A Systematic Review of Treatment Protocols in Auricular Pseudocysts

Abstract

A systematic review of literature on treatment modalities available with respect to efficacy, complications and recurrences so as to guide the clinician to better treat this enigmatic condition. A systematic search of PubMed, Google Scholar, Ovid and Cochrane databases. Articles in English that described or compared treatment were included. Articles without clear treatment end-points or follow-up data were excluded. Patients were then divided by primary treatment modality into Aspiration, Incision & Drainage (I&D), surgical deroofing, intralesional steroids (ILS) and No treatment groups and compared with respect to cure rates, complications and residual thickening using Chi-square test. Similarly confounding variables compression and suturing were compared. 85 articles were selected and reviewed (1699 patients; mean follow-up 7.8 months). Surgical deroofing had the highest cure rate (98.2%) followed by I&D (95.4%), both of which were significantly more efficacious than Aspiration with or without ILS (p < 0.001). Aspiration with ILS had the highest rate of complications (13.6%) and residual thickening (16.7%); significantly more than other treatment modalities. Aspiration with negative pressure device had a 100% cure in the few reported articles (n = 57). Compression had no significant advantage overall, but suturing significantly increased cure rates. Surgical deroofing and I&D are the most efficacious treatments. Aspiration + ILS has lower cure and significantly increased complications, hence should be avoided. Based on the results, we propose a treatment protocol for auricular pseudocyst. As only two high-quality randomized controlled trials were available in literature, further research in comparing treatment is warranted.

Introduction

The earliest reference to Auricular Pseudocyst is by Engel D in 1966 [1]. Auricular pseudocysts are intra-cartilaginous, cystic lesions with no epithelial lining, that usually develop as painless swellings on the lateral aspect of the external ear [2]. These benign cysts have been historically known by various names like endochondral pseudocyst and cystic chondromalacia. They usually contain straw coloured fluid high in glycosaminoglycans with slightly gelatinous consistency.

While they can occur spontaneously, pseudocysts are often linked to repeated minor trauma such as rubbing, sleeping on a hard pillow, wearing earphones or helmets, and minor sports injuries [2–6]. This has led to the theory that minor repetitive trauma causes cartilage degeneration and release of enzymes like lactic dehydrogenase into the cyst fluid [7, 8].

Pseudocysts develop gradually as non-tender, fluctuant swellings ranging from 1 to 5 cm [9, 10]. They most commonly affect adult men between 30 and 40 years old [2]. Though painless, they can be associated with pruritic skin conditions, neurological diseases or systemic illnesses like atopic dermatitis and lymphomas [11–13]. In contrast to auricular hematomas which are acutely painful swellings linked to trauma, pseudocysts have no known single inciting traumatic event in most cases [2].

Patients usually seek treatment for discomfort or cosmetic concerns. The aim of treatment is prevent damage to the ear structure, maintain cosmesis and prevent recurrence [14–16]. Lack of appropriate treatment can lead to thickening, floppy ear, cauliflower ear and other permanent deformities [15, 17]. There are multiple treatment methods described, including, but not limited to, aspiration [3, 18–20], incision and drainage [21, 22], surgical deroofing [14, 23–27], systemic steroids [17] and intra-lesional steroids [3, 8, 28–30]. Various modes of compression like splinting, bolster, dental cast etc. [28, 28, 31–35] and through and through suturing (with or without splints) [18, 32, 36, 37] are also combined with the above procedures.

Various complications associated with these treatment modalities are gross deformities like cauliflower ear or floppy ear (commonly seen in posterior cartilage window and intralesional steroids) [14, 16, 29, 37, 38], perichondritis and pressure dressing (commonly seen in suturing) [14, 21, 29, 35, 38], skin discoloration and ridging (commonly seen after splinting) [14, 38] and infection [37, 39].

But there are conflicting reports of efficacy and complications, very few treatment guidelines and very few randomized controlled trials for various treatment modalities in literature [40–42]. This study aims to review all the relevant literature on treatment modalities available for auricular pseudocyst with respect to efficacy, complications and recurrences so as to guide the clinician to better treat this enigmatic condition.

Methods

A systematic search of PubMed, Google Scholar, Ovid and Cochrane databases was done on 16th May, 2024. On PubMed database, query ((pseudocyst) OR (seroma) OR (cystic chondromalacia)) AND ((auricular) OR (pinna) OR (Ear)) was executed, while auricular pseudocyst, seroma AND ear OR auricular OR auricle and cystic chondromalacia pinna were used in the rest of the databases.

Full text of all studies was read and reviewed. Published randomized control trials, case series and reports in the English language that described or compared treatment modalities of auricular pseudocyst were included in the review. Any studies which were non-relevant, which had no mention of follow-up duration, treatment results or clearly defined method of treatment were excluded from the review. Also, patients with systemic connective tissue diseases like relapsing polychondritis were excluded. Finally, relevant studies were selected for the review with the consensus of all study authors.

The treatment modality used in each study was tabulated, along with basic epidemiological data. The primary treatment modality in each of the studies was classified into the following groups: (1) aspiration, (2) incision & drainage, (3) surgical deroofing, (4) aspiration with intralesional steroids and (5) no treatment.

Cure was considered as absence of recurrence or gross deformity like floppy or cauliflower pinna. Residual thickening and complications were also tabulated. Cure rates, complication rates etc. were compared between different treatment modalities using the Chi-square test with a significance level of 0.01 using IBM SPSS software. Similarly confounding variables compression and suturing were assessed to know if there is any significant difference in outcome by using these along with primary treatment modality.

Results

1832 published article results obtained with the initial search strategy, out of which, 172 were selected after applying exclusion criteria. After removing duplicates, 101 studies with full text available were selected. After reading the full text, further 16 studies were excluded based on exclusion criteria and finally 85 studies were included in the review. A 1992 study by Job and Raman [17] with 4 patients who were given only systemic steroids was not included in this review as systemic steroids alone is not indicated for the condition in current medical literature.

After final selection of articles, there were a total of 1699 unique patients in the review, with some patients being present in multiple arms of the articles included, make the total number of lesions treated to 1772. The Male to Female ratio of patients was 7.34:1.

The studies, classified according to primary mode of treatment, is tabulated below (Table 1).

Table 1.

Master table classified by primary treatment modality

		Primary treatment							Result
Author	Year	Aspiration	I&D	Deroofing	Aspiration + ILS	No treatment	Compression	Suturing	Cured	Not cured	Thickening	Recurred	Complication	Notes
A. aspiration		415							329	86	4	80	18
Yu et al. [41]	2022	28					Y		15	13			8
Yoshioka et al. [43]	2021	1					Y		1	0				1
Dong et al. [44]	2021	32							32	0	3			2
Agrawal et al. [45]	2020	1					Y		1	0			0	1
Dabholkar et al. [46]	2018	14					Y		14	0		1
Wollina et al. [47]	2017	1					Y		1	0
Gu et al. [38]	2014	25							25	0				2
Nemade et al. [16]	2014	48					Y		48	0		5	8
Lee et al. [48]	2013	1							1	0
Crowley et al. [6]	2012	1					Y	Y	1	0		1
Patigaroo et al. [10]	2012	7					Y		1	6		6
Kanotra et al. [49]	2009	29					Y		1	28		28
Ng et al. [12]	2007	1					Y		1	0		1
Salgado et al. [19]	2006	1					Y		1	0				1
Han et al. [50]	2006	1					Y		1	0
Kikura et al. [51]	2006	16							13	3		3
Kikura et al	2006	3					Y	Y	3	0		0		7
Prasad et al. [52]	2005	116					Y		92	24		24
Kaur et al. [53]	2003	2					Y		2	0				3
Oyama et al. [54]	2001	2					Y		2	0				4
Schulte et al. [55]	2001	5					Y		5	0
Bhandary et al. [42]	2000	10					Y		1	9		9
Hegde et al. [56]	1996	10					Y		10	0	1			5
Oliver et al. [57]	1994	1						Y	1	0
Ichioka et al. [9]	1993	3					Y		1	2		2
Ophir et al. [18]	1991	9					Y		9	0
Li-Xiang et al. [58]	1990	45					Y		45	0			2	6
Cohen et al. [59]	1990	1							0	1
Karakashian et al. [32]	1987	1					Y	Y	1	0
B. I&D			174						166	8	14	10	12
Djosan et al. [4]	2022		2				Y	Y	2	0			0
Bansal et al. [60]	2022		1					Y	1	0				8
Tawab et al. [21]	2019		42				Y		42	0		0	0	9
Rao et al. [15]	2018		27				Y		27	0	8	0	7
DeWitt et al. [61]	2018		1					Y	1	0		0	0
Cohen et al. [62]	2016		1				Y		1	0		1
Bhat et al. [23]	2015		30				Y		30	0	0	0	4
Purwar et al. [63]	2013		1				Y		1	0
Kindem et al. [33]	2013		1				Y	Y	1	0				10
Tupker et al. [64]	2013		1				Y		1	0
Göktay et al. [65]	2011		1				Y	Y	1	0
Reitzen et al. [66]	2011		1				Y	Y	1	0
Kanotra et al. [49]	2009		13				Y	Y	8	5	3	5
Prasad et al. [52]	2005		24				Y		24	0
Tuncer et al. [67]	2003		1				Y		1	0
Paul et al. [68]	2001		1				Y		1	0
Ramalingam et al. [69]	1998		15						15	0		1		11
Lee et al. [70]	1994		1				Y		1	0				12
Cohen et al. [71]	1991		1				Y	Y	1	0		1		13
Devlin et al. [11]	1990		1				Y		0	1	1		1
Job et al. [72]	1988		2				Y		2	0
Shanmugham et al. [73]	1985		2				Y		2	0
Glamb et al. [74]	1984		4				Y		2	2	2	2		13
C. Deroofing				877					861	16	24	22	53
Tian et al. [37]	2023			87			Y	Y	87	0			0
Chan et al. [31]	2022			31			Y		30	1		1	1	14
Yu et al. [41]	2022			28			Y		28	0			20
Beesanahalli et al. [14]	2022			16			Y	Y	16	0			2
Moreno et al. [27]	2021			1			Y		1	0				15
Agrawal et al. [45]	2020			1			Y	Y	1	0		1	1
Liu et al. [39]	2020			218				Y	216	2	8	10	11
Onkarappa et al. [36]	2019			4				Y	3	1		0	1
Lee et al. [26]	2019			15			Y	Y	15	0		0	0
Dutsch et al. [75]	2019			1			Y		1	0		0	0
Wu et al. [35]	2018			100			Y	Y	98	2		2	1
Cader et al. [76]	2018			20				Y	20	0			3
Wollina et al. [47]	2017			1					1	0
Baltu et al. [77]	2017			1			Y		1	0		0	1
Grigoryan et al. [24]	2015			1				Y	1	0
Shan et al. [34]	2014			87			Y		86	1		0	1
Bhat et al. [23]	2014			30			Y	Y	29	1		1
Zoccali et al. [78]	2014			1			Y	Y	1	0
Laschen et al. [79]	2014			1				Y	1	0
Khan et al. [25]	2013			26			Y	Y	25	1	2		3
Patigaroo et al. [10]	2012			7			Y	Y	7	0	3	0	4
Kanotra et al. [49]	2009			20			Y	Y	20	0
Ramadass et al. [80]	2006			6			Y	Y	6	0
Tan et al. [5]	2004			40			Y	Y	38	2		4
Sangeetha et al. [81]	2004			27			Y		27	0
Lim et al. [82]	2002			41			Y	Y	40	1			1
Bhandary et al. [42]	2000			25			Y		24	1	5	1	2
Secor et al. [83]	1999			1					1	0
Santos et al. [84]	1995			1			Y		1	0
Harder et al. [85]	1993			2					2	0	1
Ichioka et al. [9]	1993			2					2	0
Hoffmann et al. [86]	1993			1					1	0
Devlin et al. [11]	1990			2			Y		2	0	1
Choi et al. [87]	1984			31			Y		28	3	4	2	1
Santos et al. [88]	1974			1			Y		1	0
D. Aspiration + ILS					294				252	42	49	46	40
Yu et al. [41]	2022				28		Y		24	4			10
Parajuli et al. [29]	2020				30				30	0	3
Liu et al. [39]	2020				168				142	26	42	30	30
Rai et al. [3]	2019				30				30	0		0	0
Navarro et al. [89]	2017				1		Y		1	0		0	0
Patigaroo et al. [10]	2012				7		Y		4	3	1	3
Kim et al. [28]	2009				1		Y		1	0
Miyamoto et al. [8]	2001				9				6	3		3
Bhandary et al. [42]	2000				10		Y		4	6	3	6
Juan et al. [30]	1994				10				10	0		4
E. No treatment						12			5	7	2	3	1
Beutler et al. [90]	2015					2			0	2				16
Patigaroo et al. [10]	2012					7			4	3		3	1
Pereira et al. [13]	2003					1			0	1				17
Derrick et al. [91]	1995					1			0	1	1
Devlin et al. [11]	1990					1			1	0	1			18

1. Prosthetic mould 2. Negative pressure device 3. Oral steroids 4. Minocycline intra-lesional injection 5. Plaster of Paris cast 6. Drainage tube used 7. Bolster compression added 8. Platelet rich fibrin used 9. Drainage tube used with regular irrigation of saline and betadine. 10. Thermoplastic splint 11. Drainage tube 12. Negative pressure device used 13. Two patients had Intra-lesional steroid 14. Merocel compression dressing 15. Bilateral pseudocysts 16. Patients with movement disorders 17. Patient with lymphoma associated pruritis 18. Child with atopic eczema

In this review, out of the studies hereby tabulated for treatment modalities of auricular pseudocyst, only two are randomized control trials. There may be a bias in case reports and case series as cure, recurrence and complications are defined differently by different authors. For the purpose of the review, we have tabulated so that the definition of cure aligns to the consensus definition as mentioned in the introduction to eliminate the bias. Also, some articles may have a bias due to deviations from intended interventions, for example, when aspiration failed, deroofing was done.

The mean follow-up period for all articles included in the review is 7.8 months. The overall cure rate of all patients offered any treatment was 91.4% vs 41.7% without any treatment (p < 0.001). With treatment, the overall recurrence rate was 9.1% and complication rate was 7%.

The results of the data for cure rate, recurrence rate, complication rate and residual thickening is tabulated below (Table 2).

Table 2.

Summary of different treatment options

Treatment modality		Cured		Recurrence		Complications		Residual thickening
	Total	n	%	n	%	n	%	n	%
Aspiration	415	329	79.3	80	19.3	18	4.3	4	1
I&D	174	166	95.4	10	5.7	12	6.9	14	8
Deroofing	877	861	98.2	22	2.5	53	6	24	2.7
Aspiration + ILS	294	252	85.7	46	15.6	40	13.6	49	16.7
No Treatment	12	5	41.7	3	25	1	8.3	2	16.7
Total	1772	1613	91	161	9.1	124	7	93	5.2

As seen in Fig. 1, the highest percentage of cure is seen with Deroofing procedure (98.2%), followed by I&D procedure (95.4%).

Fig. 1.

Cure percentage for different treatment modalities

The p-values of comparison cure rate, recurrence and complications of different treatment modalities tested with Pearsons Chi-squared test is summarized in the table below (Table 3).

Table 3.

Cure rates p-values (1% level of significance)

	Aspiration	I&D	Deroofing	Aspiration + ILS	No treatment
Aspiration	–	< 0.001	< 0.001	0.03	0.002
I&D	< 0.001	–	0.025	< 0.001	< 0.001
Deroofing	< 0.001	0.025	–	< 0.001	< 0.001
Aspiration + ILS	0.03	< 0.001	< 0.001	–	< 0.001
No treatment	0.002	< 0.001	< 0.001	< 0.001	–

I&D = incision & drainage; ILS = intralesional steroids

Aspiration and Aspiration with Intralesional steroid treatments are only better than the no treatment group. Aspiration with or without intralesional steroid does not have any significant difference in cure rates (p = 0.03) (Table 3).

I&D and Deroofing treatments are both significantly better than either Aspiration (p < 0.001) or Aspiration + Intralesional steroid injection (p < 0.001). Deroofing is not significantly better than I&D (p = 0.025) (Table 2).

Aspiration with negative pressure device has a 100 percent cure rate with a sample of 57, with a significance of p < 0.001 compared to aspiration alone (Table 3).

In all cases, comparing compression dressing along with primary modality of treatment versus no compression given, there is no significant difference (Chi-square 3.79, p value = 0.051).

Comparing various forms of suturing along with primary modality of treatment versus no suturing at all, there is a significant advantage for the suturing arm (p < 0.001).

As seen in the above table (Table 4), there is no significant difference between complication rates of aspiration, I&D and deroofing procedure. But intralesional steroid significantly increases the complication rates as compared to aspiration and deroofing (p < 0.001).

Table 4.

Comparison of complications of various treatment modalities (p value)

	Aspiration	I&D	Deroofing	Aspiration + ILS
Aspiration	–	0.19	0.21	< 0.001
I&D	0.19	–	0.66	0.03
Deroofing	0.21	0.66	–	< 0.001
Aspiration + ILS	< 0.001	0.03	< 0.001	–

Aspiration with Intralesional steroids also causes significantly more residual thickening as compared to Aspiration alone (p < 0.001), I&D (p = 0.007) and deroofing (p < 0.001). I&D procedure causes significantly more residual thickening than deroofing procedure (p < 0.001) (Table 5, Fig. 2).

Table 5.

Comparison of residual thickening of various treatment modalities (p value)

	Aspiration	I&D	Deroofing	Aspiration + ILS
Aspiration	–	< 0.001	0.04	< 0.001
I&D	< 0.001	–	< 0.001	0.007
Deroofing	0.04	< 0.001	–	< 0.001
Aspiration + ILS	< 0.001	0.007	< 0.001	–

Fig. 2.

Overview of cure rate, complications rate and residual thickening in percentage

Discussion

There is a male preponderance of cases with 7.34 males for every female case reported. This may be due to the fact that trauma is an important aetiology for the condition.

In our analysis, it was seen that anterior deroofing surgery has the highest cure rate of 98.2%, followed by incision and drainage (95.4%), which are both significantly better (p-value < 0.01) than either Aspiration alone or Aspiration with Intralesional steroids.

Anterior deroofing surgery is usually done under local anaesthesia. Incision is usually made up to the anterior wall of the cyst and the skin is elevated. Then the thin anterior wall of the cyst is removed, draining the cyst fluid. The posterior wall of the cyst is then gently scraped to remove any residual cyst wall [26, 37, 41]. Depending on the location of the cyst, the incision can be made at the junction of the helix and scapha cosmetic units to make the incision inconspicuous. The posterior wall of the cyst should not be damaged to avoid a floppy ear [40]. Many surgeons also use through and through suturing after deroofing [35, 37]. Compression dressing, or bolster sutured is also commonly employed. With anterior deroofing surgery, the complication rate is similar to other techniques, and rate of residual thickening is also less. This should be considered highly significant due to the fact that, in most of the reported articles, anterior deroofing is done after other techniques have failed [42, 49, 82].

Incision and drainage is usually much more easier to perform, and requires less surgical skill than anterior deroofing surgery. Multiple methods of drainage has been described, including cruciate incision [22], incision along the helix etc. Drainage tubes have been used. Compression and suturing are also commonly employed. In this review, we find that incision and drainage is similar in efficacy to anterior deroofing procedure with similar complication rate, but residual thickening is significantly (p value < 0.001) more than any other method.

Aspiration, with or without compression is the least efficacious treatment with regards to cure (p < 0.001 significance), though the rates of complications are the least (4.3% compared to a mean of 7%). Most of the cases undergoing aspiration had compression dressing or bolster in some way (82%), hence the effect of compression on treatment outcome could not be studied meaningfully. Similarly, only a few cases had through and through suturing combined with aspiration (1.5%), hence no inference on the role of suturing could be drawn. But, notably two articles [38, 44] with a total of 57 patients, treated with a negative pressure device had a reported cure rate of 100% with very few complications. The negative pressure device is an improvised arrangement with indwelling needle and transfusion tubes. It is kept in situ for at-least 7 days, or till there is no drainage. Hence it may be cumbersome to the patient. The stated advantages are that no incision or removal of cartilage is required, and complications of compression/suturing like uneven pressure and microvascular compromise can be prevented. But as the number of patients is too low (n = 57), meaningful comparison with other methods is not possible. Future development of an easier to use, standardized negative pressure device and more trials on this technique will make it an attractive option in treatment of auricular pseudocysts.

Finally, the results show that aspiration with intralesional steroids are significantly less effective than deroofing surgery and incision & drainage for cure (p value < 0.001). It is also associated with the maximum proportion of complications (13.6%), recurrence and residual thickening (16.7%), which is significantly higher than all other types of treatment (p < 0.001). Considering all of this, intralesional steroids cannot be recommended for treatment of auricular pseudocysts.

Suturing was shown to significantly positively impact cure, most probably due to it being most commonly being combined with surgical deroofing. Compression does not significantly modify affect cure rates.

There are a multitude of treatment options reported in literature, but we could identify only two well conducted randomized controlled trials for the same. As most of the data is via case reports and case series, the definition and endpoints for cure and complications are varying or vague in many articles. We have as far as possible interpreted the results based on the standard criteria of cure as described above to reduce the bias involved. Also, as Aspiration with Negative Pressure Device had only two studies with n = 57, this modality could not be classified as a different category of treatment for meaningful comparison with other treatment modalities.

In light of the above results and discussion, we propose that surgical deroofing should be considered as the first line of treatment for all patients with auricular pseudocyst, except for the cases where the patient is not willing for a surgical procedure or surgical expertise is lacking. Incision and draining, with variations like “window” deroofing may also be considered. Aspiration with negative pressure device may be recommended if more studies are available for the same, considering the high cure rates and lower complications reported in the limited literature available. Aspiration, with or without intralesional steroids is not recommended considering lower efficacy for cure and higher rates of complication and thickening with intralesional steroids (See Fig. 3).

Fig. 3.

Suggested treatment protocol

Further controlled trials of different modalities of treatment, especially incision and drainage and aspiration with negative pressure device are imperative to shed better light on treatment options of auricular pseudocyst.

Conclusion

Anterior deroofing of the cyst wall and Incision & drainage are the most efficacious methods of treating auricular pseudocyst, compared to aspiration (with or without intralesional steroids). Aspiration with negative pressure device is a promising technique, and needs further studies to confirm its efficacy and safety. Intralesional steroids have no advantage over other techniques, and is associated with significantly higher complications and residual thickening, and hence should have no role in management of this condition.

Author Contribution

Shajul George: First author, Study design, collection of data, analysis of data, Shibu George: Study design, analysis of data. Asha C.S: Collection & Analysis of data, Corresponding author. Rajeev Kumar Madhavan: Analysis of data.

Funding

None.

Declarations

Conflict of interest   None.