Pseudocyst of the Auricle

Pseudocyst of the Auricle

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Pseudocyst of the auricle was first reported by Hartmann in 1846 and first described in the English literature in 1966 by Engel. [1] Historically, pseudocyst of the auricle has been addressed by many terms, including endochondral pseudocyst, intracartilaginous cyst, cystic chondromalacia, and benign idiopathic cystic chondromalacia. Because the condition is uncommon, it may be misdiagnosed or underreported by clinicians. Pseudocyst of the auricle is characterized as a benign, noninflammatory swelling to the ear, located on either the front or side surface. [2]

The etiology of pseudocyst of the auricle is unknown, but several pathogenic mechanisms have been proposed.

Originally, Engel postulated that lysosomal enzymes might be released from chondrocytes and cause damage to the auricular cartilage. However, analysis of pseudocyst contents revealed a fluid rich in albumin and acid proteoglycans, with a rich cytokine milieu but lacking in lysosomal enzymes.

Analysis of the cytokine profile of the fluid indicates markedly elevated levels of interleukin (IL)–6, which is believed to stimulate chondrocyte proliferation. IL-1, an important mediator of inflammation and cartilage destruction, induces IL-6. IL-1 also stimulates chondrocytes to synthesize proteases and prostaglandin E2 while inhibiting the formation of extracellular matrix components.

Others have suggested that a defect in auricular embryogenesis contributes to pseudocyst formation. This defect causes the formation of residual tissue planes within the auricular cartilage. When subjected to repeated minor trauma or mechanical stress, these tissue planes may reopen, forming a pseudocyst.

Pseudocysts usually present spontaneously or following repeated minor trauma. [2] The observation that an auricular pseudocyst often results after repeated minor trauma, such as rubbing, minor sport injuries, ear pulling, sleeping on hard pillows, or wearing a motorcycle helmet or earphones, has led to the suggestion that these minor traumas may be the mechanism. In support of this traumatic etiology, elevated serum lactic dehydrogenase (LDH) values have been reported within the pseudocyst fluid. [3, 4] Two of the elevated isoenzymes, LDH-4 and LDH-5, are proposed as major components of human auricular cartilage. These enzymes may be released from auricular cartilage degenerated from repeated minor trauma.

One article reports that pseudocysts can be regarded as simply a variation of othematoma or otoseroma. [5]

Tan and Hsu reported the epidemiological features, clinicopathologic characteristics, and success of surgical treatment in 40 patients of different Asian groups presenting with pseudocyst of the auricle. [6] Results showed a Chinese predominance (90%), followed by Malays (5%), and Eurasians (5%). All except one patient had unilateral presentations. Most (55%) presented within 2 weeks of auricular swelling. Few (10%) had a history of trauma.

Most reports of pseudocyst of the auricle have involved Chinese or white patients; however, persons of all racial groups have been affected.

Males show a higher prevalence of pseudocyst of the auricle than females. [7]

Most pseudocysts of the auricle are unilateral and occur in men aged 30-40 years, but lesions are documented in patients ranging in age from 15-85 years of both sexes.

Without treatment of pseudocyst of the auricle, permanent deformity of the auricle may occur.

Patients with pseudocyst of the auricle should be informed that even with optimal therapy, recurrence is common. Avoidance of triggers or exacerbating factors should be encouraged.

Engel D. Pseudocysts of the auricle in Chinese. Arch Otolaryngol. 1966 Mar. 83(3):197-202. [Medline].

Beutler BD, Cohen PR. Pseudocyst of the auricle in patients with movement disorders: report of two patients with ataxia-associated auricular pseudocysts. Dermatol Pract Concept. 2015 Oct 31. 5 (4):59-64. [Medline]. [Full Text].

Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase isozymes in and intralesional steroid injection therapy for pseudocyst of the auricle. Int J Dermatol. 2001 Jun. 40(6):380-4. [Medline].

Chen PP, Tsai SM, Wang HM, Wang LF, Chien CY, Chang NC, et al. Lactate dehydrogenase isoenzyme patterns in auricular pseudocyst fluid. J Laryngol Otol. 2013 May. 127(5):479-82. [Medline].

Kopera D, Soyer HP, Smolle J, Kerl H. “Pseudocyst of the auricle”, othematoma and otoseroma: three faces of the same coin?. Eur J Dermatol. 2000 Aug. 10(6):451-4. [Medline].

Tan BY, Hsu PP. Auricular pseudocyst in the tropics: a multi-racial Singapore experience. J Laryngol Otol. 2004 Mar. 118(3):185-8. [Medline].

Kanotra SP, Lateef M. Pseudocyst of pinna: a recurrence-free approach. Am J Otolaryngol. 2009 Mar-Apr. 30(2):73-9. [Medline].

Lai WS, Wang CH, Shih CP. Bilateral auricular pseudocyst. Arthritis Rheum. 2013 Apr. 65 (4):1084. [Medline]. [Full Text].

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. 2007 May. 56(5):858-61. [Medline].

Pereira FC, Chinelli PA, Takahashi MD, Nico MM. Bilateral pseudocyst of the auricle in a man with pruritus secondary to lymphoma. Int J Dermatol. 2003 Oct. 42(10):818-21. [Medline].

Stankevice D, Nielsen KO. [Two cases of auricular pseudocyst]. Ugeskr Laeger. 2009 Mar 9. 171(11):907. [Medline].

Glamb R, Kim R. Pseudocyst of the auricle. J Am Acad Dermatol. 1984 Jul. 11(1):58-63. [Medline].

Devlin J, Harrison CJ, Whitby DJ, David TJ. Cartilaginous pseudocyst of the external auricle in children with atopic eczema. Br J Dermatol. 1990 May. 122(5):699-704. [Medline].

Tuncer S, Basterzi Y, Yavuzer R. Recurrent auricular pseudocyst: a new treatment recommendation with curettage and fibrin glue. Dermatol Surg. 2003 Oct. 29(10):1080-3. [Medline].

Lim CM, Goh YH, Chao SS, Lim LH, Lim L. Pseudocyst of the auricle: a histologic perspective. Laryngoscope. 2004 Jul. 114(7):1281-4. [Medline].

Lazar RH, Heffner DK, Hughes GB, Hyams VK. Pseudocyst of the auricle: a review of 21 cases. Otolaryngol Head Neck Surg. 1986 Mar. 94(3):360-1. [Medline].

Hoffmann TJ, Richardson TF, Jacobs RJ, Torres A. Pseudocyst of the auricle. J Dermatol Surg Oncol. 1993 Mar. 19(3):259-62. [Medline].

Job A, Raman R. Medical management of pseudocyst of the auricle. J Laryngol Otol. 1992 Feb. 106(2):159-61. [Medline].

Miyamoto H, Oida M, Onuma S, Uchiyama M. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol. 1994 Mar. 74(2):140-2. [Medline].

Kim TY, Kim DH, Yoon MS. Treatment of a recurrent auricular pseudocyst with intralesional steroid injection and clip compression dressing. Dermatol Surg. 2009 Feb. 35(2):245-7. [Medline].

Patigaroo SA, Mehfooz N, Patigaroo FA, Kirmani MH, Waheed A, Bhat S. Clinical characteristics and comparative study of different modalities of treatment of pseudocyst pinna. Eur Arch Otorhinolaryngol. 2011 Oct 29. [Medline].

Lim CM, Goh YH, Chao SS, Lynne L. Pseudocyst of the auricle. Laryngoscope. 2002 Nov. 112(11):2033-6. [Medline].

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 Jul. 5(2):72-7. [Medline]. [Full Text].

Salgado CJ, Hardy JE, Mardini S, Dockery JM, Matthews MS. Treatment of auricular pseudocyst with aspiration and local pressure. J Plast Reconstr Aesthet Surg. 2006. 59(12):1450-2. [Medline].

Oyama N, Satoh M, Iwatsuki K, Kaneko F. Treatment of recurrent auricle pseudocyst with intralesional injection of minocycline: a report of two cases. J Am Acad Dermatol. 2001 Oct. 45(4):554-6. [Medline].

Cohen PR, Katz BE. Pseudocyst of the auricle: successful treatment with intracartilaginous trichloroacetic acid and button bolsters. J Dermatol Surg Oncol. 1991 Mar. 17(3):255-8. [Medline].

AlGhamdi KM, AlEnazi MM. Versatile punch surgery. J Cutan Med Surg. 2011 Mar-Apr. 15(2):87-96. [Medline].

Han A, Li LJ, Mirmirani P. Successful treatment of auricular pseudocyst using a surgical bolster: a case report and review of the literature. Cutis. 2006 Feb. 77(2):102-4. [Medline].

Cohen PR. Successful treatment of auricular pseudocyst using a surgical bolster. Cutis. 2007 Oct. 80(4):274. [Medline].

Shan Y, Xu J, Cai C, Wang S, Zhang H. Novel Modified Surgical Treatment of Auricular Pseudocyst Using Plastic Sheet Compression. Otolaryngol Head Neck Surg. 2014 Sep 12. [Medline].

 

Pseudocyst of the auricle

Chondrodermatitis chronica helices

Relapsing polychondritis

Subperichondrial hematoma

Swelling

Localized

Localized

Diffuse

Localized

Skin involvement

Rare

Yes, crusting/ulceration

Yes, erythematous

Rare

Pain

Rare

Common (from ulceration)

Common (extremely tender)

Common

Systemic Symptoms

No

No

Yes (involvement of other cartilage)

No

Histology

Intracartilaginous, cystic defect, granulation tissue

Subperichondrial granulation tissue, cystic dilatation rare

Acute inflammable cells seen; antibody deposition on basement membrane during immunofluorescence

Inflammatory cells with degraded blood products

Adapted from Lim CM, et al. “Pseudocyst of the Auricle.” 2002.

William P Baugh, MD Assistant Clinical Professor of Dermatology, Western University of Health Sciences; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center

William P Baugh, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Cynthia L Chen, DO, DO Intern, Pacific Hospital of Long Beach, California

Cynthia L Chen, DO, DO is a member of the following medical societies: American Osteopathic Association, California Medical Association, American Osteopathic College of Dermatology, Los Angeles County Medical Association

Disclosure: Nothing to disclose.

Natalie Ana Baugh California State University, Long Beach

Disclosure: Nothing to disclose.

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Kelly M Cordoro, MD Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Medical Society of Virginia, Society for Pediatric Dermatology, Women’s Dermatologic Society, Association of Professors of Dermatology, National Psoriasis Foundation, Dermatology Foundation

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Mark L. Welch, MD, and Hon Pak, MD, to the development and writing of this article.

Pseudocyst of the Auricle

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