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ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 3  |  Page : 140-143

A study on clinical presentation of pseudocyst, dermoid cyst, and sebaceous cyst of pinna and its management at a tertiary care center


Department of Otorhinolaryngology Head and Neck Surgery, Sir T Hospital and Government Medical College, Bhavnagar, Gujarat, India

Date of Submission18-May-2020
Date of Decision13-Jul-2020
Date of Acceptance21-Jul-2020
Date of Web Publication16-Dec-2021

Correspondence Address:
Dr. Vikas Sinha
B-303, Himalaya Skyz Flat, Behind Himalaya Mall, Bhavnagar - 364 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_94_20

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  Abstract 


Introduction: Swellings of pinna are common but various cystic lesions encountered in clinical practice are not reported too often. Management of these lesions if not done at the earliest may lead to disfigurement and change the entire appearance of the face. Aim and Objective: The aim and objective of the study was to determine the clinical presentation, relevant investigations, appropriate treatment, timing of surgical intervention, and prevention of complications. Materials and Methods: Our study comprised 38 cases; male and female patients presented with different types of pinna swellings. Results: A total number of pseudocyst patients were 30 and of which only four were females. Recurrence seen in pseudocyst was 13.33%. Complete resolution was seen after excision in all cases of dermoid and sebaceous cyst. Conclusions: Aspiration and drainage followed by splinting is a simple, safe, and effective surgical treatment of pseudocyst. Simple excision is the most effective surgical treatment of dermoid cyst and sebaceous cyst.

Keywords: Dermoid cyst, pseudocyst, sebaceous cyst, splinting


How to cite this article:
Sinha V, Parmar BD, Chaudhary N, Jha SG, Yadav SK. A study on clinical presentation of pseudocyst, dermoid cyst, and sebaceous cyst of pinna and its management at a tertiary care center. Indian J Otol 2021;27:140-3

How to cite this URL:
Sinha V, Parmar BD, Chaudhary N, Jha SG, Yadav SK. A study on clinical presentation of pseudocyst, dermoid cyst, and sebaceous cyst of pinna and its management at a tertiary care center. Indian J Otol [serial online] 2021 [cited 2022 Jan 24];27:140-3. Available from: https://www.indianjotol.org/text.asp?2021/27/3/140/332653




  Introduction Top


Swellings of pinna are common but various cystic lesions encountered in clinical practice are not reported too often. A pseudocyst of the auricle is an intracartilaginous cystic swelling of pinna. Hartman first reported such a condition in 1846.[1] Pseudocyst is more commonly seen in Chinese and light skin men.[2] Dermoid cyst is a benign lesion seen in the region of embryonic fusion. Dermoid cysts of the auricular area are extremely rare.[3] Sebaceous cyst is a common benign cyst caused by blockage of draining ducts of sebaceous glands leading to cystic dilation of the gland.[4]

Aim and objective

The aim and objective of the study was to determine the clinical presentation, relevant investigations, appropriate treatment, timing of surgical intervention, and prevention of complications.


  Materials and Methods Top


In this prospective analytic study, 38 cases were included, which managed for a period of 1 year from January 2019 to December 2019 at the Department of ENT and Head and Neck Surgery, Sir T General Hospital and Government Medical College, Bhavnagar, Gujarat. Both men and women of varying age groups were included in this study. A detailed clinical history regarding onset, predisposing factor, and associated conditions was documented. Pseudocyst was diagnosed by clinical examination. Dermoid and sebaceous cysts were diagnosed clinically and confirmed by ultrasonography and fine-needle aspiration cytology. Surgery was carried out under local anesthesia after informed valid and written consent.

Inclusion criteria

  • Any patient presenting with benign cystic swelling of the pinna.


Exclusion criteria

  • Any coexisting disease of the pinna, i.e., abscess, dermatological conditions, and congenital anomalies and any coexisting disease of the external or middle ear
  • Cyst with intracranial extension
  • Pregnant women.


Statistical analysis

Simple proportions were calculated.

Surgical procedure

With all aseptic precautions, first pseudocyst aspiration was done with a wide bore needle. Followed by incision and drainage over dependent part with 11 number blade and bolstered (made up of Ryle's tube piece) pressure, suturing was done with Ethilon 3-0 and mastoid bandage was given[Figure 1] and [Figure 2]. Oral antibiotics (preferably fluoroquinolones) and analgesic were given to all patients for 7 days. Follow-up was done on 2nd day, 7th day, and at 1 month. Mastoid bandage and bolstered dressing were removed on 7th day.
Figure 1: Ryle's tube splint

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Figure 2: Bolstered dressing

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Complete excision of sebaceous cyst was done in all cases. Infected cysts were treated with appropriate antibiotics before surgery. The cyst was removed by sharp dissection and care taken to keep the walls of the cyst intact to ensure complete removal. The ductal tissue leading to the cyst as well as its external opening including a small segment of the overlying skin was removed. In cases of infected cysts, unhealthy skin was also removed. Primary suturing was done with Ethilon 4-0.

Complete excision of the dermoid cyst and primary suturing was done with Ethilon 4-0 [Figure 3].
Figure 3: Dermoid cyst

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  Results Top


Out of total 38 cases, 31 cases were male and seven were female. The majority of the cases were in the age group of 20–40 years. The distribution of different lesions based on gender is shown in [Table 1].
Table 1: Distribution of pinna swelling by gender

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Out of total thirty pseudocyst cases, only four patients were female. The most common site for pseudocysts was triangular fossa [Table 2] and commonly present unilaterally. None of the cases had bilateral pseudocyst. Trauma was the second most common predisposing factor in cases of pseudocyst after spontaneous [Table 3]. Typically, straw-yellow viscous fluid similar to olive oil was found in pseudocysts. Culture of the aspirated fluid from pseudocyst was sterile in all cases. Recurrence was seen in four cases of pseudocyst which later on managed by revision procedure with same technique. This procedure was associated with some minor complications such as discoloration of the pinna noted at 2 weeks following the splint removal in three (10%) patients [Figure 4] and skin thickening over the pinna seen in six patients (20%). The skin thickening and discoloration was managed with topical emollients, which got resolved in 2 weeks. None of the patients had any major complications such as perichondritis, hematoma, or aural abscess.
Table 2: Locations of pinna swellings

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Table 3: Etiology of pinna swelling

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Figure 4: Postoperative skin changes

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The common site for dermoid cyst was posterior surface of the pinna, and cyst contents in histopathology were hyperplastic sebaceous glands, hair follicles and sweat glands, smooth muscle, and fibroadipose tissue in the wall. Males and females were equally affected. There were no complications observed.

Total six patients of sebaceous cyst were there and two patients had infection at the time of presentation. Ear lobule was the common site. Sebaceous cyst had an accumulation of sebum. There were no complications observed after excision.


  Discussion Top


A pseudocyst of the auricle is an intercartilaginous cystic swelling of the pinna. It results from an accumulation of sterile fluid within an unlined intercartilaginous space. Hartman first reported such a condition in 1846.[1] Engel coined the term “auricular pseudocyst.”[2] Pseudocyst of the auricle occurs more commonly in the Chinese and White people.[2] In this study, pseudocysts predominantly found in males (86.67%), which was similar to Lim et al.[5] Some studies similar to Engel,[2] Patigaroo et al.,[6] and Hansen[7] reported only in males, while Khan et al.,[8] Shanmugham,[9] and Ramadass and Ayyaswamy[10] reported cases in females too. The ratio was 6.5:1 for male: female in this study. In this study, pseudocysts present unilaterally in all cases, which was similar to Patigaroo et al.[6] On the contrary, there were reports of bilateral presentation by Cohen and Grossman.[11] In this study, the majority of the pseudocysts were involving triangular fossa followed by Concha. Engel[2] and Cohen and Grossman[11] also cited the scaphoid fossa and triangular fossa of the antihelix as the main sites of presentation, while Supiyaphun et al.[12] in contrast noted concha as the most common site of presentation. Patigaroo et al.[6] and Khan et al.[8] reported triangular fossa + scaphoid fossa + antihelix as the most common site of presentation. Mostly, the cause for the pseudocyst cannot be identified. Reports of pseudocysts by Tuncer et al.,[13] Salgado et al.,[14] and Tan et al.[15] similarly did not find any significant history of trauma in their study, while on the contrary, Patigaroo et al.[6] found a history of trauma in the majority of patients.

The aim of the treatment was successful resolution of pseudocyst without damage to the healthy cartilage, thus maintaining the normal contour of the auricle and to prevent its recurrence. Treatment options were simple aspiration followed by pressure dressing applied on the pinna; oral corticosteroids alone; aspiration of fluid followed by injection of various substances such as steroids, 50% trichloroacetic acid, and triamcinolone; needle aspiration plus bolstered pressure; surgical curettage and fibrin sealant; treatment by incisional biopsy; and resection of the anterior cartilaginous leaflet of the pseudocysts with repositioning of the overlying skin flap or the so-called deroofing technique.[6] Medical treatment is usually ineffective.[6] The differential diagnosis includes cellulitis, relapsing polychondritis, chondrodermatitis helicis, and subperichondrial hematoma secondary to trauma.[4]

The main disadvantage associated with intralesional steroid administration are skin pigmentation changes and cartilage atrophy. Other methods were (i) aspiration with pressure dressing using cotton – recurrence rate of 60%–96.55%;[16] (ii) incision and drainage with buttoning – recurrence rate of 38%–40%;[16] (iii) simple aspiration followed by intralesional steroid injection followed by pressure dressing – recurrence rate of 43%; (iv) in needle aspiration with intralesional steroid injection and contour dressing – recurrence rate of 85.41%; (v) surgical deroofing of the pseudocyst – recurrence rate of 10%;[5] and (vi) surgical deroofing with buttoning, no recurrence reported.[17] Compared with the abovementioned studies, in this study, the recurrence rate was 13.33%.

Ear splinting is simple, safe, minimally invasive, and economical and provides adequate esthetic outcomes. Compression of sheet is firm and provides an equal pressure on both sides of the pinna, leading to the adhesions of skin and dorsal cartilage, elimination of the dead cavity, and the inhibition of further effusion. The potential risk associated with compressive techniques, such as Aquaplast compressive ear prosthesis for pressure application, may include pressure necrosis if the device is too tight.[14] The sheet usage as splint gives optimum and uniform pressure over the auricle preventing reaccumulation of seroma and the risk of pressure necrosis and perichondritis.

Clinical features of sebaceous cyst include a cystic, smooth swelling, nontender, and enlarging slowly, and the characteristic punctum is often visible in most cases. The most effective treatment involves complete surgical excision of the cyst with the cyst wall intact.[4] The differential diagnosis includes the following: lipoma, dermoid cyst, pilar cyst, furuncle, branchial cleft cyst, milia, pilonidal cyst, and calcinosis cutis. Treatment is complete excision of the cyst along with the lining epithelium. In this study, common site was ear lobule and males affected more, which was similar to Prasad et al.[4] No complications were observed when it was removed with punctum and cyst wall.

Dermoid cyst presents as an asymptomatic cystic swelling, behind the pinna, enlarging gradually over several years.[18] Morphologically, the cyst is lined by epidermis. Dermoid cyst also possesses hyperplastic sebaceous glands, hair follicles and sweat glands, smooth muscle, and fibroadipose tissue in the wall.[3],[19] Even though they are considered to be benign lesions, several studies reported malignant transformation into squamous cell carcinoma.[20] This change is believed to be due to neoplastic changes in the squamous epithelium covering the cyst. However, postauricular dermoid cysts have not been shown to undergo malignant transformation until now. In this study also, malignant transformation was not seen. Surgical excision is the preferred method in the treatment of dermoid cysts to prevent a risk of infection and malignant degeneration. Simultaneously, it also corrects cosmetic deformity and verifies the diagnosis histopathologically. The differential diagnosis of dermoid cysts is difficult. These cystic lesions can be misdiagnosed as epidermoid cyst, cystic teratoma, hemangioma, branchial cyst, trichilemmal cyst, lymphadenopathy, sebaceous cyst, subperiosteal abscess, or hematoma.[18]

In this study, dermoid cyst occurs equally in both sexes, usually seen at the third to fifth decade of life, which is similar to Prasad et al.[4] The lesions were managed surgically with complete excision of the cyst, and there were no complications observed which was according to literature.[3],[18],[19]


  Conclusions Top


Aspiration and drainage followed by splinting is a simple, safe, and effective surgical treatment of pseudocyst. Simple excision is the most effective surgical treatment of dermoid cyst. Excision along with its punctum is the most effective treatment of sebaceous cyst.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hartmann A. Uber cystenbildung in der ohrenmuschel. Arch Ohren Nasen Kehlkopfheilkd 1846;15:156-66.  Back to cited text no. 1
    
2.
Engel D. Pseudocyst of the auricle in Chinese. Arch Otolaryngo 1966;83:197-202.  Back to cited text no. 2
    
3.
Moon IH, Lee WH, Joo JB, Cho JE. A case of postauricular dermoid cyst. Korean J Otolaryngol Head Neck Surg 2005;48:1294-6.  Back to cited text no. 3
    
4.
Prasad KC, Karthik S, Prasad SC. A comprehensive study on lesions of the pinna. Am J Otolaryngol 2005;26:1-6.  Back to cited text no. 4
    
5.
Lim CM, Goh YH, Chao SS, Lim LH, Lim L. Pseudocyst of the auricle: A histologic perspective. Laryngoscope 2004;114:1281-4.  Back to cited text no. 5
    
6.
Patigaroo SA, Mehfooz N, Patigaroo FA, Kirmani MH, Waheed A, Bhat S. Clinical characteristics and comparative study of different modalities of treatment of pseudocyst pinna. Eur Arch Otorhinolaryngol 2012;269:1747-54.  Back to cited text no. 6
    
7.
Hansen JE. Pseudocyst of the auricle in Caucasians. Arch Otolaryngol 1967;85:1-13.  Back to cited text no. 7
    
8.
Khan NA, Ul Islam M, Ur Rehman A, Ahmad S. Pseudocyst of pinna and its treatment with surgical deroofing: An experience at tertiary hospitals. J Surg Tech Case Rep 2013;5:72-7.  Back to cited text no. 8
    
9.
Shanmugham MS. Pseudocysts of the auricle. J Laryngol Otol 1985;99:701-3.  Back to cited text no. 9
    
10.
Ramadass T, Ayyaswamy G. Pseudocyst of auricle-etiopathogenesis, treatment update and literature review. Indian J Otolaryngol Head Neck Surg 2006;58:156-9.  Back to cited text no. 10
    
11.
Cohen PR, Grossman ME. Pseudocyst of the auricle. Case report and world literature review. Arch Otolaryngol Head Neck Surg 1990;116:1202-4.  Back to cited text no. 11
    
12.
Supiyaphun P, Decha W, Kerekhanjanarong V, Hirunwiwatkul P. Auricular pseudocysts: A treatment with the Chulalongkorn University vacuum device. Otolaryngol Head Neck Surg 2001;124:213-6.  Back to cited text no. 12
    
13.
Tuncer S, Basterzi Y, Yavuzer R. Recurrent auricular pseudocyst: A new treatment recommendation with curettage and fibrin glue. Dermatol Surg 2003;29:1080-3.  Back to cited text no. 13
    
14.
Salgado CJ, Hardy JE, Mardini S, Dockery JM, Matthews MS. Treatment of auricular pseudocyst with aspiration and local pressure. J Plast Reconstr Aesthet Surg 2006;59:1450-2.  Back to cited text no. 14
    
15.
Tan BY, Hsu PP. Auricular pseudocyst in the tropics: A multi-racial Singapore experience. J Laryngol Otol 2004;118:185-8.  Back to cited text no. 15
    
16.
Kanotra SP, Lateef M. Pseudocyst of pinna: A recurrence-free approach. Am J Otolaryngol 2009;30:73-9.  Back to cited text no. 16
    
17.
Choi S, Lam KH, Chan KW, Ghadially FN, Ng AS. Endochondral pseudocyst of the auricle in Chinese. Arch Otolaryngol 1984;110:792-6.  Back to cited text no. 17
    
18.
Duran A. An unusual cause of unilateral prominent ear: Dermoid cyst. Turk J Plast Surg [serial online] 2018 [cited 2020 May 8];26:177-9.  Back to cited text no. 18
    
19.
McAvoy JM, Zuckerbraun L. Dermoid cysts of the head and neck in children. Arch Otolaryngol 1976;102:529-31.  Back to cited text no. 19
    
20.
Devine JC, Jones DC. Carcinomatous transformation of a sublingual dermoid cyst. A case report. Int J Oral Maxillofac Surg 2000;29:126-7.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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