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Thread: Chondroma of the Auricle pictures - Ear Atlas

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    Default Chondroma of the Auricle pictures - Ear Atlas

    Introduction
    Extraskeletal or soft-tissue chondroma is a rare benign cartilaginous tumor that develops in the soft tissues without bone or joint involvement, occurring predominantly in the hands and feet of adults in their third and fourth decades of life.1) Cli-nically, it manifests as a slowly growing subcutaneous nodule, and the diameter is less than 3 cm in most cases, with a development in the facial area reported very rarely. However, the presence of this tumor has been described in the head and neck region, mainly in the tongue, and less likely in the cheek, neck, parotid gland, parapharyngeal space, masticatory space, and masseter muscle,2) with the age of onset usually between 30-60 years of age. The case presented here is of a particular interest because of the exceptional location of the tumor, and a matter of reconstruction of a defect after the removal. We were unable to find any analogous report in the literature except for only two reports describing cases of extraskeletal chondroma in the auricle.2,3) In the presenting case, we report a rare case of chondroma that developed in the auricle, which were treated with wedge excision and reconstructed using a Burow's triangle.

    Case Report
    52-year old male patient visited our clinic presenting with an unilateral mass of the auricle for several years. Physical examination revealed a 1.5×1.5 cm sized painless, hard mass accompanying a nodular irregularity, located on the superior portion of the helix (Fig. 1). Surgical removal was performed under a local anesthesia. A 1.0×0.8 cm sized firm, round, and well-encapsulated mass was completely removed by wedge excision (Fig. 2A), and the remaining defect was approximated with a creation of Burow's triangle in the scapha (Fig. 2B, C). Histopathologic examination revealed a mass consisted of an acidophilic hyalinized matrix with cartilage cells scattered among them, and in the center, local calcification was observ-ed. Tumor cells had cytoplasms with a distinct border, and the nuclei were of a circular or an oval form; atypical or abnormal mitosis was not observed (Fig. 3). There was no recurrence at the 12-month follow-up.

    Discussion
    Histologically, extraskeletal or soft-tissue chondroma is a lobulated nodule surrounded by a fibrous capsule filled with mature hyalinized cartilage tissue, with no association of underlying bone.1,4) Association with secondary degeneration within the matrix, such as cystic change, ossification, fibrosis, mucinous change, and calcification as in the presenting case, requires differentiation from other soft-tissue tumors. The diseases to be differentiated include tumoral calcinosis, calcifying aponeurotic fibroma, ectomesenchymal chondromyxoid tumor, and chondrosarcoma.5,6) The etiology of extraskeletal chondroma is uncertain. The following are 3 hypotheses that have been proposed.2) The first hypothesis suggests of the cartilage cells originated from the skeletal structure migrating to the adjacent connective tissue; the second proposes a conversion of the precartilaginous tissues that are in the ligament attachment area at the activation period; the last hypothesis proposes a metaplasia of synovial cells differentiating as cartilagi-nous cells.

    Treatment for chondroma usually involves wide local resection. It may recur in 10% to 15% cases; nevertheless, even in recurred cases, local resection is sufficient.1,2) However, excision of the tumor located in helix of the auricle requires a reconstruction of the defect, if it is bigger than 1 to 1.5 cm. Many techniques have been described to treat a defect of the helix secondary to tumor excision, and the advancement of the helix by placing a Burow's triangle in the scapha is preferred whenever possible. In the presenting case, the defect measuring 1.5 cm in diameter, was successfully reconstructed with advancement of the helix using a Burow's triangle in the scapha. No irregularity in form and contour was observed during a postoperative follow-up.
    Chondroma Auricle pictures Atlas attachment.php?s=d759b3862b6a1f570b65ceb77cc82f40&attachmentid=1863&d=1441390924

    Pathophysiology
    The etiology of pseudocyst of the auricle is unknown, but several pathogenic mechanisms have been proposed.

    Originally, Engel postulated that lysosomal enzymes might be released from chondrocytes and cause damage to the auricular cartilage. However, analysis of pseudocyst contents revealed a fluid rich in albumin and acid proteoglycans, with a rich cytokine milieu but lacking in lysosomal enzymes.


    Analysis of the cytokine profile of the fluid indicates markedly elevated levels of interleukin (IL)–6, which is believed to stimulate chondrocyte proliferation. IL-1, an important mediator of inflammation and cartilage destruction, induces IL-6. IL-1 also stimulates chondrocytes to synthesize proteases and prostaglandin E2 while inhibiting the formation of extracellular matrix components.

    Others have suggested that a defect in auricular embryogenesis contributes to pseudocyst formation. This defect causes the formation of residual tissue planes within the auricular cartilage. When subjected to repeated minor trauma or mechanical stress, these tissue planes may reopen, forming a pseudocyst.

    The observation that an auricular pseudocyst often results after repeated minor trauma, such as rubbing, ear pulling, sleeping on hard pillows, or wearing a motorcycle helmet or earphones, has led to the suggestion that these minor traumas may be the mechanism. In support of this traumatic etiology, elevated serum lactic dehydrogenase (LDH) values have been reported within the pseudocyst fluid.Two of the elevated isoenzymes, LDH-4 and LDH-5, are proposed as major components of human auricular cartilage. These enzymes may be released from auricular cartilage degenerated from repeated minor trauma.

    One article reports that pseudocysts can be regarded as simply a variation of othematoma or otoseroma.

    International
    Tan and Hsu reported the epidemiological features, clinicopathologic characteristics, and success of surgical treatment in 40 patients of different Asian groups presenting with pseudocyst of the auricle.Results showed a Chinese predominance (90%), followed by Malays (5%), and Eurasians (5%). All except one patient had unilateral presentations. Most (55%) presented within 2 weeks of auricular swelling. Few (10%) had a history of trauma.

    History
    A pseudocyst manifests as a painless swelling on the lateral or anterior surface of the pinna, developing over a period of 4-12 weeks. A history of trauma may accompany the clinical history, including rubbing, ear pulling, sleeping on hard pillows, or wearing of a motorcycle helmet or earphones. It has also been associated with cases of pruritic skin or systemic diseases including atopic dermatitis and lymphomas

    Physical
    A pseudocyst is a noninflammatory, asymptomatic swelling on the lateral or anterior surface of the pinna, usually in the scaphoid or triangular fossa. They range from 1-5 cm in diameter and contain clear or yellowish viscous fluid, with a consistency similar to that of olive oil. Note the image below.

    Causes
    The etiology for pseudocysts of the auricle is unknown, but several pathogenic mechanisms have been proposed, including chronic low-grade trauma and spontaneous development.[9] Some have suggested that a minor defect in auricular embryogenesis can also contribute to pseudocyst formation. This defect may cause the formation of residual tissue planes within the auricular cartilage. When subjected to repeated minor trauma or mechanical stress, these tissue planes may open, forming a pseudocyst. The auricular cartilage in particular may be more susceptible to traumatic insult because of its lack of connective tissue overlying the cartilage with firm adherence to the skin.
    Chondroma Auricle pictures Atlas attachment.php?s=d759b3862b6a1f570b65ceb77cc82f40&attachmentid=1864&d=1441390937

    Consistent with the proposed mechanism, atopic dermatitis with accompanying facial and ear involvement may be a predisposing condition for pseudocyst formation.Although the incidence of pseudocysts in patients with atopic dermatitis appears to be low, these patients have an earlier occurrence of the condition and a greater incidence of bilateral lesions compared with the general population.

    Pseudocyst has also been reported in a patient with intense pruritus who was later diagnosed with lymphoma. After chemotherapy for the lymphoma, the pruritus improved with spontaneous reduction in the volume of the pseudocyst. The authors proposed that the trauma from scratching and rubbing of the ears was the major exacerbating cause of the pseudocyst.

    Imaging Studies
    In several reports, magnetic resonance images revealed a serous fluid collection within the auricular cartilage, further enhancing the diagnosis.

    Histologic Findings
    Histologically, pseudocysts of the auricle lack pathognomonic features, but they can typically be characterized by an intracartilaginous cavity lacking an epithelial lining. They contain thinned cartilage and hyalinizing degeneration along the internal border of the cystic space. The epidermis and dermis overlying the pseudocyst are usually normal. However, a dermal perivascular lymphocytic infiltrate is commonly found, along with inflammatory cells within the cystic space.

    In one of study, calcification of the auricular cartilage was identified at least 7 days after initial clinical presentation.Although contrary to literature reports, one study postulated that an inflammatory response is crucial to the development of pseudocysts. This theory is based on a consistent perivascular inflammatory response seen in all 16 specimens studied Eosinophilic degeneration and necrosis of the cartilage is also present in some areas. Intracartilaginous fibrosis and granulation tissues are manifestations of later stages of pseudocysts.A slide of an auricular pseudocyst is shown below.

    References:
    http://emedicine.medscape.com/article/1074632-workup#c7
    A Case of Auricular Chondroma











    Last edited by Medical Photos; 09-04-2015 at 06:22 PM.

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