman, S. “Asymptomatic swelling of the right ear”. Clin Exp Dermatol. vol. 35. 2010. pp. e72-e73. (A 6-year-old boy with a history of atopic dermatitis developed a pseudocyst of the auricle. It appears that chronic rubbing and pruritus of atopic dermatitis may be associated with an earlier presentation of either unilateral or bilateral cases of auricular pseudocyts.)
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