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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 65-68

Management of earlobe pseudocysts using the bolster technique


Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Andalas University, Padang, West Sumatera, Indonesia

Date of Submission16-Aug-2021
Date of Acceptance24-Sep-2021
Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Al Hafiz Djosan
Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Andalas University, Padang, West Sumatera
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_129_21

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  Abstract 


Pseudocysts of the ear are asymptomatic noninflammatory cystic enlargements without pain, are idiopathic, and relatively rare, usually located in the lateral or posterior region of the earlobe. The definitive etiology is still unclear, but it is thought that constant compressed trauma to the earlobe can be a trigger for the pseudocyst's development. Management is mainly carried out to achieve complete resolution, preventing the possibility of recurrence and maintaining the structure of the auricle. Corticosteroid injection, needle aspiration, and suppression techniques are common management modalities. Bolster compression technique is an emphasis on both sides using gauze. There were two cases of patients reported who performed procedures with a bolster. The first case was a 35-year-old male patient with right ear pseudocyst. The second case was a 49-year-old male patient with recurrent right ear pseudocysts. Management of ear pseudocysts with suppression using a bolster is safe and effective, inexpensive, and has minimal risk for recurrence.

Keywords: Bolster, earlobe, pseudocyst, recurrence, seroma


How to cite this article:
Djosan A, Irfandy D, Azman F. Management of earlobe pseudocysts using the bolster technique. Indian J Otol 2022;28:65-8

How to cite this URL:
Djosan A, Irfandy D, Azman F. Management of earlobe pseudocysts using the bolster technique. Indian J Otol [serial online] 2022 [cited 2022 Dec 6];28:65-8. Available from: https://www.indianjotol.org/text.asp?2022/28/1/65/343748




  Introduction Top


Pseudocysts of the ear are also known as pseudo auric seromas, enchondral pseudocysts, intracartillary cysts, and cystic chondromalacia.[1] This condition is clinically characterized by asymptomatic cystic enlargement, usually up to 1–5 cm, is noninflammatory without pain, is benign and idiopathic, and rarely occurs, generally located in the anterior or posterior regions of the helix, and the lateral or anterior surface of the auricle, especially in the scaphoid or triangular fossa.[2] In general, ear pseudocysts usually form within 4–12 weeks, and pseudocysts of the auricle are caused by the accumulation of intracartillary fluid. This condition is usually difficult to manage because of frequent recurrences and other auricular deformities.[2]

The cyst drainage produces a sterile, thick liquid rich in glycosaminoglycans. Ear pseudocysts predominantly occur in young men (93%) and most were unilateral (87%). Although Engel reported the disease for the 1st time in the Chinese population in 1966, there was no evidence of racial predisposition in the pseudocysts of the ear. Race predisposition (especially China) was indeed reported in the Engel demographic report, but this disease was also found in significant numbers in other countries.[3]

The etiology of this disease is still unknown. However, many experts believe that recurring minor trauma causes the formation of pseudocysts, especially in patients with preexisting intracartillary congenital defects associated with vascular and lymph channels.[4] Other experts believe that pseudocysts are caused by cartilage degeneration caused by the release of the lysosomal chondrocyte enzyme.[5]

Histologically, auricular pseudocysts have the characteristics of intracartillary cavity that lacks an epithelial layer, so they are called pseudocysts. Furthermore, there is an irregular depletion and hyalinization of the peripheral cartilage in the cavity. The further stage of pseudocysts is also shown in the presence of intracartillary fibrosis and granulation tissue.[6] Quoted from Lim et al., in a histological review of 16 cases, the presence of perivascular mononuclear infiltrates with predominant lymphocytes was found in all cases. This inflammatory response, which is seen in connective tissue that is near the surface of the anterior segment of the auricular cartilage, contradicts previous research that states that a pseudocyst is a noninflammatory disease. Needle aspiration from these lesions produces a yellowish, viscous, oily liquid containing albumin and has osmolarity, glucose, and plasma concentrations similar to plasma.[7]

Where the ideal management for this disease varies according to the literature, the best results are obtained by incision drainage techniques, followed by chemical and mechanical obliteration such as bolster compression dressings and compression sutures,[4] and the diagnosis is based on clinical manifestations and the absence of signs of infection. The differential diagnosis of earlobe pseudocysts includes cellulitis, relapsed polychondritis, helical chondrodermatitis, and subperichondrial hematoma secondary to trauma.[3]


  Case Reports Top


First case

A 35-year-old man came to the polyclinic of the Dr. M. Djamil Hospital, Padang, on July 29, 2016. The main complaint of the patient was swelling on the right earlobe for 1 week before entering the hospital. There was no pain and history of trauma in the right ear, no history of insect bites, and the patient's right ear was often squeezed during sleep.

Based on physical examination results, nasal and throat examinations were within normal limits. Edema was found in the examination of the right earlobe, no hyperemia, and no pain [Figure 1]. The right ear canal was found within normal limits. The examination of the left ear was all within normal limits.
Figure 1: Earlobe with pseudocyst in the first-case patient. (a) Before surgery; (b) rear bolster mounting; (c) front bolster mounting; (d) 1 week after surgery; (e) 2 months after surgery

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The working diagnosis in this case was the right earlobe pseudocyst. Pseudocyst incision and exploration in general anesthesia were planned. The results of routine blood laboratory tests, prothrombin time, activated partial thromboplastin time were obtained within normal limits.

On August 1, 2016, surgery was performed. The patient lay on his back on the operating table under general anesthesia. Aseptic and antiseptic procedures were done in the surgery. Infiltration with adrenaline 1:200,000 was performed in the superficial temporal artery branching of the right ear. An incision was made in the concha area horizontally, clear liquid ±2 ccs came out, and it was explored until clean. The bolster was then mounted with gauze on the anterior and posterior sides of the auricle, fixed with suture 3.0 silk thread. The operation was completed with closing the right ear with gauze.

Postoperative diagnosis is postincision and exploration of the right earlobe pseudocyst. IVFD RL therapy was given for 8 h/kolf, drip tramadol 50 mg in an infusion of RL, and 2 × 1 g ceftriaxone intravenously. At follow-up on the 1st day after surgery, there was pain in the right ear, no discharge from the ear tampon gauze, and no fever. The patient was allowed to go home and given clindamycin 3 × 300 mg, and mefenamic acid 3 × 500 mg. The patient went to the ENT polyclinic 3 days after out from the hospital for health control monitoring.

On August 5, 2016 (4-day postoperation), the patient went to the ENT clinic with ear pain symptoms. Physical examination of general conditions and vital signs were shown within normal limits. The nose and throat were within normal limits. The right ear was attached to a tampon with no blood and pus. The patient was diagnosed with postincision and pseudocyst exploration of the auricle and then given clindamycin 3 × 150 mg and mefenamic acid 3 × 500 mg for treatment.

On August 8, 2016 (1-week postoperation), the patient reported no complaints. Physical examination, general condition, and vital signs were within normal limits. Nose and throat examination was within normal limits. The right ear was attached to tampon gauze. The patient was then discharged from the bolster. Evaluation of the edema of the right ear was minimal, with no fluctuation, hyperemia, and pus. On August 15, 2016 (2-week postoperation), the patient reported no complaints and no swelling in the ear. There was edema of the right ear, hyperemia, and no complications such as cauliflower ear. On September 30, 2016 (2-month postoperation), the patient reported no complaints and no swelling in the ear.

Second case

A 49-year-old man came to the ENT polyclinic of the Padang Private Hospital on August 8, 2016, with the main complaint of swelling in the right earlobe for 1 week, and the patient has felt swelling in the ear for 1 month. The patient had carried out aspiration and casts on the right ear at a private hospital 3 weeks previously. There was no pain in the right ear and no history of trauma to the ear. The patient's right ear was often squeezed when wearing a helmet, with no history of insect bites, fever, cough, and runny nose.

On physical examination, the generalist status results were within normal limits. The nose and throat were within normal limits. The examination of the right ear found edema, with the absence of tear and pain [Figure 2]. The examination of the right and left ear canal was found within normal limits. Blood and internal medicine tests, carried out to plan surgical action, were within normal limits.
Figure 2: Earlobe with pseudocyst in second-case patient. (a) Before surgery; (b) after surgery (after 2-month postoperation)

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On August 9, 2016, surgery was performed. The patient lay on his back on the operating table under general anesthesia. Aseptic and antiseptic procedures were done in the surgery field. The adrenaline of 1:200,000 was infiltrated in the superficial temporal artery branching on the right earlobe. Incisions were made horizontally in the concha area, clear liquid ±1 cc came out, and it was explored until clean. The next step was to install bolster with gauze on the anterior and posterior sides of the earlobe, fixed with suture silk 3.0 so that the anterior and posterior gauze bolsters were fixed. The operation was complete with covering the right ear with tampon gauze. Postoperation diagnosis was postincision and exploration of the right earlobe pseudocyst. IVFD RL therapy was given 8 h/kolf, drip tramadol 50 mg in an infusion of RL, and 2 × 1 g ceftriaxone intravenously.

On the 1st day after surgery, there was a pain in the right ear, with no fever and discharge from the ear tampon. The patient was allowed to go home and given clindamycin 3 × 300 mg and mefenamic acid 3 × 500 mg. The patient takes health control in 3 days after out of the hospital to ENT polyclinic.

On August 13, 2016 (4-day postoperation), the patient went to the ENT clinic with no complaint. Physical examination of general conditions and vital signs was within normal limits. The nose and throat examination was within normal limits. The right ear was attached to tampon gauze, with no blood discharge and pus. The patient was diagnosed with postincision and pseudocyst exploration of the right ear. The patient was then given clindamycin 3 × 300 mg.

On August 16, 2016 (1-week postoperation), the patient reported no complaint. Physical examination of general condition and vital signs was within normal limits. The nose and throat examination was within normal limits. The right ear was attached to a gauze. The patient was then discharged from the bolster. The edema evaluation of the right ear was absent, with no fluctuation, hyperemia, and pus. On September 30, 2016 (2-month postoperation), the patient reported no complaint and swelling in the right ear.


  Discussion Top


In general, effective pseudocyst management is expected to have complete resolution without recurrence and to prevent a recurrence, a bolster or compression technique is used after the drainage procedure, with the accumulation of cystic fluid mostly occurring after fluid aspiration or incision and drainage. The bolster technique is performed using cotton or gauze bolsters and Aquaplast compressive ears prostheses. Compression using clips or buttons has been done successfully.[2] The use of the bolster technique as management of auricular pseudocysts was first described by Cohen et al. and Katz.[8] After the cyst was developed, they gave 50% trichloroacetic acid intracavitary to trigger fibrosis. To allow pressure on the surface, the surgical scar was then sutured with the help of shirt buttons placed on the anterior and posterior surfaces of the auricle. No recurrence was found 9 months after the action.[9],[10]

With no recurrence found in all patients, and the results obtained looking cosmetically feasible,[10] pressure compression and bolster technique without intralesional medication have been reported to be effective as a follow-up to aspiration or drainage of the cyst. This is as quoted from one of the Ophir and Marshak studies, which managed nine patients with auricular pseudocyst using aspiration and bolster technique.[10] In this case, the incision and drainage were performed. The incision was made horizontally in the concha region which was then explored and cured until clean. The bolster was then fitted with gauze on the anterior and posterior area of the earlobe, fixed with suturing silk 3.0 thread. The right ear was covered with tampons. The gauze was chosen as a bolster because it was cheap and easy to obtain, as well as being safe and acceptable to the body.[11]

On the other hand, the use of casts was proved to be less effective because its hermetic nature can lead to constant friction which can increase the risk of recurrence.[9]

As a safe and effective method, especially when compared to the injection or more complicated surgical techniques that have a higher risk of deformity and recurrence, incision and drainage techniques as well as bolster techniques can be used as the first choice for the management of ear pseudocysts.[2] Further, based on previous research as well as the treatment results in patients, additional medical administration such as the use of corticosteroids or intralesional trichloroacetic acid, which both aim to compress lesions, is assumed to be unnecessary because this medical administration can be replaced with gauze or buttons bolster.


  Conclusion Top


The bolster technique is a safe and effective treatment for pseudocysts. Bolster technique procedures are relatively easy, safe, and can reduce the risk of recurrence.

Acknowledgment

The author would like to thank the Polyclinic of Dr. M. Djamil Hospital, Padang, and Faculty of Medicine of Andalas University who have facilitated this research. The author would also like to thank the two patients who had agreed to have their pseudocyst cases reported.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Paul A, Pak HS, Welch ML, Toner CB, Yeager J. Pseudocyst of the auricle: Diagnosis and management with a punch biopsy. J Am 2001;45:230-2.  Back to cited text no. 1
    
2.
Han A, Li LJ, Mirmirani P. Successful treatment of auricular pseudocyst using a surgical bolster: A case report and review of the literature. Cutis 2006;77:102-4.  Back to cited text no. 2
    
3.
Ramadass T, Ayyaswamy G. Pseudocyst of auricle - Etiopathogenesis, treatement update and literature review. Indian J Otolaryngol Head Neck Surg 2006;58:156-9.  Back to cited text no. 3
    
4.
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. 4
    
5.
Kanotra SP, Lateef M. Pseudocyst of pinna: A recurrence-free approach. Am J Otolaryngol 2009;30:73-9.  Back to cited text no. 5
    
6.
Laschen J, Datema FR, Koot VC, Lohuis PJ. Bilateral auricular pseudocyst: Recognizing and treating. Facial Plast Surg 2014;30:690-3.  Back to cited text no. 6
    
7.
Rehman A, Sangoo MA, Hamid S, Wani AA, Kirmani MH, Khan NA. Recurrent pseudocyst pinna: A rational approach to treatment. IJSRP 2013;3:1-4.  Back to cited text no. 7
    
8.
Cohen V, Riberdy GF, Saliba I, Davar S. A case of auricular pseudocyst. JCMS 2016;20:573-4.  Back to cited text no. 8
    
9.
Singh D, Goswami R, Dudeja V. Management of auricular pseudocyst: A comparative study. IJMRR 2014;2:457-62.  Back to cited text no. 9
    
10.
Göktay F, Aslan C. Successful treatment of auricular pseudocyst with clothing button bolsters alone. J Dermatolog Treat 2011;22:285-7.  Back to cited text no. 10
    
11.
Kim TY, Kim DH, Yoon MS. Treatment of a recurrent auricular pseudocyst with intralesional steroid injection and clip compression dressing. Dermatol Surg 2009;35:245-7.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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