Pseudocyst of the pinna is also known as benign idiopathic cystic chondromalacia of pinna. As the name suggests it is a benign, idiopathic, asymptomatic cystic swelling over the lateral aspect of the pinna. It was first described by Hartmann in 1846.

In this condition, there is a spontaneous accumulation of straw-colored sterile fluid in the intracartilaginous plane. The etiology of pseudocyst is still incompletely understood, but several mechanisms for its pathogenesis have been put forth. Originally, Engel hypothesized that the abnormal release of lysosomal enzymes from local chondrocytes caused progressive dilatation and the formation of an intracartilaginous cavity.[1] However, this was disproved. Another theory hypothesized that congenital embryonic dysplasia of the auricular cartilage is a factor in the development of pseudocyst.[2] Choi suggested that repeated minor trauma led to an overproduction of glycosaminoglycans, which, starting as microcysts within the cartilage, coalesce to form a larger lesion or pseudocyst.[3]

Diagnosis is based on clinical characteristics with no evidence of infection. The differential diagnosis of this condition includes cellulitis, relapsing polychondritis, chondrodermatitis helicis, and subperichondrial hematoma secondary to trauma.[4] Despite various treatment modalities explained in the literature, managing this condition is a big task for the surgeon as it is known for its high recurrence rate. Hence, the main aim of treating this condition includes the prevention of recurrence along with preservation of normal contour of the pinna.

This study aimed at evaluating the effectiveness of window deroofing with dental roll suturing technique in the treatment of pseudocyst pinna with respect to recurrence and postprocedural sequelae.

The prospective study was conducted at a tertiary care hospital, for 2 years from January 2019 to December 2020. All patients presenting to the ENT outpatient department with a diagnosis of pseudocyst pinna and willing for surgical treatment were included in the study group. Patients were explained the various treatment options and the success rate of each option. Written informed consent was obtained from all individual participants included in the study. The patients in the study group were treated surgically by window deroofing with the dental roll suturing method under local anesthesia. They were followed up after 7 days for suture removal and to watch for any signs of recollection or complication. They were later reviewed after 1 month to look for any recurrence.

Surgical technique

After obtaining consent, cases were operated on under local anesthesia. A horizontal incision of 1 cm was made along the pinna curvature on the lateral surface of the pinna over the lateral wall of the pseudocyst. Fluid was drained following which a small triangular piece of skin along with perichondrium was excised. After that, two dental rolls made of gauze pieces were contoured to pinna at the site of the pseudocyst on either side of the pinna and were sutured using Nylon 3-0 suture, through and through the cartilage, in the pattern of the figure of 8 for compression. A simple pressure dressing was applied. The patient was prescribed oral cefpodoxime, 200 mg, twice daily and oral aceclofenac, 100 mg, with serratiopeptidase 15 mg for 1 week. The sutures and the dental rolls were removed after 1 week, and recurrence if any was noted. The patients are then followed up after 1 month to look for any recurrence and other cosmetic deformities and sequelae. The findings were noted and the results analyzed [Figure 1].

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Ethical clearance

Ethical approval for this study was provisionally provided by the Institional Ethics Review Board of SS Institute of Medical Sciences and Research Centre on 30.11.2022 (IERB-620).

Out of 16 patients, 12 patients were male. The mean age was 38 years with a range of 27–51 years. Eleven (68.75%) patients had right-sided lesion, whereas 5 (31.25%) patients had left-sided lesion. The most common presenting symptom was a painless swelling of the pinna. The average duration of symptoms before presentation was 14.2 days, ranging from 7 to 25 days. The pseudocyst was located in the concha in 10 (62.5%) patients, in the scaphoid fossa in 5 (31.25%) patients, and in 1 (6.25%) patient, it was noted in both scaphoid fossa and concha. All 16 patients underwent window deroofing with dental roll suturing. The patients were followed up after a week and after 1 month. No recurrence was noted, but two patients (12.5%) had skin thickening. No other complications were noted.

It is also known as auricular seroma, enchondral pseudocyst, and intracartilaginous cyst.[5] Engel in 1966 coined the term “auricular pseudocyst” as this intracartilaginous cyst lacks an epithelial lining.

In our study, out of 16 cases, 14 had a history of spontaneous development of swelling supporting idiopathic etiology, while the remaining two were secondary to helmet usage. Males were affected more commonly. Seroma of the pinna involves predominantly males with the most common age group of presentation being 30–40 years which is similar to our study.[6],[7]

Tan explained the right-sided predominance of pseudocysts on the basis that most people sleep on their right side.[8] This was replicated in our study with the right preponderance, but none of our patients gave a history of this sleeping habit.

In our series, the most common site of pseudocyst was the concha which is similar to that reported by Tan and Hsu and Zhu and Wang.[8],[9] However, Choi described the scaphoid fossa as being the most common site of the pseudocyst.[3]

The lack of a uniform treatment strategy implies the fact that the various management modalities described in the literature all have their pitfalls. Treatment options range from simple aspiration with pressure dressing to more radical options like window deroofing with corrugated drain placement.

We evaluated the effectiveness of surgical window deroofing with dental roll suturing. Deroofing reduces the chances of recollection as the cavity has been marsupialized and cross-suturing the cavity with dental roll aids in the obliteration of the remnant cavity which heals by fibrosis.

None of the sixteen patients in our study developed recurrence. Simple aspiration followed by pressure dressing applied on the pinna for 2 weeks resulted in recurrence.[4] Aspiration alone will not obliterate the cavity completely and recurrence chances are more [Table 1].

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Another option is to make a window in the medial surface of the pinna and closure of the incision and bolster the application. The results were not satisfactory as the patients developed hardening of the cartilage and deformities. Although this method obliterates the cavity, the resultant fibrosis because of the handling of the dense tissue in the medial aspect of the pinna may lead to consequent deformities.

The use of intralesional steroids is controversial. A literature search reveals evidence both for and against this approach. Intralesional steroid injection has higher recurrence chances compared to surgery but less sequela. The potential disadvantages include permanent deformity (Cauliflower ear), skin pigmentation changes, skin, soft tissue, and cartilage atrophy.[11],[14]

Yu et al. compared three techniques – (1) Simple aspiration combined with pressure dressing, (2) Local steroid injection, and (3) Surgery.[10] They concluded that the effective rate of surgery was 100%, the highest of the three groups, indicating that surgical therapy is the most effective method for auricular pseudocyst.

Button suturing is another modification of the pressure dressing where sterile shirt buttons are sutured to lateral and cranial surfaces of the pinna. However, without deroofing of the pseudocyst cavity, this technique has chances of recurrence.[11] Furthermore, button suturing may not provide uniform compression over the cavity as it may not conform to the varied shapes and sizes of the pseudocyst.

Corrugated drain sheet usage as a splint gives optimum and uniform pressure over the auricle preventing re-accumulation of seroma and thus preventing the risk of pressure necrosis and perichondritis. However, due to the rough surface with ridges and nonporosity of the drain sheet ridging over the skin, skin thickening, and discoloration were noted following the splint removal.[12]

A more cosmetically acceptable option for splint would be silicone-based molds (used to make hearing aid molds).[13] Alternatively, fibrin glue has been used as a sealant and to obliterate the intracartilaginous cavity with good cosmetic results.[15]

In our study, even though two out of sixteen patients developed skin thickening; none of them showed:

The results need to be validated with a study design with more number of cases and a longer follow-up period.

Pseudocyst of pinna poses a great challenge in management due to the high recurrence rate and cosmetic sequelae. Many treatment modalities have been described in the literature with varying recurrence and complications rate. We found combining window deroofing along with dental roll suturing to be a simple yet effective solution for treating this notorious condition. This technique is one of the better treatment options which minimizes recurrence and has acceptable cosmetic results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.