Our Experience at Tertiary Medical College: Comparative Study Between Surgical Deroofing with Buttoning Technique and Posterior Cartilage Window with Pressure Gauze Dressing Technique in Patients with Pseudocyst of Pinna

Abstract

A pseudocyst of pinna is benign, painless, rare and asymptomatic swelling on the lateral or anterior surface of the pinna resulting from intracartilaginous accumulation of fluid. The condition auricular pseudocyst was first described by Engel (Arch Otolaryngol 83:197–202, 1966). Pseudocyst of in majority of cases presents as unilateral lesions, predominantly in 35–40 years mean age group and affecting predominantly males (Ramadass and Ayyaswamy in Indian J Otolaryngol Head Neck Surg 58:156–192, 2006). Commonly these cysts shows no symptoms but occasionally, there may be presence of minor discomfort and mild inflammatory signs. The pseudocyst of pinna typically involves in its descending order of involvement as scaphoid fossa, triangular fossa of the antihelix, and the Cymba concha (Ramadass and Ayyaswamy in Indian J Otolaryngol Head Neck Surg 58:156–192, 2006). Diagnosis of psuedocyst is based mainly on the clinical characteristics without evidence of infection (Ramadass and Ayyaswamy in Indian J Otolaryngol Head Neck Surg 58:156–192, 2006). There are wide range of treatment modalities described in the literature for this condition ranging from medical line of management including minimally invasive Intralesional steroid therapy, intralesional sclerosant therapy, systemic steroid therapy to surgical line of management including aspiration and pressure dressing, quilting suture with corrugated rubber drain, incision and drainage with mastoid dressing, cartilage curettage with drainage tube, surgical de-roofing and cartilage window procedure. Although multiple treatment options are available for this condition,there is no gold standard option is found In literature as more invasiveness of procedure associated with more complications and less invasiveness is associated with more recurrence (Bhat et al. in J Clin Diagn Res 8:KC05–KC07, 2014). The main aim of treatment is preservation or restoration of normal Anatomy or architecture of the auricle without recurrence or complications in postoperative duration (Schulte et al. in J Am Acad Dermatol 44:285–286, 2001). In our study we are going to compare the surgical deroofing with buttoning technique with Posterior Cartilage window with Pressure Gauze dressing technique in patients with pseudocyst on the basis of recurrence and complications. To compare effectiveness in terms of recurrence and complications between surgical deroofing with buttoning technique and posterior cartilage window with Pressure Gauze dressing technique in patients with pseudocyst of pinna. Prospective observational study done for duration of one year from June 2021 till June 2022 at Ashwini Rural medical college and Hospital, Solapur. Study was done on 30 patients aged between 20 and 70 years with pseudocyst of who are diagnosed on the basis of clinical presentation and characteristics of the aspirated fluids with no signs of infection or inflammation. Among 30 patients with pseudocyst 15 patients were undergone surgical deroofing with buttoning technique and remaining 15 patients were undergone posterior cartilage window with Pressure Gauze dressing technique. The age distribution of patients with psuedocyst of pinna in our study ranged from 20 to 70 years with maximum number of cases (i.e. 16) in the age group of 30–40 years which comprised of about 53% of study population. Among 30 cases in our study 26 were males (86.7%). All cases were of unilateral pseudocyst with left ear involvement more than right ear i.e. 20 and 10 cases respectively which indicates predominantly affecting left ear (66.6%). In our study we observed the site of involvement of pinna by pseudocyst showing maximum number of cases involving combined scaphoid fossa and triangular fossa i.e. 15 cases (50%) and minimum number of cases involving Concha i.e. 2 cases (6.6%). In our study we found that the aspirated fluid from pseudocyst of pinna was sterile in all cases i.e. 30 cases (100%). In our study we observed that the aspirated fluid was serous in majority of cases i.e. 21 cases (70%) and serosanguinous in few of them i.e. 3 cases (10%). Success rate in our study for surgical deroofing with buttoning technique was 66.6% and for posterior cartilage window with Pressure Gauze dressing technique was 100% but in terms recurrence of pseudocyst of pinna, 2 groups were not statistically significant. Success rate in our study for posterior cartilage window with Pressure Gauze dressing technique was 100% with no recurrence. Among patients who have undergone surgical deroofing with buttoning technique 2 cases have minor complications like pressure discoloration of skin i.e. 1 case and thickening of skin of pinna i.e. 1 case. All these complications are temporary one and show recovery in follow up duration. Among patients who have undergone Posterior cartilage window with Pressure Gauze dressing technique 1 case had perichondritis at 1 week follow up which was resolved spontaneously at the end of 2 weeks and 2 cases had painless thicknening of pinna which also resolved spontaneously at the end of 2 weeks. Pseudocyst of pinna occurs commonly in middle aged males as unilateral lesions with left ear involvement in majority of cases. The most common involvement of pinna by pseudocyst is combined scaphoid fossa and triangular fossa, the least common site is concha. Most of the pseudocyst of pinna contain sterile serous fluid. Success rate in our study for surgical deroofing with buttoning technique was 66.6% and for posterior cartilage window with Pressure Gauze dressing technique was 100% but in terms recurrence 2 groups were not statistically significant. Both surgical treatment groups have few and temporary complications but in terms of complications 2 groups were not statistically significant.

Introduction

A pseudocyst of pinna is benign, painless, rare and asymptomatic swelling on the lateral or anterior surface of the pinna resulting from intracartilaginous accumulation of fluid.

The condition auricular pseudocyst was first described by Engel [1]. Terminology for auricular pseudocyst includes endochondral pseudocyst, intracartilaginous auricular seroma cyst, cystic chondromalacia, and benign idiopathic cystic chondromalacia [2]. Differential diagnosis of for pseudocyst of pinna includes Subperichondrial hematoma secondary to trauma, cellulitis, relapsing polychondritis, chondrodermatitis helicis [2].

Pseudocyst of in majority of cases presents as unilateral lesions, predominantly in 35–40 years mean age group and affecting predominantly males [2]. Commonly these cysts shows no symptoms but occasionally, there may be presence of minor discomfort and mild inflammatory signs. The pseudocyst of pinna typically involves in its descending order of involvement as Scaphoid fossa, triangular fossa of the antihelix, and the Cymba concha [2]. The size of the cyst varies from 1 to 5 cm in diameter and contains viscous straw-yellow fluid but in some cases shows a clear pale yellow fluid [2]. The etiology for this condition is unknown but many believe the cause as repeated minor injuries in patients with preexisting congenital intracartilaginous defects associated with lymphatic and vascular channels while some believe the cause as cartilaginous degeneration due to chondrocyte lysosomal enzymes [3].

Diagnosis of psuedocyst is based mainly on the clinical characteristics without evidence of infection [2]. There are wide range of treatment modalities described in the literature for this condition ranging from medical line of management including minimally invasive Intralesional steroid therapy, intralesional sclerosant therapy, systemic steroid therapy to surgical line of management including aspiration and pressure dressing, quilting suture with corrugated rubber drain, incision and drainage with mastoid dressing, cartilage curettage with drainage tube, surgical de-roofing and cartilage window procedure. Although multiple treatment options are available for this condition,there is no gold standard option is found In literature as more invasiveness of procedure associated with more complications and less invasiveness is associated with more recurrence [4].

The main aim of treatment is preservation or restoration of normal Anatomy or architecture of the auricle without recurrence or complications in postoperative duration [5]. One of the Literature shows that the best method that can be undertaken in the management of auricular Pseudocysts is the surgical deroofing followed by buttoning technique based on the rate of success [6], while on the other hand another literature shows cartilage window with buttoning technique is an excellent method for the treatment of pseudocyst of pinna with less complications [7].

In our study we are going to compare the surgical deroofing with buttoning technique with posterior cartilage window with Pressure Gauze dressing technique in patients with pseudocyst of pinna the basis of recurrence and complications.

Material and Methods

Aims and Objective

To compare effectiveness in terms of recurrence and complications between surgical deroofing with buttoning technique and posterior cartilage window with Pressure Gauze dressing technique in patients with pseudocyst of pinna.

Study design—prospective observational study.

Study duration—one year from June 2021 till June 2022.

Study site—Ashwini Rural medical college and Hospital, Solapur.

Sample size—30.

Study population—study population comprised of 30 patients in the age group 20–70 years.

Place of study—ENT Department of Ashwini Rural medical college and Hospital, Solapur.

Inclusion Criteria

1. Patients aged between 20 and 70 years with pseudocyst of who are diagnosed on the basis of clinical presentation and characteristics of the aspirated fluids.

2. Any size or site of pseudocyst over pinna.

Exclusion Criteria

1. Patients with signs of infection or inflammation in pseudocyst.

2. Patients with benign or malignant tumours of pinna.

3. Patients with insect bite, atopic dermatitis, eczema over pinna.

4. Patients with any food or drug allergy.

5. Patients aged < 20 years and > 70 years.

Methodology

This study will be performed in a tertiary institute of Solapur. A total of 30 cases will be included in the study. This is a prospective study of patients presenting to ENT department with the complaints of noninflammatory, asymptomatic swelling on the lateral or anterior surface of the pinna. Patients are thoroughly examined based on clinical presentation, characteristics of the aspirated fluids and those who are falling in inclusion criteria will be first administered an informed consent and written consent were obtained from those who agreed to participate in the study. A case record (PROFORMA) form was filled by the patient.

Surgical Technique

Among 30 patients with pseudocyst 15 patients were undergone surgical deroofing with buttoning technique and remaining 15 patients were undergone posterior cartilage window with Pressure Gauze dressing technique.

All 30 patients were performed under local anaesthesia. The procedure was performed under local anaesthesia using 2% xylocaine with 1:200,000 adrenaline. The entire pinna was anesthetized by infiltrating along the postauricular sulcus, the root of the helix, and the external auditory canal. In both procedure under all aseptic precautions painting and draping done. About 0.1–0.2 mL of fluid was aspirated from all patients and observed for characteristics of aspirated fluid and also sent for culture. We have not used drains or sclerosant injections in both procedure.

Postoperative Care and Follow Up in Both Procedures

Postoperatively, antibiotics with anti-inflammatory drugs are given for one week. The sutures and the buttons are removed after one week. Patients were followed for 3 months after completion of Successful treatment.

Operative Procedure

1. Fifteen cases of pseudocyst of pinna who have undergone surgical treatment by surgical deroofing with buttoning technique were included in this study.

A helical incisionis made over the skin of psuedocyst. The skin flap is then elevated well beyond the anterior cartilage segment followed by Excision of the anterior wall of the cyst releasing the straw coloured fluid (Fig. 1). Curettage of the posterior wall of the pseudocyst is then done to remove any soft tissue debris with removal of anterior leaflet of cartilage with approximation of skin using 3–0 ethilon suture material followed by buttoning. Sterilized shirt button of appropriate size are then sutured on the anterior surface (Fig. 2). Surfaces of the auricle using a 4–0 silk material on a straight needle to compress the raised skin flap on to the cartilage. No external dressing was given.

• (B)Fifteen cases of pseudocyst of pinna who have undergone surgical treatment by posterior cartilage window technique with Pressure Gauze dressing technique were included in this study.

Fig. 1.

Separation and removal of anterior leaflet of cartilage in case of pseudocyst of pinna

Fig. 2.

Application of sterilized shirt button of appropriate size by suturing it on the anterior surfaces of the auricle using a 4–0 silk

A linear incision is made over the posterior aspect of the pinna corresponding to the size and location of pseudocyst. Underlying cartilage is exposed after elevation of overlying skin (Fig. 3). This step is followed by Excision of rectangular piece of cartilage and suctioning of serious fluid in pseudocyst (Fig. 4). Wound closure done with 3–0 ethilon suture material leaving behind small posterior cartilage window left (Fig. 5). Pressure Gauze dressing applied over site opposite to skin incision (Fig. 6). Suture removal done at the end of one week.

Fig. 3.

Exposed conchal cartilage after elevation of overlying skin of posterior aspect of pinna

Fig. 4.

Excision of rectangular piece of cartilage followed by suctioning of serous fluid in pseudocyst of pinna

Fig. 5.

Wound closure using 3–0 ethilon leaving behind the small posterior cartilage window open

Fig. 6.

Pressure Gauze dressing applied over site opposite to skin incision over the pinna

Discussion

A pseudocyst of pinna is a benign, painless, rare and asymptomatic swelling on the lateral or anterior surface of the pinna resulting from intracartilaginous accumulation of fluid. Pseudocyst of pinna first reported in literature by Hartmann [8].

There are several hypothesis described in literature for its causation. The exact etiology for this condition is unknown but many believe the cause as repeated low grade injuries leading to glycosaminoglycans overproduction with resultant microcysts formation and further coalescence to a large lesion, while some believe the cause as cartilaginous degeneration due to elevated chondrocyte lysosomal Isoenzymes mainly LDH-4 and LDH-5 leading to progressive dialatation of intercartilaginous tissue planes [2, 9]. Some suggests reopening of residual tissue planes in congenital embryonic dysplasia of the auricular cartilage [10]. Histological study shows that pseudocyst is characterized by an intracartilaginous cavity containing thinned cartilage without epithelial lining [11] with hyaline degeneration and granulation tissue formation [2].

Pseudocyst of in majority of cases presents as unilateral lesions, predominantly in 35–40 years mean age group and affecting predominantly males because of role of hormonal influence in modulation of inflammation in males [12, 13]. Commonly these cysts shows no symptoms but occasionally, there may be presence of minor discomfort and mild inflammatory signs. The pseudocyst of pinna typically involves the in its descending order of involvement as Scaphoid fossa, triangular fossa of the antihelix, and the Cymba concha [2]. The size of the cyst varies from 1 to 5 cm in diameter and contains viscous straw-yellow fluid but in some cases shows a clear pale yellow fluid [2].

The condition auricular pseudocyst was first described by Engel in 1966 in the Chinese population and white Men showing male preponderance that is 84.2% were males and 15.8% were females [1]. Similar study done by Lim where he reported the incidence of the disease among males and females were 87 and 13% respectively [10]. Similar study done by Hansen where he reported series of six cases in Caucasian males and agreed that the term Pseudocyst is more appropriate in place of intracartilaginous cysts [11].

Maximum number of patients in our study were farmers by profession followed by labourers while businessmen and employees comprised the minimum number we have not analyzed trauma as cause for pseudocyst.

Similar study done by Khan et al. found that the maximum number of patients were labourers followed by businessmen with least number of patients were government employees because of nature of work by each group leading to ear trauma [6].

Diagnosis of psuedocyst is based mainly on the clinical characteristics without evidence of infection [2]. There are wide range of treatment modalities described in the literature for this condition ranging from medical line of management which includes minimally invasive intralesional steroid therapy, intralesional sclerosant therapy, intralesional injections of minocycline hydrochloride (1 mg/mL) two to three times at 2-weeks intervals [14], systemic steroid therapy to surgical line of management which includes incision and drainage with Curettage and pressure dressing [11], needle aspiration plus bolstered pressure sutures applied over both surface of pseudocyst [14], aspiration and pressure dressing, quilting suture with corrugated rubber drain, incision and drainage with mastoid dressing, cartilage curettage with drainage tube, surgical curettage and fibrin sealant to obliterate the cystic cavity [15], surgical de-roofing with buttoning technique [16] and cartilage window procedure [4]. Although multiple treatment options are available for this condition,there is no gold standard option is found in the literature as more invasive procedures are associated with more complications and less invasive are associated with more recurrence [4].

We have not measured LDH isoenzymes in pseudocyst and also have not done histopathological examination of sample in post-operative duration because of financial issues.

Results

Our study is a prospective observational study showing our experience at tertiary unit ENT Department of Ashwini Rural medical college and Hospital with the aim to compare effectiveness between surgical deroofing with buttoning technique and posterior cartilage window with Pressure Gauze dressing technique in patients with pseudocyst of pinna. Study involves 30 patients in the age group 20 to 70 years for a duration of one year from June 2021 till June 2022.

The age distribution of patients with psuedocyst of pinna in our study ranged from 20 to 70 years with maximum number of cases (i.e. 16) in the age group of 30 to 40 years which comprised of about 53% of study population. Among 30 cases in our study 26 were males (86.7%) 4 patients were female (13.3%) with preponderance of pseudocyst of pinna in male population. All cases were of unilateral pseudocyst with left ear involvement more than right ear i.e. 20 and 10 cases respectively which indicates predominantly affecting left ear (66.6%).

Similar study done Khan et al. shown that this condition commonly seen in middle aged population with male preponderance with more common unilateral involvement [6]. Similar study by Engel [1] and Hansen [11] found all the cases with male preponderance. The incidence of pseudocyst of pinna in males is 87% given by Lim et al. [17].

In our study we observed the site of involvement of pinna by pseudocyst showing maximum number of cases involving combined scaphoid fossa and triangular fossa i.e. 15 cases (50%) followed by triangular fossa alone i.e. 5 cases (16.6%) followed by diffuse swelling of entire pinna i.e. 4 cases (13.3%) followed by scaphoid fossa i.e. 4 cases (13.3%) and minimum number of cases involving Concha i.e. 2 cases (6.6%). In our study we observed that the aspirated fluid was serous in majority of cases i.e. 21 cases (70%) and serosanguinous in few of them i.e. 3 cases (10%). In our study the size of swelling of pseudocyst of pinna ranges from 1.2 to 5 cm in largest diameter. The volume of the fluid ranged from 1 to 4.5 mL in our study.

Similar study done by Ramdas et al. found that pseudocyst of pinna typically involves in its descending order of involvement as Scaphoid fossa, triangular fossa of the antihelix, and the Cymba concha [2]. The size of the cyst varies from 1 to 5 cm in diameter and contains viscous straw-yellow fluid but in some cases shows a clear pale yellow fluid [2] and also similar study by Cohen et al. found that pseudocysts contain olive oil like straw yellow viscous fluid in majority cases with few cases contained serous or serosanguinous fluid [18]. Similar study done by Ramdas et al. observed the size ranging from 1 to 5 cm in diameter [2] and Khan et al. found it between 1.5 and 4.5 cm [6].

In our study we found that the aspirated fluid from pseudocyst of pinna was sterile in all cases i.e. 30 cases (100%).

Similar study done by Khan et al. found that the aspirated fluid from pseudocyst of pinna was sterile in all cases [6].

Recurrence of pseudocyst of pinna between 2 groups i.e. surgical deroofing with buttoning technique and Posterior cartilage window with Pressure Gauze dressing technique were not statistically significant.

Success rate in our study for surgical deroofing with buttoning technique was 66.6% and for posterior cartilage window with Pressure Gauze dressing technique was 100% but in terms recurrence of pseudocyst of pinna between 2 groups were not statistically significant (Table 1).

Table 1.

Number of patients with recurrence of pseudocyst of pinna in 2 groups

Surgical technique used	Recurrence present	Recurrence absent	Total
Surgical deroofing with buttoning technique	5	10	15
Posterior cartilage window with Pressure Gauze dressing technique	0	15	15

Fischer’s exact test. The two-tailed p value = 1.00. Since this value is more than 0.05, deviation from the null hypothesis is not statistically significant, and the null hypothesis is not rejected

Similar study done by Khan et al. found success rate for surgical deroofing with buttoning technique as 96% with recurrence only in one patient [6]. Similarly study done by Choi et al., Chang et al., Kanotra and Lateef, Patigaroo et al. found this technique successful in majority of cases with no recurrence [19–21].

Success rate in our study for posterior cartilage window with Pressure Gauze dressing technique was 100% with no recurrence (Table 1).

Similar study done by Dr Asif Mahajan et al. found 100% success rate with no Recurrence and no complications like perichondritis, structural deformity of pinna [7]. Similar study done by Koirala et al. found 100% success rate with no recurrence with no complications [22].

Among patients who have undergone surgical deroofing with buttoning technique 2 cases have minor complications like pressure discoloration of skin i.e. 1 case and thickening of skin of pinna i.e. 1 case. All these complications are temporary one and show recovery in follow up duration (Table 2).

Table 2.

Number of patients with complications of 2 groups of surgical techniques

Surgical technique used	Complications present	Compilations absent	Total
Surgical deroofing with buttoning technique	2	13	15
Posterior cartilage window with Pressure Gauze dressing technique	3	12	15

Fischer’s exact test. The two-tailed p value = 1.00. Since this value is more than 0.05, deviation from the null hypothesis is not statistically significant, and the null hypothesis is not rejected. The association between rows (groups) and columns (outcomes) is considered to be statistically not significant i.e. complications between 2 groups i.e. surgical deroofing with buttoning technique and posterior cartilage window with pressure gauze dressing technique were not statistically significant

Similar study done by Khan et al. found recurrence after surgical deroofing with buttoning technique in patients with psuedocyst of pinna in 1 case, Redness in 1 case, tenderness in 1 case, erythema of pinna in 1 case, Thickening of the pinna in 2 cases without deformity of the pinna [6]. Similar study done by Bhat et al. found recurrence in 1 case after surgical deroofing with buttoning technique without any complications [4].

Among patients who have undergone Posterior cartilage window with Pressure Gauze dressing technique 1 case had perichondritis at 1 week follow up which was resolved spontaneously at the end of 2 weeks and 2 cases had painless thicknening of pinna which also resolved spontaneously at the end of 2 weeks (Table 2).

Similar study done by Dr Asif Mahajan et al. found 100% success rate with no recurrence and no complications like perichondritis, structural deformity of pinna [7]. Similar study done by Koirala et al. found 100% success rate with no recurrence with no complications [22].

Conclusion

Pseudocyst of pinna occurs commonly in middle aged males as unilateral lesions with left ear involvement in majority of cases. The most common involvement of pinna by pseudocyst is combined scaphoid fossa and triangular fossa, the least common site is concha. Most of the pseudocyst of pinna contain sterile serous fluid.

Success rate in our study for surgical deroofing with buttoning technique was 66.6% and for posterior cartilage window with Pressure Gauze dressing technique was 100% but in terms recurrence 2 groups were not statistically significant.

Both surgical treatment groups have few and temporary complications but in terms of complications 2 groups were not statistically significant.

Funding

Not applicable.

Declarations

Conflict of interest

All the authors declare that they have not any conflict of interest.

Human or Animal Rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration.

Ethical Approval

Ethical approval taken from institutional ethical committee of Ashwini Rural Medical College & Hospital Solapur as per ICMR guidelines.

Informed Consent

Informed consent was obtained from all individual participants involved in the study.