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the scaphoid fossa , triangular fossa of the antihelix , and the cymba concha are typically involved .
various terms for this condition are endochondral pseudocyst , intracartilaginous auricular seroma cyst , cystic chondromalacia , and benign idiopathic cystic chondromalacia .
males are commonly affected and the mean age of presentation is 35 - 40 years .
usually these cysts are asymptomatic but occasionally , minor discomfort and mild inflammatory signs may be present .
the size of the cyst ranges from 1 to 5 cm in diameter and contains viscous straw - yellow fluid while sometimes a clear pale yellow may be encountered .
the etiology of this condition is unknown but at the same time many investigators believe that repeated minor injuries were responsible for the formation of pseudocysts , particularly in patients with preexisting congenital intracartilaginous defects associated with lymphatic and vascular channels while some believe that the cause is cartilaginous degeneration caused by the release of chondrocyte lysosomal enzymes . diagnosis is based on the clinical characteristics and no evidence of infection .
the differential diagnosis of this condition includes cellulitis , relapsing polychondritis , chondrodermatitis helicis , and subperichondrial hematoma secondary to trauma .
the ideal treatment is the preservation of the anatomical architecture of the pinna and prevention of recurrence .
most accomplished results were obtained by incisional drainage , followed by chemical and mechanical obliteration such as pressure dressing with button bolsters and compression suture therapy .
resection of the anterior cartilaginous leaflet of the pseudocysts with repositioning of the overlying skin flap or the so - called deroofing technique followed by buttoning is seen to produce best results in the literature .
we present our experience of 26 patients of pseudocyst of auricle diagnosed in our medical colleges from april 2011 to april 2013 in terms of clinical features and its management with surgical deroofing and buttoning .
this prospective study was done in the department of ent and head and neck surgery , of skims medical college , srinagar and government medical college , srinagar .
twenty - six patients with pseudocysts of the pinna were enrolled in the study for a period of 2 years from april 2011 to april 2013 after they understood and accepted the procedure .
pseudocysts were diagnosed on the basis of clinical presentation , characteristics of the aspirated fluids , no evidence of infection , and absent signs of inflammation .
all patients irrespective of the size of pseudocyst underwent incision and drainage with removal of anterior leaflet of cartilage followed by buttoning for 12 days .
about 0.1 - 0.2 ml of fluid was aspirated from all groups by a 1-ml syringe which was physically inspected and sent for culture .
an incision was given superiorly over the swelling , and the skin was elevated beyond the margin of the cyst [ figure 1 ] .
the posterior cartilage lining of the cyst wall was usually left intact . when the swelling was seen to extend to posterior aspect of pinna , we removed a small window cartilage posteriorly .
incision over the pseudocyst the incision was closed with 5 - 0 prolene , and buttons of appropriate site were applied on the anterior and posterior aspect and tied with through and through 4 - 0 silk sutures [ figures 2 and 3 ] .
buttons tied to pseudocyst buttons being tied to pseudocyst anti - inflammatory and antibiotics drugs were prescribed for 5 days , and the buttons were removed after 12 days .
rebuttoning was done in cases who failed primary butting after a gap of 1 month .
about 0.1 - 0.2 ml of fluid was aspirated from all groups by a 1-ml syringe which was physically inspected and sent for culture .
an incision was given superiorly over the swelling , and the skin was elevated beyond the margin of the cyst [ figure 1 ] .
the posterior cartilage lining of the cyst wall was usually left intact . when the swelling was seen to extend to posterior aspect of pinna , we removed a small window cartilage posteriorly .
incision over the pseudocyst the incision was closed with 5 - 0 prolene , and buttons of appropriate site were applied on the anterior and posterior aspect and tied with through and through 4 - 0 silk sutures [ figures 2 and 3 ] .
buttons tied to pseudocyst buttons being tied to pseudocyst anti - inflammatory and antibiotics drugs were prescribed for 5 days , and the buttons were removed after 12 days .
rebuttoning was done in cases who failed primary butting after a gap of 1 month .
total number of patients enrolled in the study were 26 and only two were females .
maximum numbers ( i.e. 11 ) of patients were in the age group of 31 - 40 comprising about 42% of study population [ table 1 ] .
maximum number ( i.e. 10 ) of patients had swelling involving predominantly triangular , scaphoid , and antihelix [ figure 4 ] followed by triangular fossa ( 5 ) [ figure 5 ] while minimum number ( 3 ) involved concha [ figure 6 and table 2 ] .
age and sex distribution of patients pseudocyst involving antihelix , triangular fossa , and scaphoid fossa pseudocyst predominantly involving triangular fossa pseudocyst predominantly involving concha culture of the aspirated fluid from pseudocyst was sterile in all cases .
the maximum number ( 10 ) of patients were laborers by profession while government employees comprised the minimum number [ table 3 ] .
involvement of both right and left ears was seen , but left ear was involved more than right with 16 and 10 cases , respectively .
the fluid aspirated was straw serum colored in majority of patients ( 15 ) while few of them ( 2 ) had serosanguinous fluid .
the size of the swelling ranged from 1.5 to 4.5 cm in largest diameter [ table 4 ] .
profession of patients characteristics of pseudocyst pinna reaccumulation of fluid was seen in only one patient after primary incision and drainage and buttoning [ table 5 ] . the success rate was 96% in primary cases .
one patient that failed primary i and d and buttoning underwent incision and drainage with removal of anterior cartilage leaflet and buttoning as a secondary procedure after a month 's gap and there was no recurrence after this procedure [ table 6 ] .
findings / complications after 10 days of completion of treatment surgical outcome with deroofing and buttoning this procedure was associated with some minor complications .
pain and inflammation of the auricle developed in three patients during the postoperative period that responded promptly to a course of antibiotics and analgesics . in two cases ,
a mild thickening of the auricle at the site of incision was noticed which persisted . no cauliflower ear developed in patients [ table 5 ] .
the first report of pseudocyst of pinna was by hartmann , who described 12 cases of intracartilaginous cyst - like swelling of the pinna .
hansen reported a similar series of six cases in otherwise healthy caucasian males and labelled them as intracartilaginous cysts but agreed that the term pseudocyst is more appropriate .
although our cases were not histologically confirmed , they shared all the characteristics of pseudocysts .
however , four children ( two boys and two girls ) with severe atopic eczema were reported to have the auricular pseudocysts at between 5 and 6 years of age .
majority of the pseudocysts were involving scaphoid fossa , triangular fossa , and antihelix followed by concha .
engel and cohen and grossman also cited the scaphoid fossa and triangular fossa of the antihelix as the main sites of predilection while supiyaphun and decha in contrast noted concha as the most common site of predilection .
pseudocysts occur more commonly on the right side as reported by many authors but we found them more on the left side . similar to our study , one study noted pseudocyst to occur more commonly on the left side .
we did not find any bilateral involvement , but the fact is that bilateral lesions are found in only 13% of the patients and are mainly reported in the pediatric age group .
typically the straw - yellow viscous fluid similar to olive oil is seen in the pseudocysts ; however , serosanguineous and serous fluid may sometimes be observed .
the volume of the aspirates was reported to have a range between 0.5 and 10 ml and we found it between 1 and 4 ml . typically , the swelling develops in 4 - 12 weeks .
the size ranged from 1 to 5 cm in diameter and we found it between 1.5 and 4.5 cm .
histologically , pseudocyst is characterized by an intracartilaginous cavity lacking in epithelial lining ( hence named pseudocyst ) , and contain thinned cartilage and hyalinising degeneration along the internal border of the cystic space and granulation tissue . the maximum number of patients in our study were laborers by profession followed by businessmen while government employees comprised the minimum number .
although we did not statistically analyzed trauma as a cause of pseudocyst pinna but we are of opinion that trauma to ear as such is more likely to be seen in laborers and businessmen because of the nature of work they do .
the ultimate aim of treatment is successful drainage of the pseudocyst without damage to healthy cartilage and to prevent its recurrence .
different formsof treatment have been described in several case reports and small series to overcome the recurrence : simple observation for 3 months ; simple aspiration followed by pressure dressing applied on the pinna for 2 weeks ; aspiration of fluid followed by injection of various substances such as steroids , 50% trichloroacetic acid , and triamcinolone ; oral corticosteroids alone ; incision and drainage with curettage and pressure dressing ; needle aspiration plus bolstered pressure sutures applied over both aspects of the cyst ; surgical curettage and fibrin sealant has been shown to be effective in obliterating the cystic cavity ; treatment by incisional biopsy ; resection of the anterior cartilaginous leaflet of the pseudocysts with repositioning of the overlying skin flap or the so - called deroofing technique followed by buttoning . simple punch biopsy followed by the application of a bolster for approximately 2 weeks ; cu - vac technique ; drainage tube inserted into the pseudocyst using a guide needle
; a piece of cartilage removed posteriorly and corrugated drain kept in place ; intralesional injections of minocycline hydrochloride ( 1 mg / ml ) two to three times at 2-week intervals have shown efficacy .
the most effective technique for pseudocyst is incision and drainage with removal of anterior leaflet of cartilage with approximation of skin followed by buttoning the so - called surgical deroofing technique .
the success rate in our study with this procedure was 96% and recurrence was seen in only one patient .
lim et al . in their series found that none of the patients had recurrence following excision and compression buttoning of the pseudocyst .
choi et al . performed this procedure and the majority of cases they treated by this procedure was successful .
harder and zachary in their series found a normal - appearing auricle with minimal scarring or recurrence .
hoffman et al . and mohammed and jakubikova successfully treated patients with this technique . a previous study in our department by patigaroo et al .
although this procedure is the best , it is associated with minor complications as seen in our study .
we did not see any patient with frank perichondritis , the most dreaded complication expected due to the exposure of the perichondrium because we took all possible care to do incision and drainage under aseptic conditions .
proper surgical and postoperative care of the wound can minimize if not prevent most of the complications and hence this procedure can be recommended for treating auricular pseudocysts .
pseudocyst of the pinna is a painless benign condition commonly encountered in middle - aged persons .
many modalities of treatment have been recommended in the literature with varied recurrence and failure rates .
considering the rate of success , we would like to advocate incision and drainage with removal of anterior cartilage leaflet and buttoning ( deroofing procedure ) as being the best method that can be undertaken in the management of auricular pseudocysts .
introduction : pseudocyst of pinna is an uncommon condition hardly encountered in routine ent practice . 
 the involvement is usually seen in scaphoid , triangular fossa , and antihelix . 
 medical treatment is ineffective . 
 various treatments are suggested in the literature . 
 the aims of the paper were to study the clinical characteristic of patients with pseudocysts and to share our experience with surgical deroofing and buttoning as a definitive treatment.materials and methods : twenty - six patients were diagnosed with pseudocyst of the auricle between april 2011 and 2013 in two medical college hospitals . 
 clinical characteristics were noted . 
 all patients underwent incision and drainage with removal of anterior cartilage leaflet followed by buttoning for 12 days.results and observations : out of 26 patients , only two were females . 
 involvement of left side was seen more than right one . 
 none had bilateral involvement . 
 adults in the age group of 31 - 40 were commonly affected . 
 most common site of involvement was scaphoid and triangular fossa . 
 the success rate with primary i and d and buttoning was 96%.conclusions : pseudocyst of the pinna is a benign condition of unknown etiology affecting the pinna , commonly encountered in middle - aged men . 
 many modalities of treatment have been recommended in the literature with varied recurrence and failure rates . 
 the best form of treatment with minimum recurrence is incision and drainage with removal of anterior cartilage leaflet with buttoning .