DOI: 10.7860/JCDR/2014/9609.

4978
Original Article

Deroofing of Auricular
Ear, Nose and Throat

Pseudocyst: Our Experience

Section

Vinay.S.bhat1, Shilpa2, Nitha3, Ravi K S4

ABSTRACT following the procedure. The recurrence in the case could be

Aim: To ascertain a definitive treatment modality for a frequently attributed to the usage of improper buttons for compression.
recurring condition, pseudocyst of pinna in the form of deroofing Conclusion: Despite numerous treatment options for
and compression. pseudocyst of pinna, there remains high recurrence rate in
Materials and Methods: Thirty patients were diagnosed with patients. Additionally, some treatments carry the risk of cartilage
pseudocyst of pinna from July 2011 to March 2013. All 30 damage or visible distortion of the auricle. Surgical deroofing
patients underwent surgical deroofing of the pseudocyst along followed by compression using buttons can be considered as
with compression by buttoning. The patients were followed up first line treatment of this entity as it is associated with very less
for a period of six months. rate of recurrence and gives a cosmetically acceptable result.
Results: No recurrence was seen in 29 patients in the follow up
period of six months (96.7%). One patient had recurrence 15 d

Keywords: Auricle, Deroofing, Pseudocyst

INTRODUCTION MATERIALs AND METHODS

First reported by Hartmann in 1846 and first described in English Thirty patients with clinical diagnosis of pseudocyst of pinna [Table/
literature by Engel in 1966, pseudocyst of the auricle is a benign, Fig-3] from July 2011 to March 2013 were included in this study. All
idiopathic, painless, spontaneous dome shaped cystic swelling on 30 patients underwent surgical deroofing of the pseudocyst along
the anterior surface of the auricle [1-3]. Common sites are cymba with compression by buttoning. The patients were followed up for a
concha [Table/Fig-1], scaphoid fossa and triangular fossa [Table/ period of six months.
Fig-2,3] [4]. Size varies from 1 to 5 cm. It is predominantly found
in males [5]. Right sided predominance is common [6]. It is also SURGICAL PROCEDURE
named endochondral pseudo cyst, intracartilaginous cyst and The procedure was performed under local anaesthesia using
benign idiopathic cystic chondromalacia [7]. 2% xylocaine with 1:200 000 adrenaline. The entire pinna was
Histologically, it is an intracartilaginous cyst devoid of an epithelial anesthetized by infiltrating along the postauricular sulcus, the root
lining(hence named pseudocyst). It contains straw or yellow of the helix, and the external auditory canal. A helical incision is
coloured, viscous, albumin containing fluid with osmolarity, glucose made [Table/Fig-4] and the skin flap is elevated well beyond the
and protein concentration similar to that of plasma [8]. anterior cartilage segment and the anterior wall of the cyst is excised
It is a difficult condition to treat medically or surgically and a large along the margin with release of the straw coloured fluid [Table/
number of treatment modalities have been described in the literature. Fig-5]. Curettage of the posterior wall of the pseudocyst is then
Definitive treatment still remains controversial. Goal of the treatment done to remove any soft tissue debris. Two sterilized shirt buttons
should be to preserve or restore the normal architecture of the of appropriate size are then sutured on the anterior and posterior
auricle with no recurrence [8]. Surgical deroofing first described surfaces of the auricle using a 2/0 silk suture on a straight needle
by Choi and modified by Lim using buttoning as a compression so as to compress the raised skin flap on to the cartilage [Table/
method has resulted in the significant decrease in recurrence rates Fig-6]. No external dressing is required. Postoperatively, antibiotics
with good cosmetic outcome in all patients [4]. Aim of our study was with anti-inflammatory drugs are given for one week. The sutures
to prove the effectiveness of surgical deroofing with buttoning as a and the buttons are removed after one week.
standard approach to treat this condition.

[Table/Fig-1]: Pseudocyst involving concha [Table/Fig-2]: Pseudocyst in female patient involving triangular fossa [Table/Fig-3]: Pseudocyst involving triangular fossa (site of
incision marked) [Table/Fig-4]: Incision made along the margins of the pseudocyst

Journal of Clinical and Diagnostic Research. 2014 Oct, Vol-8(10): KC05-KC07 5

 Vinay.S.bhat et al., Auricular Pseudocyst: Our Experience with Deroofing and Compression Procedure www.jcdr.net

There has been no gold standard treatment till date. Various treatment
modalities like simple aspiration, intralesional corticosteroids and
aspiration in combination with bolstered pressure sutures, invasive
techniques like incision and drainage followed by its obliteration
by curettage and inserting a small drainage tube into the cavity
with a guide wire have been tried [13-17]. Sclerosing agent like
Minocycline and open deroofing have also been recommended
[18,19]. Recently fibrin glue as a sealer between the 2 cartilaginous
[Table/Fig-5]: Exposed cartilage after excision of ant wall of pseudocyst [Table/ leaves as a mode of treatment has been reported by Tuncer [20]. In
Fig-6]: compression by buttoning compression by buttoning a study conducted by Ayaz Rehman et al., 22 patients underwent
deroofing and compression procedure. None of the patients in study
Age Group Number of Patients
group had recurrence [21]. Similarly Nazir A Khan et al., showed
<20 0
96% efficacy of deroofing procedure in their study [22]. Most of the
21-30 1 treatment modalities have resulted in significant rates of recurrence
31-40 14 as seen in study conducted by Ayaz Rehman et al., [21] where
41-50 15 significant number of patients had recurrence following aspirations
and incision and drainage of pseudocyst of pinna. Surgical deroofing
>50 0
with compression with buttons has shown promising results with
[Table/Fig-7]: Age distribution
least recurrence rates.
Male Female Total

29 1 30
CONCLUSION
In our study a total of 30 patients underwent surgical deroofing and
[Table/Fig-8]: Sex distribution buttoning and were followed up for six months. Barring a single case
of recurrence which could be attributed to improper technique of
Right Side Left Side
buttoning there was no recurrence in rest of the patients. This rational
57% 43% approach to treatment of pseudocyst has accomplished the twin
[Table/Fig-9]: Side of involvement objectives of complete resolution of the condition and maintenance
of normal architecture with avoidance of repeated drainage, pain,
Sites of Involvement % of Patients
perichondritis and utmost cosmetic value. It could therefore be
Scaphoid Fossa 56% used as a standard approach to treat this rare condition.
Triangular Fossa 27%
Concha 17% Refrences
[1] Beck K. “Uber Zystenbildung am Nasenfl”ugel. European Archives of Oto-Rhino-
[Table/Fig-10]: Sites of involvement Laryngology. 1911;85(4):304-07.
[2] Engel D. Pseudocysts of the auricle in Chinese. Archives of Otolaryngology.
RESULTS 1966;83(3):197-202.
[3] Chen Q, Zhao T, Yang X. The immunological cause of auricular pseudocyst.
Thirty patients were diagnosed to have pseudocyst of the pinna Zhonghua er bi yan hou ke za zhi. 1999;34(4):236-37.
from July 2011 to March 2013.The age distribution in our study [4] Choi S, Lam K, Chan K, Ghadially F, Ng A. Endochondral pseudocyst of the
ranged from 35 y to 50 y [Table/Fig-7]. Male preponderance of auricle in Chinese. Archives of Otolaryngology. 1984;110(12):792-96.
[5] Cohen P, Grossman M. Pseudocyst of the auricle: case report and world literature
96.7 % was seen [Table/Fig-8]. Right sided lesion (57%) was more
review. Archives of Otolaryngology-Head & Neck Surgery. 1990;116(10):1202-
common than the left (43%) [Table/Fig-9]. The lesion was seen more 04.
in the scaphoid fossa (56%) followed by the triangular fossa (27%) [6] Tan B, Hsu P. Auricular pseudocyst in the tropics: a multi-racial Singapore
and cymba concha (17%) [Table/Fig-10]. Surgical deroofing with experience. The Journal of Laryngology & Otology. 2004;118(03):185-88.
[7] Chen Q, Fei Y, Zhao T, Luo D, Wu B, Yang X. [Research on the immunological
buttoning was done in all the patients. They were followed after one
cause of auricular pseudocyst]. Lin chuang er bi yan hou ke za zhi = Journal of
month, three months and six months. All (96.7%) except one patient clinical otorhinolaryngology. 2001;15(7):304-05.
had recurrence after 15 d for whom the reason could be attributed [8] Schulte KW, Neumann NJ, Ruzicka T. Surgical pearl: the close-fitting ear cover
to the improper usage of buttons. The procedure was repeated cast—a noninvasive treatment for pseudocyst of the ear. J Am Acad Dermatol.
2001;44(2):285-86.
again and he had no recurrence on follow up. The inference that [9] Yamamoto, T, Yokoyama, A, and Umeda, T. Cytokine profile of bilateral
surgical deroofing with buttoning is a reliable technique could be pseudocyst of the auricle {letter}. Acta Derm Venereol. 1996;76:92–93.
substantiated in our study. [10] Posma E, Moes H, Heineman M, Faas M. The Effect of Testosterone on Cytokine
Production in the Specific and Non-specific Immune Response. American
Journal of Reproductive Immunology. 2004;52(4):237-43.
DISCUSSION [11] Lee J, Panarese A. Endochondral pseudocyst of the auricle. Journal of clinical
Pseudocyst of the pinna is a rare condition occurring commonly in pathology. 1994;47(10):961-63.
young adults. Common sites of occurrence of this condition include [12] Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase isozymes in and
intralesional steroid injection therapy for pseudocyst of the auricle. Int J Dermatol.
Scaphoid fossa, followed by triangular fossa, and cymba concha.
2001;40:380-84.
The aetiology of this condition is obscure. Several hypothesis [13] Lim C, Goh Y, Chao S, Lynne L. Pseudocyst of the auricle. The Laryngoscope.
have been put forward for its pathogenesis. A hormonal 2002;112(11):2033-36.
[14] Chang C, Kuo W, Lin C, Wang L, Ho K, Tsai K. Deroofing surgical treatment for
influence modulating the inflammatory process explains the male pseudocyst of the auricle. The Journal of otolaryngology. 2004;33(3):177-80.
preponderance [9,10]. Engel hypothesized that abnormal release [15] Hegde R, Bhargava S, Bhargava K. Pseudocyst of the auricle: a new method of
of lysosomal enzymes from local chondrocytes caused progressive treatment. The Journal of Laryngology & Otology. 1996;110(08):767-69.
[16] Ophir D, Marshak G. Needle aspiration and pressure sutures for auricular
dilatation and formation of an intracartilaginous cavity [2]. Another
pseudocyst. Plast Reconstr Surg. 1991;87:783-84.
theory proposed congenital embryonic dysplasia of the auricular [17] Zhu LX, Wang XY. New technique for treating pseudocyst of the auricle. J
cartilage with reopening of residual tissue planes resulting in Laryngo Otol. 1990;104:31-32.
the pseudocyst formation [11]. Another factor postulated in [18] Oyama N, Satoh M, Iwatsuki K, Kaneko F. Treatment of recurrent auricle
pseudocyst with intralesional injection of minocycline: a report of two cases.
pathogenesis is chronic low grade trauma leading to overproduction
Journal of the American Academy of Dermatology. 2001;45(4):554-56.
of glycosaminoglycans resulting in formation of microcysts which [19] Harder M, Zachary C. Pseudocyst of the ear : Surgical treatment.J Dermatol
coalesce to form a large lesion or pseudocyst with elevated Surg Oncol. 1993;19:585–88.
isoenzymes LDH-4 and LDH-5 [12].
6 Journal of Clinical and Diagnostic Research. 2014 Oct, Vol-8(10): KC05-KC07
www.jcdr.net Vinay.S.bhat et al., Auricular Pseudocyst: Our Experience with Deroofing and Compression Procedure

[20] Tuncer S, Basterzi Y, Yavuzer R. Recurrent auricular pseudocyst: a new treatment [22] Khan NA, ul Islam M, ur Rehman A, Ahmad S. Pseudocyst of pinna and its
recommendation with curettage and fibrin glue. Dermatol Surg. 2003; 29:1080-83. treatment with surgical Deroofing: An experience at tertiary hospitals. J Surg
[21] Rehman A, Sangoo M, Hamid S, Wani A, Khan N. Recurrent Pseudocyst Pinna: A Tech Case Report. 2013;5:72-77.
Rational Approach to Treatment. International Journal of Scientific and Research
Publications. 2013;3(7):1-4.

PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Ear, Nose and Throat, Adichunchanagiri Institute of Medical Sciences, B.G Nagara, Mandya District, Karnataka, India.
2. Resident, Department of Ear, Nose and Throat, Adichunchanagiri Institute of Medical Sciences, B.G Nagara, Mandya District, Karnataka, India.
3. Resident, Department of Ear, Nose and Throat, Adichunchanagiri Institute of Medical Sciences, B.G Nagara, Mandya District, Karnataka, India.
4. Assistant Professor, Department of Ear, Nose and Throat, Adichunchanagiri Institute of Medical Sciences, B.G Nagara, Mandya District, Karnataka, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Vinay S Bhat,
Room No 11, Kalpataru Bhavan, AIMS Campus,
B.G Nagara, Nagamangala Taluk, Mandya District, Karnataka, India. Date of Submission: Apr 12, 2014
Phone : 8495945704, E-mail : [email protected] Date of Peer Review: Jul 19, 2014
Date of Acceptance: Aug 06, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Oct 20, 2014

Journal of Clinical and Diagnostic Research. 2014 Oct, Vol-8(10): KC05-KC07 7