Auris Nasus Larynx 46 (2019) 576–582

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Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Surgical deroofing in the treatment of patients with auricular

pseudocyst
Yoon Jae Lee a, Jin Geun Kwon b, Hyun Ho Han b,*
a
Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
b
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Article history: Objective: An auricular pseudocyst is a fluid filled cavity, characterized by a lack of epithelium, in
Received 15 July 2018 the intra-cartilaginous space. Clinically, it presents as a painless lump on the upper anterior surface
Accepted 29 October 2018 of the ear. Various treatment methods have been discussed in the literature, including aspiration,
Available online 20 November 2018
incision and drainage, or steroid injection. However, these approaches are associated with a high rate
of recurrence and results are often esthetically unsatisfactory; therefore, a need for improved
Keywords:
treatment approaches remains.
Pseudocyst
Treatment
Methods: From March, 2015, to June, 2017, 15 patients with auricular pseudocyst were treated with
Auricle surgical deroofing followed by local contour pressure dressing with a simple bolster. In addition, the
Recurrence structure of the auricular pseudocyst was assessed at a microscopic level.
Deformity Results: Patients were followed up for a mean period of 12 months, during which time there were no
reports of postoperative complications or recurrence. The results were cosmetically excellent in all
patients and no cartilage deformity was seen. Considering the composition of pseudocysts seen on
microscopic evaluation, deroofing to remove the anterior leaflet and removal of debris from the
posterior leaflet is an appropriate treatment modality.
Conclusion: This reliable and simple approach may be recommended as first line treatment for
auricular pseudocysts to avoid recurrence and complications associated with other treatment
modalities, such as cartilage deformity, skin depigmentation, and scarring.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction Pseudocyst of the auricle is a difficult condition to treat

Pseudocyst of the auricle is a rare, benign, asymptomatic lesion
characterized by the formation of an intercartilaginous cyst that
affects the upper half of the anterior aspect of the ear. The
terminology of ‘pseudocyst’ was first used by Hartmann in 1846 and
later reported by Engel in 1966 [1,2]. The fluid filled cavity is not
lined by epithelium and contains sterile straw-colored fluid [2–4].
* Corresponding author at: Department of Plastic and Reconstructive
Surgery, Asan Medical Center, University of Ulsan College of Medicine,
88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
E-mail address: tripleh@amc.seoul.kr (H.H. Han).
medically or surgically, although a variety of treatment
modalities are described in the literature. Simple aspiration
or incision and drainage alone causes reaccumulation of cystic
fluid in most cases [5]. Other treatment modalities include
incision and drainage with cyst curettage and pressure
application [6,7], aspiration followed by intralesional and oral
steroid administration [8,9] and incision and drainage with
intralesional injection of iodine or trichloroacetic acid with or
without pressure application [2,10]. Although these approaches
can achieve acceptable results with fewer recurrences,
complications such as ear deformity and perichondritis remain
problematic. Although a definitive treatment remains contro-

https://doi.org/10.1016/j.anl.2018.10.017
0385-8146/© 2018 Elsevier B.V. All rights reserved.
 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582 577

Fig. 1. Operative technique. (A) Auricular pseudocyst along the triangular fossa and cocha. (B) Helical incision. (C) Skin flap elevation. (D) Radical exposure of the
outer layer of the anterior leaflet. (E) Excision of the anterior leaflet followed by curettage of debris on the posterior leaflet. (F) Skin redraping with primary repair. (G)
Local contour compression using a simple bolster for 7 days. (H) Aesthetically satisfactory result without recurrence or complication.

versial, the goal should be to maintain or restore the normal
anatomical structure of the auricle with no recurrence [11].
In this report, we present cases of auricular pseudocyst
treated with surgical deroofing [12].
2. Methods
Fifteen patients with pseudocyst of the auricle, diagnosed on
the basis of clinical presentation from March, 2015, to June, 2017,
Table 1
Patient demographics.
were enrolled in this study. Differential diagnosis of pseudocyst
(rather than hematoma or other cystic lesion) was performed by
preoperative imaging with sonography or computed tomography.
All patients underwent surgical deroofing as the primary
treatment approach and follow up was conducted for a period
of 12 months. As surgical outcomes, postoperative complication,
episode of recurrences, and cosmetic results were evaluated. In
details, cosmetic results were determined whether depression or
contracture occurred, and skin texture was preserved.

Patient number Age, years Gender Etiology Side Cyst size, cm2, left/right Location Follow up, months Complication Recurrence
1 (case 3) 31 Male Unknown Right 1.0 Concha fossa 12 - -
2 (case 1) 47 Male Unknown Right 2.5 Concha fossa 18 - -
3 (case 2) 66 Male Unknown Right 3.0 Scaphoid fossa 18 - -
4 46 Male Unknown both 1.0/0.5 Scaphoid fossa 12 - -
5 16 Male Repetitive helmet use Left 1.5 Scaphoid fossa 12 - -
6 26 Male Unknown both 1.0/1.5 Scaphoid fossa 12 - -
7 28 Male Unknown Right 2.0 Triangular fossa 6 - -
8 35 Male Unknown Left 1.5 Triangular fossa 6 - -
9 37 Male Unknown Right 1.0 Scaphoid fossa 12 - -
10 40 Male Unknown Right 1.5 Scaphoid fossa 12 - -
11 29 Male Unknown Left 1.0 Concha fossa 12 - -
12 36 Male Repetitive headphone use Left 2.0 Scaphoid fossa 12 - -
13 42 Male Unknown Right 1.5 Concha fossa 12 - -
14 38 Male Unknown Right 2.0 Triangular fossa 12 - -
15 50 Male Unknown Left 1.5 Scaphoid fossa 12 - -
578 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582

>1 cm2, a drain was inserted. Postoperatively, Vaseline gauze

was rolled up in a circular shape and fixed in the lesion for
7 days with nylon 3–0 horizontal mattress sutures. The
postoperative dressing and sutures were removed after 7 days.
All specimens were examined microscopically.

3. Results

Demographic data from the fifteen patients are summarized

Fig. 2. Common locations of auricular pseudocyst.
2.1. Operative technique
The operative technique is illustrated in Fig. 1; all
procedures were performed under local anesthesia. An incision
was made along the helical or antihelical line of the skin
according to the location of the pseudocyst. The skin flap was
elevated from the anterior leaflet of cartilage until the outer
most layer of the pseudocyst was exposed. The anterior leaflet
of cartilage consisting of the roof of the cyst was excised by
cutting along the circumference of the swelling and the serous
fluid was drained. The anterior surface of posterior leaflet was
gently curetted to remove debris and granulation tissue. The
skin flap was returned to its normal anatomical position and
secured with 4–0 black silk sutures. If the size of the cyst was
in Table 1. The mean age was 37.8 years (range 16–66) and all
patients were male. The mean follow-up period was 12 months
(range 6–18). In eight patients (53.3%), the lesion was on the
right side and in five patients (33.3%), it was on the left; two
patients (13.3%) had bilateral pseudocyst. The lesions were
most common in the scaphoid fossa (53.3%), followed by the
concha (26.7%) and triangular fossa (20.0%; Fig. 2). Surgical
deroofing with compression dressing was performed success-
fully in all patients. There were no postoperative complications
or episodes of recurrence during the follow-up period. The post-
surgical appearance of the auricle was excellent in all patients,
with no deformity of the cartilage.
3.1. Microscopic findings
Microscopic examination revealed a cystic space lined by
granulation tissue without epithelium lining and surrounded by
cartilage (Fig. 3). The anterior leaflet of the cyst was
composed of perichondrium and regenerative cartilage; the
posterior leaflet comprised auricular cartilage and perichon-
drium. At the outer margin of the cyst, the cartilage was
normal; however, the cartilage was degenerated and frag-
mented in the inner side.

Fig. 3. Microscopic characteristics of auricular pseudocyst. The specimen was obtained from the margin of the cyst and both anterior and posterior walls were
retained. The anterior leaflet (A) is composed of perichondrium (!) and regenerative cartilage ()) and the posterior leaflet (B) is composed of regenerative cartilage
()) and perichondrium (!). Intra-cartilage cavity (C) shows a lack of epithelial lining with mucinous material and debris (>) filling the space. Magnification  40.
 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582 579

Fig. 4. Case 1 surgical procedure. (A) Right auricular pseudocyst in a 47-year-old male. (B) Immediately after helical incision, the anterior leaflet was tagged by
forceps. (C) The skin flap was elevated (tagged with skin hook), and the anterior leaflet (indicated by forceps) was ready for excision. (D) After the anterior leaflet of
the cyst was excised, curettage of the posterior wall was performed to remove any debris. (E) Silastic drain was inserted and skin suture performed before application
of a bolster contour compressing dressing. (F) 18 months post-surgery.

Case 1 was successfully performed with excellent esthetic results.

A 47-year-old male presented with a 3-year history of
swelling involving the entire concha of the right auricle (Fig. 4).
The patient had no history of trauma. He had a non-tender,
fluctuant 2.5-cm2 mass at the right superior antihelix with
normal overlying skin. A helical incision was made and the skin
flap was elevated, then the anterior wall of the cyst was excised.
Straw-colored fluid was released and curettage of the posterior
wall of the pseudocyst was performed to remove any remaining
soft tissue debris. A Vaseline gauze dressing was used to
compress the raised skin flap on to the cartilage. The sutures and
the compression dressing were removed after 1 week. The
patient had no recurrence during 18 months of follow up.
There was no recurrence during 18 months of follow up.
Case 3
A 31-year-old male presented with a 1-cm2 cyst on the right
auricle at the concha fossa (Fig. 6). There was no previous
history of trauma, but the patient frequently wore a helmet
whilst playing ice hockey. The lesion had been aspirated
previously but the procedure had failed. Surgical deroofing was
performed, with no recurrence during 15 months of follow up
4. Discussion

Case 2 Pseudocyst of the auricle is a rarely-reported condition that

A 66-year-old male presented with a 3-cm2 mass on the occurs most commonly in young adults. However, lesions are
scaphoid fossa, upper helix of the right ear (Fig. 5). Deroofing likely to be more prevalent than the number of reported cases
580 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582

Fig. 5. Case 2 surgical procedure. (A) Right auricular pseudocyst in a 66-year-old-male. (B) Helical incision was made along the margin of the cyst and the anterior
leaflet was tagged by a skin hook. The skin flap was elevated and the anterior leaflet (held with forceps) was ready for excision. (C) Excised specimen of anterior
leaflet of pseudocyst. (D, E) After skin suture, a bolster contour compressing dressing was fixed with horizontal mattress sutures. (F) 15 months post-surgery.

Fig. 6. Clinical case 3. (A) Right auricular pseudocyst in a 31-year-old male. (B) Bolster was applied after excision as a contour compressing dressing. (C) 12 months
post-surgery.
 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582
[4] because accurate diagnosis can be challenging and
appropriate treatment is not always undertaken.
Pseudocyst of the auricle is defined as a collection of fluid in
a tissue space without an epithelial lining [2–5]. The scaphoid
fossa is the most common site of involvement followed by the
triangular fossa and cymba concha [4,8,10,13]. Pseudocysts are
an endochondral cystic lesion that show clinical and pathologic
features that differ from other cystic lesions of the auricle
[14]. Clinically, pseudocyst of the auricle is usually asymp-
tomatic, although mild inflammatory signs may occasionally
occur.
In this study, the main age group was 30–50 years,
accounting for almost 70% of all patients, which is similar
to results seen in other studies [4,6–14]. The cysts are
commonly unilateral and are 1.5 times more common on the
right ear than the left ear [14]. Differential diagnosis
includes subperichondrial hematoma caused by accumula-
tion of blood secondary to trauma, relapsing polychondritis
and cellulitis.
The pathogenesis of pseudocyst development remains
unknown. Engel et al. hypothesized that it results from a
defect in embryogenesis in which residual planes of tissues are
created during the folding of the brachial process that fuse to
form the auricle [2,15]. The excess tissues could theoretically
reopen when subjected to mechanical stress in patients who
have predisposing factors for pseudocyst development. Other
studies have proposed that repeated mechanical irritation
contributes to pseudocyst formation as it leads to disturbance of
the local microcirculation, leading to ischemia and subsequent
cartilaginous degeneration [3,8,16]. In this study, the fact that
all of the patients were male and the location of the lesion was
mainly on the upper half of the ear, suggests that the cause may
be associated with mechanical irritation and chronic trauma.
Indeed, in our patients pseudocysts developed after daily use of
a motorcycle helmet or headphones in several patients,
supporting our hypothesis.
A differential and accurate diagnosis of the pseudocyst is
important and a histology-based approach is key to making a
final diagnosis. A consistent histologic finding of pseudo-
cyst of the auricle is an expanded inter-cartilaginous cystic
space containing serous fluid. At the margin of the cyst, the
cartilage architecture is normal, but in the center of anterior
leaflet of the cyst, degeneration of the cartilage is common.
Differential diagnosis can be made by the presence of
Table 2
Various treatment modalities of pseudocyst.
Method of treatment Advantages
Surgical deroofing with buttoning [12] No recurrence,
excellent
cosmetic results
Aspiration and local pressure [11] Minimally invasive
Incision and drainage with curettage [6,10] Non-invasive,
Simple
Intralesional steroid injection Non-invasive, Simple
and oral steroid administration [16]
581
inflammatory cells within the cystic space and the absence
of an epithelial lining on the inner surface of the intra-
cartilaginous cavity [17,18].
Several treatment modalities for pseudocysts are discussed
in the literature. As shown in Table 2, non-surgical methods,
such as injection of steroid or trichloroacetic acid, are
associated with a high recurrence rate and may lead to serious
auricular deformities, such as skin pigmentation and atrophy of
the skin, soft tissue and cartilage [6,8,16]. Kanotra and Lateef
reported that of 13 patients undergoing incision and drainage
with curettage followed by compression by buttoning, five
showed recurrence and three showed permanent auricular
deformity [5]. To avoid recurrence, the definitive surgical
procedure should aim to terminate the serous effusion, by
removing debris on the anterior surface of the remaining
posterior leaflet, which could be the pathologic origin of
effusions [17,18].
In our study, all patients underwent deroofing surgery
followed by contour pressure dressing with a simple bolster and
excellent results were achieved with no incidents of recurrence.
Previously, deroofing surgery has not been performed as first
line treatment but reserved for patients with recurrence after the
failure of other treatment modalities, such as incision and
drainage and steroid injection [16].
5. Conclusion
Pseudocyst of the auricle is a benign disease and a variety of
treatment options are available. However, conservative treat-
ments often result in recurrence and unsatisfactory esthetic
results. In deroofing surgery, anterior cartilage (the origin of the
serous effusion) is completely excised. Eliminating debris and
granulation tissue on the anterior surface of posterior leaflet is
key to avoiding recurrence. In addition, the procedure is simple
and can be performed under local anesthesia. Therefore,
considering the excellent results and lack of recurrence seen in
this study, we would recommend deroofing surgery as first line
treatment for all patients with pseudocyst.
Source of funding
The authors have no financial interest to declare in relation to
the content of this article. No funding was received for this
research.
Disadvantages Complications Recurrence rate
Relatively complex procedure Low
Fluid re-accumulation Pressure necrosis High
Poor aesthetic result Perichondritis High
Chemical irritation
Thickening of the cartilage Permanent ear deformity High
582 Y.J. Lee et al. / Auris Nasus Larynx 46 (2019) 576–582
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