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Surgical pearl: The close-fitting ear cover cast— a noninvasive treatment for pseudocyst of the ear
PEARLS Stuart J. Salasche, MD Surgical Pearls Editor
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: The close-fitting ear cover cast— A noninvasive treatment for pseudocyst of the ear Klaus W. Schulte, MD, Norbert J. Neumann, MD, and Thomas Ruzicka, MD Duesseldorf, Germany
A
uricular pseudocysts (APs) are a rarely reported disease, characterized often by a unilateral asymptomatic swelling of the helix or antihelix. Commonly located in the scaphoid fossa (80%), the AP is usually filled with a sterile, oily, yellowish fluid similar to olive oil (Fig 1). Although AP is generally observed in all age groups, it is mostly described in the third decade of life.1-3 The pathogenesis of AP is still unknown. One theory proposed a “potential space” originating during the embryogenesis of the auricular cartilage. Another theory invokes repeated minor trauma (wearing motorcycle helmets or headphones, hard sleeping pillows), leading to cartilage fragmentation and subsequent cystic cavity formation.1 The lesion appears histopathologically as an intracartilaginous accumulation of fluid without an epithelial lining. The lack of the epithelial lining led to the name “pseudocyst.”1,2,4 In general, the objective of treatment is to remove the AP without damaging the healthy cartilaginous tissues and to prevent its recurrence. Various more or less successful treatment modalities have been reported in the literature, including simple aspiration, intralesional injection of corticosteroids, or aspiration in combination with bolstered pressure sutures.1,3-5 All therapeutic strategies are based on pressure application to the lesion via invasive procedures to decrease the opportunity for fluid reaccumulation. Unfortunately, invasive treatment modalities carry the risk of perichondritis complicated by
From the Department of Dermatology, Heinrich-Heine-University Duesseldorf. Reprint requests: K. W. Schulte, MD, Department of Dermatology, Heinrich-Heine-University Duesseldorf, Moorenstr 5, D-40225 Duesseldorf, Germany. E-mail: [email protected]. J Am Acad Dermatol 2001;44:285-7. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/74/111616 doi:10.1067/mjd.2001.111616
Fig 1. Pseudocyst of the ear in typical location before and after treatment.
the formation of floppy ear or cauliflower deformity and may be followed by recurrence.1,4 Our goal was to find a new treatment modality without damaging the healthy cartilaginous tissue and without the need of incision, curettage, or suturing. Therefore we combined aspiration of the fluid with a single corticosteroid injection followed by application of a noninvasive and inexpensive ear covering technique. To apply the required pressure to the cystic area, a close-fitting ear cover cast has to be manufactured. Such a cast can be fashioned (Fig 2) with a piece of low-temperature, lightweight polyethylene (Turbocast, T-Tape Company, Kapellen, Belgium). This is a thermoplastic material used routinely in surgery departments for immobilizing joints or extremities and is mainly composed of polycaprolactone and polyurethane. Low-temperature polyethylene can be easily molded in a hot (140°F-159°F) water bath. Out of the bath, the temperature will drop to approximately 95°F within 10 seconds without emitting toxic gases or vapors during its application. Thus the material can be applied directly to the ear without inducing any burn285
286 Pearls
J AM ACAD DERMATOL FEBRUARY 2001
Fig 2. The molded close-fitting ear cover cast.
Fig 3. The correctly applied close-fitting ear cover cast.
ing or skin damage. Wet hands are necessary to form and to smooth the surface during application. Therefore within 60 seconds it is possible to mold the close-fitting ear cover cast, which will be strong enough for daily use after it cools completely. Sharp edges can be removed with a scissor or trimmed by sandpaper. If molded and attached correctly to the ear, the cast follows the exact contours of the treated area without sticking to body hairs. In addition, the cast is tamponed with an absorbent material (eg, surgical cotton wool) to soak up further secretions (Fig 3). The cast is applied permanently for 8 to 10 consecutive days, but can be removed and replaced readily for observation. In the past 2 years, we have applied the closefitting ear cover cast to 5 patients and, so far, no recurrences or complications have occurred (Fig 1). In contrast to invasive treatment modalities, our technique is easy to perform and avoids damage or permanent loss of cartilage. Moreover, the cast can substitute for the usually ineffective adhesive ban-
dage and serves as a protective cap against mechanical irritation. Because of its light weight (approximately 6 g), the cast is not irritating and is well tolerated by all patients. On the basis of our experience with this new technique in AP, we also used the close-fitting ear cover cast to apply pressure and to protect ears after other surgical procedures, such as skin transplants and flaps.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
REFERENCES 1. Harder M, Zachary C. Pseudocyst of the ear: surgical treatment. J Dermatol Surg Oncol 1993;19:585-8. 2. Lee JA, Panarese A. Endochondral pseudocyst of the auricle. J Clin Pathol 1994;47:961-3. 3. Job A, Raman R. Medical managment of pseudocyst of the auricle. J Laryngol Otol 1992;106:159-61. 4. Hoffmann T, Richardson T, Jacobs R, Torres A. Pseudocyst of the auricle. J Dermatol Surg Oncol 1993;19:259-62. 5. Miyamoto H, Oida M, Onuma S, Uchiyama M. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol (Stockh) 1994;74:140-2.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.
Pearls 287
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
IOTADERMA #85 What condition consists of congenital hypertrichosis, cardiomegaly, and osteochondrodysplasia and is sometimes associated with coarse facial features and deep plantar creases? Robert I. Rudolph, MD Answer will appear in the March issue of the Journal.
JANUARY IOTADERMA (#84) The “deck chair sign” refers to sparing of the creases in skin folds in an erythroderma consisting of confluent flat-topped pink papules and associated with a peripheral eosinophilia. What is the eponymic name for the disease in which the “deck chair sign” occurs? Answer: Papuloerythroderma of Ofuji REFERENCES Ofuji S, Furukawa F, Miyachi Y, Ohno S. Papuloerythroderma. Dermatologica 1984;169:125-30. Tay YK, Tan KC, Wong WK, Ong BH. Papuloerythroderma of Ofuji: a report of three cases and review of the literature. Br J Dermatol 1994;130:773-6.
O
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Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: The close-fitting ear cover cast— A noninvasive treatment for pseudocyst of the ear Klaus W. Schulte, MD, Norbert J. Neumann, MD, and Thomas Ruzicka, MD Duesseldorf, Germany
A
uricular pseudocysts (APs) are a rarely reported disease, characterized often by a unilateral asymptomatic swelling of the helix or antihelix. Commonly located in the scaphoid fossa (80%), the AP is usually filled with a sterile, oily, yellowish fluid similar to olive oil (Fig 1). Although AP is generally observed in all age groups, it is mostly described in the third decade of life.1-3 The pathogenesis of AP is still unknown. One theory proposed a “potential space” originating during the embryogenesis of the auricular cartilage. Another theory invokes repeated minor trauma (wearing motorcycle helmets or headphones, hard sleeping pillows), leading to cartilage fragmentation and subsequent cystic cavity formation.1 The lesion appears histopathologically as an intracartilaginous accumulation of fluid without an epithelial lining. The lack of the epithelial lining led to the name “pseudocyst.”1,2,4 In general, the objective of treatment is to remove the AP without damaging the healthy cartilaginous tissues and to prevent its recurrence. Various more or less successful treatment modalities have been reported in the literature, including simple aspiration, intralesional injection of corticosteroids, or aspiration in combination with bolstered pressure sutures.1,3-5 All therapeutic strategies are based on pressure application to the lesion via invasive procedures to decrease the opportunity for fluid reaccumulation. Unfortunately, invasive treatment modalities carry the risk of perichondritis complicated by
From the Department of Dermatology, Heinrich-Heine-University Duesseldorf. Reprint requests: K. W. Schulte, MD, Department of Dermatology, Heinrich-Heine-University Duesseldorf, Moorenstr 5, D-40225 Duesseldorf, Germany. E-mail: [email protected]. J Am Acad Dermatol 2001;44:285-7. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/74/111616 doi:10.1067/mjd.2001.111616
Fig 1. Pseudocyst of the ear in typical location before and after treatment.
the formation of floppy ear or cauliflower deformity and may be followed by recurrence.1,4 Our goal was to find a new treatment modality without damaging the healthy cartilaginous tissue and without the need of incision, curettage, or suturing. Therefore we combined aspiration of the fluid with a single corticosteroid injection followed by application of a noninvasive and inexpensive ear covering technique. To apply the required pressure to the cystic area, a close-fitting ear cover cast has to be manufactured. Such a cast can be fashioned (Fig 2) with a piece of low-temperature, lightweight polyethylene (Turbocast, T-Tape Company, Kapellen, Belgium). This is a thermoplastic material used routinely in surgery departments for immobilizing joints or extremities and is mainly composed of polycaprolactone and polyurethane. Low-temperature polyethylene can be easily molded in a hot (140°F-159°F) water bath. Out of the bath, the temperature will drop to approximately 95°F within 10 seconds without emitting toxic gases or vapors during its application. Thus the material can be applied directly to the ear without inducing any burn285
286 Pearls
J AM ACAD DERMATOL FEBRUARY 2001
Fig 2. The molded close-fitting ear cover cast.
Fig 3. The correctly applied close-fitting ear cover cast.
ing or skin damage. Wet hands are necessary to form and to smooth the surface during application. Therefore within 60 seconds it is possible to mold the close-fitting ear cover cast, which will be strong enough for daily use after it cools completely. Sharp edges can be removed with a scissor or trimmed by sandpaper. If molded and attached correctly to the ear, the cast follows the exact contours of the treated area without sticking to body hairs. In addition, the cast is tamponed with an absorbent material (eg, surgical cotton wool) to soak up further secretions (Fig 3). The cast is applied permanently for 8 to 10 consecutive days, but can be removed and replaced readily for observation. In the past 2 years, we have applied the closefitting ear cover cast to 5 patients and, so far, no recurrences or complications have occurred (Fig 1). In contrast to invasive treatment modalities, our technique is easy to perform and avoids damage or permanent loss of cartilage. Moreover, the cast can substitute for the usually ineffective adhesive ban-
dage and serves as a protective cap against mechanical irritation. Because of its light weight (approximately 6 g), the cast is not irritating and is well tolerated by all patients. On the basis of our experience with this new technique in AP, we also used the close-fitting ear cover cast to apply pressure and to protect ears after other surgical procedures, such as skin transplants and flaps.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
REFERENCES 1. Harder M, Zachary C. Pseudocyst of the ear: surgical treatment. J Dermatol Surg Oncol 1993;19:585-8. 2. Lee JA, Panarese A. Endochondral pseudocyst of the auricle. J Clin Pathol 1994;47:961-3. 3. Job A, Raman R. Medical managment of pseudocyst of the auricle. J Laryngol Otol 1992;106:159-61. 4. Hoffmann T, Richardson T, Jacobs R, Torres A. Pseudocyst of the auricle. J Dermatol Surg Oncol 1993;19:259-62. 5. Miyamoto H, Oida M, Onuma S, Uchiyama M. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol (Stockh) 1994;74:140-2.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.
Pearls 287
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
IOTADERMA #85 What condition consists of congenital hypertrichosis, cardiomegaly, and osteochondrodysplasia and is sometimes associated with coarse facial features and deep plantar creases? Robert I. Rudolph, MD Answer will appear in the March issue of the Journal.
JANUARY IOTADERMA (#84) The “deck chair sign” refers to sparing of the creases in skin folds in an erythroderma consisting of confluent flat-topped pink papules and associated with a peripheral eosinophilia. What is the eponymic name for the disease in which the “deck chair sign” occurs? Answer: Papuloerythroderma of Ofuji REFERENCES Ofuji S, Furukawa F, Miyachi Y, Ohno S. Papuloerythroderma. Dermatologica 1984;169:125-30. Tay YK, Tan KC, Wong WK, Ong BH. Papuloerythroderma of Ofuji: a report of three cases and review of the literature. Br J Dermatol 1994;130:773-6.
O
N THE MOVE? Send us your new address at least six weeks ahead
Don’t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here.
OLD ADDRESS:
NEW ADDRESS:
Affix the address label from a recent issue of the journal here.
Clearly print your new address here. Name Address City/State/ZIP
COPY AND MAIL THIS FORM TO: Mosby Subscription Customer Service 6277 Sea Harbor Dr Orlando, FL 32887
OR FAX TO: 407-363-9661
OR PHONE: 1-800-654-2452 Outside the U.S., call 407-345-4000