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ORIGINAL ARTICLE
Year : 2013  |  Volume : 19  |  Issue : 3  |  Page : 140-142

Frequency and etiology of chondrodermatitis nodularis chronica helicis


1 Clinic of Pathology, Çankiri State Hospital, Çankiri, Turkey
2 Department of Dermatology, Hitit University Faculty of Medicine, Çorum, Turkey

Date of Web Publication2-Sep-2013

Correspondence Address:
Engin Senel
Clinic of Dermatology, Çankiri State Hospital, 18100, Çankiri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.117471

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  Abstract 

Objectives: Chondrodermatitis nodularis chronica helicis (CNH) is a painful nodule affecting the pinna. The etiology of the disease is unknown. We devised to show a correlation between CNH and systemic health problems of the patients. Materials and Methods: This study included 17 patients with CNH and the other lesions of the ear that incoming differential diagnoses of CNH, including basal cell carcinoma, squamous cell carcinoma, verruca vulgaris, neurofibroma, fibroepithelial polyp, seborrheic ceratose, and cystic lesions, a total of 131 patients that were diagnosed between 2011 and 2012 in the Clinics of Dermatology and Pathology of Çankırı State Hospital. Cardiovascular problems of the patients were queried meticulously and recorded. Results: With 17 patients 12.97% of the 131 patients were CNH. The mean age of the patients was 47.41 and the age range of the CNH patients was 32-79 years, with a mean age of 54.9 years (SD ± 13.23 years). The mean diameter of the lesions was 4.57 mm for CNH patients. The lesions were located at the right air mostly (85.71%) and all of them were located at the helix of ear. The laboratory results of the CNH patients showed that most of them (88.2%, 15 patients) have high cholesterol and lipid levels. By the way six of them (35.2%) also had cardiac problems. Conclusion: Our results showed that the main problem is the defect of arterial blood supply of the pinna. Also we detected that12.97% of the lesions were CNH, while cystic lesions take the first place among all other ear lesions.

Keywords: Chondrodermatitis nodularis chronica helicis, Cardiovascular diseases, Ear


How to cite this article:
Karabulut YY, Senel E, Dölek Y. Frequency and etiology of chondrodermatitis nodularis chronica helicis. Indian J Otol 2013;19:140-2

How to cite this URL:
Karabulut YY, Senel E, Dölek Y. Frequency and etiology of chondrodermatitis nodularis chronica helicis. Indian J Otol [serial online] 2013 [cited 2019 Jun 18];19:140-2. Available from: http://www.indianjotol.org/text.asp?2013/19/3/140/117471


  Introduction Top


Chondrodermatitis nodularis chronica helicis (CNH) usually presents as a benign painful nodule affecting the pinna. [1],[2] CNH was first reported with eight cases by Max Winkler in 1915. [3] Later than, Foerster [4] presented four cases with the diagnoses of CNH. In 1925, Foerster reported eight additional cases and described the clinical, microscopic, and treatment of the condition. [5] The lesion prefer older male population. [6],[7],[8],[9] The age range of the lesion is between 58 and 72 years. [9],[10] In the literature CNH was described in a few cases in childhood. [11],[ 12] The lesion prefer right ear. [13],[14] Only in a few studies, an equal distribution or predominant manifestation on the left ear was mentioned. [9],[15] CNH usually develops on the superior pole and less frequently the antihelix, scapha, and concha are affected. [10],[16] Typical clinical findings of CNH, is a skin-colored papule with a centrally delled or crusty surface measured 4-5 mm in large. [17] The papule is tender to touch or pressure, firm, and bound to the underlying cartilage. With long duration of CNH centrally ulcerated nodules with elevated borders may develop. The ulcerated center is covered by serous or hemorrhagic crusts. Typically, the patients report that they can no longer sleep on the side of the affected ear. [17]

Differential diagnosis of chondrodermatitis nodularis helicis includes actinic keratosis, basal cell carcinoma, keratocanthoma, and squamous cell carcinoma. Surgical treatment includes wedge excision, curettage, electrocauterisation, ablation by carbon dioxide laser, and simple excision of skin and cartilage. [18],[19] The aim is to remove the damaged cartilage, but it can cause disfigurement, and Moncrieff and Sassoon showed that recurrence in a surgically treated group was 34%. [20]


  Materials and Methods Top


This study included 17 patients with CNH and the other lesions of the ear that incoming differential diagnoses of CNH, including basal cell carcinoma (19 patients), squamous cell carcinoma (17 patients), verruca vulgaris (9 patients), neurofibroma (3 patients), fibroepithelial polyp (8 patients), seborrheic ceratose (17 patients), and cystic lesions (41 patients), a total of 131 patients that were diagnosed between 2011 and 2012 in the Clinic of Pathology of Çankırı State Hospital. Data were retrospectively reviewed, and age at the time of diagnosis, patient demographics, clinical presentation and prediagnosis of the patients, laboratory results and extent of surgery performed were noted.

Statistical analysis

Statistical analysis was performed by the SPSS 15 Statistical Package for Word. Numerical variables were shown as mean ± SD and the number of cases and percentages were used for nominal data. A p value less than 0.05 was considered as significant.


  Results Top


With 17 patients 12.97% of the 131 patients were CNH. The mean age of the patients was 47.41 and the age range of the CNH patients was 32-79 years, with a mean age of 54.9 years (SD ± 13.23 years). Except a woman with the age of 55 years, all other CNH patients were man [Table 1]. The mean diameter of the lesions was 4.57 mm for CNH patients. The lesions were located at the right air mostly (85.71%) and all of them were located at the helix of ear [Figure 1]. The laboratory results of the CNH patients showed that most of them (88.2%, 15 patients) have high cholesterol and lipid levels. By the way six of them (35.2%) also had cardiac problems.
Figure 1: Nodule located right ear helix

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Table 1: Diagnose groups with main age and gender

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On histological examination epidermal acanthosis associated with a horny, partly parakeratotic, plug, ulceration, and crust was the most common finding [Figure 2]. Within the superficial dermis there is fibrin, sclerosis, perichondrial fibrosis, and a varying degree of cartilage degeneration. All of the patients revealed several areas of vessel thickening and hyalinization [Figure 3].
Figure 2: Epidermal acanthosis associated with an ulcer and cartilage. H and E ×100

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Figure 3: Hyalinized vessels around the cartilage. H and E ×200

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  Discussion Top


This is the first report that research the patients' cardiovascular problems, which can lead perichondrial arteriolar changes as the possible cause of underlying cartilage necrosis resulting in CNH. Uptil et al. [21] maintained the perichondrial vasculitis theory which was initially hypothesized by Halter. [22] They claimed that arteriolar narrowing in perichondrium region of the pinna most remote from arterial blood supply and this has lead to ischemic changes and death of the metabolically active underlying cartilage with necrosis and extrusion leading to a cycle of severe local inflammation secondary to a foreign body reaction. We agree with this theory and decided to confirm it by searching a systemic vascular pathology for clearing this situation in the CNH patients. Really, the results of patients' health investigation support our vascular theory. 15 of 17 patients had cardiovascular problems such as hyperlipidemia, hypertension, and cardiac failure. Because of the rarity of the condition, statistical studies on incidence and prevalence of CNH have not been performed yet. Data in the literature on gender distribution reveal with few exceptions repeatedly a marked male dominance; [8] similarly, we determined just one female patient. During the time bilateral occurrence or multiple lesions of CNH was reported just for a few patients. [12],[22],[23] In our study, right ear and the superior pole of the helix are preferentially affected by CNH similar with published literature. Several theories have been suggested including trauma from cold, actinic damage, or prolonged and excessive pressure. [21] The results of our study let us to thought that the main problem is the defect of arterial blood supply of the pinna. The laboratory results and histopathological findings of the patients support this, but we cannot explain why the target is right ear. It may be possible that right is preferred side to lie on in bad. And also we cannot explain the male predominance. However, there is a fact that cardiovascular problems and vascular diseases are most frequently seen among men. Perhaps other predispositional factors affect the both sexes equally. In the study we also tried to determine the frequency of the lesion among all other ear lesions and detected that 12.97% of the lesions were CNH, while cyctis lesions take the first place.

 
  References Top

1.Bard JW. Chondrodermatitis nodularis chronica helicis. Dermatologica 1981;163:376-84.  Back to cited text no. 1
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2.Munnoch DA, Herbert KJ, Morris AM. Chondrodermatitis nodularis chronica helicis et antihelicis. Br J Plast Surg 1996;49:473-6.  Back to cited text no. 2
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3.Winkler M. Kno¨tchenfo¨rmige Erkrankung am Helix. Chondrodermatitis nodularis chronica helicis. Arch Dermatol Syph 1915;121:278-85.  Back to cited text no. 3
    
4.Foerster OH. A painful nodular growth of the ear. J Cutan Dis 1918;36:154-6.  Back to cited text no. 4
    
5.Foerster OH. Painful nodular growth of the ear. Arch Dermol Syph 1925;11:149-65.  Back to cited text no. 5
    
6.Shuman R, Helwig EB. Chondrodermatitis helicis: Chondrodermatitis nodularis chronica helicis. Am J Clin Pathol 1954;24:126-44.  Back to cited text no. 6
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7.Cox NH. Posterior auricular chondrodermatitis nodularis. Clin Exp Dermatol 2002;27:324-7.  Back to cited text no. 7
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8.Feldman AL, Manstein CH, Manstein ME. Chondrodermatitis nodularis auricularis: A new name for an old disease. Plast Reconstr Surg 2009;123:25e-6.  Back to cited text no. 8
    
9.Hurwitz RM. Painful papule of the ear: A follicular disorder. J Dermatol Surg Oncol 1987;13:270-4.  Back to cited text no. 9
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10.Rickli H, Hardmeier T. Chondrodermatitis nodularis chronica helicis Winkler. Pathologe 1988;9:25-9.  Back to cited text no. 10
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11.Rogers NE, Farris PK, Wang AR. Juvenile chrondrodermatitis nodularis helicis: A case report and literature review. Pediatr Dermatol 2003;20:488-90.  Back to cited text no. 11
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12.Grigoryants V, Qureshi H, Patterson JW, Lin KY. Pediatric chondrodermatitis nodularis helicis. J Craniofac Surg 2007;18:228-31.  Back to cited text no. 12
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13.Calnan J, Rossatti B. Chondrodermatitis nodularis chronica helicis or glomus tumor of the helix? A report on twentyone cases. Br J Plast Surg 1959;12:55-68.  Back to cited text no. 13
    
14.Timoney N, Davison PM. Management of chondrodermatitis helicis by protective padding. A series of 12 cases and a review of literature. Br J Plast Surg 2002;55:387-9.  Back to cited text no. 14
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15.Bard JW. Chondrodermatitis nodularis chronica helicis. Dermatologica 1981;163:376-84.  Back to cited text no. 15
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16.Shuman R, Helwig EB. Chondrodermatitis helicis. Am J Clin Pathol 1954;24:126-44  Back to cited text no. 16
    
17.Wagner G, Liefeith J, Sachse MM. Clinical appearance, differential diagnoses and therapeutical options of chondrodermatitis nodularis chronica helicis Winkler. J Dtsch Dermatol Ges 2011;9:287-91.  Back to cited text no. 17
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18.Lawrence CM. The treatment of chondrodermatitis nodularis with cartilage removal alone. Arch Dermatol 1991;127:530-5.  Back to cited text no. 18
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19.Kromann N, Høyer H, Reymann F. Chondrodermatitis nodularis chronica helicis treated with curettage and electrocauterization: Follow-up of a 15-year material. Acta Derm Venereol 1983;63:85-7.  Back to cited text no. 19
    
20.Moncrieff M, Sassoon EM. Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach. Br J Dermatol 2004;150:892-4.  Back to cited text no. 20
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21.Uptil T, Patel NN, Jerjes W, Singh NU, Sandison A, Michaels L. Advances in the understanding of chondrodermatitis nodularis chronica helices: The perichondrial vasculitis theory. Clin Otolaryngol 2009;34:147-50.  Back to cited text no. 21
    
22.Halter K. Zur pathogenese der chondrodermatitis nodularis chronic helices. Dermat Ztshur 1936;73:270-84.  Back to cited text no. 22
    
23.Hesse G, Schmoeckel C, Wichmann-Hesse A. Argonlasertherapie der Chondrodermatitis nodularis chronica helicis. Hautarzt 1994;45:222-4.  Back to cited text no. 23
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