An Unusual Cause of Unilateral Prominent Ear: Dermoid Cyst.
The etiology of ear protrusion is multifactorial and poorly understood. Prominent ear deformities with an autosomal inheritance pattern are found in 5% of white population. Pathological causes are very rare. The most common location of a dermoid cyst is the fronto-orbital upper lateral quadrant of the orbit. Other locations are midline of the nose or neck, sublingual region and sternal, perineal, scrotal, and sacral areas. To the best of our knowledge, there have been only few case reports of postauricular dermoid cysts in literature and little is known about dermoid cysts in the subcutaneous tissue of the postauricular region. [1-9] Postauricular dermoid cysts are typically present as an asymptomatic mass behind the ear. The only dermoid cyst case causing prominent ear deformity was reported by Meagher and Morrison in English literature.  We present a case of postauricular dermoid cyst causing unilateral prominent ear deformity.
A healthy 21-year-old male was admitted to our outpatient clinic with longstanding postauricular mass. He had right-sided prominent ear and was keen to have the problem surgically corrected [Figures 1 and 2]. There was no family history about any postauricular mass, and there had been no previous surgery or trauma to the auricular area. The mass had been present since childhood. Physical examination revealed a fixed mass behind the auricle. The overlying skin was thinned without any fistula opening. Contrasted MR scans revealed a subcutaneous smooth surfaced mass measuring 12 mm x 28 mm with the broad base sitting on the bony surface. The mass had no connection with intracranial or inner ear structures [Figure 3]. Tumor was surgically removed, and the protruded ear was returned to a more anatomically and cosmetically appealing shape by Furnas-type horizontal mattress sutures from concha to the mastoid periosteum. No surgical alteration was performed to the external cartilaginous structure of the ear.
Histopathological studies confirmed the diagnosis that the mass was a dermoid cyst with a stratified squamous epithelium lining, contents from products of adnexal structures and hair follicles [Figures 4 and 5].
Dermoid cysts are benign congenital lesions, situated predominantly close to the lines of embryonic fusion lines. They are postulated to originate from the congenital inclusion of ectoderm and mesoderm layers lined by stratified epithelium covered by laminated keratin material containing adnexal structures of the skin such as hair follicles, sebaceous and sweat glands, smooth muscle, and fibro-adipose tissue. These slowly expanding, unilocular, cystic masses may produce only minor symptoms. Clinically, they are characterized as asymptomatic masses in infants which are usually present at birth and predominantly in males. Previously, two studies have reported postauricular dermoid cysts that caused deformities in the auricle due to mass effect. The first of these studies was published by Ikeda in 1994. Ikeda described two superior pole-based cases in his study.  The first patient was a 15-year-old male with mild microtia accompanying a dermoid cyst. The second patient had a superior pole based mass measuring 3 cm x 5 cm and displacing the superior portion of the auricle anteriorly. Ikeda proposed that auricle-based dermoid cysts occurred during the fusion of first branchial arch because all the five cases in Japanese literature were placed in the superior pole. Meagher and Morrison reported the only case of the bilateral prominent ear due to postauricular dermoid cysts in English literature.  In their study, they adjusted the protruded auricles by concha-mastoid sutures. Similarly, we also fixed the protrusion by Furnas' otoplasty technique with concha mastoid sutures in our case. The differential diagnosis of dermoid cysts is difficult. These cystic lesions can be misdiagnosed as epidermoid cyst, cystic teratoma, hemangioma, branchial cyst, trichilemmal cyst, lymphadenopathy, sebaceous cyst, subperiosteal abscess, or hematoma. Preoperative computed tomography and magnetic resonance imaging scans are beneficial to identify the location and neighboring structures of the mass. Dermoid cysts appear as unilocular, capsulated masses with thin walls. Even though they are considered to be benign lesions, several studies report malignant transformation to squamous cell carcinoma.  This change is believed to be due to neoplastic changes in the squamous epithelium covering the cyst. However, postauricular dermoid cysts have not been shown to undergo malignant transformation until now. Surgical excision is the preferred method in the treatment of dermoid cysts to prevent a risk of infection and malignant degeneration; correct cosmetic deformity; and verify the diagnose histopathologically.
No matter how rare they are, dermoid cysts should be considered in the differential diagnosis of lesions in the postauricular region. We believe that, in the treatment of postauricular dermoid cysts leading to prominent ear deformity, surgical excision and correcting the deformity following the basic rules of otoplasty is crucial to achieve an esthetically acceptable outcome and excellent prognosis with no further complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
This report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Conflicts of interest
There are no conflicts of interest.
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Department of Plastic, Reconstructive and Aesthetic Surgery, Avicenna Hospital, Istanbul, Turkey
Address for correspondence: Dr. Alpay Duran, Avicenna Hospital, Istanbul, Turkey.
How to cite this article: Duran A. An unusual cause of unilateral prominent ear: Dermoid cyst. Turk J Plast Surg 2018;26:177-9.
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|Title Annotation:||Case Report|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Oct 1, 2018|
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