|Year : 2016 | Volume
| Issue : 3 | Page : 168-170
Steroid injection and negative pressure application in successful treatment of auricular seroma
D Anand Karthikeyan, Karunagaran Alalasundaram
Department of ENT, SRM Medical College and Research Centre, Potheri, Chennai, Tamil Nadu, India
|Date of Web Publication||8-Aug-2016|
Dr. D Anand Karthikeyan
B-3, 307, Sriram Sankari Apartments, Thangappapuram, Guduvanchery, Chennai - 603 202, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: There are various treatment modalities for auricular seroma. The location of seroma and pathogenesis ushered new concepts in management like steroid injection and negative pressure application. Aim: To apply a novel approach- steroid injection and negative pressure application in treating auricular seroma. Methodology: Thirty four auricular seroma patients were treated by the authors in a two year period by aspirating the seroma, steroid irrigation and negative pressure application. Results: 94.11% showed improvement with single instance and had neither recurrences nor complications. Conclusion: This novel approach was based on the pathogenesis of seroma and to arrest it in early stages, steroid was used. Negative pressure was applied owing to the demerits of positive pressure application. This cost effective, conservative treatment was successful in treating seroma without any complications.
Keywords: Auricular pseudocyst, Negative pressure, Seroma, Steroid irrigation
|How to cite this article:|
Karthikeyan D A, Alalasundaram K. Steroid injection and negative pressure application in successful treatment of auricular seroma. Indian J Otol 2016;22:168-70
|How to cite this URL:|
Karthikeyan D A, Alalasundaram K. Steroid injection and negative pressure application in successful treatment of auricular seroma. Indian J Otol [serial online] 2016 [cited 2019 Nov 20];22:168-70. Available from: http://www.indianjotol.org/text.asp?2016/22/3/168/187975
| Introduction|| |
There are various treatment modalities outlined for the treatment of auricular seroma, aptly known as pseudocyst of the pinna, each one of them having their own merits and rates of recurrences. In developing countries, managing this cyst involves considering many factors such as recurrences mounting to the number of hospital visits, cost of treatment, consenting for surgical methods, complications, and finally disfigurement.
This cystic swelling has no definite etiopathogenesis, but microtrauma is implicated in most of the patients. This pseudocyst is more common in middle-aged males, though we saw cases as young as 6 years of age. Most of them were solitary and located in scaphoid fossa. This concave location poses difficulties in applying pressure once the intracartilaginous sterile fluid was aspirated. Surgeons around the world tried buttoning, plaster of Paris casting, clip application, contour dressing, etc. We tried a novel cost-effective method which had good results as opposed to others.
| Methodology|| |
This study was conducted among patients who attended ENT outpatient department in SRM Medical College and private clinics of the authors from 2014 January to 2015 December. A total of 34 patients were treated for auricular seroma. Twenty-nine (85%) were males and five (15%) were females. Thirty-three (97%) were unilateral. Patients' age ranged from 6 to 52 years (mean = 25.7 years). None of the patients had a history of trauma, fever, or pain. All of them presented for the first instance of seroma and were not recurrences.
With proper asepsis, the cyst is aspirated with a wide-bore needle and the collapsed cavity is irrigated twice with normal saline and injected with 40 mg of triamcinolone acetate [Figure 1]. Then, a scalp vein (s.v) set of 24-gauge is taken with its needle decapitated and the cut edge beveled [Figure 2]. This is inserted into the cavity holding the steroid, the latter is aspirated. The s.v set is held in position by small adhesive strips. Negative suction pressure is applied using a 20 cc syringe, maintaining the suction using the plunger of a 2 cc syringe [Figure 3]. A standard Glasscock dressing is applied and allowed to stand for 24 h. The patients were asked to sleep with the affected side up to avoid the syringe being accidentally pulled off. After 24 h, the dressing and negative pressure are removed. The patients are asked to follow-up on 3rd, 7th, and 21st day. If there is collection again, the procedure is repeated. Antibiotics such as quinolones, anti-inflammatory drugs, and proteolytic enzymes were given.
| Results|| |
Thirty-two patients (94.11%) improved with a single instance of negative pressure bandaging and showed no recurrences or complications. Two (5.88%) showed seroma refilling and needed repeat procedure on day 3 and showed success thereafter. No complications were noted.
| Discussion|| |
There are various methods proposed for the treatment of auricular seroma. The first approach to the management involves draining the fluid either by simple aspiration or cruciate incision with or without drain. Malgonde and Kumar used a corrugated rubber drain as splint to avoid refilling of the cavity for 72 h. In our study, we aspirated the cavity with a wide-bore needle only. Purwar et al. prevented the seroma from filling up again by applying positive pressure dressing. Applying uniform positive pressure conforming to the contour of the pinna remains a challenge as does the maintenance of the pressure for a day or two days. Positive pressure application was tried in many ways, namely, contour dressing, plaster of paris cast application, clipping, buttoning, and fashioned stainless steel wire. The application of positive pressure has its demerits ranging from patient noncompliance, discomfort, pain, and rarely ischemic necrosis of the skin. In our study, we used negative pressure to keep the cavity collapsed. The application of negative pressure opposes the layers of the cyst and prevents refilling without the demerits of positive pressure application.
A study by Zhang et al. concluded that auricular pseudocyst can be divided into the early period (acute exudative period), the middle period (cartilage formation period), and the late period (proliferative and organized period). The treatment should be based on the pathological findings of auricular pseudocyst. It was also found that elevated lactate dehydrogenase (LDH) isoenzyme 4 and 5 levels were present more in the seroma fluid  as compared to serum levels. LDH was released by ongoing cartilage disruption and so seroma was considered to be a pattern of chondromalacia. Ongoing cartilage neogenesis at the roof of the cyst, lymphocyte infiltration, and fibrous deposition at later stages prompted the use of steroid injection to halt such pathogenesis in preliminary and initial recurrences. The effectiveness of triamcinolone in the treatment of seroma has been documented in earlier studies. Kim et al. found intralesional steroid injection and clip compression dressing to be helpful in the treatment of recurrent auricular pseudocyst. In our study, we used triamcinolone acetate 40 mg infused into cavity postaspiration. Triamcinolone prevents cartilage neogenesis which if formed might render the seroma at a later stage amenable only to surgical deroofing. Although LDH isoenzyme 4 and 5 levels were found in auricular seroma fluid, Miyamoto et al. found no relation between the LDH levels and intralesional steroid injection  and opposed the current rationale. No conclusive data for using or not using steroids are available to date. However, based on the pathogenesis, it seems an apt candidate.
As an alternative to steroids, recently, an antitumor glycopeptide pingyangmycin is also tried intralesionally for seroma of pinna  in China based on the same ideology of halting the aforementioned pathogenesis.
The ideology behind this novel approach is that there is a proper opposition of the layers of the pseudocyst. The results are cosmetically acceptable. The cost of treatment is less and patients can allay the fear of surgery. The only disadvantage is that patients find the syringe hanging beside the ear uncomfortable in the initial 24 h. Otherwise, the result of this technique is far better than aspiration and positive pressure application with mastoid dressing only.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mahesh Bhat T, Rao VV, Rosario D. Cruciate incision for treatment of primary/recurrent cases of seroma/hematoma of pinna: A novel approach. J Clin Diagn Res 2015;9:MC01-2.
Malgonde MS, Kumar M. Auricular seroma: A new concept in management. Plast Aesthet Res 2014;1:13-5.
Purwar A, Shetty V, Khanna S, Gupta S. Pressure appliance to prevent the recurrence of auricular seroma: A new clinical trial. J Oral Biol Craniofac Res 2013;3:42-4.
Salgado CJ, Hardy JE, Mardini S, Dockery JM, Matthews MS. Treatment of auricular pseudocyst with aspiration and local pressure. J Plast Reconstr Aesthet Surg 2006;59:1450-2.
Zhang XT, Sun B, Ling Y, Zhang Y, Zhang Q, Kang AJ, et al.
Investigation of clinical pathology and treatments on the auricle pseudocyst. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2010;45:640-4.
Chen PP, Tsai SM, Wang HM, Wang LF, Chien CY, Chang NC, et al.
Lactate dehydrogenase isoenzyme patterns in auricular pseudocyst fluid. J Laryngol Otol 2013;127:479-82.
Ichioka S, Yamada A, Ueda K, Harii K. Pseudocyst of the auricle: Case reports and its biochemical characteristics. Ann Plast Surg 1993;31:471-4.
Kim TY, Kim DH, Yoon MS. Treatment of a recurrent auricular pseudocyst with intralesional steroid injection and clip compression dressing. Dermatol Surg 2009;35:245-7.
Khan NA, Ul Islam M, Ur Rehman A, Ahmad S. Pseudocyst of pinna and its treatment with surgical deroofing: An experience at tertiary hospitals. J Surg Tech Case Rep 2013;5:72-7.
Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase isozymes in and intralesional steroid injection therapy for pseudocyst of the auricle. Int J Dermatol 2001;40:380-4.
Guo Z, Di X, Yan G. Curative effect of combined treatment recurrent auricular pseudocyst by intralesional injection of pingyangmycin with plaster external fixation. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2013;27:382-3.
Bage AM, Bage NN, Karthikeyan DA, Vijayasundaram. Pseudocyst of the auricle: Management options. Natl J Clin Anat 2012;1:181-5.
[Figure 1], [Figure 2], [Figure 3]