Letter to the Editor
Bilateral Auricular Pseudocyst: Recognizing and Treating Jonas Laschen, MD1 Frank R. Datema, MD, PhD2 Peter J. F. M. Lohuis, MD, PhD1 1 Department of Head and Neck Surgery and Oncology, The
Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands 2 Department of Otolaryngology/Head and Neck Surgery, Erasmus Medical Center, Rotterdam, The Netherlands 3 Department of Dermatology, Diakonessenhuis, Utrecht/Zeist/ Doorn, The Netherlands
Veronica C. M. Koot, MD, PhD3
Address for correspondence Jonas Laschen, MD, Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute— Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands (e-mail: [email protected]).
Facial Plast Surg 2014;30:690–693.
Abstract
Keywords
► ► ► ► ►
auricular pseudocyst bilateral etiology surgical excision treatment
An auricular pseudocyst is a benign cystic lesion of the auricular cartilage. When not recognized, it is a clinical presentation that can easily be misdiagnosed and subsequently be mistreated leading to unsatisfactory esthetical results or disease recurrence. A patient was presented with bilateral pseudocysts, which were surgically excised. The aim of the treatment of a pseudocyst is to have recurrence-free resolution and to restore the original auricular architecture while removing the cystic lesion. Three alternatives to surgery are described in the literature and all seem not to be sufficient. When the pseudocyst is treated at an early stage, surgical excision shows high success rates and preservation of the auricular architecture. According to the success rate described in the literature combined with the preservation of the auricular architecture, we recommend surgical excision for the management of auricular pseudocysts.
Auricular pseudocyst is characterized by an asymptomatic, benign cystic lesion of the anterior or posterior helix. The lesion is a very uncommon entity of the ear and frequently seen in young adults. An inflammatory response, usually because of repetitive trauma, is believed responsible, but in many cases there is no evidence of trauma. Bilateral pseudocysts are rare and usually present metachronously, but can also occur synchronously. Because pseudocysts are fairly unknown, they can be misdiagnosed and as a consequence mistreated. Once the lesion is recognized as a pseudocyst, appropriate surgical treatment can avoid late complications or relapse. We report a case of a bilateral, auricular pseudocyst, and present a review of the different treatment options based on the literature.
Issue Theme Filler Complications; Guest Editor, Eckart Haneke, MD, PhD
Case The dermatologist presented us a 76-year-old woman with a bilateral, slowly progressive, and painful swelling of the upper auricle. There was no preceding trauma, insect bite, or inflammation. Physical examination showed a 1.5 cm skincolored, fluctuant lesion on both the sides of the antihelix (►Fig. 1). The differential diagnosis included auricular pseudocyst, subperichondrial hematoma secondary to trauma, relapsing polychondritis, and traumatic perichondritis. Fine needle aspiration showed a viscous straw-yellow fluid. The diagnosis of an auricular pseudocyst was based on the typical clinical findings as described earlier, and on the macroscopical characteristics of aspirated fluid. Both the cysts were
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1396528. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
690
Laschen et al.
Fig. 1 Patient with pseudocyst (arrow) of the right auricle.
surgically excised under local anesthesia with the technique described later. Macroscopical examination revealed an intracartilaginous cyst devoid of epithelial lining, with sparse inflammatory cells (►Fig. 2). Reactive changes of the cartilage were evident. The postoperative results were good with preservation of the auricular architecture. No recurrences were seen within 1-year follow-up period.
Fig. 3 (A) Incision of the antihelical fold (pseudocyst is exposed, arrow). (B) Tangential incision of the lateral wall of the cyst (lateral cartilage is marked, arrow).
Surgical Technique The surgical field was sterilized with chlorhexidine and prepared for surgery. The incision in the antihelical fold was precisely marked for aesthetical reasons. After local infiltration with lidocaine 2.0% and adrenaline 2.0%, the incision was made and the cyst was exposed (►Fig. 3A). Then, a tangential incision of the lateral wall of the cyst
Fig. 2 Histological slide with hematoxylin and eosin staining. (A) Cyst filled with proteinaceous material. (B) Cartilage lining (no epithelium). (C) Chondrocyte.
Fig. 4 (A) The lateral cartilaginous leaflet was resected and the borders were smoothened. (B) Flap was set back and the skin was closed with mattress sutures. Facial Plastic Surgery
Vol. 30
No. 6/2014
691
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Bilateral Auricular Pseudocyst
Bilateral Auricular Pseudocyst
Laschen et al.
was made (►Fig. 3B). The lateral cartilaginous leaflet was resected—similar to the removal of the top of an eggshell— and the borders were smoothened (►Fig. 4A) to prevent secondary chondrodermatitis by pressure necrosis when sleeping. The skin flap was sutured back with a 4.0 Vicryl suture and additional 4.0 Vicryl mattress sutures were placed to prevent hematoma (►Fig. 4B).
Discussion The etiology of the pseudocyst is unknown, but several hypotheses have been formulated. The dermatologist referred this patient with a bilateral, synchronously appearing auricular pseudocyst. The synchronous appearance suggests a congenital etiology of the disease. In this perspective, infection could give rise to a preexistent fragility in the intercartilaginous space of the auricle, which could lead to the formation of the pseudocyst. As shown in ►Fig. 2, the pseudocyst lacks epithelial lining demonstrative of the term “pseudocyst.” Moreover, it shows hyaline changes, characteristic for reactive changes. If these findings are combined with the fact that this entity is extremely rare, but very susceptible to trauma, we conclude that the auricular pseudocyst has a congenital origin. This is partially in line with the theory that chronic, lowgrade trauma of the auricle, might induce the release of lysosomal enzymes causing progressive dilatation and the formation of a cystic space. The aim of the treatment of a pseudocyst is to have recurrence-free resolution and to restore the original auricular architecture while removing the cystic lesion. Three alternatives to surgery show up in the literature (see ►Table 1) with varying success. Simple observation has been described as insufficient, because without treatment auricular pseudocysts are reported to cause further cartilaginous destruction, possibly resulting in cauliflower ear. However, Patigaroo et al advocate for an observation period of 3 months, because their study shows that pseudocysts do shrink with time and many recover completely. Corticosteroid injections have been used with variable results. These intralesional corticosteroid injections are administered with an interval of 3 weeks. Some studies, for example, the study of Bhandary and Mannil, find modest
Table 1 Different treatment modalities and recurrence rates (%)1–3 Study
Simple aspiration
Corticosteroid injection
Surgical excision
Patigaroo et al (n ¼ 7)
85
43
0
Lim et al (n ¼ 9)
100
–
0
Bhandary and Mannil (n ¼ 10)
90
60
0
Facial Plastic Surgery
Vol. 30
No. 6/2014
Fig. 5 Follow-up 1-year postoperatively.
success in the treatment with corticosteroid injection. Of the 10 patients, 6 patients had recurrent pseudocysts and 3 suffered from thickening of the pinna. Especially, the risk of atrophy, deformities of the auricle, and the high chance of recurrence limit the use of this therapy. Thus, the overall consensus is that corticosteroid injections are not successful in the treatment of auricular pseudocysts. A simple needle aspiration of fluid with tight pressure bandage is a more frequently applied alternative to surgery. Fluid is aspirated until the swelling disappears followed by compression with button bolsters for an average of 7 days. Aspiration alone almost always results in prompt reaccumulation of the pseudocyst with recurrence in all the cases. Compressing after aspiration has been suggested to decrease the amount of recurrences. There are no complications associated with this procedure, but because of the high-recurrence rate this therapy is not recommended as well. The best treatment for the pseudocyst of the auricle is incision and drainage with removal of the anterior leaflet of the cartilage followed by pressure buttoning. This method is also called the deroofing procedure. Adjacent to the excellent results with respect to the recurrence-free course and the preservation of the auricular architecture, the deroofing procedure is associated with minor complications. In rare cases, perichondrial infection or hematoma can also be seen. We treated our patients with incision of the antihelical fold and excision of the lateral cartilaginous wall of the cyst. It is an easy procedure (►Figs. 3 and 4) and shows excellent results in long-term follow-up with preservation of the architecture of the auricle (►Fig. 5). When surgery is performed adequately, the risk of complications is low.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
692
Bilateral Auricular Pseudocyst
In summary, according to our experience and considering the success rate described in the literature combined with the preservation of the auricular architecture, we recommend surgical excision for the management of auricular pseudocysts. It is important to recognize and treat the pseudocyst at an early stage to avoid progression with cartilage destruction. When surgery is performed adequately, no recurrences or complications are seen.
693
References 1 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 2012;269(7):1747–1754 2 Lim CM, Goh YH, Chao SS, Lynne L. Pseudocyst of the auricle. Laryngoscope 2002;112(11):2033–2036 3 Bhandary S, Mannil TV. A comparative study in the management of auricular pseudocysts. Indian J Otolaryngol Head Neck Surg 2000; 52(3):246–250
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Conclusion
Laschen et al.
Facial Plastic Surgery
Vol. 30
No. 6/2014
Copyright of Facial Plastic Surgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Bilateral Auricular Pseudocyst: Recognizing and Treating Jonas Laschen, MD1 Frank R. Datema, MD, PhD2 Peter J. F. M. Lohuis, MD, PhD1 1 Department of Head and Neck Surgery and Oncology, The
Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands 2 Department of Otolaryngology/Head and Neck Surgery, Erasmus Medical Center, Rotterdam, The Netherlands 3 Department of Dermatology, Diakonessenhuis, Utrecht/Zeist/ Doorn, The Netherlands
Veronica C. M. Koot, MD, PhD3
Address for correspondence Jonas Laschen, MD, Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute— Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands (e-mail: [email protected]).
Facial Plast Surg 2014;30:690–693.
Abstract
Keywords
► ► ► ► ►
auricular pseudocyst bilateral etiology surgical excision treatment
An auricular pseudocyst is a benign cystic lesion of the auricular cartilage. When not recognized, it is a clinical presentation that can easily be misdiagnosed and subsequently be mistreated leading to unsatisfactory esthetical results or disease recurrence. A patient was presented with bilateral pseudocysts, which were surgically excised. The aim of the treatment of a pseudocyst is to have recurrence-free resolution and to restore the original auricular architecture while removing the cystic lesion. Three alternatives to surgery are described in the literature and all seem not to be sufficient. When the pseudocyst is treated at an early stage, surgical excision shows high success rates and preservation of the auricular architecture. According to the success rate described in the literature combined with the preservation of the auricular architecture, we recommend surgical excision for the management of auricular pseudocysts.
Auricular pseudocyst is characterized by an asymptomatic, benign cystic lesion of the anterior or posterior helix. The lesion is a very uncommon entity of the ear and frequently seen in young adults. An inflammatory response, usually because of repetitive trauma, is believed responsible, but in many cases there is no evidence of trauma. Bilateral pseudocysts are rare and usually present metachronously, but can also occur synchronously. Because pseudocysts are fairly unknown, they can be misdiagnosed and as a consequence mistreated. Once the lesion is recognized as a pseudocyst, appropriate surgical treatment can avoid late complications or relapse. We report a case of a bilateral, auricular pseudocyst, and present a review of the different treatment options based on the literature.
Issue Theme Filler Complications; Guest Editor, Eckart Haneke, MD, PhD
Case The dermatologist presented us a 76-year-old woman with a bilateral, slowly progressive, and painful swelling of the upper auricle. There was no preceding trauma, insect bite, or inflammation. Physical examination showed a 1.5 cm skincolored, fluctuant lesion on both the sides of the antihelix (►Fig. 1). The differential diagnosis included auricular pseudocyst, subperichondrial hematoma secondary to trauma, relapsing polychondritis, and traumatic perichondritis. Fine needle aspiration showed a viscous straw-yellow fluid. The diagnosis of an auricular pseudocyst was based on the typical clinical findings as described earlier, and on the macroscopical characteristics of aspirated fluid. Both the cysts were
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1396528. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
690
Laschen et al.
Fig. 1 Patient with pseudocyst (arrow) of the right auricle.
surgically excised under local anesthesia with the technique described later. Macroscopical examination revealed an intracartilaginous cyst devoid of epithelial lining, with sparse inflammatory cells (►Fig. 2). Reactive changes of the cartilage were evident. The postoperative results were good with preservation of the auricular architecture. No recurrences were seen within 1-year follow-up period.
Fig. 3 (A) Incision of the antihelical fold (pseudocyst is exposed, arrow). (B) Tangential incision of the lateral wall of the cyst (lateral cartilage is marked, arrow).
Surgical Technique The surgical field was sterilized with chlorhexidine and prepared for surgery. The incision in the antihelical fold was precisely marked for aesthetical reasons. After local infiltration with lidocaine 2.0% and adrenaline 2.0%, the incision was made and the cyst was exposed (►Fig. 3A). Then, a tangential incision of the lateral wall of the cyst
Fig. 2 Histological slide with hematoxylin and eosin staining. (A) Cyst filled with proteinaceous material. (B) Cartilage lining (no epithelium). (C) Chondrocyte.
Fig. 4 (A) The lateral cartilaginous leaflet was resected and the borders were smoothened. (B) Flap was set back and the skin was closed with mattress sutures. Facial Plastic Surgery
Vol. 30
No. 6/2014
691
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Bilateral Auricular Pseudocyst
Bilateral Auricular Pseudocyst
Laschen et al.
was made (►Fig. 3B). The lateral cartilaginous leaflet was resected—similar to the removal of the top of an eggshell— and the borders were smoothened (►Fig. 4A) to prevent secondary chondrodermatitis by pressure necrosis when sleeping. The skin flap was sutured back with a 4.0 Vicryl suture and additional 4.0 Vicryl mattress sutures were placed to prevent hematoma (►Fig. 4B).
Discussion The etiology of the pseudocyst is unknown, but several hypotheses have been formulated. The dermatologist referred this patient with a bilateral, synchronously appearing auricular pseudocyst. The synchronous appearance suggests a congenital etiology of the disease. In this perspective, infection could give rise to a preexistent fragility in the intercartilaginous space of the auricle, which could lead to the formation of the pseudocyst. As shown in ►Fig. 2, the pseudocyst lacks epithelial lining demonstrative of the term “pseudocyst.” Moreover, it shows hyaline changes, characteristic for reactive changes. If these findings are combined with the fact that this entity is extremely rare, but very susceptible to trauma, we conclude that the auricular pseudocyst has a congenital origin. This is partially in line with the theory that chronic, lowgrade trauma of the auricle, might induce the release of lysosomal enzymes causing progressive dilatation and the formation of a cystic space. The aim of the treatment of a pseudocyst is to have recurrence-free resolution and to restore the original auricular architecture while removing the cystic lesion. Three alternatives to surgery show up in the literature (see ►Table 1) with varying success. Simple observation has been described as insufficient, because without treatment auricular pseudocysts are reported to cause further cartilaginous destruction, possibly resulting in cauliflower ear. However, Patigaroo et al advocate for an observation period of 3 months, because their study shows that pseudocysts do shrink with time and many recover completely. Corticosteroid injections have been used with variable results. These intralesional corticosteroid injections are administered with an interval of 3 weeks. Some studies, for example, the study of Bhandary and Mannil, find modest
Table 1 Different treatment modalities and recurrence rates (%)1–3 Study
Simple aspiration
Corticosteroid injection
Surgical excision
Patigaroo et al (n ¼ 7)
85
43
0
Lim et al (n ¼ 9)
100
–
0
Bhandary and Mannil (n ¼ 10)
90
60
0
Facial Plastic Surgery
Vol. 30
No. 6/2014
Fig. 5 Follow-up 1-year postoperatively.
success in the treatment with corticosteroid injection. Of the 10 patients, 6 patients had recurrent pseudocysts and 3 suffered from thickening of the pinna. Especially, the risk of atrophy, deformities of the auricle, and the high chance of recurrence limit the use of this therapy. Thus, the overall consensus is that corticosteroid injections are not successful in the treatment of auricular pseudocysts. A simple needle aspiration of fluid with tight pressure bandage is a more frequently applied alternative to surgery. Fluid is aspirated until the swelling disappears followed by compression with button bolsters for an average of 7 days. Aspiration alone almost always results in prompt reaccumulation of the pseudocyst with recurrence in all the cases. Compressing after aspiration has been suggested to decrease the amount of recurrences. There are no complications associated with this procedure, but because of the high-recurrence rate this therapy is not recommended as well. The best treatment for the pseudocyst of the auricle is incision and drainage with removal of the anterior leaflet of the cartilage followed by pressure buttoning. This method is also called the deroofing procedure. Adjacent to the excellent results with respect to the recurrence-free course and the preservation of the auricular architecture, the deroofing procedure is associated with minor complications. In rare cases, perichondrial infection or hematoma can also be seen. We treated our patients with incision of the antihelical fold and excision of the lateral cartilaginous wall of the cyst. It is an easy procedure (►Figs. 3 and 4) and shows excellent results in long-term follow-up with preservation of the architecture of the auricle (►Fig. 5). When surgery is performed adequately, the risk of complications is low.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
692
Bilateral Auricular Pseudocyst
In summary, according to our experience and considering the success rate described in the literature combined with the preservation of the auricular architecture, we recommend surgical excision for the management of auricular pseudocysts. It is important to recognize and treat the pseudocyst at an early stage to avoid progression with cartilage destruction. When surgery is performed adequately, no recurrences or complications are seen.
693
References 1 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 2012;269(7):1747–1754 2 Lim CM, Goh YH, Chao SS, Lynne L. Pseudocyst of the auricle. Laryngoscope 2002;112(11):2033–2036 3 Bhandary S, Mannil TV. A comparative study in the management of auricular pseudocysts. Indian J Otolaryngol Head Neck Surg 2000; 52(3):246–250
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Conclusion
Laschen et al.
Facial Plastic Surgery
Vol. 30
No. 6/2014
Copyright of Facial Plastic Surgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
