A CLINICAL STUDY OF BENIGN LESIONS OF PINNA

By

Dr.SHIVANAGOUDA PATIL MBBS

A Dissertation Submitted to

The Rajiv Gandhi University of Health Sciences Karnataka, Bangalore,

in partial fulfillment

of the requirements for the degree of

MASTER OF SURGERY

In

OTORHINOLARYNGOLOGY

Under the guidance of

Dr. T.M.NAGARAJ, MS (ENT)

Professor

DEPARTMENT OF ENT AND HEAD & NECK SURGERY,

RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL,

BANGALORE – 560074

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ii

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A CLINICAL STUDY OF BENIGN

LESIONS OF PINNA ” is a bonafide and genuine research work carried out by me under the

guidance of Dr. T.M.NAGARAJ, MS, Professor, Department of ENT and Head and Neck

Surgery, RajaRajeswari Medical College and Hospital, Bangalore.

Date: Dr SHIVANAGOUDA PATIL

Place: Bangalore Postgraduate in Otorhinolaryngology,

RajaRajeswari Medical College and Hospital,

Bangalore

iii

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A CLINICAL STUDY OF BENIGN

LESIONS OF PINNA ” is a bonafide research work done by Dr.SHIVANAGOUDA PATIL in

partial fulfillment of the requirement for the degree of Master of Surgery in

Otorhinolaryngology.

DR. T.M.NAGARAJ M S (ENT)

Professor

Department of ENT and Head & Neck Surgery

RajaRajeswari Medical College and Hospital, Bangalore.

iv

ENDORSEMENT BY

THE HEAD OF THE DEPARTMENT AND

DIRECTOR

This is to certify that the dissertation entitled “A CLINICAL STUDY OF BENIGN

LESIONS OF PINNA” is a bonafide research work done by Dr.SHIVANAGOUDA PATIL

under the guidance of DR. T.M.NAGARAJ,MS, Professor, Department of ENT And Head and

Neck Surgery, RajaRajeswari Medical College and Hospital, Bangalore

Dr. T.M.NAGARAJ,MS. Dr. D L RAMACHANDRA Professor and Head Medical Director

Dept. of ENT And Head and Neck Surgery,

RajaRajeswari Medical College and Hospital,

Bangalore

Date: Date:

Place: Bangalore Place: Bangalore

v

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, shall

have the rights to preserve, use and disseminate this dissertation in print or electronic format for

academic/research purpose.

Date: Dr SHIVANAGOUDA PATIL

Postgraduate in Otorhinolaryngology,

Place: Bangalore Department of ENT And Head and Neck Surgery,

RajaRajeswari Medical College and Hospital,

Bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

vi

ACKNOWLEDGEMENT

It is my honour and privilege to thank Dr T M Nagaraj MS(ENT),my guide, Professor &

HOD of ENT & HNS, Rajarajeswari Medical College and Hospital, Bangalore who helped

me in choosing the subject for this study and guided me at every stage. His valuable suggestions

and timely advice were of immense help to me throughout all phases of this study.

I express my gratitude towards Dr. Praveen Kumar MS(ENT), Associate

Professor of ENT & HNS, Rajarajeswari Medical College and Hospital Bangalore , for his

valuable suggestions. His practical guidance during the course of my study was without parallel.

I also thank Dr. Vishwas K V MS(ENT) DOHNS, Assistant Prof, for his constant encouragement and

guidance. I also like to thank Dr. Prashanth V MS(ENT) FELLOW H&N ONCOLOGY Assistant Prof, &

Dr. Vijay Kumar MS(ENT) , Associate professors of ENT for helping me out in every possible

way to complete the study.

I am very thankful to my colleagues Dr.Roshna, Dr. Madhav D, Dr. George, Dr. Moby,

Dr. Soumya, Dr. Kavyashree & Dr. Vinay who helped me in preparing this dissertation.

My Sincere gratitude to all the patients without whose co-operation, this study

would have not been possible.

My family members especially my dear wife Smt.Aparna, my sister smt.Kalpana

Premjith and my brothers Vijay Kumar and Suresh for their untiring support and

encouragement. And my kids Hrithik and Aashish for their co-operation and support.

My sincere thanks to my department staff Smt. Savitha, Smt. Geetha, Miss.

Sudha Rani, Miss. Gangamani for helping in completing the thesis.

I express gratitude to my mother Smt.Meenaxi for all her love and to whom I dedicate

this work.

vii

LIST OF ABBREVIATIONS

NIH National institute of Health

ENT Ear Nose and Throat

LDH Lactate dehydrogenase

Ig Immunoglobulin

IC Immunocomplex

ANA Anti nuclear antibody

ENA Extractable nuclear antibody

RRMCH Rajarajeswari Medical College & Hospital

OPD Outpatient department

viii

ABSTRACT

“A CLINICAL STUDY OF BENIGN LESIONS OF PINNA.”

DrShivanagouda Patil; Dr T M Nagaraj

Department Of Otorhinolaryngology

RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL.

BANGALORE.

BACKGROUND AND OBJECTIVES:

To evaluate aetiopathological factors and prevalence and management options and to study all

the clinical aspects of benign lesions of pinna.

METHODS:

The study included 115 patients, which included keloids, seromas, sebaceous cyst, preauricular

sinus, haemangioma, dermoid and neurofibroma. Clinical evaluation done for aetiopathological

factors and management options.

CONCLUSION:

The various benign lesions of pinna presenting to OPD in our study are Keloid, Pseudocyst of

auricle, Sebaceous cyst, pre auricular sinus or cyst, haemangioma, dermoid and Neurofibroma of

pinna. They present with swelling of the pinna with or without pain.

Trauma is the most important factor in causation of number of benign lesions of pinna. Other

factors are ear piercing as in keloids, Diabetes mellitus plays a significant role in a few of the

conditions and should be controlled simultaneously.

Wide bore needle aspiration can be done for some of the cases of seroma. Patients who had

recurrence can be managed by window procedure. Other lesions like Keloid, sebaceous cyst, pre

auricular sinus or cyst can be managed by complete excision. Haemangioma and dermoid cases

were managed by complete surgical excision with no recurrences and complications.

A firm pressure bandage to be applied in most of cases after surgery. Neurofibroma can be

managed conservatively.

ix

CONTENTS

SL NO

CONTENTS

PAGE NO.

1.

INTRODUCTION

1

2.

OBJECTIVES

3

3.

REVIEW OF LITERATURE

4

4.

MATERIALS AND METHODS

25

5.

MANAGEMENT PROTOCOL FOLLOWED

27

6.

RESULTS AND OBSERVATIONS

29

7.

DISCUSSION

53

8.

CONCLUSION

58

9.

SUMMARY

60

10.

BIBLIOGRAPHY

61

11.

ANNEXURES

66

i).

PROFORMA

66

ii).

KEY TO MASTER CHART

73

iii).

MASTER CHART

74

x

LIST OF TABLES

LIST OF TABLES Pg No

Table No: 01 Age distribution of cases 29

Table No: 02 Sex distribution of cases 30

Table no: 03 Socioeconomic distributions of cases 31

Table no: 04 Distributions of total cases 32

Table no: 05 Sex distribution of Keloid cases 33

Table no: 06 Keloid cases 34

Table no: 07 Predisposing factors for Keloid 35

Table no: 08 Management of keloid 36

Table no: 09 Sex distribution of pseudocyst of auricle 37

Table no: 10 Predisposing factors for pseudocyst of auricle 38

Table no: 11 Management of pseudocyst of auricle 39

Table no: 12 Percentage of case responding to treatment 40

Table no: 13 Summary of predisposing factors 42

Table no: 14 Summary of treatment options 44

xi

LIST OF FIGURES

FIGURES PAGE NO.

Figure no. 01: Anatomy of pinna 11

Figure no. 02: Cartilage of pinna 12

Figure no: 03 Auricular muscles 13

Figure no: 04 Nerve supply of pinna 14

Figure no.05. Development of the external ear 15

Figure no: 06 window procedure 17

Figure no. 07. Seroma 18

Figure no: 08 Age distributions of cases 30

Figure no: 09 Sex distribution of cases 31

Figure no: 10 Socioeconomic status of cases 32

Figure no: 11 Case distribution 33

Figure no: 12 Sex distributions of keloid cases 34

Figure no: 13 Laterality of keloid cases 35

Figure no: 14 Predisposing factors for keloid 36

Figure no: 15 Management of keloid cases 37

Figure no: 16 Sex distribution of seroma cases 38

Figure no: 17: Predisposing factors for seroma 39

Figure no: 18 Management options of seroma 40

Figure no: 19 Percentage of cases responding to treatment 41

Figure no: 20 Predisposing factors for all cases 43

Figure no: 21 Treatment options of all cases 45

xii

LIST OF PLATES

PLATES

PAGE No.

Plate no: 01 Histology of neurofibroma 46

Plate no: 02 ‘Ear piercing’ predisposing factor for Keloid 46

Plate no: 3 Keloid 47

Plate no: 04 Pseudocyst of auricle 47

Plate no: 05 Sebaceous cysts in the post-auricular area 48

Plate no: 6 infected sebaceous cyst 48

Plate no: 7 Pseudo auricular cyst 49

Plate no: 8 Haemangioma 49

Plate no: 09 Patient with multiple keloids 50

Plate no: 10 Pre auricular sinus. 50

Plate no: 11 Neurofibroma of pinna 51

Plate No:12 Infected sebaceous cyst. 51

Plate No:13 Extensive Keloid 52

Plate No:14 Dermoid cyst 52

xiii

1

INTRODUCTION

Pinna contributes enormously to the facial aesthesis and is an important

part of peripheral auditory system1. The peripheral auditory system functions

to receive mechanical vibrations conduct these vibrations to the site of the

primary receptor cells and thereby transduce this energy into an encoded

electrical signal form, appropriate for conduction into and analysis by central

nervous system. The Reception, Conduction and Transduction processes are

strictly determined by structural and functional characteristics of this special

receptor. Corresponding to these functions, human ear can be by both

convention and convenience separated into three parts – external, middle and

internal - for descriptive purposes. This convention has served well, but must

be integrated into advances in the knowledge of how ear works as an essential

component of survival. The ear functions as an early warning system by

detecting and locating potentially threatening environmental sounds.

External ear, which is also called as Pinna or Auricle apart from

playing a important part in communication system by collecting sound waves

and concentrating them into the external auditory meatus, contributes

enormously to the facial aesthesis. Any lesion effecting pinna may not hinder

the hearing to incapacitating levels, however may cause a serious alteration in

the cosmetic appearance of the individual. This may take its toll on the

individual not only socially but psychologically as well.

Although lesions of pinna are not uncommon, a comprehensive study

on various lesions encountered in clinical practice have seldom been carried

out. However, smaller studies on individual lesions have been done lacking

comprehensiveness.

2

Pinna being a delicate, vulnerable and outwardly projected structure is

more liable for trauma, and its incidence is more frequently being reported due

to increasing violence, accidents, and high ear piercing. Various lesions of

pinna can be easily recognized and diagnosed with the help of good clinical

history and examination without the aid of any special investigations.

Trauma is the major predisposing factor for various lesions of the

pinna. In practice, an otorhinolaryngologist comes across various conditions

which may range from benign conditions like seroma and hematoma to

dreaded condition like perichondritis. Management of these lesions should be

done at the earliest to avoid overt disfigurement. Thereby preventing changes

to the entire appeal of the face.

The aim of this clinical study is to ascertain various benign lesions of

pinna presenting in the Outpatient and to manage them with appropriate and

timely intervention.

3

OBJECTIVES OF THE STUDY

To find out the prevalence of the disease at Rajarajeswari Medical

College & Hospital attending patients. Hospital based study.

To evaluate aetiopathological factors of the disease.(Benign lesions of

pinna)

4

REVIEW OF LITERATURE:

In a study conducted by Kishore Chandra Prasad, Karthik. S. and Sampath

Chandra Prasad, on patients presenting with swelling of pinna, wide bore needle

aspirations was done for majority of cases of seroma and hematoma. Patients who had

recurrences were managed by window procedure. Incision and drainage with or without

curettage of diseased cartilage was performed for perichondritis. Other lesions like

Keloid, haemangioma, dermoid cyst, sebaceous cyst, and malignancy were managed by

complete excision. A firm pressure dressing was applied in all cases after surgery. To

sum it up, surgical intervention at the earliest followed by a firmed pressure dressing

under antibiotic cover decreases the morbidity, and Diabetes was found to play major role

in conditions of pinna1.

A prospective study by Ming et al showed that the Pseudo cyst of auricle is a

benign condition predominantly affecting young Asian males. Histologically it revealed

an intracartilaginous cyst devoid of epithelium lining, and there are no pathognomic

features. They postulated that an inflammatory response is crucial to the development of

this condition on the basis of a consistent perivascular mononuclear infiltrates of

lymphocytes evident in the connective tissue layer just superficial to the anterior segment

of the cartilage2.

In a retrospective descriptive analysis by Lim et al, of Pseudo cyst of auricle 87%

of patients were male and the mean age was 38.9 years old. There was no racial

predisposition. All 9 patients who had simple aspiration of the cyst had prompt re-

accumulation of the pseudo cyst. None of the patients had recurrence following excision

and compression buttoning of the pseudo cyst. The complication rate in study was 2.4%.

Only one patient developed initial perichondritis with a resultant cauliflower deformity

following surgical excision3.

5

Paul et al, in a case study of Pseudo cyst of auricle determined that Pseudo cyst

of auricle can be diagnosed and treated with a 3mm punch biopsy and pressure dressing

applied later. It was found to be effective and no recurrences were noted in the study4.

Kaur S, Thami GP, Bhalla M based on their study stated that combined needle

aspiration and pressure dressing on Pseudocyst, with a short course of oral corticosteroids

have a excellent result without recurrence. It has an additional advantage of being non-

invasive modality of treatment5.

K W Schulte, N J Neumann, T Ruzicka advocated the close-fitting ear cover

cast as a noninvasive treatment for pseudocyst of the ear6.

N Oyama et al based on their study determined that recurrent Pseudocyst can be

treated effectively by intralesional injection of minocycline hydrochloride 1mg/mL, 2 to

3 times at 2-week intervals. Profibrotic action of minocycline may be the reason for its

use7.

H Miyamoto, M Okajima, I Takahashi in their study reported that patients in

their study were successfully treated with intralesional steroids injections. They also

showed that lactate dehydrogenase, levels of cystic fluid and LDH-4 and LDH-5

isoenzyme were found to be high but their corresponding kevels in the serum were found

to be normal. Of the patients treated, three suffered recurrences. It was also postulated

that Auricular pseudo cyst recurrences, show no relationship with either the LDH levels

or isoenzyme pattern. An undiluted solution of steroid fluid needs to be used in order to

prevent recurrences8.

In a study done by Q Chenet al, to elucidate the relationship between the

auricular pseudo cyst and the immunological function of patients, cyst fluid and blood

sample were detected for contents of IgG, IgA, IgM and complement C3 by radial

immunodiffusion, immunocomplex (IC) contents by polyethylene glycol turbidimetry in

55 cases, anti-nuclear antibody (ANA) by immuno-fluorescent technique in 23 cases,

extractable nuclear antibody (ENA) by immunotransfer technique in 24 cases. The frozen

6

sections of cyst wall tissue of 24 cases were detected for immune complexes by immune

enzyme histochemistry method. The reactions were observed separately between the

auricle tissue of healthy white rat, human embryo and cyst fluid, serum of patient and

normal serum. They concluded that contents of IgG, IgA, IgM and C3 in the cyst fluid

were lower than the serum significantly (P < 0.01). No IC, ANA and ENA could be

found both in serum so the reason of auricular pseudo cyst may be related with the local

autoimmune status of patient9.

SerhanTuncer, YavuzBasterzi, RehaYavuzer in their study on bilateral pseudo

cyst concluded that, the use of fibrin glue both to obliterate the pseudo cyst space and to

make the two leaves of the cartilage adhere to each other should be kept in mind in this

rare disorder in order to avoid recurrences10

.

In a retrospective study by Chao-Hs et al, consisting of 10 patients with auricular

pseudo cyst that were unresponsive to aspiration followed by intralesional steroid

injection or who declined conservative treatment were treated surgically with the de-

roofing method under local anesthesia. It was concluded that de-roofing surgery for

pseudo cyst of the auricle is a safe, easy, and reliable procedure. If conservative measures

fail or are declined by the patient, removal of the anterior cartilaginous leaflet of the

lesion is an alternative method that can yield excellent results11

.

Amy Han, Lian-Jie Li, Paradi Mirmirani treated a patient with an auricular

pseudo cyst of the left ear using needle aspiration followed by application of a surgical

bolster and advocated this technique as first-line approach to the management of this

disease12

.

Jeniffer et al have illustrated a technique to give high-dose –rate brachytherapy

as an adjuvant to Keloid excision, which prevent recurrence of stubborn keloids13

.

7

Daniel J Rosen et al did a retrospective analysis of 64 patients representing 92

ear keloids treated between 1982 and 1997. The treatment protocol consisted of excision

with an intraoperative and two postoperative steroid injections. All patients were treated

by a single physician. Long-term follow-up was obtained at a minimum of 5 years.

Success was achieved in 74 of 92 keloids (80 percent) excised. Prior excision of the

keloid was significantly associated with protocol failure (p = 0.0068). Keloid recurrence

was seen in 10 of 43 (23 percent). Statistically significant differences were noted in

keloids that had undergone prior excision as compared with those presenting for initial

treatment. These differences included growth rate (p = 0.0026), protocol failure (p =

0.0149), and total postoperative steroid injections administered (p = 0.0104) it was

concluded that the primary protocol presented for the treatment of ear keloids produces

durable results, with an acceptably low recurrence rate14

.

Apirag et al evaluated the efficacy of 5% imiquimod cream in the prevention of

recurrence of excised keloids. After 7 days of suture removal Imiquimod 5% cream was

applied to the scar 7 days after stitches removal. The patients were follow-up for

recurrence and drug side effect at 4, 6, 8, 16, and 24 weeks. 2.9% of the total patients had

recurrence. Side effects were found in thirteen patients (37.1%). These were abrasions of

the skin around the wound areas in ten patients and hyperpigmentation of the skin around

the wounds in three patients. They concluded that Imiquimod 5% cream could effectively

prevent recurrence of the excised keloids, especially in the area that had less tension such

as pinna.15

Peter Donkor in a clinical review of patients presenting with new and recurrent

keloid of the head and neck determined that 40 mg triamcinolone injected into the

residual lesion, primarily between 10 and 14 days postoperative. The injection was

repeated on 2 more occasions at monthly intervals. All patients were followed up for at

least 2 years. Eighteen patients were successfully treated with no sign of recurrence in

any of them. The technique was found to be effective for the treatment of moderately

sized new and recurrent keloid scars.16

8

Charles E Stewart, John Y Kim in a series of 10 patients showed that

recurrence of keloid when treated with surgical excision and the application of topical

mitomycin-C had a success rate of 90% even with 7-14 months of follow up. 17

According to A Cagri Uysal Topical interferon-alpha2b application after Keloid

excision is supposed to prevent the recurrence of keloids. 18

In a study conducted by Zouboulis et al Intralesional cryosurgery enhances the

involution of auricular keloids. A 67.4 +/- 23 % reduction of scar volume at the end of

the 18-month follow-up period after a single intralesional treatment (p < 0.005) was

noted. Significant reduction of hardness, elevation, and redness as well as itching, pain,

and tenderness was documented. The major advantages of the intralesional cryoprobe,

including the marked efficacy of a single treatment, may have a major importance in the

clinical application of cryosurgery in the treatment of keloids.19

In a similar study by Tomas Fikrle, KarelPizinger intralesional cryosurgery was

found to be effective in all study patients treated with cryosurgery as the monotherapy.

The freeze time and the number of sessions varied depending on the clinical findings, the

effect of the treatment, and the patient‟s tolerance. Cryotherapy was started 6 to 24

months after keloid development. No recurrence was observed within 1 to 4.5 years of

follow-up in this study. 20

In another study by Christophfolz et al, on complications related to body

piercing, male to female ratio was 1:2.2. Most of the recorded complications were related

to the new vogue of piercing, with the ear affected most commonly. The overall

complication rate of ear piercing was found to be 35 percent. High ear piercing accounted

for most of the complications in the current study. Auricular perichondritis is the most

commonly generated by S. aureus, Streptococcus, Proteus species, and Pseudomonas

aeruginosa were also been identified.21

Masellis M., Ferrara M.M did a study on repairing of an exposed area after

Keloid excision with a dermo-epidermal full-thickness skin graft and found it to cause

9

both general and specific modifications in the healing process. There were no recurrences

and did not require supplementary assistance of medical or physical therapy. 22

According to a study by Myron. W. Yencha, James P. Oberman combination

therapy including compression therapy, laser excision, and serial steroid injection, on 6

patients had excellent results. Full thickness excision of Keloid was done using carbon

dioxide lasers followed by triamcinolone injection in to the surgical bed. They did not

report any recurrences and had good cosmetic outcomes.23

According to E C Ho, S Jajeh and N Molony the standard treatment of a pinna

hematoma involves drainage and compression to prevent recurrence and subsequent

disfigurement. Compressive methods can be non-invasive or invasive, utilizing a head

bandage or through and through sutures, respectively, to keep compression in place.

Leonard buttons are effective alternative compressive devices. They are simple to use and

easily available.24

Vitally E. Kisilevky et al stated that the most common complication from blunt

trauma to the ear is the formation of auricular hematoma. Collection of blood or serous

fluid between the perichondrium and cartilage may be successfully treated by needle

aspiration under sterile conditions followed by the application of a pressure dressing. If a

hematoma recurs within 48 hours, formal incision and drainage are then required.25

Azhar M Shaida, Matthew W Young have determined that nerurofibroma of

pinna being relatively rare, commonly presents with cosmetic deformity: functional

impairment in the form of hearing loss is again rare. In their study, surgical excision gave

excellent and satisfactory cosmetic results.26

10

ANATOMY OF PINNA

Pinna also called as auricle is a flexible appendage of thin elastic cartilage

covered by perichondrium and skin. It projects at a variable angle from the side of the

head and has some function in collecting sound.

Anteriorly, the skin is firmly attached, while posteriorly the skin is separated from

the cartilaginous surface by a distinct layer of subcutaneous tissue that allows dissection

during pinnaplasty surgery. The tight adherence of the skin to the cartilage results in

ridges and concavities of the auricular cartilage. The absence of subcutaneous tissue layer

between skin and cartilage anteriorly makes the auricle susceptible to frostbite despite a

rich blood supply of superficial blood vessels. The skin over the auricle is covered by fine

hairs and, most noticeably in the concha and scaphoid fossa, there are sebaceous glands

opening into the root canals of these hairs. On the tragus and intertragic notch coarse,

thick hairs may develop in the middle-aged and older male.

The prominences and depressions present on the lateral surface are different in

every individual even among identical twins. This unique pattern is comparable to

fingerprints and can allow the identifications of persons on the physiognomy of their

auricles.27

The curved rim is called helix, which often has a small prominence known as

Darwin‟s tubercle at its posterosuperior aspect. Anterior to and parallel with the helix is

another prominence, the antihelix. Superiorly, this divides into two crura, between which

is the triangular fossa; the scaphoid fossa lies above the superior of two crura. In front of

the antihelix, and partly encircled by it, is the concha. This is divided into two portions by

the descending limb of the anterior superior portion of the helix, known as the crus of the

helix, which rests just above the external auditory meatus. The smaller superior portion is

the cymba conchae and is the direct lateral relation to the suprameatal triangle of the

temporal bone. The larger inferior portion is known as cavum conchae. Below the crus of

the helix and overlapping the external auditory meatus is the tragus, which is a small

blunt triangular prominence pointing posteriorly. Opposite the tragus, at the inferior limit

of the antihelix, is the antitragus. The intertragic notch separates the tragus from the

antitragus. The lobule lies below the antitragus and is soft, being composed of fibrous and

11

adipose tissue. The medial (cranial) surface of the auricle has elevations corresponding to

the depressions on the lateral surface, and posses‟ corresponding names, for example the

eminentia conchae.

Figure no. 01: Anatomy Of Pinna

The body of the auricle is formed from an elastic fibrocartilage and is a single

plate except for a narrow gap between the tragus and the anterior crus of the helix, where

it is replaced by a dense fibrous tissue band. This gap is the site for an endaural incision

which, properly performed, should not damage cartilage or its perichondrium and which

by splitting the soft-tissue ring surrounding the bony ear canal allows wide exposure of

the deeper parts.

12

Figure no. 02: Cartilage Of Pinna

The cartilage extends about 8 mm down the ear canal to its lateral third. The

cartilage of the auricle is covered with perichondrium from which it derives its supply of

nutrients, as cartilage itself is avascular. Stripping the perichondrium from the cartilage,

as occurs following injuries that cause hematoma, can lead to cartilage necrosis with

crumpled up „boxers‟ ear‟.

The cartilage of the auricle is connected to the temporal bone by two extrinsic

ligaments. The anterior ligament runs from the tragus and from a cartilaginous spine on

the anterior rim of the crus of the helix to the root of the zygomatic arch. A separate

posterior ligament runs from the medial surface of the concha to the lateral surface of the

mastoid prominence. Intrinsic ligaments connect various parts of the cartilaginous

auricle; that between the helix and tragus and another runs from antihelix to the

posteroinferior portion of the helix. Extrinsic and intrinsic muscles are attached to the

perichondrium of the cartilage. Temporal and posterior auricular branch of facial nerve

supply the extrinsic muscle and, while being functionally unimportant, they give rise to

13

post-auricular myogenic response following appropriate auditory stimulation.28

. There

are three extrinsic muscles; auricularis anterior, superior and posterior, the last being

supplied by the posterior auricular branch of facial nerve. All the three radiate out from

the auricle to insert into the epicranial aponeurosis. The intrinsic muscles – six in number

– are small, inconsistent and without function.

Figure no: 03 Auricular Muscles

Arterial branches of external carotid supply the auricle. The posterior auricular

appears to be the dominant artery and supplies the medial surface (except the lobule), the

concha, the middle and lower portions of the helix and the lower part of antihelix. The

anterior auricular branches of the superficial temporal supplies the upper portion of helix,

antihelix, triangular fossa, tragus and lobule.28

The superior auricular artery has a constant

course and connects the superior temporal artery and posterior auricular artery network.

This branch can provide a reliable vascular pedicle for retroauricular flaps.27

A small

auricular branch from the occipital artery may assist the posterior auricular artery in

supplying the medial surface.

14

Both cranial branchial nerves and somatic cervical nerves supply the auricle.

Their distribution is heterogeneous and the overlap may be extensive. Branches of the

fifth and tenth cranial nerves and the third spinal nerve provide sensory innervation to the

auricle. The greater auricular nerve, a branch of third spinal nerve, innervates the medial

side of the auricle29

; the upper portion is innervated by lesser occipital nerve. The lateral

side of the auricle is innervated by the twigs from the greater auricular nerve crossing

over the helix and small region in the root of helix by a branch of fifth cranial nerve, the

auriculo-temporal nerve. The auricular branch of tenth cranial nerve innervates a small

portion of pinna, which is concha, antihelix and ementia concha.

Figure no: 04 Nerve Supply Of Pinna

The lymphatic drainage from the posterior surface is to the lymph nodes at the

mastoid tip, from the tragus and from the upper part of the anterior surface to the

preauricular nodes, and from rest of the auricle to the upper deep cervical nodes.30

15

EMBRYOLOGY

First branchial cleft is the precursor of the external auditory canal. Around the

sixth week of embryonic life, a series of six tubercles appear around the first branchial

cleft. They progressively coalesce to form the pinna. Tragus develops from the tubercle

of first arch while rest of the auricle develops from the remaining five tubercles of second

arch. Failure or faulty fusion between the first and second arch tubercles cause

preauricular sinus or cyst, which is commonly seen between the tragus and the crus of

helix. By 20th

week, pinna achieves adult shape. Initially the pinna is located low on the

side of the neck and then moves on to a more lateral and cranial position.

Figure no.05. Development of the external ear. The external ear develops from six

mesenchymal condensations known as auricular hillocks.

16

PSEUDOCYST OF AURICLE

It is also called Endochondral pseudocyst, Intracartilaginous cyst, Cystic

Chondromalacia, Benign idiopathic cystic chondromalacia and more commonly

Seroma.31

Pseudocyst or seroma is an uncommon asymptomatic, non-inflammatory swelling

of pinna, characterized by endochondral cyst formation. First case of seroma was

documented in mid 1800 and Hartmann was the first to report such a condition in the year

1846. Engel coined the term “Auricular Pseudocyst”. 31

The etiology of Pseudocyst of auricle is unknown but several mechanisms have

been proposed, but ischemia was considered the most likely cause by Glamb and Kim.

Hansen has suggested that planes are created with in the cartilage as a result of the

complex embryonic development of the auricle, and these may be the sites for further

Pseudocyst formation32

. Choi et al have stated that it is a degenerative process of

unknown etiology with release of lysosomal enzymes especially GAGs, occurring in the

auricular cartilage, leading to the formation of a cavity containing an oily yellow fluid

which is sterile.33

The cavity may be lined by granulation tissue, but not by epithelium,

hence the title Pseudocyst. Heffner and Hyams proposed that, Pseudocyst is the process

of chondromalacia, based on histological features of the lesions.

Repeated minor trauma has long been suspected to have some part in the

pathogenesis of auricular Pseudocyst. This includes sleeping on hard pillows31

, carrying

large weights on the shoulder33

, motorcycle helmets, and wearing stereo headphones.

Histologically it presents as thinned cartilage and hyalinizing degeneration along the

internal border of the cystic space with dermal perivascular lymphocytic infiltrate

followed by fibrosis and granulation tissue sometimes. The presenting feature is a

painless, asymptomatic cystic swelling of the pinna. Pseudocyst of the auricle is

characterized by a unilateral, asymptomatic, cystic swelling of the helix or the antihelix,

most often located in the scaphoid fossa Because the etiology is obscure, various

treatments are as followed:

1. Wide bore needle aspiration and pressure dressing.

17

2. Curettage of the Pseudocyst wall following incision and drainage and subsequent

contour pressure dressing.32

3. De-roofing procedure by excision of the anterior wall of the cyst33

4. Systemic steroids, oral prednisolone 60 mg daily dose for 5 days and tapering the

dose subsequently34

.

5. Insertion of a small drainage tube into the Pseudocyst with a guided needle35

.

6. Excision of Pseudocyst with buttoning technique.

7. Intralesional injection of minocycline hydrochloride 1 mg/ml after drainage of

cyst.

Figure no: 06 window procedure: incision is made along the solid line and the skin flap

is reflected over the dotted line so as to create a skin flap in the form of a window panel.

18

Figure no. 07. Seroma. A, Seroma of the auricle. B, Seroma incised and evacuated. C,

Anterior dental rolls tied to posterior dental roll on the surface of the ear. D, Side view,

showing how bolsters are secured.

The condition usually resolves without any sequel. Occasionally it can get infected which

can be managed by antibiotic administration.

19

KELOID

Ear piercing is performed for both aesthetic and cultural reasons. Keloid

formation is a recognized complication of this procedure. Keloid formation is a frequent

problem in black community. Auricular Keloid may be unsightly and often causes

distress to the patient. They usually occur as a result of trauma after ear piercing or "high"

piercing, which requires puncture through the cartilage of the upper third of the pinna,

lacerations or surgical scars

Keloid is a benign connective tissue hypertrophy characterized by smooth, pink,

rounded scar like tumour that invariably follows trauma or incision in the skin. It appears

to be secondary to a defect in collagenase, which results in overgrowth of collagen as

opposed to hypertrophied scar, which is composed of immature collagen that has failed to

convert from tertiary to quaternary form22

.

They grow continuously but intermittently, and show no evidence of significant

regression.

During the initial phase of development and during the period of active growth,

the lesions are reddish or violet, with modest vascularization and small blood vessels

visible beneath the skin covering.

During the phase of development and in periods of quiescence, keloids are less

tense and vascularized, but remain raised and more compact than normal tissue. Unlike

hypertrophic scars, they do not cause retraction. The commonest age for the onset of

keloids is between 15 and 45 yr. They are more frequent in females and a certain degree

of familial heredity has been reported. Blacks are the most frequently affected race, in

particular Africans and East Indians.

A skin lesion even of limited dimensions such as acne or smallpox pustule, a wart,

an insect bite, a vaccination scratch, a tattoo, an electro cauterization, or a surgical

operation can trigger the onset. The typical features of keloids, i.e. their non-regression in

time, tendency to recidivation, and spreading to normal tissue, are useful in diagnosis for

differentiating from hypertrophic scars22

.

20

These features will however appear in time and thus it is not always possible to

make an early clinical differentiation between a hypertrophic scar and a keloid.36

The histological picture of the keloid is well defined. The condition usually

affects the dermis and is characterized by the presence of thick collagenous fibres of

vitreous and hyalinized aspect. A limited number of related fibroblasts are present,

embedded in a rich matrix of mucinous material22

.

In the early stages the formation tends to be more vascularized, especially in

peripheral zones; in the more mature phase the appearance is more hyalinized, with a

lower vascular component and an almost scar-like appearance. The overlying epidermis

may appear normal or acanthoid.

The fibroblasts present a clearly evident Golgi complex and a well-developed

rough endoplasmic reticulum22

.

In fresh keloids, chemical analysis indicates the presence of a disproportionate

increase in the synthesis of collagen, protocollagen, and fibronectin compared with

hypertrophic scars and mature keloids, confirming that the anabolic phase in keloids is

exaggeratedly accelerated.

Under the polarized-light microscope the bi-refrangent collagen fibers appear

yellow-green in colour and composed of thick fibers arranged in parallel or irregular

bundles. No myofibroblasts are present.

Keloid can be strictly defined by Cosman et al‟s clinical criteria; they spread beyond the

boundaries of original wound and do not regress.

Clinical features include itching, irritation, and occasionally pain. A variety of treatments

for auricular Keloid scarring have been described, alone or in combination with varying

degree of success ranging from 0% to 100%. 36

These include: -

21

Massage with topical silicon.37

Corticosteroid injection intralesionally; triamcinolone acetonide 10 mg/ml,

depending on the length of the scar at 4 weekly intervals for 4 months37

.

Use of pressure devices36

: This is known to reduce the amount of scar tissue as a

result of localized hypoxia resulting in fibroblast degeneration and cell

breakdown.

Cryosurgery

CO2 or argon laser ablation.

Surgical excision with or without flap reconstruction.

Extralesional excision of the scar and immediate postoperative adjuvant

radiotherapy37

.

Ear lobe keloids have a higher risk of recurrence rate than other anatomical sites.

Patients with a positive family history and a past history of Keloid with prior treatment

failures are at a greater risk of recurrence37

.

22

SEBACEOUS CYST

It is a common benign cyst caused by blockage of draining ducts of sebaceous

glands leading to cystic dilatation of the gland as a result of accumulation of sebum.

Retention or epidermal cyst is relatively common around the auricle, especially in the

postauricular sulcus and lobule because it is rich in sebaceous glands. Some may arise

from the hair follicle (pillar cyst).

They are usually soft and fairly mobile and occasionally there is a definable cyst

apex. Symptoms are usually absent unless the cyst becomes very large or infected. It may

present with cystic, smooth swelling, non tender, enlarging slowly and the characteristic

punctum is often visible in most cases.

Complete excision may be indicated for cosmetic purpose, because of secondary

infection, or if malignant degeneration is suspected. Simple incision and drainage is

invariably followed by recurrence. Successful treatment requires complete excision of the

cyst along with the lining epithelium.38

KERATOACANTHOMA

Keratoacanthoma is a benign tumor resembling carcinoma and is believed to be

related to actinic exposure. The common location of the tumor is anterior to the tragus. It

is characterized by a central crater that contains a keratin plug. The lesion tends to grow

rapidly after its initial appearance and then slowly regresses. Although the disease is self-

limiting, excisional biopsy is required to rule out a malignant tumor.38

PREAURICULAR PITS AND SINUSES

Preauricular pits and sinuses are of congenital origin, arising from faulty

developmental closure of the hillocks of first and second branchial arches that form the

auricle. They present as small openings in the skin just anterior to the crus of the helix

(Figure 8–11). From this opening, a long branched tract may run under the skin between

the helix and tragus and anterior to the tragus. The tract, which is lined with squamous

23

cell epithelium, is often cystic, and the patient is frequently seen initially because of

infection of the cyst. Treatment is not necessary unless recurrent infection occurs.

Treatment includes complete removal of the cyst along with the fistula tract. Incomplete

removal is associated with the formation of draining sinuses, requiring even more

difficult and radical surgery for their elimination. The difficulty of the surgery is caused

by the branching of the fistula, which makes it hard to define the complete extent of the

tract. One suggestion to aid in their removal is to inject the tract before the operation with

methylene blue so that the stained tissue may be used as a rough guide to the extent of the

fistula.38

VASCULAR TUMORS

Angiomas are congenital tumors and are one of the most common tumors of

childhood. They may involve the auricle together with other areas of the face and neck.

These tumors occur in various forms. Capillary hemangioma consists of masses of

capillary-sized vessels and may form a large flat mass. A central large vessel feeds the

“portwine stain” or spider nevus, which is a branching network of capillaries. The spider

nevus is not a major problem, being small and fixed in size. Treatment, when necessary,

usually consists of needle coagulation of the central vessel. The port-wine stain is much

more of a problem, increasing in size gradually until adolescence, and generally is

disfiguring.

Cavernous hemangioma is the most alarming of these lesions, consisting of raised

masses of blood filled endothelial spaces. Often termed a “strawberry tumor,” it increases

rapidly in size during the first year of life but usually regresses there after. Much less

common is the lymphangioma. It has the appearance of multiple pale circumscribed

lesions, like a cluster of fish or frog roe. The major problem in these tumors is cosmetic.

In general, the lesion should be allowed to regress maximally and the residual tumor

treated. Various modalities have been recommended, including cryosurgery, surgical

excision and skin grafting, radiation, electrolysis, and tattooing for port-wine staining.

Therapy should only be undertaken with caution and after the best available consultation

has been sought.38

24

WINKLER’S NODULE (CHONDRODERMATITIS NODULARIS

CHRONICA HELICIS)

Chondrodermatitis nodularis chronica helicis is a benign nodular growth usually

occurring on the rim of the helix in older men. It appears as a firm elevated nodular lesion

with a grayish crust on the surface. It is characterized by exquisite tenderness with digital

compression, out of proportion to its size. It must be differentiated from other lesions

such as basal cell carcinomas. The cause of chondrodermatitis nodularis chronica helicis

is unknown. It can be treated with injection of a corticosteroid for pain relief. Definitive

treatment requires full-thickness excision, including a wedge of cartilage.38

NEUROFIBROMA OF PINNA

Neurofibromas are relatively common lesions of nervous system. They may

develop anywhere in the body, including cranial and peripheral nerves. While

neurofibroma of head and neck are not uncommon but neurofibroma of pinna are rare.

Neurofibromas are circumscribed but non-encapsulated neoplasms of the nervous

system. They can arise in all peripheral nerve elements, including Schwann‟s cells,

neurons, fibroblasts, and perineural cells. This may occur in isolation or as a part of Von

Recklinghausen‟s syndrome. The disease may be inherited as autosomal dominant trait

with variable penetrance in 50 percent of cases, or it may occur as a result of spontaneous

mutation. Neurofibroma are usually benign, but some cause local destruction secondary

to pressure effects. Malignant transformation is also been reported in 2 to 16 percent of

cases.

Patient may present with cosmetic deformity, Treatment is usually by surgical

excision. Deformity of pinna, is of much concern to patient, excision can be performed

with re construction of pinna 26

.

25

MATERIALS AND METHODS

STUDY SETTING-

This study was carried out at a tertiary referral hospital Raja Rajeswari Medical

college & Hospital Bangalore .

STUDY DESIGN-

Prospective study.

STUDY DURATION-

This study was carried out during the period January 2013 to December 2013.

STUDY POPULATION-

All patients attending Otolaryngology outpatient with benign lesions of pinna were

counseled for inclusion. A total of 115 patients got listed with written informed consent

and were studied.

SAMPLE SIZE

-115 patients.

SOURCE OF DATA:

Pre structured questionnaire including socio demographic profile about the risk factors

leading to benign lesions of pinna, history taking and clinical examination were done.

METHODS OF COLLECTION OF DATA:

The Proforma was designed based on the objectives of the study. It was pre-tested

and used after modifications.

The selection criteria included patients presenting with swellings of pinna. A detailed

clinical history regarding onset, predisposing factors and associated conditions was

documented. In addition to the routine blood and urine examination, blood sugar levels

were measured in relevant cases. Surgery was carried out under local anesthesia in all of

the cases after obtaining written consent and, from parents/guardians in case of children.

26

WORKING INDICES:

Analysis of data:

The data thus obtained was analyzed statistically, with the aid of tabulation and

calculation presented in the form of tables, figures, graphs and diagrams wherever

necessary.

The findings are discussed in the light of findings in other similar studies conducted

elsewhere based on the objectives of the study in the foregoing chapter.

INCLUSION CRITERIA:

1. All the patients attending ENT department of RRMCH Bangalore with clinical features

of benign lesions of pinna.

2. Patients willing to participate in present study.

EXCLUSION CRITERIA:

1. Inflammatory conditions of pinna.

2. Infections of the pinna.

3. Malignant conditions of the pinna.

4. Patients who do not give consent to participate in the study.

27

MANGAGEMENT PROTOCOL FOLLOWED

SEROMA:

On initial review, some cases with minimum accumulation were managed by

wide bore needle aspiration under antibiotic cover with aseptic precautions and

application of a firm pressure bandage to prevent reaccumulation. Patients were

supplemented with multivitamins and multiminerals. Cases that recurred and the

remaining cases were taken up for window procedure. An incision was made at the

maximum bulge of the swelling, and the skin flap was reflected in the form of a window

panel. The fluid was drained and the skin flap is repositioned without suturing so as to

freely drain any accumulated fluid. A firm pressure dressing was applied, and case

reviewed after 3, 6 and 12 days post-operatively.

SEBACEOUS CYST:

Complete excision of cyst was done. Infected cysts were treated with appropriate

antibiotics before surgery. The cysts were removed by sharp dissection, care being taken

to keep the walls of the cyst intact to ensure complete removal. The ductal tissue leading

to the cyst as well its external opening was removed by including a small segment of the

overlying skin.

PRE AURICULAR SINUS OR CYST:

Complete excision of pre auricular sinus or cyst was done. Infected cysts were

treated with appropriate antibiotics before surgery. The sinus tract or cysts were removed

by sharp dissection, care being taken to keep the walls of the cyst intact to ensure

complete removal. Methylene blue is injected in to sinus tract intra operatively to trace

the tract.

28

KELOID:

Initial treatment consisted of total excision of the lesion with clear margins of

healthy tissue on most of the cases except few cases where keloid swelling was not

obvious but just palpable; these cases were managed by only triamcinolone (kenocort)

10mg/ml, 0.5 mL, injections intralesionally at weekly interval for a month. Surgically

treated patients received similar dose of triamcinolone into the surgical bed for same

duration to prevent recurrences, starting 2 weeks post-operatively.

HAEMANGIOMA:

Haemangioma was managed by complete surgical excision .

DERMOID:

Dermoid was managed by complete surgical excision.

NEUROFIBROMA:

It was managed by complete surgical excision with reconstruction of pinna .

29

RESULTS AND OBSERVATIONS

This study was carried out at Rajarajeswari medical college & hospital Bangalore.

A total of 115 cases attending ENT OPD with swelling of the pinna were studied

evaluated and managed. The following observations were made:

TABLE NO: 01 Age Distribution Of Cases

Age group (years) No: of cases Percentage

0-10 20 17.4

10-19 46 40

20-29 35 30.4

30-39 8 7

40-49 4 3.5

50-59

2 1.7

Total

115 100

Most of the patients in our study were in the age group of 10 to 19 years, i.e.46

patients constituting 40 percent. Next common age group was 20 to 29 with 35 patients or

30 percent.

30

Figure no: 08 Age Distributions Of Cases

Table no: 02 Sex Distribution Of Cases

Sex No: of cases Percentage

Male 44 38.3

Female 71 61.7

Total 115 100

0

20

46

35

8 4 2

Age group(years)

0-10 0-19 20-29 30-39 40-49 50-59

No

. of cases

31

Figure no: 09 Sex Distribution Of Cases

71 of patients (62 percent) in the study were females, and 44 i.e. 38 percent were males.

The male to female ratio was found to be 1:1.4.

Table no: 03 Socioeconomic Distributions Of Cases

Socioeconomic status No: of cases Percentage

Lower class 35 30.4

Middle class 74 64.3

Upper class 6 5.2

Total 115 100

35 of patients i.e. 30 percent, belonged to lower socioeconomic status and 74 patients i.e.

64 percent belonged to middle class. Only 4 patients (03 percent) were of upper class.

0

10

20

30

40

50

60

70

80

Male Female

No

. of p

atients

sex of patient

32

Figure no: 10 Socioeconomic Status Of Cases

Table no: 04 Distributions Of Total Cases

Diagnosis No: of cases Percentage

Keloid 66 57.4

Pseudocyst of auricle 33 28.7

Pre auricular cyst 03 2.6

Haemangioma 01 0.9

Sebaceous cyst 10 8.7

Neurofibroma 01 0.9

Dermoid 01 0.9

Total 115 100

66 cases (58 percent) presented with Keloid, followed by 33 cases (29 percent) of

pseudocyct of auricle, pre auricular cyst 3 cases (2.6 percent). Sebaceous cyst were seen

in 10 cases each i.e. 9 percent. Only 1 case each of Neurofibroma, Haemangioma and

Dermoid were diagnosed (<1percent each).

0

10

20

30

40

50

60

70

80

Lower class Middle class Upper class

No

. of cases

Socio economic status

33

Figure no: 11 Case Distribution

KELOID

The following observations were made in patients presenting with keloids.

Table no: 05 Sex Distribution Of Keloid Cases

Most of the cases presenting with Keloid were females. 62 patients out of total 66 cases

were females i.e. 94 percent, only 6 percent or 4 cases were males.

0

10

20

30

40

50

60

70

No

. of p

atients Diagnosis

Sex No: of cases Percentage

Male 04 06

Female 62 93.9

Total 66 100

34

Figure no: 12 Sex Distributions Of Keloid Cases.

Table no: 06 Keloid cases

Keloid No: of cases Percentage

Unilateral 58 87.8

Bilateral 08 12.1

Total 66 100

Keloid was unilateral in 58 patients (88 percent) and bilateral in 8 cases (12 percent).

0

10

20

30

40

50

60

70

Male female

No

. of cases

sex of patient

35

Figure no: 13 Laterality Of Keloid Cases

Table no: 07 Predisposing Factors For Keloid

Predisposing factors for

keloid

No: of cases Percentage

Trauma 0 0

Ear piercing/iatrogenic 66 100

Burns 0 0

Unknown 0 0

Total

66

100

0

10

20

30

40

50

60

70

Unilateral Bilateral

No

. of cases

Laterality

36

Figure No: 14 Predisposing Factors For Keloid.

Ear piercing was the only factor seen in our studies.

Table no: 08 Management Of Keloid

Treatment No: of cases Percentage

Only Intralesional

triamcinolone

04 06

Excision with post op

Intralesional

triamcinolone

62 93.9

Total 66 100

62 cases (94 percent) were managed with complete excision of the lesion followed by

intralesional triamcinolone and 4 cases (6 percent) were instituted only intralesional

triamcinolone.

0

10

20

30

40

50

60

70

Trauma Earpiercing/iatrogenic

Burns Unknown

No

. of cases

Pre disposing factor

37

Figure No: 15 Management Of Keloid Cases

PSEUDOCYST OF AURICLE

The observations made with patients presenting with pseudocyst of auricle are 33

Table no: 09 Sex Distribution Of Pseudocyst Of Auricle

Sex No: of cases Percentage

Male 30 90.9

Female 03 9.1

Total 33 100

Of 33 cases of pseudocyst of auricle 30 patients (91 percent) were males and 3 patients (9

percent) were females in our study.

0

10

20

30

40

50

60

70

Only Intralesionaltriamcinolone

Excision with post opIntralesional

triamcinolone

No

. of cases

Management

38

Figure No: 16 Sex Distribution Of Seroma Cases

Table no: 10 Predisposing factors for pseudocyst of auricle

Predisposing factors for

pseudocyst of auricle

No: of cases Percentage

Trauma 11 34

Diabetes mellitus 03 9

Unknown 19 57

Total 33 100

0

5

10

15

20

25

30

35

Male female

No

. of cases

Sex of patient

39

Figure No: 17: Predisposing Factors For Seroma

Trauma was seen in 11 cases (34 percent), diabetes also was seen in 3 cases (9 percent).

Rest of the cases 19 in no. (57 percent) did not have any specific etiology.

Table no: 11 Management of pseudocyst of auricle

Treatment No: of cases

Percentage

Aspiration O2

6

Window procedure 27 82

2 cases (100 percent) were managed by aspiration and 4 cases (31 percent), which had

reaccumulation of fluid after aspiration initially, required window procedure. And rest 27

cases managed with window procedure.

0

2

4

6

8

10

12

14

16

18

20

Trauma Diabetes mellitus Unknown

No

. of cases

Pre disposing factors

40

Figure No: 18 Management Options Of Seroma

Table no: 12 Percentage of case responding to treatment

Treatment

Total No: of

cases

Percentage of

responders

Percentage of

failures

Initial Aspiration

06

33

67

Window procedure

31

100

00

0

5

10

15

20

25

30

Aspiration Window procedure

No

. of cases

Management

41

Of 6 patients, which underwent aspiration of fluid, 33 percent (2 cases) responded

to the treatment. 31 cases, were treated with window procedure and 100 percent response

was seen.

Figure No: 19 Percentage Of Cases Responding To Treatment

0

20

40

60

80

100

120

Aspiration Window procedureP

ercentage o

f respo

nd

ers

42

Table No: 13 Summary Of Predisposing Factors

Diagnosis

Trauma

Ear

piercing/iatrogenic

Diabetes

mellitus Unknown

Keloid -

66 - -

Pseudocyst of

auricle

11 - 03 19

Sebaceous

cyst

-

- - 10

neurofibroma - - - 01

Preauricular

sinus/cyst

- - - 03

Haemangioma - - - 01

Dermoid - - - 01

Total 11(9%) 66(57%) 03(3%) 35(30%)

43

11 (9 percent) of all cases had trauma as a predisposing factors, 66 cases or 57

percent had ear piercing or iatrogenic as predisposing factors. Diabetes was a factor in 3

cases (3 percent) and no factors could be elicited in 35 cases (30 percent).

Figure No: 20 Predisposing Factors For All Cases

0

10

20

30

40

50

60

70

Trauma Earpiercing/iatrogenic

Diabetes mellitus Unknown

44

Table No: 14 Summary Of Management Options

Diagnosis

Aspiration

Window

procedure

Complete

excision

Only

Intralesional

steroid Conservative

Keloid -

- 62 04 -

Pseudocyst of

auricle

06 31 - - -

Sebaceous

cyst

-

- 10 - -

neurofibroma - - 01 - -

Pre auricular

sinus/cyst

- - 03 - -

Haemangioma - - 01 - -

Dermoid - - 01 - -

Total 6(5%) 31(27%) 78(67%) 04(3%) -

45

6 cases (5 percent) were treated by aspiration of fluid, 4 cases that recurred after

aspiration underwent window procedure along with rest of 27 cases. 78 cases (68 percent)

by complete excision of the lesion, 4 cases (3 percent) by intralesional triamcinolone

injections only .

Figure No: 21 Treatment Options Of All Cases

0

10

20

30

40

50

60

70

80

90

Aspiration windowprocedure

complete excision only intra lesionalsteroid

conservative

No

. of cases

46

Plate No: 01 Histology of neurofibroma

Plate No: 02 ‘Ear Piercing’ Predisposing Factor For Keloid

47

Plate No: 3 Keloid

Plate No: 04 Pseudocyst Of Auricle

48

Plate No: 05 Sebaceous Cysts In The Post-Auricular Area

Plate No: 6 Infected Sebaceous Cyst.

49

Plate No: 7 Pseudo Auricular Cyst

Plate No: 8 Haemangioma

50

Plate No: 09 Patient With Multiple Keloids

Plate No: 10 Pre Auricular Sinus.

51

Plate No: 11 Neurofibroma Of Pinna

Plate No: 12 Infected Sebaceous Cyst.

52

Plate No: 13 Patient With Extensive Keloid

Plate No: 14 Dermoid

53

DISCUSSION

A total of 115 cases who presented to the ENT OPD with complaint of ear

swelling were examined and diagnosed clinically before subjecting them to minimum

relevant investigations and managed with appropriate timely intervention under strict

aseptic precautions.

Our study is a prospective study.

AGE INCIDENCE:

Patients of all age have participated in our study. Maximum number of patients 46

in number belonged to the age group of 10 to 19 years followed by 35 patients in 20 to 29

years age group. Most of the patients in our study were young because young people are

more concerned about their cosmetic appearance and since pinna is very important part of

facial aesthesis, any lesions attracts their attention early. Another reason that could

explain the high incidence in this active working age group is the hazards they encounter

in their occupation.

In a retrospective descriptive analysis by Lim et al, of Pseudocyst of auricle

Eighty-seven percent of patients were male and the mean age was 38.9 years old3.

This is in close accordance with our study.

SEX INCIDENCE:

71 of patients (62 percent) in the study were females, and 44 i.e. 38 percent were

males. The male to female ratio was found to be 1:1.6. It shows that both males and

females equally participated in our study.

SOCIOECONOMIC STATUS:

Socioeconomic status was based on modified Kuppuswamy scale. Here the

education level, occupation of head of the family and per capita family income was taken

into account.

54

In our study 74 of patients i.e. 64 percent, belonged to middle socioeconomic

status. Only 6 patients (05 percent) were of upper class and the rest i.e. 35 patients (30

percent) belonged to lower class. This is because lesions of pinna like keloid are quite

common in middle and lower socioeconomic status, since poor hygienic conditions and

aseptic ear piercing is widely practiced in this group. Also unhealthy social practices are

not uncommon which predispose to various lesions of pinna. Moreover illiteracy, lack of

knowledge about asepsis and delayed seeking of medical assistance predisposes to more

complication rates.

DISTRIBUTION OF CASES:

Of total 115 cases in our study, 66 cases (57 percent) presented with Keloid,

followed by 33 cases (29 percent) of pseudocyst of auricle, sebaceous cyst were seen in

10 cases i.e. 9 percent and Only 1 case of Neurofibroma , Haemangioma and dermoid

was diagnosed (<1percent each).

The increased prevalence of Keloid could be attributed to increase in the “high piercing”

i.e. ear piercing in the cartilaginous part of the pinna, and ear lobule piercing which is

considered fashion and traditional customs in society.

This can be substantiated by a study by Christophfolz et al on complications related to

body piercing, male to female ratio was 1:2.2. Most of the recorded complications were

related to the new vogue of piercing, with the ear affected most commonly. The overall

complication rate of ear piercing was found to be 35 percent. High ear piercing accounted

for most of the complications in their study12

.

KELOID:

In our study most of the cases presenting with Keloid were females. 62 patients

out of total 56 cases were females i.e. 94 percent; only 6 percent or 4 cases were males.

The reason for female preponderance is the custom of compulsory ear piercing by the

females of our Indian society.

In our study keloid were unilateral in 58 patients or 88 percent and bilateral in 8 cases (12

percent).

55

Laterality of keloids depends on the site of ear piercing as well as on the genetic

predilection of the individual to develop Keloid.

PREDISPOSING FACTORS FOR KELOID:

In our study ear piercing was the only factor seen in causation of keloid.

MANAGEMENT OF KELOID:

In our study 62 cases (94 percent) were managed with complete excision of the

lesion followed by intralesional triamcinolone acetonide 10 mg/mL, 0.5 to 2 mL,

depending upon the length of the scar at monthly intervals for 4 months, starting 2 weeks

post-op as early institution may result in wound dehiscence. 4 cases (6 percent) which

had no visible swelling but Keloid could be palpated and found to <5mm in dimensions

were instituted only intralesional triamcinolone in a dose mentioned above for 4 months.

Patients were followed up for 6 months with no recurrences and no complications.

Daniel J Rosen et al did a retrospective analysis of 64 patients representing 92 ear

keloids. The treatment protocol consisted of excision with an intraoperative and two

postoperative steroid injections. Success was achieved in 74 of 92 keloids (80 percent)

excised5.

Peter Donkor in a clinical review of patients presenting with new and recurrent

keloid of the head and neck determined that 40 mg triamcinolone injected into the

residual lesion, primary between 10 and 14 days postoperative. The injection was

repeated on 2 more occasions at monthly intervals. All patients were followed up for at

least 2 years. Eighteen patients were successfully treated with no sign of recurrence in

any of them17

.

The results of our study are in accordance with the above mentioned studies.

PSEUDOCYST OF AURICLE:

Predisposing factors for pseudocyst of auricle:

In our study Trauma was the most common factor in causation of pseudocyst of auricle,

seen in 11 cases (34 percent), 3 cases (9 percent) had diabetes mellitus which if

56

uncontrolled can lead to delayed fluid resorbtion and in worst scenario may even cause

perichondritis followed by destruction of auricular cartilage. Rest of the cases 19 in no:

(57 percent) did not have any specific etiology.

Our results are comparable with the study conducted by Kishore Chandra Prasad,

Karthik. S. and Sampath Chandra Prasad, who with their experience of 116 cases of

seroma found trauma as the leading predisposing factors accounting for 82 cases,

followed by insect bite in 13 and ear piercing in 21 cases1.

MANAGEMENT OF PSEUDOCYST OF AURICLE:

In our study 6 cases of pseudocyst of auricle were initially managed by aspiration

under aseptic precautions followed by pressure bandage for 5 days with multi vitamin

and multiminerals supplementation. 2 cases (33 percent) responded very well to

aspiration and pressure bandage alone.4 cases (67 percent) who had recurrence following

aspiration and also rest of the of the patients (27) were managed by window procedure

with broad spectrum antibiotic cover. Pressure dressing was applied in all cases.

Following window procedure all cases i.e. 31 cases (100 percent) were treated

successfully. These results are in close comparison with below mentioned study.

In a retrospective descriptive analysis by Lim et al, of Pseudocyst of auricle, All 9

patients who had simple aspiration of the cyst had prompt re-accumulation of the

pseudocyst. None of the patients had recurrence following excision and compression

buttoning of the pseudocyst. The complication rate in study was 2.4%. Only one patient

developed initial perichondritis3

SEBACEOUS CYST:

10 cases of postauricular sebaceous cyst were included in our series and were

managed with complete excision without any recurrences.

It was in correlation with the study by Kishore Chandra Prasad, Karthik. S. and Sampath

Chandra Prasad, who in their study of 39 cases of sebaceous cyst, managed them by

complete excision and did not observe any recurrence1.

57

HAEMANGIOMA :

One case of haemangioma of pinna was observed in our study. This was managed

with

Complete surgical excision.

DERMOID :

One case of dermoid of pinna was observed and was managed by complete

Surgical excision.

NEUROFIBROMA:

Only 1 case of Neurofibroma of pinna was observed in our study. This patient

was managed with complete surgical excision with reconstruction of pinna.

58

CONCLUSION

The various benign lesions of pinna presenting to OPD in our study were found to

be Keloid, pseudocyst of auricle, pre auricular sinus or cyst, sebaceous cyst,

haemangioma, dermoid and Neurofibroma of pinna.

A total of 115 cases were enrolled in the study. The main presenting complaint of

the patient was swelling of the pinna with or without pain. Patients of all age participated

in our study. Maximum number of patients, 46 in number belonged to the age group of 10

to 19 years followed by 35 patients of 20 to 29 patients. 71 of patients (62 percent) in the

study were females, and 44 i.e. 38 percent were males. The male to female ratio was

found to be 1:1.6. Most of the patients i.e. 64 percent belonged to middle socioeconomic

status and just 35 patients (30 percent) belonged to lower class.

Of total 115 cases in our study, 66 cases (57 percent) presented with Keloid,

followed by 33 cases (29 percent) of pseudocyst of auricle, sebaceous cyst were seen in

10 cases i.e. 9 percent and Only 1 case of Neurofibroma, Haemangioma, and dermoid

was diagnosed (<1percent).

94 percent of patients presenting with Keloid were females. 88 percent of them

had unilateral and just 12 percent had bilateral disease. Ear piercing was the only factor

seen in our study. 94 percent were managed with complete excision of the lesion

followed by intralesional triamcinolone acetonide and 6 percent of patients which had no

visible swelling but Keloid mass was palpated to be less then 5mm, were instituted only

intralesional triamcinolone with complete regression of the keloid. Of all the cases

operated none of the cases developed recurrences and complications in six months follow

up.

Trauma was the factor in causation of pseudocyst of auricle in 11 cases (34

percent), diabetes also was seen in 3 cases (9 percent). Of all 33 cases of pseudocyst of

auricle 27 cases (82 percent) were managed by window procedure and 6 cases (18

59

percent) were managed with aspiration. Of these 6 cases, in 4 cases reaccumulation of

fluid occurred and window procedure is carried out for these patients also. Pressure

dressing was applied in all cases. No case developed perichondritis post operatively and

no recurrences were noted.

Three cases of pre auricular sinus or cyst were studied in our series and all of

them were managed by complete surgical excision using methylene blue injecting in to

sinus tract for tracing the tract. No recurrences and complications were noted in six

months follow up.

10 cases of postauricular sebaceous cyst were studied in our series and all of them

were managed with complete excision without any recurrences

One case of haemangioma was observed and was promptly managed by complete

surgical excision with no recurrence and no complications.

Only 1 case of Neurofibroma of pinna was observed in our study. This patient

was managed by complete surgical excision with reconstruction of pinna.

One case of dermoid was observed and was managed by complete surgical excision with

no complications and recurrences.

THE INFERENCES DRAWN FROM THIS STUDY ARE:

The various benign lesions of pinna presenting to OPD in our study are Keloid,

Pseudocyst of auricle, Sebaceous cyst, pre auricular sinus or cyst, haemangioma, dermoid

and Neurofibroma of pinna. They present with swelling of the pinna with or without pain.

Trauma is the most important factor in causation of number of benign lesions of pinna.

Other factors are ear piercing as in keloids, Diabetes mellitus plays a significant role in a

few of the conditions and should be controlled simultaneously.

Wide bore needle aspiration can be done for some of the cases of seroma. Patients who

had recurrence can be managed by window procedure. Other lesions like Keloid,

sebaceous cyst, pre auricular sinus or cyst can be managed by complete excision.

Haemangioma and dermoid cases were managed by complete surgical excision with no

recurrences and complications.

A firm pressure bandage to be applied in most of cases after surgery.

Neurofibroma can be managed conservatively.

60

SUMMARY

Pinna contributes enormously to the facial aesthesis. Lesions affecting the pinna

can lead to overt disfigurement and change the entire appeal of the face. Gross deformity

can occur because of a delay in diagnosis and mismanagement. This study was

undertaken with an objective in mind to diagnose various lesions of pinna as early as

possible and manage them promptly taking care of their predisposing factors and

complications.

Diagnosis of lesions of pinna does not require any special investigations but detailed

history and a through clinical examination is sufficient enough to diagnose most of the

cases of pinna.

In our study a total of 115 cases, who presented to the ENT department at

Rajarajeswari Medical College & Hospital Bangalore with complaint of ear swelling

were examined and diagnosed clinically, were managed with prompt, timely and

appropriate interventions. Wide bore needle aspiration was done for some cases of

seroma. Patients who had recurrence and other majority of cases were managed by

window procedure. Other lesions like Keloid, sebaceous cyst, haemangioma and

dermoid were managed by complete surgical excision. A firm pressure bandage was

applied in most of the cases after surgery. Neurofibroma was managed by surgical

excision. All of cases were done under local anesthesia.

The data thus collected was complied and analyzed and following observations

were made. The various benign lesions of pinna presenting to OPD in our study are

Keloid, Pseudocyst of auricle, sebaceous cyst, haemangioma, dermoid and Neurofibroma

of pinna. The commonest presentation is swelling of the pinna with or without pain.

Trauma is the most important factor in causation of number of benign lesions of pinna.

Other factors being high ear piercing through the cartilage. Diabetes mellitus plays a

significant role and should be controlled simultaneously.

Wide bore needle aspiration can be done for some of the cases of seroma Patients

who have recurrence and other cases can be managed by window procedure. Other

lesions like Keloid, sebaceous cyst, haemangioma and dermoid can be managed by

complete surgical excision. A firm pressure bandage should be applied in most of the

cases after surgery.

61

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study on lesions of pinna: American journal of Otolaryngology-head and neck medicine

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2. Ming et al: Pseudocyst of the auricle: a histologic perspective: Laryngoscope: 2004 Jul;

114 (7): 1281-4.

3. Lim et al: Pseudocyst of the auricle: Laryngoscope. 2002 Nov; 112 (11): 2033-6.

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5. Kaur S, Thami GP, Bhalla M.: Pseudocyst of the auricle. Indian J Dermatol Venereol

Leprol 2003; 69:85-6.

6. K W Schulte, N J Neumann, T Ruzicka: Surgical pearl: The close-fitting ear cover cast--a

noninvasive treatment for pseudocyst of the ear: J Am AcadDermatol. 2001 Feb; 44 (2):

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7. N Oyama et al: Treatment of recurrent auricle pseudocyst with intralesional injection of

minocycline: a report of two cases: J Am AcadDermatol. 2001 Oct; 45 (4): 554-6.

8. H Miyamoto, M Okajima, I Takahashi: Lactate dehydrogenase isozymes in and

intralesional steroid injection therapy for pseudocyst of the auricle: Int J Dermatol. 2001

Jun ;40 (6):380-4.

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9. Q Chen et al: Research on the immunological cause of auricular pseudocyst: Lin Chuang

Er Bi Yan HouKeZaZhi. 2001 Jul; 15 (7): 304-5.

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treatment recommendation with curettage and fibrin glue: Dermatol Surg. 2003 Oct; 29

(10):1080-3.

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2004 Jun; 33:177-80.

12. Amy Han, Lian-Jie Li, ParadiMirmirani: Successful treatment of auricular pseudocyst

using a surgical bolster: a case report and review of the literature: Cutis. 2006 Feb; 77

(2): 102-4.

13. Jeniffer et al: Adjuvant radiation of bilateral postauricular keloids: Med Dosim. 2007 ;32

(4):278-80.

14. Daniel J Rosen et al: A primary protocol for the management of ear keloids: results of

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Surg. 2007 Oct; 120 (5): 1395-400.

15. Apirag et al: The efficacy of 5% imiquimod cream in the prevention of recurrence of

excised keloids: J Med Assoc Thai. 2007 Jul; 90 (7): 1363-7.

16. Peter Donkor: Head and neck keloid: treatment by core excision and delayed 25.

Intralesional injection of steroid: J Oral Maxillofac Surg. 2007 Jul ;65 (7):1292-6.

17. Charles E Stewart , John Y Kim: Application of mitomycin-C for head and neck keloids:

Otolaryngol Head Neck Surg. 2006 Dec; 135 (6): 946-50.

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18. A CagriUysal: Topical interferon-alpha2b and keloid treatment: a place for pretreatment?

: PlastReconstr Surg. 2006 Apr 15; 117 (5): 1645-6.

19. Zouboulis et al: Intralesional cryosurgery enhances the involution of recalcitrant auricular

keloids: a new clinical approach supported by experimental studies: Wound Repair

Regen. ;14 (1):18-27.

20. Tomas Fikrle, KarelPizinger: Cryosurgery in the Treatment of Earlobe Keloids: Report of

Seven Cases: Dermatol Surg. 2005 Dec 1;31 (12):1728-1731.

21. Christoph folz et al: Perichondritis of the auricle and its management: J Laryngol Otol.

2007 Feb 26; 1-5.

22. Masellis M., Ferrara M.M: extensive keloids in the auricle-surgical treatment by means

of autologous grafts: Annals of Burns and Fire Disasters - vol. XII - n° 4 - December

1999.

23. Myron. W. Yencha, James P. Oberman: combined therapy in treatment of auricular

keloids: ENT journal Feb 2006; volume 85, number-2.

24. 34. E C Ho, S Jajeh and N Molony: Treatment of pinna haematoma with compression

using Leonard buttons: The Journal of Laryngology & Otology (1992), 106: 159-161.

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64

27. Feenstra L, Van der Lugt C. Ear Witness. Journal of Laryngology and Otology.2000;

114: 497-500.

28. Imanishi N, Nakajima H, Aiso, arterial anatomy of the ear. Okajimas folia anatomica

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29. Peuker TE, FillarJT, The nerve supply of the human auricle. Clinical anatomy. 2002; 15:

35-7.

30. Tony wright, Peter Valentine.Scott-Brown‟s Otorhinolaryngology, Head and neck

surgery.7th edition, volume 3; 225: 3105-3106.

31. Engel D. Pseudocyst of auricle in Chinese. Arch Otolaryngol 1966;83:197-202.

32. Hansen JE.Pseudocyst of auricle in Caucasians. Arch Otolaryngol 1967; 85:13-4.

33. Choi S, Lam KH, Chan KW, et al. Endochondral Pseudocyst of auricle in Chinese.

34. Job A, Raman R. Medical management of pseudocyst of the auricle. J LaryngolOtol

1992; 106:159-61.

35. Zhu LX, Wang XY, New technique for treating pseudocyst of auricle. J LaryngolOto

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36. Russell R, Horlock N, Gault D, Zimmer splintage: a simple effective treatment for

keloids following ear-piercing, Br J PlastSurg 2001; 54:509-10.

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65

38. Diseases of the External Ear

Timothy T. K. Jung, MD, PhD, Tae Hoon Jinn, MD; Ballenger‟s Otorhinolaryngology;

16th

edition; page 230-247.

66

PROFORMA

NAME: OP/IP NO.: SL.NO:

AGE: RELIGION: DATE:

SEX: M / F OCCUPATION:

ADDRESS: INCOME:

URBAN/RURAL

EDUCATIONAL STATUS: Illit / Primary / Middle / Sec / Deg. / Master Degree

CONSENT FORM

I _________________________ have been clearly explained about the need of

examination to be conducted on me. All details pertaining to my disease and other

associated infections have been explained to me in my own language.

I here by give my consent for the examination and also to record the data pertaining to

me and my disease.

SIGNATURE OF THE PATIENT

PRESENTING COMPLAINTS AND DURATION:

Swelling of external ear/in front/behind/below the ear

Pain in the pinna.

Fever.

Any other complaints

67

HISTORY OF PRESENTING ILLNESS:

EAR COMPLAINTS: R L

1. Ear discharge:

Duration

Quantity (copious/scanty)

Color

Nature (watery/mucoid/

mucopurulent/purulent/

blood stained)

Smell (Foul/non-foul)

Periodicity (intermittent/continuous)

2. Ear pain:

Duration

Onset : Sudden / Gradual

Site : Superficial / Deep

Post auricular/Preauricular/Infra auricular

Severity (mild/moderate/severe)

Nature (dull/sharp/stabbing)

3. Deafness

Duration

Onset : Sudden / Gradual

Degree (mild/moderate/severe)

Progressing /stationary/regressing

Periodicity (constant/intermittent)

4. Itching yes/no yes/no

5. Blocking/Fullness in the ear yes/no yes/no

6. Tinnitus yes/no yes/no

7. Vertigo yes/no yes/no

8. Facial weakness yes/no yes/no

68

. Swelling in the ear :

Onset : Sudden / Insidious

Progression : Progressive / Stationery

(Single/multiple)

Site

Painful/Painless

Any other complaints

General symptoms: Fever/Headache/Malaise/Nausea/Vomiting

PAST HISTORY :

History suggestive of : Hypertension / Diabetes Mellitus / Tuberculosis

H/o similar complaints

in the past Yes / No

Treatment history if any Yes / No

FAMILY HISTORY:

Marital status : Married / Unmarried / Divorced / Widow /

Widower / Separated

H/O Tuberculosis / Syphilis / Leprosy in the family

H/O similar complaints in the family members/partners.

PERSONAL HISTORY:

Diet : Veg / Mixed

Appetite : Good / Decreased

Sleep : Sound / Disturbed

Bowel : Regular / Constipation / Diarrhea

Bladder : Regular / Increased frequency

Habits : Alcohol / Smoking / Tobacco chewing / Drugs

H/o exposure

to risk of STD‟s : Yes / No

69

OBSTETRIC HISTORY:

CYCLES : Regular / Irregular

NO.OF PREGNANCY :

NO. OF MISCARRIAGES :

MENOPAUSE :

GENERAL PHYSICAL EXAMIATION:

BUILT : Poor / Moderate / Well

NUTRITION : Poorly nourished / Well nourished

PALLOR / ICTERUS / CYANOSIS / CLUBBING / EDEMA

LYMPHNODES : Single / Multiple

Submandibular / Axillary / Epitrochlear / Inguinal

Others

Discrete / Matted

Tender/Soft/Hard

PULSE: R.R:

B.P.: TEMP.: Afebrile / Febrile

ENT Examination:

EAR: - Right Left

Pre/post auricular

Pinna

EAC

Tympanic membrane

70

Facial nerve

Tuning fork tests

Rinne

Weber

ABC

Fistula test

Swelling of the pinna:

Inspection: size

Shape

Number

colour

Skin over and surrounding

Surface/margins/punctum

Palpation confirm inspector findings

Tenderness/temperature

Consistency

Compressibility/reducibility

Fluctuation/pulsations

NOSE: -

External appearance

Inspection

Palpation

Dorsum/Tip/Columella

Vestibule

Cold spatula test

Anterior Rhinoscopy

Nasal mucosa: Congested / Pale / Atrophic / Crusting

Septum : Deviated to right /left/central / Spur / Perforation

Discharge :Mucoid / Mucopurulent / Purulent / Blood stained

Scanty / Profuse

71

Turbinate : Normal / Hypertropic / Atrophic

Meati : Normal / Discharge / Excessive discharge

Floor of the nose

Paranasal Sinus Tendernes : Present / Absent

Maxillary sinus

Ethmoid sinus

Frontal sinus

Posterior Rhinoscopy

Discharge Present / Absent

Type :

Any growth in the Nasopharynx :

Condition of Eustachian openings :

Adenoids Present / Absent

ORAL CAVITY: -

Mouth opening

Angle of mouth

Oral hygiene

Lips (upper/lower)

Teeth

Gingiva

Vestibule/GB sulcus

Tongue

Floor of mouth

Buccal mucosa

Hard palate

Retromolartrigone

OROPHARYNX

Anterior/Posterior pillar

Tonsil

Soft palate/Uvula

Posterior pharyngeal wall

72

Indirect Laryngoscopy : Posterior third of tongue

Vallecula

Epiglottis

Pyriform fossa

Aryepiglottic fold

Arytenoids

Vocal cord Movement

HEAD AND NECK

SYSTEMIC EXAMINATION:

CVS:

P/A:

CNS:

RS:

INVESTIGATIONS:

Blood Hb TC DC ESR TLC

Urine Albumin

Microscopy

Sugar

SEROLOGICAL TESTS – RBS, PPBS

Culture and Sensitivity of pus

Biopsy when necessary

Histopathological examination when necessary

Others

DIAGNOSIS:

TREATMENT GIVEN:

FOLLOW UP:

73

KEY TO MASTERCHART

AGE - in years

SEX

M = Male

F = Female

ONSET-

I = Insidious

S = Sudden

SES = SOCIOECONOMIC STATUS

U = Upper class

M = Middle class

L = Lower class

PROGRESSION

Y = Progressive

N = Non progressive

HISTORY OF TRAUMA

# = Present

_ = Abscent

DM = diabetes Mellitus

# = Present

_ = Abscent

74

DIAGNOSIS

SC = Sebaceous cyst

PAS = pre auricular sinus/cyst

NF = Neurofibroma

TREATMENT

ILT = Intralesional Triamcenalone

I & D- incision and drainage

# Present

FOLLOW UP

NR = No Recurrence