Rugby injury-associated pseudocyst of the auricle: Report and review of sports-associated dermatoses of the ear
1. Medical School, Baylor College of Medicine, Houston, Texas
PURPOSE: To describe a man with pseudocyst of the auricle, summarize the salient features of this condition, and review other sports-associated dermatoses of the ear. BACKGROUND: Pseudocyst of the auricle is an intracartilaginous collection of viscous straw-colored fluid typically located in the triangular fossa of the upper half of the auricle. It is usually asymptomatic. It can result in a permanent auricular deformity. MATERIALS and METHODS: A 63-year-old man developed a pseudocyst of the auricle following a traumatic rugby-related injury to his left ear. The lesion has persisted for many years; chronic massage has slightly decreased its size. RESULTS: The etiology of pseudocyst of the auricle has been described as either traumatic or developmental. Our patient developed his pseudocyst after a rugby-related injury. This condition is usually unilateral. Aspirate of the content is usually sterile. Histology shows an intracartilaginous cyst devoid of an epithelial lining. Treatment involves either partial removal of the cartilage or chemical irritation to enhance adhesiveness. Subsequent compression (via button bolsters) minimizes recurrence. CONCLUSIONS: Pseudocyst of the auricle is a benign cystic dilatation, which is intracartilaginous, devoid of an epithelial lining, and may be traumatic or non-traumatic in origin. A man with rugby-associated trauma to his left ear developed this condition. Auricular pseudocyst can be added to the list of sports-associated dermatoses of the ear.
Pseudocyst of the auricle is an intracartilaginous cystic nodule that contains viscous straw-colored fluid. It is usually located in the triangular fossa of the upper half of the auricle [1, 2]. It has been postulated that an inflammatory response, usually as a result of trauma, is integral to the development of pseudocysts [3, 4]. We describe a man with a rugby injury-associated pseudocyst of the left auricle, summarize the salient features of auricular pseudocysts, and review other sports-associated dermatoses of the ear.
A 63-year-old man was originally diagnosed with metastatic melanoma to the lungs of indeterminate cutaneous origin. He was successfully treated with wedge resection of the affected lobes and lymph node removal without adjuvant therapy. He was referred to the Dermatology clinic for cutaneous skin cancer surveillance.
Cutaneous examination revealed an asymptomatic firm nodule on the auricle of his left ear. Additional history revealed that the man began to play rugby in 1969 during his sophomore year of college. He recalls, 12 years into his athletic career, that another player smashed his helmet into his left ear during a scrum.
A scrum is a formation in which a set of players lock heads and push forcefully upon one another in an effort to gain possession of the rugby ball. The scrum contains eight players arranged in four rows. The front row is made up of three players who wear helmets. The second row is made up of two players who do not wear helmets. The remaining three players occupy the last two rows. Our patient’s position was second row. Without a helmet, his ear collided with the helmet of a player from the opposing team. After this blunt trauma, his left ear became erythematous and swollen.
Correlation of the history and clinical presentation was consistent with a pseudocyst of the left auricle. Because the lesion did not functionally or cosmetically bother the patient, no treatment was performed. However, both the patient and his wife would periodically massage the pseudocyst, which caused it to slightly regress in size. Presently, the cystic lesion is firm, nontender, and measures 6 x 4 x 2 cm (Figures 1, 2a, and 2b).
Pseudocyst of the auricle was first described in 1966 among Chinese patients by Engel . Patients are usually adult men between 30 to 40 years of age. This condition does not favor a specific ethnicity [1, 6].
Pseudocyst of the auricle typically presents as a painless swelling that can progressively develop over a 4 to 12 week period. The diagnosis of this condition is usually based on the clinical appearance of the lesion. However, auricular pseudocysts may mimic other conditions of the ear such as chondrodermatitis nodularis helicis, relapsing polychondritis, subperichondrial hematoma, and traumatic perichondritis .
Two etiologies have been proposed for pseudocysts of the auricle. The first involves acute or repetitive aural trauma [6, 7]. Ear pulling, rubbing, sleeping on one side, using ear phones, or wearing a motorcycle helmet have been described as potential causative factors . Evidence of this also includes increased levels of human cartilage-specific lactate dehydrogenase isozymes in pseudocyst fluid as compared to the serum [8, 9]. Ming et al postulate that an inflammatory response is crucial to the development of this condition based on the observed perivascular inflammatory response in histologic specimens of patients with auricular pseudocysts .
The second proposed pathogenesis for auricular pseudocyst involves an abnormality during development of the first and second branchial pouches that later form the auricle . This results in excess tissue planes that can allow for pseudocyst formation. Interestingly, pseudocysts of the auricle have also been associated with atopic dermatitis .
Several treatments for pseudocyst of the auricle have been described. Successful modalities combine both agents that cause resolution of the lesion (via chemical irritation or excision) and agents that allow maintenance of normal auricular architecture (via pressure application). For example, Cohen and Katz described a technique using 50 percent trichloroacetic acid as a chemical irritant causing the cartilage to adhere and eliminating the pseudocystic space . Subsequently, button bolsters were sutured to the anterior and posterior surfaces of the auricle in order to provide contour pressure without tissue necrosis. Systemic corticosteroids have not been shown to be efficacious; intralesional corticosteroids can cause permanent ear deformities [11, 12]. Needle aspiration almost always results in recurrence, even with additional application of the pressure dressing . However, one group successfully treated a patient with an auricular pseudocyst of the left ear using 22-gauge needle aspiration followed by application of a surgical bolster .
In addition to auricular pseudocysts, there are multiple sports-associated conditions of the ear (Table 1) [1, 3, 6-8, 11, 13-28]. Auricular hematomas and subsequent “cauliflower ear” deformations often occur in contact sports like boxing, rugby, and wrestling . Direct blows and shear forces result in serum collection, which intercalates between the perichondrium and cartilage. Because the perichondrium supplies nutrition to the underlying cartilage, the resulting dissection causes devitalization of the cartilage and fibrosis. This subsequently distorts the ear anatomy and leads to deformities resembling a cauliflower .
Unfortunately, there is no optimal treatment strategy for auricular hematomas. The most ubiquitous technique is incision and suction of the auricular hematoma followed by compression sutures tied over wet cotton to obliterate the fluid space resulting from the suction. Cotton bolsters, splints, and removable auricular stents may also be used for compression. The most effective prevention is adequate ear protection when participating in contact sports .
Exercise is known to increase an individual’s immune function and, thereby, reduce the risk of infections. However, heavy exercise has been shown to suppress many immune parameters and paradoxically increase the risk of infectious diseases .
Herpes simplex is a common rugby-associated dermatosis of the ear resulting from the extensive skin-to-skin contact of the sport. It has conveniently been termed “herpes rugbeiorum” or “scrum pox.” Players are at highest risk of acquiring herpes rugbeiorum during the scrum, in which traumatic contact occurs among huddled players. The forwards are at greatest risk for infection [24, 25].
Similar to herpes infections at other body sites, this classically presents as tender grouped vesicles overlying an erythematous base. A Tzanck smear or viral culture may be utilized to confirm the diagnosis. Differential diagnosis can include acne vulgaris, atopic dermatitis, impetigo, and tinea corporis, all of which can occasionally be difficult to distinguish from herpetic lesions. The treatments options for primary and recurrent herpes rugbeiorum are summarized in Table 2 [24, 25].
Herpes infections among wrestlers, called “herpes gladiatorum,” are extremely common because of intense skin-to-skin contact. The clinical presentation and treatment options are identical to herpes rugbeiorum. Herpetic infections do not only occur on the ear of the wrestler but also on other exposed sites [24, 25]. Although Adams states that the transmission of Herpes simplex via fomites is uncommon, he mentions that conservative practices for the prevention of herpetic infections include wearing sandals in public showers and avoidance of sharing clothing, towels, razors, and equipment .
Many aural dermatoses commonly occur in swimmers and people who play aquatic sports. Acute diffuse otitis externa, commonly known as “swimmer’s ear,” is the most common condition [22, 23]. Pseudomonas aeruginosa is the most common etiology, with Staphylococcus aureus also playing a major role. S. aureus isolates have been shown to be uniformly resistant to penicillin and erythromycin but often sensitive to clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and vancomycin . Oxacillin may be adequate; however, some S. aureus species (methicillin-resistant S. aureus) are resistant [31, 32].
Clinical manifestations of otitis externa include itching, otalgia, otorrhea, and conductive hearing loss. Otoscopic evaluation reveals an erythematous and edematous external auditory canal that may be filled with debris and exudates.
Treatment of mild otitis externa includes topical antibiotics, often in combination with corticosteroids in a liquid preparation. Analgesics may also be given for pain control. If present, the clinician may need to extract debris and exudates from the ear canal. Oral antibiotics, usually directed toward pseudomonas, may be necessary for more severely afflicted patients. Prevention of this condition involves refraining from swimming in polluted waters, drying ears after swimming, wearing ear plugs or swimming caps, and avoiding frequent cotton-tip use .
“Surfer’s ear” (exostoses of the external auditory canal) are bony growths that cause narrowing of the external auditory canal. Frequent exposure to cold water is a proposed etiology. Ear exostoses usually present bilaterally and can result in accumulated cerumen, otorrhea, and conductive hearing loss. Light microscopy shows multiple superimposed concentric layers of lamellar bone. The treatment is transmeatal surgical removal of the tumors .
Traumatic eardrum perforations may occur during water skiing or deep-sea scuba diving. Clinical manifestations include otalgia, otorrhea, tinnitus, and vertigo. Deep sea diving may also result in sudden sensorineural hearing loss when rupture of the round or oval window membrane occurs. Patients are observed for spontaneous healing of perforations; tympanoplasty is occasionally necessary .
Contact dermatitis has afflicted many swimmers who are allergic to the rubber accelerators that are commonly found in ear plugs. This usually presents as well defined, erythematous, scaling plaques on the ears. The diagnosis may be suspected based on the characteristic distribution. However, pressure urticaria and noncontact dermatitis can mimic its appearance. The diagnosis can thus be confirmed with patch testing of suspected irritants. Treatment includes short-term use of low- to medium-potency topical corticosteroids. A single triamcinolone acetonide injection or short course of oral corticosteroids may be used for severe cases. Topical immunomodulators, like pimecrolimus, can be used for milder or chronic conditions. Patients are advised to wear non-sensitizing earplugs for further prevention [14, 15].
Sunburns, increased ultraviolet damage, and skin cancer are prominent issues studied among outdoor sportsmen. Only about half of the skiers and snowboarders surveyed in 1998 had worn sunscreen. Of those individuals, half would neglect to apply it to their neck or ears. Individuals engaged in baseball, cycling, golf, and triathlons suffer from gross exposure to high levels of ultraviolet radiation despite sunscreen application. Skiers, snowboarders, and swimmers suffer from reflectance of ultraviolet rays from surfaces. Sweating, high temperatures, and high winds result in increased susceptibility to ultraviolet radiation, all of which are common in most outdoor activities [19, 20].
The clinical manifestations of sunburn are usually obvious: diffuse, sharply demarcated areas of erythema ending at clothing lines. The ears are a prominent target for photosensitive reactions after sun exposure.
Frostbite is another common condition that can affect the ears, nose, scrotum, and penis of any winter outdoor athlete, but especially those who spend a great deal of time in harsh weather and at high speeds (such as cross-country skiers, cyclists, lugers, runners, ski jumpers, snowmobilers, and speed skaters). Frostbite is categorized as either superficial (frostnip) or deep. Frostbite presents as blue-white or waxy discoloration with numbness and swelling on the affected areas. In superficial frostbite the skin is somewhat pliable, but in deep frostbite the skin becomes firm. Lack of pain suggests a deep frostbite [17, 18].
Treatment options for frostbite are divided into three categories: prewarming, warming, and postwarming. Prewarming encompasses a period of observation and care to not aggravate the injuries. This includes avoiding additional trauma (such as rubbing) and engaging in transient thawing with mild heat. Warming includes rapid immersion in 104°F–108°F water for 15–30 minutes. Vesicles or bulla may develop 6 to 24 hours afterwards. Throbbing, swelling, and burning may persist for many weeks. Postwarming includes daily whirlpool, elevation, and protection from trauma. Minor injuries become asymptomatic within one month. Sequelae of severe injuries include a black eschar, ischemic neuritis, and autoamputation; these develop over months .
Chilblain is another condition related to cold temperatures that differs from frostbite because it is a nonfreezing injury. Ice fisherman commonly acquire chilblains – also known as “pernio,” “perniosis,” or “kibe” – on the ears, face, nose, or acral skin . Chilblain results from neuronal and endothelial damage induced by repetitive cold exposure. Patients present with small, erythematous macules and papules. Persistent vasospasm results in itching, burning, swelling, or tenderness. Blue nodules and ulcerations may ultimately develop. The management of chilblains consists of supportive therapy with gentle rewarming of the skin and application of a dry bandage. Nifedipine, a calcium channel blocker, has been shown to be effective, possibly by prevention of arterial vasospasm .
A pseudocyst of the auricle is an intracartilaginous cystic collection of sterile viscous yellow fluid usually located in the triangular fossa of the upper half of the auricle, the origin of which may be traumatic or atraumatic. In addition to trauma, a postulated etiology of pseudocyst of the auricle is congenital aberrations. The ear, over weeks to months, eventually develops a painless swelling. Microscopy demonstrates an intracartilaginous cystic space devoid of an epithelial lining. The goal of treatment is to reduce the size of the nodule and maintain proper architecture. This is usually achieved by initially using chemical irritants or by excision of the cartilage wall. Subsequently, button bolsters are commonly used for post-treatment pressure to prevent recurrence. We describe a 63-year-old second-row rugby player whose auricular pseudocyst developed after trauma while in the scrum formation. Many other sports-related conditions affect the ear. Auricular hematomas and subsequent “cauliflower ear” deformations often occur in contact sports. Herpes rugbeiorum and herpes gladiatorum infections may occur in rugby and wrestling, respectively. Many athletic-related dermatoses of the ear, such as acute otitis externa, “surfer’s ear,” and traumatic ear drum rupture, commonly occur in aquatic sports. Contact dermatitis of the ears has afflicted many swimmers who are allergic to the rubber accelerators that are commonly found in ear plugs. Aural sunburns are common in outdoor sports, especially with scant application of sunscreen. Aural frostbite and frostnip commonly affect athletes in freezing weather. Chilblain is a less severe condition that occurs in nonfreezing conditions. Pseudocyst of the auricle can be added to the list of sports-associated dermatoses of the ear.
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