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Article history: Objective: An auricular pseudocyst is a fluid filled cavity, characterized by a lack of epithelium, in
Received 15 July 2018 the intra-cartilaginous space. Clinically, it presents as a painless lump on the upper anterior surface
Accepted 29 October 2018 of the ear. Various treatment methods have been discussed in the literature, including aspiration,
Available online 20 November 2018
incision and drainage, or steroid injection. However, these approaches are associated with a high rate
of recurrence and results are often esthetically unsatisfactory; therefore, a need for improved
Keywords:
treatment approaches remains.
Pseudocyst
Treatment
Methods: From March, 2015, to June, 2017, 15 patients with auricular pseudocyst were treated with
Auricle surgical deroofing followed by local contour pressure dressing with a simple bolster. In addition, the
Recurrence structure of the auricular pseudocyst was assessed at a microscopic level.
Deformity Results: Patients were followed up for a mean period of 12 months, during which time there were no
reports of postoperative complications or recurrence. The results were cosmetically excellent in all
patients and no cartilage deformity was seen. Considering the composition of pseudocysts seen on
microscopic evaluation, deroofing to remove the anterior leaflet and removal of debris from the
posterior leaflet is an appropriate treatment modality.
Conclusion: This reliable and simple approach may be recommended as first line treatment for
auricular pseudocysts to avoid recurrence and complications associated with other treatment
modalities, such as cartilage deformity, skin depigmentation, and scarring.
© 2018 Elsevier B.V. All rights reserved.
https://doi.org/10.1016/j.anl.2018.10.017
0385-8146/© 2018 Elsevier B.V. All rights reserved.
Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582 577
Fig. 1. Operative technique. (A) Auricular pseudocyst along the triangular fossa and cocha. (B) Helical incision. (C) Skin flap elevation. (D) Radical exposure of the
outer layer of the anterior leaflet. (E) Excision of the anterior leaflet followed by curettage of debris on the posterior leaflet. (F) Skin redraping with primary repair. (G)
Local contour compression using a simple bolster for 7 days. (H) Aesthetically satisfactory result without recurrence or complication.
versial, the goal should be to maintain or restore the normal were enrolled in this study. Differential diagnosis of pseudocyst
anatomical structure of the auricle with no recurrence [11]. (rather than hematoma or other cystic lesion) was performed by
In this report, we present cases of auricular pseudocyst preoperative imaging with sonography or computed tomography.
treated with surgical deroofing [12]. All patients underwent surgical deroofing as the primary
treatment approach and follow up was conducted for a period
2. Methods of 12 months. As surgical outcomes, postoperative complication,
episode of recurrences, and cosmetic results were evaluated. In
Fifteen patients with pseudocyst of the auricle, diagnosed on details, cosmetic results were determined whether depression or
the basis of clinical presentation from March, 2015, to June, 2017, contracture occurred, and skin texture was preserved.
Table 1
Patient demographics.
Patient number Age, years Gender Etiology Side Cyst size, cm2, left/right Location Follow up, months Complication Recurrence
1 (case 3) 31 Male Unknown Right 1.0 Concha fossa 12 - -
2 (case 1) 47 Male Unknown Right 2.5 Concha fossa 18 - -
3 (case 2) 66 Male Unknown Right 3.0 Scaphoid fossa 18 - -
4 46 Male Unknown both 1.0/0.5 Scaphoid fossa 12 - -
5 16 Male Repetitive helmet use Left 1.5 Scaphoid fossa 12 - -
6 26 Male Unknown both 1.0/1.5 Scaphoid fossa 12 - -
7 28 Male Unknown Right 2.0 Triangular fossa 6 - -
8 35 Male Unknown Left 1.5 Triangular fossa 6 - -
9 37 Male Unknown Right 1.0 Scaphoid fossa 12 - -
10 40 Male Unknown Right 1.5 Scaphoid fossa 12 - -
11 29 Male Unknown Left 1.0 Concha fossa 12 - -
12 36 Male Repetitive headphone use Left 2.0 Scaphoid fossa 12 - -
13 42 Male Unknown Right 1.5 Concha fossa 12 - -
14 38 Male Unknown Right 2.0 Triangular fossa 12 - -
15 50 Male Unknown Left 1.5 Scaphoid fossa 12 - -
578 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582
3. Results
Fig. 3. Microscopic characteristics of auricular pseudocyst. The specimen was obtained from the margin of the cyst and both anterior and posterior walls were
retained. The anterior leaflet (A) is composed of perichondrium (!) and regenerative cartilage ()) and the posterior leaflet (B) is composed of regenerative cartilage
()) and perichondrium (!). Intra-cartilage cavity (C) shows a lack of epithelial lining with mucinous material and debris (>) filling the space. Magnification 40.
Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582 579
Fig. 4. Case 1 surgical procedure. (A) Right auricular pseudocyst in a 47-year-old male. (B) Immediately after helical incision, the anterior leaflet was tagged by
forceps. (C) The skin flap was elevated (tagged with skin hook), and the anterior leaflet (indicated by forceps) was ready for excision. (D) After the anterior leaflet of
the cyst was excised, curettage of the posterior wall was performed to remove any debris. (E) Silastic drain was inserted and skin suture performed before application
of a bolster contour compressing dressing. (F) 18 months post-surgery.
Fig. 5. Case 2 surgical procedure. (A) Right auricular pseudocyst in a 66-year-old-male. (B) Helical incision was made along the margin of the cyst and the anterior
leaflet was tagged by a skin hook. The skin flap was elevated and the anterior leaflet (held with forceps) was ready for excision. (C) Excised specimen of anterior
leaflet of pseudocyst. (D, E) After skin suture, a bolster contour compressing dressing was fixed with horizontal mattress sutures. (F) 15 months post-surgery.
Fig. 6. Clinical case 3. (A) Right auricular pseudocyst in a 31-year-old male. (B) Bolster was applied after excision as a contour compressing dressing. (C) 12 months
post-surgery.
Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582 581
[4] because accurate diagnosis can be challenging and inflammatory cells within the cystic space and the absence
appropriate treatment is not always undertaken. of an epithelial lining on the inner surface of the intra-
Pseudocyst of the auricle is defined as a collection of fluid in cartilaginous cavity [17,18].
a tissue space without an epithelial lining [2–5]. The scaphoid Several treatment modalities for pseudocysts are discussed
fossa is the most common site of involvement followed by the in the literature. As shown in Table 2, non-surgical methods,
triangular fossa and cymba concha [4,8,10,13]. Pseudocysts are such as injection of steroid or trichloroacetic acid, are
an endochondral cystic lesion that show clinical and pathologic associated with a high recurrence rate and may lead to serious
features that differ from other cystic lesions of the auricle auricular deformities, such as skin pigmentation and atrophy of
[14]. Clinically, pseudocyst of the auricle is usually asymp- the skin, soft tissue and cartilage [6,8,16]. Kanotra and Lateef
tomatic, although mild inflammatory signs may occasionally reported that of 13 patients undergoing incision and drainage
occur. with curettage followed by compression by buttoning, five
In this study, the main age group was 30–50 years, showed recurrence and three showed permanent auricular
accounting for almost 70% of all patients, which is similar deformity [5]. To avoid recurrence, the definitive surgical
to results seen in other studies [4,6–14]. The cysts are procedure should aim to terminate the serous effusion, by
commonly unilateral and are 1.5 times more common on the removing debris on the anterior surface of the remaining
right ear than the left ear [14]. Differential diagnosis posterior leaflet, which could be the pathologic origin of
includes subperichondrial hematoma caused by accumula- effusions [17,18].
tion of blood secondary to trauma, relapsing polychondritis In our study, all patients underwent deroofing surgery
and cellulitis. followed by contour pressure dressing with a simple bolster and
The pathogenesis of pseudocyst development remains excellent results were achieved with no incidents of recurrence.
unknown. Engel et al. hypothesized that it results from a Previously, deroofing surgery has not been performed as first
defect in embryogenesis in which residual planes of tissues are line treatment but reserved for patients with recurrence after the
created during the folding of the brachial process that fuse to failure of other treatment modalities, such as incision and
form the auricle [2,15]. The excess tissues could theoretically drainage and steroid injection [16].
reopen when subjected to mechanical stress in patients who
have predisposing factors for pseudocyst development. Other 5. Conclusion
studies have proposed that repeated mechanical irritation
contributes to pseudocyst formation as it leads to disturbance of Pseudocyst of the auricle is a benign disease and a variety of
the local microcirculation, leading to ischemia and subsequent treatment options are available. However, conservative treat-
cartilaginous degeneration [3,8,16]. In this study, the fact that ments often result in recurrence and unsatisfactory esthetic
all of the patients were male and the location of the lesion was results. In deroofing surgery, anterior cartilage (the origin of the
mainly on the upper half of the ear, suggests that the cause may serous effusion) is completely excised. Eliminating debris and
be associated with mechanical irritation and chronic trauma. granulation tissue on the anterior surface of posterior leaflet is
Indeed, in our patients pseudocysts developed after daily use of key to avoiding recurrence. In addition, the procedure is simple
a motorcycle helmet or headphones in several patients, and can be performed under local anesthesia. Therefore,
supporting our hypothesis. considering the excellent results and lack of recurrence seen in
A differential and accurate diagnosis of the pseudocyst is this study, we would recommend deroofing surgery as first line
important and a histology-based approach is key to making a treatment for all patients with pseudocyst.
final diagnosis. A consistent histologic finding of pseudo-
cyst of the auricle is an expanded inter-cartilaginous cystic Source of funding
space containing serous fluid. At the margin of the cyst, the
cartilage architecture is normal, but in the center of anterior The authors have no financial interest to declare in relation to
leaflet of the cyst, degeneration of the cartilage is common. the content of this article. No funding was received for this
Differential diagnosis can be made by the presence of research.
Table 2
Various treatment modalities of pseudocyst.
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