Pseudocyst of the auricle

Introduction

Pseudocyst of the auricle is a rare, asymptomatic, cystic, swelling of the upper portion of the auricle. It results from spontaneous collection of an oily, serous fluid within an unlined intracartilaginous cavity.[1] The etiology and pathogenesis of this condition is not known. Although various medical and surgical therapeutic approaches have been described, the treatment of pseudocyst of auricle is difficult and recurrences are frequent.[2] We describe two patients treated successfully with a combination of needle aspiration and pressure dressing and a short course of systemic corticosteroids.

Case Report

A 30-year-old male presented with an asymptomatic swelling of the right pinna of 15 days duration. There was no history of trauma to the ear prior to onset of the swelling and he had no significant illness in the past. On examination there was a 2.5 x 3cm cystic, non-tender swelling involving the concha of the right pinna with normal overlying skin [Figure - 1]. A clinical diagnosis of pseudocyst of the auricle was made.

Taking strict aseptic precautions, the pseudocyst was aspirated completely with a No. 20G needle. Thereafter a tight dressing was applied over the pinna with a roller bandage, encircling the forehead. The bandage was removed after one week and the oral prednisolone was continued for another three weeks, reducing the dose by 10mg each week. Complete resolution of the auricular swelling was observed, without any complications.

Case 2: A 25-year-old male presented with a one-week history of a painless swelling in the upper part of left ear. There was no preceding history of trauma to the ear and his general health was preserved. On examination of the left ear there was a cystic, non-tender 2.5 x 3.5 cm sized swelling over the concha. A clinical diagnosis of pseudocyst of the auricle was made. The swelling was aspirated with a No. 20G needle under aseptic precautions and pressure dressing with bandage was applied, which was removed after one week. A 4-week course of oral prednisolone was given, starting with 40mg daily and reducing the dose 10mg each week. The swelling disappeared completely, without any complications or recurrence over 2 months follow up.

Discussion

Pseudocyst of the auricle is characterized by a unilateral, asymptomatic, cystic swelling of the helix or the antihelix, most often located in the scaphoid fossa.[1] Engel in 1966 first reported the pseudocyst of auricle in the Chinese.[3] This rare disorder results from spontaneous accumulation of a sterile, oily yellowish fluid, resembling olive oil. It is mostly observed in young adult males and presents clinically as a solitary, fluctuant, non-inflammatory swelling of the upper portion of the auricle with normal overlying skin.[1],[2],[3]

The etiopathogenesis of auricular pseudocyst is still unknown. Reported minor trauma leading to cartilage fragmentation and cystic cavity formation has been proposed, while another study supports the hypothesis of congenital embryonic dysplasia as the origin of formation of pseudocyst of the auricle.[2]

Histopathology reveals an intracartilaginous accumulation of fluid without an epithelial lining. The lack of epithelial lining led to the term ′pseudocyst′. In early lesions, the cystic space is surrounded by fibrosed cartilage while in some areas necrosis and total dissolution of the cartilage may be present.1 In later stages, intracavity foci of granulation tissue and more extensive intracartilaginous fibrosis is present.[4]

Several treatment modalities have been described with variable success. The aim of treatment is successful resolution of the pseudocyst without damage to the healthy cartilage and to prevent its recurrences.[5] Various treatments reported in literature include simple aspiration, intralesional injection of corticosteroids, and aspiration in combination with bolstered pressure sutures or plaster of paris cast.[5],[6],[7],[8],[9] More invasive techniques like incision and drainage of the cavity followed by its obliteration by curettage, sclerosing agent and pressure dressing; open deroofing that involves removal of the anterior cartilaginous leaflet of pseudocyst with repositioning of the overlying flap of skin have also been recommended.[2] However, the invasive treatment modalities carry the risk of perichondritis complicated by formation of floppy ear or cauliflower deformity and may be followed by recurrences.[5]

Although intralesional corticosteroid injections have been employed,[7] oral corticosteroid therapy has not been commonly utilized for these patients. Raman et al have reported successful treatment of four patients with high dose oral prednisolone therapy.[10] They proposed that corticosteroids might help to prevent intracartilaginous fibrosis and formation of intracavitary granulation tissue. The anti-inflammatory action of corticosteroids may also contribute to prevent edema and fibrosis of the dermis. The accumulated fluid is gradually resorbed with good cosmetic results.[10]

We combined needle aspiration and pressure dressing with a short course of oral corticosteroids. Both the patients responded well to treatment without any complications or recurrences. However, further studies are required to establish firmly the role of oral corticosteroids, which have the advantage of being a non-invasive therapeutic modality.