THIEME

178 Original Research

Incision and Drainage with Daily Irrigation for

the Treatment of Auricular Pseudocyst
Hazem M. Abdel Tawab1,2 Salim M. Sloma Tabook1

1 Department of Otorhinolaryngology, Sultan Qaboos Hospital, Address for correspondence Hazem M. Abdel Tawab, MD,
Salalah, Oman Department of Otorhinolaryngology, Faculty of Medicine,
2 Department of Otorhinolaryngology, Faculty of Medicine, Cairo Cairo University, Cairo 12111, Egypt
University, Cairo, Egypt (e-mail: hazemabdeltawwab77@yahoo.com).

Int Arch Otorhinolaryngol 2019;23:178–183.

Abstract Introduction Pseudocyst of the pinna is a rare condition that occurs when fluid
accumulates in the intercartilagenous space of the auricle. The main goal when
treating this condition is to keep acceptable cosmetic results with no recurrence rate.
Objective To demonstrate the superior impact of incision and drainage of auricular
pseudocysts with the insertion of a catheter drain and daily irrigation as the treatment
of this condition.
Methods A total of 42 patients with auricular pseudocysts were enrolled in the
present study in the period between May 2011 and May 2017. All of the patients were
treated with incision and drainage with compression. The average follow-up time
reached  6 months in all of the cases.
Results All of the patients had satisfactory cosmetic results with no recurrence and no
Keywords complications.
► pseudocyst Conclusion Among the different methods of surgical treatment of pseudocyst of the
► pinna pinna, incision and drainage with daily irrigation is a significantly efficient method both
► incision for the eradication of auricular pseudocysts and for good cosmetic results.

Introduction metic appearance. Many treatment options have been men-

tioned in the literature, such as simple aspiration and pressure,
Auricular pseudocyst of the pinna is a benign painless condi- intralesional steroid injection, deroofing, compression buttons,
tion characterized by the accumulation of fluid in the inter- sclerosing agents, and excision of the anterior cartilage, but
cartilagenous space of the auricle. It was described as auricular with a recurrence rate or some complications, encountered
pseudocyst by Engel, in 1966, due to the fact that it lacks an especially in the simple aspiration of the cyst.4 In the present
epithelial lining.1 The most common sites of affection encoun- work, we present 42 patients with pseudocyst of the pinna who
tered are the cymba concha, the scaphoid fossa, and the were treated with incision, drainage, and insertion of a catheter
triangular fossa.2 Other synonyms for this condition are endo- drain with compression for 10 days, with no recurrence over an
chondral auricular pseudocyst, cystic chondromalacia, and average period of 6 months, and with no complications or
benign idiopathic cystic chondromalacia.3 In most of the cases, deformities. The objective of the present study is to demon-
pseudocyst of the pinna is asymptomatic; however, sometimes strate the superior results of incision, drainage and daily
it can produce some sense of discomfort. Its size ranges from 1 irrigation in the treatment of auricular pseudocysts.
to 5 cm in diameter, and its content is usually a viscous straw-
yellow fluid, although, sometimes, a clear pale yellow fluid
Methods
might be seen.3 The aim of the treatment of this condition is the
preservation of the normal shape and characters of the pinna The present retrospective study included 42 patients with
and the prevention of recurrence, while keeping a good cos- pseudocyst of the pinna who presented to the outpatient

received DOI https://doi.org/ Copyright © 2019 by Thieme Revinter

December 31, 2017 10.1055/s-0038-1676124. Publicações Ltda, Rio de Janeiro, Brazil
accepted ISSN 1809-9777.
October 12, 2018
published online
February 6, 2019
 Incision and Drainage with Daily Irrigation Tawab, Tabook 179

clinic of our department of otorhinolaryngology from Surgical Technique

May 2011 to May 2017.
Before the start of data collection, ethical approval was The swelling was assessed for size and site (►Fig. 1). The
obtained from the local ethics committee. pinna was disinfected with Betadine, and then drapped.
All of the files of the patients were retrieved from our Between 0.1 and 0.2 ml of fluid was aspirated from the
computer system and from the paper medical reports. Full swelling for the inspection of the character of the fluid. Local
history details were obtained, especially the onset and anesthesia infiltration with 2% xylocaine and 1:200,000
duration of the swelling, any possible relation with a trau- adrenaline was performed at the proposed sites of incision.
matic episode, as well as the presence of discomfort or pain The swelling was then incised from its upper and lower ends,
related to the condition. with squeezing of the content of the cyst and dissection
Cases with a previous attempt of aspiration, injection or inside the cavity with an artery forceps. The insertion of a
incision of the cyst were excluded from the study. Since 1999, drain catheter from the upper to the lower incision keeping
various methods of treatment had been implemented in our its upper free and lower free ends seen from the incision
department for this condition, such as simple aspiration and sites. The drain catheter was provided with two to three
pressure, as well as the deroofing technique, but due to pores along its lumen to facilitate daily irrigation with
cosmetically unsatisfactory results or to recurrence of the sodium chloride 0.9% and Betadine later on. The drain was
swelling, these methods had been replaced with incision, held in place with one nylon 3-0 stitch in its upper part
drainage, insertion of a catheter drain, and pressure, with (►Fig. 2). In some cases with large pseudocysts we added
daily irrigation for a minimum period of 10 days. another stitch to the lower part of the drain catheter.
Age and gender of the patients, history of trauma, later-
ality of the lesion, duration, site, size and content of the
swelling have been documented for any possible or surpris-
ing importance.
Informed consent was obtained from all patients after
they received an explanation of the procedure, of the post-
operative care, and of the follow-up.

Fig. 1 The pseudocyst as seen before the procedure. Fig. 2 Drain catheter stitched to the upper incision site.

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180 Incision and Drainage with Daily Irrigation Tawab, Tabook

Fig. 4 Daily irrigation with sodium chloride 0.9% and betadine.

Fig. 3 Vaseline gauze to protect the pinna from the edges of the drain The average age of the patients included in the present
catheter. study was 34.9 years old. The age groups of the patients are
demonstrated in ►Table 1.
The most common site of occurrence of pseudocysts of the
Vaseline gauze to protect the ear pinna from any possible auricle in the present study was the scaphoid fossa (22 cases,
injury by the drain free upper and lower edges (►Fig. 3). 52.38%). The sites of occurrence of pseudocysts of the pinna
After cleaning and evacuating the cyst, a mastoid dressing in the present study are demonstrated in ►Table 2
was applied. It was changed daily, along with irrigation with The incidence of pseudocysts was higher in the right ear
sodium chloride 0.9% and Betadine for 10 days using a 3 mm (33 cases), with only 9 cases in the left ear.
syringe through the drain, followed by squeezing of any The sizes of the pseudocysts encountered in the present
accumulated secretions. The mastoid dressing was reapplied study ranged from1 to 4.5 cm, with an average size of 2.96 cm.
each time after dressing gauze (►Fig. 4). The content of the pseudocysts was straw fluid in 34 cases
Some cases and their results are presented in ►Figs. 5–8. and dark yellowish fluid in 8 cases.
The patients were followed-up for residual or recurrent The average duration of the swelling in the patients was of
swelling or other complications for an average period of 3.5 months.
6 months. All of the patients had undergone incision and drainage
with the insertion of a catheter drain in the wound as
described above. The patients had been followed-up for
Statistical Data
between 6 and 30 months, with an average of 6 months.
Demographic data are expressed in numbers and percen- We did not encounter any complications during the whole
tages as needed. follow-up period, and all of the patients had a satisfactory
cosmetic appearance with no recurrence of the swelling.

Results
Discussion
The present retrospective study was conducted on all of the
patients who presented with painless auricular swelling of Pseudocyst of the pinna is a rare asymptomatic condition in
long duration. It involved 42 patients, of which 40 were male which an accumulation of intercartilagenous fluid occurs with
(95.2%), and two were female (4.8%). no surrounding epithelium. The etiology of this condition is

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 Incision and Drainage with Daily Irrigation Tawab, Tabook 181

Fig. 5 Pseudocyst of one patient.

Fig. 7 Psudocyst in one patient after the insertion of the drain.

not well known; however, many theories have been postu-

lated. The first is congenital embryonic dysplasia of the
auricular cartilage leading to the formation of potential spaces
in the auricle.5 Another accepted theory is the occurrence
of minor repeated traumas, which can result in the fragmen-
tation of the cartilage and in the formation of cavities.6 In the
literature, auricular pseudocyst has been correlated with
repeated minor traumas, such as rubbing, ear pulling, sleeping
on hard pillows, or wearing a motorcycle helmet or earphones.
This finding has supported the theory of traumatic pseudocyst
formation. In one study, 22 out of 28 cases had a clear history of
trauma preceding the formation of the pseudocyst.7 In the
present study, all of the patients denied any history of trauma,
and there was no similar condition in the family.
Most of the studies showed a higher prevalence in males,
such as the study by Kantora et al, for example.8 However,
another study documented a higher prevalence in females,
corresponding to 57% out of 14 cases included in the study.9
In the present study, males represented 95.2% of the 42
patients included.
Choi et al presented an average age of  42.8 years old for
the occurrence of pseudocysts of the pinna.2 This was similar
to the findings of the study by Wang et al, in which the
average age was 43.8 years old.9 In the present study, the
Fig. 6 Same patient after 1 month of treatment. average age was  34.9 years old.

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182 Incision and Drainage with Daily Irrigation Tawab, Tabook

In the present study, the ratio of occurrence of pseudocysts

between the pinna of the right ear and the pinna of the left ear
was of 3.66:1. The higher incidence in the right ear might be
correlated with the habit of sleeping on the right side, which
was mentioned by most of the patients in the study.
Kantora et al documented a higher incidence of auricular
pseudocysts in the concha fossa (72.1%),8 while Choi et al
found a higher incidence in the scaphoid fossa (80.6%).2 In
the present study, the incidence of pseudocysts in the
scaphoid fossa alone reached  52.38%.
Several methods of treatment for pseudocysts of the
auricle have been discussed in the literature. The main aim
of all these modalities is to preserve the healthy cartilage and
to prevent recurrence of the swelling.11
All methods of compression dressings, such as traditional
contour dressing, compression suture therapy,4 clip com-
pression dressing,12 bolstered pressure suture,13 and cloth-
ing button bolster8 after aspiration can decrease the chances
of recurrence. However, the prevention of recurrence of the
lesions cannot be guaranteed.
The introduction of systemic or intralesional steroids for the
treatment of pseudocysts of the auricle is still controversial.
While Juan14 reported good results in treating pseudo-
cysts with a maximum of three intralesional steroid injec-
tions, Glamb et al15 reported permanent deformity of the ear
despite the use of local or systemic steroids.
Surgical deroofing of the pseudocysts of the pinna has also
been discussed in the literature, with some reports stressing
its benefits for good cosmetic appearance and no recurrence
rate.8,9 However, there are also reports documenting some
Fig. 8 Same patient after the removal of the drain catheter, in which complications of this technique, such as perichondrial reac-
the pseudocyst disappeared. tions, and thickness of the pinna.7
Singh et al, in their study in 2014, documented the benefits of
incision and drainage with glove drain insertion. They described
Table 1 Age groups of the patients
this minimally invasive technique in 20 cases enrolled in their
study, with no recurrences over the 3-month period of follow-
Age group Number of patients
up.16 They mentioned the drawback of the requirement of good
20 5 compliance on the part the patient for multiple visits to the
21–30 4 hospital in order to change the dressing and to clean the wound.
31–40 23 One thing to be added here is the requiremente of a longer
period of follow-up after the procedure.
41–50 9
In the present study, incision and drainage with the
> 50 1
insertion of a catheter drain under local anesthesia proved
to be effective in all of the 42 patients, without complica-
Table 2 Sites of occurrence of auricular pseudocyst
tions, with good cosmetic results, and with no recurrence
rate over an average follow-up period of 6 months. Daily
Site n
irrigation helped to prevent infection and to clean any
Scaphoid fossa 22 reaccumulating fluid, and this, in particular, contributed to
Scaphoid and triangular fossae 9 the efficacy of the incision and drainage as a trusted method
Triangular fossa 7 for the treatment of auricular pseudocysts. This method
required good compliance on the part of the patients, since
Concha 4
they needed to attend to the hospital for daily dressing and
cleaning.

Tan et al documented a higher incidence of pseudocysts in

Conclusion
the right ear than in the left ear, with a ratio of 1.8:1.10
However, in another study, the incidence of pseudocysts in Incision and drainage of auricular pseudocysts with the
the right ear and in the left ear were equal (1:1).9 insertion of a catheter drain and daily dressing and cleaning

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 Incision and Drainage with Daily Irrigation Tawab, Tabook 183

of the wound for 10 days proved to be a minimally invasive 4 Karabulut H, Acar B, Seluck K. Treatment of the non-traumatic
technique with no recurrence rate over a long follow-up auricular pseudocyst with aspiration and intralesional steroid
period, and this method presented good cosmetic results injection. N J Med 2009;26:117–119
5 Ichioka S, Yamada A, Ueda K, Harii K. Pseudocyst of the auricle:
with no complications.
case reports and its biochemical characteristics. Ann Plast Surg
1993;31(05):471–474
Ethics Committee Approval 6 Hoffmann TJ, Richardson TF, Jacobs RJ, Torres A. Pseudocyst of the
The present study was approved by the local ethics auricle. J Dermatol Surg Oncol 1993;19(03):259–262
committee. 7 Patigaroo SA, Mehfooz N, Patigaroo FA, Kirmani MH, Waheed A,
Bhat S. Clinical characteristics and comparative study of different
modalities of treatment of pseudocyst pinna. Eur Arch Otorhino-
Informed Consent
laryngol 2012;269(07):1747–1754
A signed informed consent was obtained from all the 8 Kanotra SP, Lateef M. Pseudocyst of pinna: a recurrence-free
participants of the present study. approach. Am J Otolaryngol 2009;30(02):73–79
9 Wang H-L, Kuen-Yao Ho. Sheau-Fang Yang, Yu-Jen Wu, Hsun-Mo
Conflicts of Interest Wang. The Experience of Reliable Surgical Management for Intract-
able Auricular Pseudocysts. Int Adv Otol 2013;9(03):313–318
The authors have no conflicts of interest to declare.
10 Tan BY, Hsu PP. Auricular pseudocyst in the tropics: a multi-racial
Singapore experience. J Laryngol Otol 2004;118(03):185–188
Financial Disclosure 11 Schulte KW, Neumann NJ, Ruzicka T. Surgical pearl: The close-
The authors declare that the present study received no fitting ear cover cast–a noninvasive treatment for pseudocyst of
financial support. the ear. J Am Acad Dermatol 2001;44(02):285–286
12 Kim TY, Kim DH, Yoon MS. Treatment of a recurrent auricular
pseudocyst with intralesional steroid injection and clip compres-
sion dressing. Dermatol Surg 2009;35(02):245–247
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