ARTICLE
Otolaryngologists are familiar with cystic swellings of the concha of
the ear that lack serious inflammation. These lesions are frequently diagnosed
as othematoma or otoseroma and may be caused by traceable traumas or microtraumas
(e.g. headphones or helmets). Such unspecific swellings must be
differentiated from inflammatory lesions like erysipelas as well as from
neoplastic conditions of any kind [1-5]. Exact knowledge about localization
and morphology of different diseases of the outer ear is therefore of
diagnostic value (Table I).
The question arises whether the so-called "pseudocyst of the auricle"
can be regarded as an intracartilagineous cavity due to chondromalacia
[6, 7], representing a distinctive clinicopathological entity or is nothing
but a variation on the theme of othematoma or otoseroma, a later stage
of othematoma.
Four patients with such swellings of the ventral aspect of the anthelix
of the ear are presented with special emphasis on clinical and histopathological
findings, thus clarifying that the term "pseudocyst of the auricle" has
been widely misinterpreted.
Materials and methods
Clinical data
1. A 31-year-old female patient had a four week history of painless
firm swelling of the ear. Traumatic influence was not traceable. Clinically
the lesion appeared as 2 x 1 cm wide thickening on the anthelix of her
left ear showing a smooth, discretely erythematous surface. "Pseudocyst
of the auricle" was diagnosed (Fig.
1).
2. A 29-year-old male patient presented with an asymptomatic swelling
on his left ear lacking any previous trauma. Clinically, the diagnosis
pseudocyst of the auricle was established.
3. A 38-year-old male patient reported freezing his right ear when hiking
in a snowstorm. Two weeks later the painless swelling occurred.
4. A 17-year-old motorcyclist, wearing a helmet intermittently, showed
the same clinical findings with swelling and thickening of the left concha.
Biopsies
Punch biopsies were performed perforating the skin and the cartilage
from the dorsal side of the concha for cosmetical reasons. Specimens were
put into formaldehyde solution for at least eight hours before embedding
in paraffin. 5 µm thick paraffin sections were stained with hematoxylin
and eosin.
Results
Histopathological findings
Histopathological examination of the biopsy specimens showed nearly
identical findngs in all patients, namely regular epidermis and dermis
overlying normal perichondrium and cartilage. The biopsy obtained from
the concha of patient 1 additionally offered a tiny intracartilaginous
cavity, measuring approximately 0.5 mm x 0.2 mm (Fig.
2).
Treatment
In all patients incisional biopsies from the dorsal side of the auricular
concha was performed to release the contents of the cysts. Approximately
2 ml of serous fluid was drained. A firm compressive dressing was applied
for four to six days using cotton gauze bolsters and adhesive.
Three weeks later the ears showed their normal shape in all patients.
Recurrence of the cysts was not observed over a follow-up period ranging
from 22 to 36 months.
Discussion
We present four new examples of so-called "pseudocyst of the auricle"
in three male patients and one female patient characterized clinically
by non-inflammatory, merely painless swellings on the anthelix part of
the ears (Fig. 1). No
history of previous trauma was given by patients 1 and 2. The third patient
reported freezing his right ear during a hike and patient 4 was used to
wearing a motorcycle helmet. Punch biopsies taken from the dorsal side
of the concha released about 2 ml of viscous serous fluid in all four
patients. Histopathological examination of the biopsy specimens showed
the strating of normal skin, a regular perichondrium, cartilage, and a
small zone of compressed fibrous tissue in the lower levels. However,
in the sample of patient 1 subtle signs of degenerative chondromalacia
were present, to wit, a minor cystic cavity (size approximately 0.5 mm
x 0.2 mm) within the cartilage (Fig.
2). This micro cyst might contain some few µl of liquid,
but the relatively large amount of 2 ml of serous fluid, that was drained
after incision of the cyst, must have been situated outside the cartilage.
The history of the "pseudocyst of the auricle" dates back to 1846, when
Hartmann reported 12 patients with cystic swellings on the concha of their
ears [8]. At that time microscopic examination was not yet part of the
investigative routine in pathology. Later, in 1866, the German pathologist
Meyer worked on the same subject preferring the term "Ohrenblutgeschwulst"
(= othematoma). Performing detailed histopathological examinations in
25 patients he found intracartilaginous cavities, interpreting them as
the morphological hallmark of chondromalacia [6]. According to the drawings
provided by Meyer, these cavities were revealed to be about the same size
as the one we found in the specimen of patient 1.
In 1966, more than a century after the first
report on cystic swellings of the auricle by Hartmann, the Swiss pathologist
Engel, who worked in Hongkong at that time, reported on "pseudocyst of
the auricle" in 13 Chinese patients with asymptomatic ear swellings. He
again found intracartilaginous cystic spaces without epithelial lining
[9]. Identical findings have been reported by several authors in the following
years and all of them emphasized that the cystic hollows in pseudocysts
of the auricle were located within the cartilage [10-14].
Lapins, in 1982, was the first who established criteria for the differentiation
of "pseudocyst of the auricle" from othematoma and otoseroma [15] (Table
II).
Careful revision of the literature on "pseudocyst of the auricle" defined
them as being localized within the cartilage due to their origin based
on the theory of cystic chondromalacia. As previous reports never reflected
on the size of these lesions and the amount of liquid they were supposed
to contain, their intracartilaginous localisation can only be incorrect.
In fact "real" pseudocysts of the auricle may be found incidentially as
chondromalacic micro cysts as originally shown by Meyer and in our patient
1 (Fig. 2). They arise
due to degenerative processes within the cartilage representing a histopathological
reaction pattern presumably induced by minimal recurrent trauma [7]. These
tiny intracartilaginous cavities are too small by far to contain the amount
of liquid usually found in "pseudocysts of the auricle" reported and shown
in our patients.
Different approaches, such as surgical treatment, compression suture
therapy, or intracartilaginous trichloroacetic acid and button bosters,
have been described for the treatment of so-called "pseudocyst of the
auricle" [16-19]. Incisional biopsies from the dorsum of the concha and
application of a compressive dressing as performed in our patients can
be regarded as a simple and effective type of management for these cystic
swellings of the auricle.
CONCLUSION
We therefore conclude: i) small intracartilaginous cavities may occur
due to degenerative processes of the cartilage (chondromalacia) representing
a common histopathological reaction pattern first described and depicted
by Meyer more than 100 years ago, they could be defined as "real pseudocysts
of the auricle"; ii) these cavities are far too small to contain the amount
of serous fluid released by incision of the lesions that have been reported
as "pseudocyst of the auricle" by many authors; iii) accordingly, cystic
swellings of the concha of the ear containing 2 or more ml of fluid, commonly
being denominated as "pseudocyst of the auricle", cannot be situated within
the cartilage.
In brief, the term "pseudocyst of the auricle" as understood in the
literature is nothing but a variation on the theme of othematoma and otoseroma.
Article accepted on 18/5/00
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