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Swelling of the Right Ear



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Am Fam Physician. 2007 May 1;75(9):1379-1380.

A 22-year-old man presented for evaluation of a painless swelling on his right ear that he first noticed about five months earlier. He denied any history of trauma. The patient was otherwise healthy with no significant medical history. The scaphoid fossa of the right auricle demonstrated a nontender, noninflammatory, almond-shaped nodule approximately 1.5 cm × 1 cm (see accompanying figure).

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Chondrodermatitis nodularis chronica helicis.

B. Othematoma.

C. Pseudocyst of the auricle (benign idiopathic cystic chondromalacia).

D. Relapsing polychondritis.

E. Subperichondral abscess.

Discussion

The answer is C: pseudocyst of the auricle. An auricular pseudocyst, also referred to as benign idiopathic cystic chondromalacia, is an uncommon condition characterized by a painless, cystic swelling of the concha of the pinna.1 It most commonly affects healthy young men2 and rarely is there a history of antecedent trauma. There appears to be no racial predisposition.3 The exact etiology is unknown, but it is thought to be related to degenerative cartilage.4

The diagnosis can usually be made on clinical grounds, and routine histology is rarely necessary. However, when biopsy is performed, a characteristic finding is an intracartilaginous space with no epithelial lining.3 Needle aspiration of the cyst typically reveals a clear or yellow sterile fluid with the consistency of olive oil.5

Treatment goals include permanent removal of the pseudocyst with good aesthetic outcome and preservation of the normal anatomic architecture.3 It should be noted that simple needle aspiration of the pseudocyst, without additional treatment, always results in prompt reaccumulation of fluid, usually in less than three days.3 Definitive treatment by surgical excision with pressure dressing or compression buttoning usually results in a satisfying outcome; surgical excision remains the treatment of choice.6

Other treatment options include high-dose oral corticosteroids, simple aspiration with compression bolsters, and punch biopsy with pressure dressing.7 Intralesional injection of corticosteroids,8,9 sclerosing agents,10 and minocycline4 also have been attempted with varying degrees of success. Aspiration followed by intralesional triamcinolone acetonide (Kenalog) is another option and may be attempted up to three times before moving to surgical treatment.8,9

Chondrodermatitis nodularis chronica helicis, the most common diagnosis to exclude in the work-up, typically presents as an exquisitely tender nodule on the outer helix that may interfere with sleep. There is often a preceding history of trauma. It is most common in men older than 40 years.

An othematoma invariably involves a history of notable trauma and may demonstrate clinical signs of inflammation, including pain and redness.

Relapsing polychondritis is a rare multisystem autoimmune disease that can affect all cartilage throughout the body, including the ear, eyes, nose, and respiratory system.11 Relapsing polychondritis of the ear is manifested as a painful, red, swollen superior portion of the pinna, sparing the noncartilaginous ear lobe.

Subperichondral abscess typically presents with pain and surrounding erythema. Diagnosis can be confirmed by aspiration of purulent fluid.

Selected Differential Diagnosis of Auricular Swelling

Condition Characteristics

Chondrodermatitis nodularis chronica helicis

Exquisitely tender nodule on the outer helix; often a history of trauma

Othematoma

History of trauma; may demonstrate pain and redness

Pseudocyst of the auricle

Painless, cystic swelling of the concha of the pinna; usually no history of trauma

Relapsing polychondritis

Autoimmune cartilage disease; ear manifestations are a painful, red, swollen superior portion of the pinna, sparing the noncartilaginous earlobe

Subperichondral abscess

Pain and surrounding erythema; purulent aspirate

Selected Differential Diagnosis of Auricular Swelling

View Table

Selected Differential Diagnosis of Auricular Swelling

Condition Characteristics

Chondrodermatitis nodularis chronica helicis

Exquisitely tender nodule on the outer helix; often a history of trauma

Othematoma

History of trauma; may demonstrate pain and redness

Pseudocyst of the auricle

Painless, cystic swelling of the concha of the pinna; usually no history of trauma

Relapsing polychondritis

Autoimmune cartilage disease; ear manifestations are a painful, red, swollen superior portion of the pinna, sparing the noncartilaginous earlobe

Subperichondral abscess

Pain and surrounding erythema; purulent aspirate

Address correspondence to Abel D. Jarell, MD, at ajarell@partners.org. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

REFERENCES

1. 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;10:451–4.

2. Cohen PR, Grossman ME. Pseudocyst of the auricle. Case report and world literature review. Arch Otolaryngol Head Neck Surg. 1990;116:1202–4.

3. Lim CM, Goh YH, Chao SS, Lynne L. Pseudocyst of the auricle. Laryngoscope. 2002;112:2033–6.

4. 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;45:554–6.

5. Ophir D, Marshak G. Needle aspiration and pressure sutures for auricular pseudocyst. Plast Reconstr Surg. 1991;87:783–4.

6. Choi S, Lam KH, Chan KW, Ghadially FN, Ng AS. Endochondral pseudocyst of the auricle in Chinese. Arch Otolaryngol. 1984;110:792–6.

7. Paul AY, Pak HS, Welch ML, Toner CB, Yeager J. Pseudocyst of the auricle: diagnosis and management with a punch biopsy. J Am Acad Dermatol. 2001;45:(6 suppl)S230–2.

8. Kunachak S, Prakunhungsit S. A simple treatment for endochondral pseudocyst of the auricle. J Otolaryngol. 1992;21:139–41.

9. Miyamoto H, Oida M, Onuma S, Uchiyama M. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol. 1994;74:140–2.

10. Zhu LX, Wang XY. New technique for treating pseudocyst of the auricle. J Laryngol Otol. 1990;104:31–2.

11. Gergely P Jr, Poor G. Relapsing polychondritis. Best Pract Res Clin Rheumatol. 2004;18:723–38.

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