LETTERS AND COMMUNICATIONS
Successful Treatment of a Pseudocyst of the Auricle Using Intralesional Sodium Tetradecyl Sulfate Injection
Pseudocyst of the auricle is a rare condition of the anterior aspect of the ear presenting as a painless cystic swelling resulting from intracartilaginous fluid collection.1 Pseudocyst occurs predominantly in young adult men and often contains sterile yellowish viscous to serosanguineous fluid.1–3 Although a variety of treatments have been described in previous studies, there are no reports on the use of sodium tetradecyl sulfate (STS). Herein we describe the successful treatment of a pseudocyst of the auricle with intralesional injection of 1% STS. This minimally invasive technique is simple to perform in the outpatient setting and can provide a good cosmetic outcome. A 62-year-old Korean man visited our clinic with a 2-week history of asymptomatic swelling on the left auricle. He reported no history of trauma, scrubbing, or contributing sleep habits such as the use of a hard pillow at the site. He was not taking any medications and was otherwise healthy. Physical examination revealed a skin-colored, nonmobile, marked swelling with a diameter of 3.2 by
(A)
(B)
1.3 cm on the left scaphoid fossa (Figure 1A). A review of systems was unremarkable. A punch biopsy was performed at the site of the left scaphoid fossa, and minimal drainage of yellowish clear serosanguineous fluid mixed with blood was observed (Figure 1B). Pathologic analysis revealed an intracartilaginous cystic cavity lined by degenerative cartilage without an epithelial lining. Based on these findings, the patient was diagnosed with a pseudocyst of the auricle. We decided to treat the lesion with STS, which is known to induce endothelial destruction in various conditions. In our case, STS (3% Tromboject, Omega Laboratories Ltd, Montreal, Quebec) was diluted with sterile saline to 1% for injection. After local anesthesia with 2% lidocaine, 0.24 mL of STS was injected at the lesional site until blanching was observed. The patient received no post-treatment other than simple dressing. The lesion had disappeared almost completely at the 4-week follow-up visit (Figure 1C). The patient did not experience any adverse effects or recurrence over 5 months of follow-up and was satisfied with the cosmetic outcome.
(C)
Figure 1. (A) Before treatment: a skin-colored, nonmobile, marked swelling with a diameter of 3.2 by 1.3 cm on the left scaphoid fossa was observed. (B) Immediately after punch biopsy, the size of the swelling decreased slightly. (C) At 4 weeks after treatment, the lesion disappeared almost completely.
1938
DERMATOLOGIC SURGERY
LETTERS AND COMMUNICATIONS
Discussion Hartmann first described pseudocyst of the auricle in 1884, and Engel, who reported 17 cases in the Chinese population, provided a detailed histopathologic presentation in 1966.1,2 The term pseudocyst was used because of the pathologic absence of a true epithelial lining. In addition to the absence of a true epithelial lining, the pathologic characteristics of pseudocysts include intracartilaginous cyst formation, hyalinizing degenerated cartilage, perivascular inflammatory infiltrates, and granulomatous changes with fibroblastic responses that occur because of severe inflammation in the surrounding area. There are two main theories explaining the development of pseudocysts.1,2 The first states that an abnormality in the development of the branchial arch associated with congenital embryologic dysplasia causes pseudocyst formation. The second hypothesizes that chronic microtrauma leads to excessive production of glycosaminoglycan, which leads to increases in the activities of lactate dehydrogenase and lysosomal enzymes, resulting in pseudocyst formation. Various treatment modalities are available for pseudocyst of the auricle, and they all have common goals of preserving the cosmetic shape and removing the lesions without recurrence.2,3 Noninvasive treatment modalities commonly used include incision and drainage, needle aspiration, intralesional steroids, and compressive dressing with various types of dressing materials such as button suture, prosthesis, bolster using clips, cotton, or close-fitting ear cover cast. Patigaroo and colleagues reported recently that simple observation could be as effective as intralesional steroids,3 but incision and drainage and needle aspiration are frequently associated with recurrence of the lesion or structural changes in the external ear. Intralesional steroids, which was the most frequently used procedure in the past, cause discoloration and skin atrophy. Compressive
dressing with various types of dressing materials is easy to perform and is noninvasive, but patients frequently complain of treatment-related disturbances of daily life activities. Anterior wall excision is the most commonly used surgical intervention method, but it is rarely used as an initial treatment because it may result in floppy ear deformity if support for the posterior wall is too weak. As for the sclerosing agent used in cases of chemical obliteration, studies have described the use of minocycline, fibrin glue, iodide, and trichloroacetic acid, but to our knowledge, no study has shown the use of STS for the treatment of pseudocysts. STS, a detergent sclerosant, is known to destroy the blood vessel wall selectively and trigger thrombotic occlusion, particularly in endothelial cells in various vascular malformations.4 Its precise mechanism has not been elucidated, but it is speculated that it works by promoting intracartilaginous cystic cavity wall destruction and an inflammatory reaction leading to fibrosis. Although similar to a digital mucous cyst with no true epithelial lining, a pseudocyst is a benign skin tumor for which positive treatment effects can be expected through the destruction of the cell wall using STS. Audebert and colleagues proposed obstructing the flow of synovial fluid within the cyst as a therapeutic strategy for digital mucous cysts.5 Adverse effects that may occur because of the use of STS include pain, irritation, discoloration, and necrosis, but these complications occur with low frequency and do not occur when using low concentrations of STS.4 To prevent such complications, an experienced dermatologist must inject a concentration of less than 3% STS at the right depth and precise location. Needle aspiration or ultrasound guidance performed in advance can provide clues to the exact location and depth of the lesion. Postinjection monitoring is essential because of the potential for immediate complications after injection, such as blistering, swelling, necrosis, and skin atrophy caused by sclerosant extravasation or an allergic reaction that arises at the site of the injection.
39:12:DECEMBER 2013
1939
LETTERS AND COMMUNICATIONS
Herein we report the case of a successfully treated pseudocyst, a condition for which the selection of the appropriate treatment modality is difficult because of the high risk of recurrence and structural changes. We suggest that intralesional STS injection is an effective method because of its simplicity of administration and satisfactory cosmetic results.
References 1. Glamb R, Kim R. Pseudocyst of the auricle. J Am Acad Dermatol 1984;11:58–63. 2. Ramadass T, Ayyaswamy G. Pseudocyst of auricle— etiopathogenesis, treatment update and literature review. Indian J Otolaryngol Head Neck Surg 2006;58:156–9. 3. Patigaroo SA, Mehfooz N, Patigaroo FA, Kirmani MH, et al. Clinical characteristics and comparative study of different
modalities of treatment of pseudocyst pinna. Eur Arch Otorhinolaryngol 2012;269:1747–54. 4. Duffy DM. Sclerosant: a comparative review. Dermatol Surg 2010;36:1010–25. 5. Audebert C. Treatment of mucoid cysts of fingers and toes by injection of sclerosant. Clin Exp Dermatol 1986;11:510–3.
JIN YONG LEE, MD CHANG SUN YOO, MD CHUL WOO KIM, MD SANG SEOK KIM, MD Department of Dermatology Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul, Korea
Multiple Squamous Cell Carcinomas After Megavoltage Electron Beam Radiation Therapy
Megavoltage electron beam radiation therapy is a commonly used and effective treatment for cutaneous carcinomas. Multiple squamous cell carcinomas (SCC) and keratoacanthomas (KA) developing soon after megavoltage radiotherapy are rarely reported. We report one patient receiving megavoltage electron beam radiation therapy for an SCC on the leg that developed 10 new well-differentiated SCC within and adjacent to the radiation treatment field. All SCC developed within an 8-month period and were treated using Mohs micrographic surgery and adjunctive acitretin. A radiation oncologist referred a 67-year-old Caucasian woman to our Mohs surgery clinic after multiple lesions arising within a radiation field failed to resolve after 3 months of observation. These lesions began to arise 2 weeks after definitive radiotherapy (RT) for an individual SCC (Figure 1) on the right lower leg for which the patient’s original dermatologist had referred her for radiotherapy. The initial treatment was with 9 mega-electronvolt (MeV) electrons (60 Gy/30 fractions), and a 6-MeV electron boost (10 Gy/5 fractions) to the right lower
1940
DERMATOLOGIC SURGERY
Figure 1. Original squamous cell carcinoma on the right lower leg. Nests of atypical squamous cells infiltrating the dermis with slight nuclear atypia and inflammatory infiltrate (hematoxylin and eosin, 940).
leg, for a total dose of 70 Gy over a 2-month period (Figure 2). Initial examination in our clinic 4 months after completion of radiation revealed a central depressed scar at the site of the previous SCC and multiple scaly erythematous plaques within the radiation treatment field. Several punch biopsies were taken that proved to be well-differentiated SCC
Successful Treatment of a Pseudocyst of the Auricle Using Intralesional Sodium Tetradecyl Sulfate Injection
Pseudocyst of the auricle is a rare condition of the anterior aspect of the ear presenting as a painless cystic swelling resulting from intracartilaginous fluid collection.1 Pseudocyst occurs predominantly in young adult men and often contains sterile yellowish viscous to serosanguineous fluid.1–3 Although a variety of treatments have been described in previous studies, there are no reports on the use of sodium tetradecyl sulfate (STS). Herein we describe the successful treatment of a pseudocyst of the auricle with intralesional injection of 1% STS. This minimally invasive technique is simple to perform in the outpatient setting and can provide a good cosmetic outcome. A 62-year-old Korean man visited our clinic with a 2-week history of asymptomatic swelling on the left auricle. He reported no history of trauma, scrubbing, or contributing sleep habits such as the use of a hard pillow at the site. He was not taking any medications and was otherwise healthy. Physical examination revealed a skin-colored, nonmobile, marked swelling with a diameter of 3.2 by
(A)
(B)
1.3 cm on the left scaphoid fossa (Figure 1A). A review of systems was unremarkable. A punch biopsy was performed at the site of the left scaphoid fossa, and minimal drainage of yellowish clear serosanguineous fluid mixed with blood was observed (Figure 1B). Pathologic analysis revealed an intracartilaginous cystic cavity lined by degenerative cartilage without an epithelial lining. Based on these findings, the patient was diagnosed with a pseudocyst of the auricle. We decided to treat the lesion with STS, which is known to induce endothelial destruction in various conditions. In our case, STS (3% Tromboject, Omega Laboratories Ltd, Montreal, Quebec) was diluted with sterile saline to 1% for injection. After local anesthesia with 2% lidocaine, 0.24 mL of STS was injected at the lesional site until blanching was observed. The patient received no post-treatment other than simple dressing. The lesion had disappeared almost completely at the 4-week follow-up visit (Figure 1C). The patient did not experience any adverse effects or recurrence over 5 months of follow-up and was satisfied with the cosmetic outcome.
(C)
Figure 1. (A) Before treatment: a skin-colored, nonmobile, marked swelling with a diameter of 3.2 by 1.3 cm on the left scaphoid fossa was observed. (B) Immediately after punch biopsy, the size of the swelling decreased slightly. (C) At 4 weeks after treatment, the lesion disappeared almost completely.
1938
DERMATOLOGIC SURGERY
LETTERS AND COMMUNICATIONS
Discussion Hartmann first described pseudocyst of the auricle in 1884, and Engel, who reported 17 cases in the Chinese population, provided a detailed histopathologic presentation in 1966.1,2 The term pseudocyst was used because of the pathologic absence of a true epithelial lining. In addition to the absence of a true epithelial lining, the pathologic characteristics of pseudocysts include intracartilaginous cyst formation, hyalinizing degenerated cartilage, perivascular inflammatory infiltrates, and granulomatous changes with fibroblastic responses that occur because of severe inflammation in the surrounding area. There are two main theories explaining the development of pseudocysts.1,2 The first states that an abnormality in the development of the branchial arch associated with congenital embryologic dysplasia causes pseudocyst formation. The second hypothesizes that chronic microtrauma leads to excessive production of glycosaminoglycan, which leads to increases in the activities of lactate dehydrogenase and lysosomal enzymes, resulting in pseudocyst formation. Various treatment modalities are available for pseudocyst of the auricle, and they all have common goals of preserving the cosmetic shape and removing the lesions without recurrence.2,3 Noninvasive treatment modalities commonly used include incision and drainage, needle aspiration, intralesional steroids, and compressive dressing with various types of dressing materials such as button suture, prosthesis, bolster using clips, cotton, or close-fitting ear cover cast. Patigaroo and colleagues reported recently that simple observation could be as effective as intralesional steroids,3 but incision and drainage and needle aspiration are frequently associated with recurrence of the lesion or structural changes in the external ear. Intralesional steroids, which was the most frequently used procedure in the past, cause discoloration and skin atrophy. Compressive
dressing with various types of dressing materials is easy to perform and is noninvasive, but patients frequently complain of treatment-related disturbances of daily life activities. Anterior wall excision is the most commonly used surgical intervention method, but it is rarely used as an initial treatment because it may result in floppy ear deformity if support for the posterior wall is too weak. As for the sclerosing agent used in cases of chemical obliteration, studies have described the use of minocycline, fibrin glue, iodide, and trichloroacetic acid, but to our knowledge, no study has shown the use of STS for the treatment of pseudocysts. STS, a detergent sclerosant, is known to destroy the blood vessel wall selectively and trigger thrombotic occlusion, particularly in endothelial cells in various vascular malformations.4 Its precise mechanism has not been elucidated, but it is speculated that it works by promoting intracartilaginous cystic cavity wall destruction and an inflammatory reaction leading to fibrosis. Although similar to a digital mucous cyst with no true epithelial lining, a pseudocyst is a benign skin tumor for which positive treatment effects can be expected through the destruction of the cell wall using STS. Audebert and colleagues proposed obstructing the flow of synovial fluid within the cyst as a therapeutic strategy for digital mucous cysts.5 Adverse effects that may occur because of the use of STS include pain, irritation, discoloration, and necrosis, but these complications occur with low frequency and do not occur when using low concentrations of STS.4 To prevent such complications, an experienced dermatologist must inject a concentration of less than 3% STS at the right depth and precise location. Needle aspiration or ultrasound guidance performed in advance can provide clues to the exact location and depth of the lesion. Postinjection monitoring is essential because of the potential for immediate complications after injection, such as blistering, swelling, necrosis, and skin atrophy caused by sclerosant extravasation or an allergic reaction that arises at the site of the injection.
39:12:DECEMBER 2013
1939
LETTERS AND COMMUNICATIONS
Herein we report the case of a successfully treated pseudocyst, a condition for which the selection of the appropriate treatment modality is difficult because of the high risk of recurrence and structural changes. We suggest that intralesional STS injection is an effective method because of its simplicity of administration and satisfactory cosmetic results.
References 1. Glamb R, Kim R. Pseudocyst of the auricle. J Am Acad Dermatol 1984;11:58–63. 2. Ramadass T, Ayyaswamy G. Pseudocyst of auricle— etiopathogenesis, treatment update and literature review. Indian J Otolaryngol Head Neck Surg 2006;58:156–9. 3. Patigaroo SA, Mehfooz N, Patigaroo FA, Kirmani MH, et al. Clinical characteristics and comparative study of different
modalities of treatment of pseudocyst pinna. Eur Arch Otorhinolaryngol 2012;269:1747–54. 4. Duffy DM. Sclerosant: a comparative review. Dermatol Surg 2010;36:1010–25. 5. Audebert C. Treatment of mucoid cysts of fingers and toes by injection of sclerosant. Clin Exp Dermatol 1986;11:510–3.
JIN YONG LEE, MD CHANG SUN YOO, MD CHUL WOO KIM, MD SANG SEOK KIM, MD Department of Dermatology Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul, Korea
Multiple Squamous Cell Carcinomas After Megavoltage Electron Beam Radiation Therapy
Megavoltage electron beam radiation therapy is a commonly used and effective treatment for cutaneous carcinomas. Multiple squamous cell carcinomas (SCC) and keratoacanthomas (KA) developing soon after megavoltage radiotherapy are rarely reported. We report one patient receiving megavoltage electron beam radiation therapy for an SCC on the leg that developed 10 new well-differentiated SCC within and adjacent to the radiation treatment field. All SCC developed within an 8-month period and were treated using Mohs micrographic surgery and adjunctive acitretin. A radiation oncologist referred a 67-year-old Caucasian woman to our Mohs surgery clinic after multiple lesions arising within a radiation field failed to resolve after 3 months of observation. These lesions began to arise 2 weeks after definitive radiotherapy (RT) for an individual SCC (Figure 1) on the right lower leg for which the patient’s original dermatologist had referred her for radiotherapy. The initial treatment was with 9 mega-electronvolt (MeV) electrons (60 Gy/30 fractions), and a 6-MeV electron boost (10 Gy/5 fractions) to the right lower
1940
DERMATOLOGIC SURGERY
Figure 1. Original squamous cell carcinoma on the right lower leg. Nests of atypical squamous cells infiltrating the dermis with slight nuclear atypia and inflammatory infiltrate (hematoxylin and eosin, 940).
leg, for a total dose of 70 Gy over a 2-month period (Figure 2). Initial examination in our clinic 4 months after completion of radiation revealed a central depressed scar at the site of the previous SCC and multiple scaly erythematous plaques within the radiation treatment field. Several punch biopsies were taken that proved to be well-differentiated SCC
