The pseudocyst of auricle is a rare and benign condition of the ear that is caused by intracar-tilaginous collection of serous fluid in the anterior aspect of the auricle. The auricular pseudocyst has a cavity that is not lined by epithelium. The term pseudocyst of the auricle was first defined by Hartman in 18461 .
Although this condition occurs in both sexes, it occurs predominantly in men as noted by Grossman and Cohen2. Most cases are seen unilaterally but bilateral cases have alsobeen defined2. Clinically, this condition presents a painless, prominent, fluctuant swelling on the upper anterior surface of the auricle with normal or delicately inflamed overlying skin.
Although low-grade minor trauma such as hard pillows, stereo headphones and motorcycle helmets was blamed as an inducing factor of this condition, etiology is unclear and most cases do not have a history of acute trauma3 .
The aim of the treatment is to restore the original auricular structure while removing the cystic lesion. In the literature,treatment of this condition varies widely. Most accomplished results were obtained by incisional drainage,followed by chemical and mechanical obliteration such as pressure dressing with button bolsters and compression suture therapy. Chemical obliteration is performed by intracartilaginous trichloroacetic acid4 and intralesional corticosteroid3,5. If the incision and drainage or aspiration were performed alone, multiple recurrences and ear deformites could be seen. In 1985, Okuma reported three patients who were successfully treated with needle aspiration, followed by local steroid injection 5. The other method of treatment is intramuscular corticosteroid therapy 3.
Here, we present the treatment of an auricular pseudocyst by needle aspiration and local steroid injection in a nontraumatic and nonrecurrent case.
CASE
A 22-year-old man was admitted to our clinicwith a history of painless swelling of the left auricle at the superior scaphoid fossa for two weeks. The patient had no history of microtrauma associated with occupational or behavioural activities and declined any history of trauma. On physical examination, the patient had two prominent, fluctuant swelling at the left superior scaphoid fossa with a normal overlying skin. The lesions that affected the superior scaphoid fossa were 16x16 mm and 10x10 mm in diameter, respecti-vely (Figure 1). The diagnosis of the lesion depen-ded on the typical history and clinical findings.
Figure 1. The lesions that affected the superior scaphoid fossa were 16x16 mm and 10x10 mm in diameter, respectively
Figure 2. There were foamy macrophages in a proteineous background (PapX40)
The treatment was made by local anesthesia (%1 w/v lidocaine, 1 ml). The anesthetized area was penetrated with a sterile needle and all the pseudocystic collection was aspirated into an empty injector. Using another injector, steroid fluid (triamsinolone suspension) was injected into the pseudocystic cavities until they achieved the original sizes. Then gauze was pressed onto the auricular surface to stop the bleeding. The aspirated fluid was examined histopathologically. There were foamy macrophages in a proteineous background (PapX40) (Figure 2). Four weeks after the intervention, there was no recurrence of the pseudocyst with an enviable cosmetic outcome (Figure 3).
Figure 3. Four weeks after the intervention, there was no recurrence of the pseudocyst with an enviable cosmetic outcome
DISCUSSION
Although histopathologic findings are well described in preview reports2 the precise mechanism of pseudocyst formation is yet unknown. It is shown that there is no proliferation of inflammatory cells. Eosinophilic degeneration and necrosis of the cartilage can occur in some areas. In our case, fine needle aspiration biopsy of the cyst revealed foamy macrophage in a proteinaceous background.
The differential diagnosis of this condition includes subperichondral haematoma secondary to trauma, cellulitis and relapsing polychondritis. Despite its unclear etiology, most of the physicians accepted that chronic low-grade trauma is the major etiological factor of this condition. However in our case, the patient had no history of microtrauma associated with occupational or behavioural activities as previously reported by Salgado6 and Tuncer7.
The aim of the treatment should provide best cosmetic outcome for the patient while using minimal invasive technique that provides no recurrence. In the literature, various treatment methods of auricular pseudocysthave been applied. Although incisional drainage or needle aspiration followed by a compressive dressing is one of the most commonly applied methods this therapy is inadequate due to its high recurrence rate. Chemical or mechanical obliteration of the cavity is necessary for a successfull treatment as reported in the previous studies. Miyamoto et al9 applied intracystic steroid injections to treat their patients.
In addition, when the treatment is planned with simple aspiration or incision and drainage, recurrence rates increase. Recurrent auricular pseudocysts were treated by several authors with reasonable success by achieving aspiration followed by either oral or intralesional steroid administration3,9. But intralesional steroid admi-nistration has some disadvantages such as skin pigmentation changes, skin, soft tissue and cartilage atrophy and potential systemic side affects. In our case, this side effects were not seen postoperatively after 4 weeks of follow up.
At recurrent cases, more invasive surgical approaches are necessary to prevent recurrences and poor cosmetic appearances. Anterior wall excision was defined for recurrent cases10. In this technique if the posterior wall is weak, cosmetic deformites such as ‘floopy ear deformity’ may ocur. Tuncer et al. described one stage treatment with surgical curettage, followed by intralesional fibrin glue administration for obliteration of the cystic cavity7.
We suggested that the needle aspiration and intralesional steroid injection therapy are minimally invasive, easy to apply in an office setting and give a good cosmetic outcome. Complications associated with intralesional steroid administration such as skin, soft tissue and cartilage atrophy, skin pigmentation changes and potential systemic side effects were not seen in our case. Eventually we think that, in non-traumatic and non-recurrent cases, this technique can be performed confidently and successfully.