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Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 204-206

Preauricular iatrogenic epidermoid cyst through middle-ear surgery

Department of Otorhinolaryngology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Hatice Celik
Saglik Bakanligi Ankara Egitim Ve Arastirma Hastanesi, Sakarya Mh. Ulucanlar Cd. No: 89 Altindag, 06230 Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_40_18

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Iatrogenic implantation of squamous epithelium during middle-ear surgery may cause epidermoid cyst (EC) development. These cysts may arise in different localizations of the head and neck following otological surgery. In this rare case, a giant EC with a size of 56 mm × 30 mm, which appeared in the preauricular area growing in the past 1 year in a 40-year-old male patient who underwent type 1 tympanomastoidectomy due to chronic otitis media without cholesteatoma 8 years ago, was discussed with the literature in terms of clinical findings and differential diagnosis.

Keywords: Cholesteatoma, epidermoid cyst, preauricular cyst

How to cite this article:
Celik H, Akkoca O, Ibas M. Preauricular iatrogenic epidermoid cyst through middle-ear surgery. Indian J Otol 2018;24:204-6

How to cite this URL:
Celik H, Akkoca O, Ibas M. Preauricular iatrogenic epidermoid cyst through middle-ear surgery. Indian J Otol [serial online] 2018 [cited 2023 Mar 21];24:204-6. Available from: https://www.indianjotol.org/text.asp?2018/24/3/204/249873

  Introduction Top

Epidermoid cysts (ECs) are one of the common skin tumors, and generally, they are seen on the scalp, face, neck, dorsal, and ventral trunk region.[1] Commonly, they are small in dimension; however, rarely, they reach 5 cm or larger sizes.[2] Congenital and acquired factors make up the etiology. Acquired ECs usually occur due to surgical trauma.[3] In this article, an EC case with an approximately 56 mm × 30 mm dimension that formed 8 years after type 1 tympanomastoidectomy, which totally infiltrated the mastoid cavity and expanded to the preauricular region from the antrum and zygomatic root, is presented.

  Case Report Top

A 40-year-old male patient presented to our clinic with a painless lump in front of the left ear which occurred 1 year ago and showed rapid progression in the past 3 months. His history was specific for type 1 tympanomastoidectomy operation while no complaints of hearing loss or otorrhea were present postoperatively. On physical examination, a painless, soft, mobile mass lesion with a size of approximately 56 mm × 30 mm located 2 cm in front of the left tragus through the midline and inferiorly extending 2 cm above the attachment level of the auricle from the ear lobule was palpated [Figure 1]. It was noted that the mass reached the postauricular antrum level and deviated the auricle anteroinferiorly. On the otoscopic and microscopic examination of the left ear, the graft membrane was observed intact and normal. Other physical examination findings of the patient were all normal.
Figure 1: The clinical presentation of the epidermoid cyst

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The computed tomography (CT) of the temporal bone revealed a mass lesion with fluid density surrounded with a capsule of 56 mm × 30 mm in size with smooth margins originating subcutaneously from the superior part of the left temporal bone's squamous part, expanding the scalp and inferiorly reaching the antrum and the mastoid by passing the left external auditory canal [Figure 2]. On magnetic resonance imaging (MRI) of the ear, an approximately 56 mm × 30 mm-sized cystic mass lesion with bilobulated contours on the left temporal region superior to the external auditory canal inside the subcutaneous fat tissue was detected. No significant relation between the lesion and external auditory canal was present. The mass was observed hypointense on T1-weighted images, while it was hyperintense on T2-weighted images. No significant contrast uptake was detected on postcontrast images. The patient who underwent needle biopsy and who reported keratinous cyst was operated. The incision starting from tragus to the lobule was combined with the postauricular incision top to bottom during the operation. The cholesteatoma sack which infiltrated the antrum and mastoid was observed to extend toward the tragus anteriorly and the lobule level, over passing the subcutaneous tissues from the zygomatic root. In addition, it was observed to be advanced approximately 1 cm to the neck from the mastoid apex posteriorly [Figure 3]. Canal wall down tympanoplasty procedure was done to the patient whose middle ear and ossicles were normal. The pathology report was compatible with EC and cholesteatoma. Written informed consent was obtained from the patient for publication of the report.
Figure 2: The computed tomography image of the epidermoid cyst (black arrow)

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Figure 3: The cholesteatoma sack inside the antrum and mastoid

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  Discussion Top

ECs are defined as cystic masses filled with keratin debris and surrounded with stratified squamous epithelium.[4] As it may be present in any part of the body, commonly, they are seen on the face, neck, scalp, and both anterior and posterior thoracic area. Cysts surrounded with an epithelial wall are frequently observed by a few millimeter dimensions; however, rarely, they may reach to a size of 5 cm. They are mobile unless fibrosis has developed.[5],[6] ECs may occur due to congenital or acquired factors. While congenital ECs develop because of the ectodermal implantation into the epithelial fusion layers during closure, acquired ones develop because of the implantation of the superficial epidermal tissue into the dermis or subcutaneous tissue as a result of surgical trauma.[3]

ECs may develop in areas as the tympanic membrane, middle ear, parapharyngeal region, parotid gland, and temporal fossa as a result of surgical procedures as tympanomastoid surgery, ventilation tube insertion, and stapedectomy.[7] Trauma-related cases are usually seen on digits, palms, or the plantar side of feet.[8] In this case, the EC is thought to be developed because of the epithelial implantation during middle-ear surgery.

In preoperative diagnosis, CT and MRI are used. ECs are seen as smooth lesions with sclerotic margins based on the cyst content. On MRI, they are seen isointense or slightly hyperintense compared to the surrounding muscular tissue on T1-weighed images, while on T2-weighted images, they are seen as hyperintense lesions.[5]

In differential diagnosis, cholesteatoma, dermoid cyst, hemangioma, hydatid cyst, eosinophilic granuloma, aneurysmal bone cyst, giant cell granuloma, meningioma, neurilemmoma of the face, and acoustic neuroma must be kept in mind.[3]

Cholesteatoma relapse is a common complication that is seen after tympanomastoidectomy. In literature, a parapharyngeal region EC is reported in a case 5 years postoperatively in which modified radical mastoidectomy procedure was done due to cholesteatoma.[8] In this case, during the initial surgery, cholesteatoma was not encountered. The disease was not developed due to a residual or recurrent cholesteatoma. The existence of the preauricular cyst and the related cholesteatoma sack in the mastoid cavity and antrum made us think that the development of the cholesteatoma and EC was caused by the iatrogenic implantation of the squamous epithelium in the prior surgery.

Abscess formation, hemorrhage, and malignant transformation are reported to be the complications of ECs. Repeated incomplete resections and the frequent infection of the cyst are thought to increase the risk of malignant transformation.[3]

The treatment of the cyst is complete excision with the whole skin wall surgically. Incomplete resections and remnants of the cyst wall will always trigger relapse. ECs may sometimes get infected. Surgical excision is difficult in inflamed cysts, therefore, before doing any surgical procedure, giving medical treatment to reduce the inflammation is a correct approach.[3],[6] In this case, no infection finding was observed preoperatively, and during the surgery, the cyst was completely excised with its capsule without any perforation.

Consequently, in tympanomastoid surgery, the microscopic implantation of the squamous epithelium may lead to macroscopic issues in the future, and these issues may be confused with the common causes of where they emerge. Regular follow-up of patients after otological surgery has great importance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cho Y, Lee DH. Clinical characteristics of idiopathic epidermoid and dermoid cysts of the ear. J Audiol Otol 2017;21:77-80.  Back to cited text no. 1
Kang SG, Kim CH, Cho HK, Park MY, Lee YJ, Cho MK, et al. Two cases of giant epidermal cyst occurring in the neck. Ann Dermatol 2011;23 Suppl 1:S135-8.  Back to cited text no. 2
Lee DH. Intradiploic epidermoid cyst of the temporal bone: Is it the same as or different from cholesteatoma? J Craniofac Surg 2011;22:1973-5.  Back to cited text no. 3
Ozcan KM, Dere H, Ozcan I, Gun T, Unal T. An epidermal cyst in the parotid gland following ear surgery: A case report. B-ENT 2006;2:193-5.  Back to cited text no. 4
Boffano P, Roccia F, Campisi P, Zavattero E, Gallesio C, Bosco GF, et al. Epidermoid cyst of the temporal region. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e113-6.  Back to cited text no. 5
Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician 2002;65:1409-12, 1417-8, 1420.  Back to cited text no. 6
Manz D, Bankfalvi A, Lehnerdt G. Epidermal cyst of the parotid gland. HNO 2011;59:64-7.  Back to cited text no. 7
Ulku CH, Uyar Y, Kocaogullar Y, Avunduk MC. Iatrogenic epidermal inclusion cyst of the parapharyngeal space: Unusual complication of ear surgery, an interdisciplinary approach. Skull Base 2004;14:47-51.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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