Chronic Inflammatory Lesion in the Auricle: Chondrodermatitis Nodularis Helicis (CNH)

A Chronic Inflammatory Lesion That Can Be Confused With Auricular Skin Tumor

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle

Patient's Story

Despite medical treatment in the pinna, 3 months is available, and growing lesion does not heal existing 80-year-old female patient was admitted to our department.  On examination, there is a slightly painful lesion with a necrotic center, with an inflamed discharge, approximately 1 cm in diameter, on the anterior surface of the auricle.

Preliminary Diagnoses: Basal cell carcinoma (BCC), cellulitis, squamous cell carcinoma (SCC), Chondrodermatitis nodularis helicis (CNH)

Treatment Plan

The patient was planned for a full-thickness biopsy operation including cartilage + skin, and a postauricular free graft transplant under local anesthesia (general anesthesia was not preferred due to cardiological problems).

Operation Details

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photo above, the excision area of the lesion on the right outer auricle of the patient and the incision area behind the auricle are seen

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photo above, the biopsy material containing skin + cartilage, excised from the patient's right outer auricle, is seen. After the crust in the middle of the lesion is removed, the middle part is seen as a pit and the underlying cartilage tissue can be seen

After the local anesthetic injection, the lesion area consisting of unilateral skin + skin was excised from the anterior surface of the auricle, along with the intact skin border around the lesion and the cartilage under the lesion. It was evaluated macroscopically that the skin behind the auricle was normal and the lesion did not reach the lower part of the cartilage. A 2x1 cm skin graft was removed from the back of the auricle and placed in the auricle excision area as a free flap. It was sutured to the periphery border with 6/0 Vicryl. The flap area on the back of the auricle was sutured with 5/0 vicryl. In the photos above and below, you can see the images before and immediately after the operation, and 3 weeks after the operation.

Histopathological Evaluation Result and Diagnosis

As a result of the histopathological examination of the excised biopsy material, focal ulceration, keratosis, epithelial hyperplasia, inflammatory granulation tissue and fibrinoid necrosis were reported. No malignancy or atypia was detected, no lesions were detected in the surgical margins, and the histopathological diagnosis was reported as "Chondrodermatitis nodularis helicis (CNH)". If you look at similar patient photos on the internet, you can see that the lesions are almost in the same shape and in the same place.

Chondrodermatitis Nodularis Helicis (CNH) Definition

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photograph above, the lesion excision area and biopsy material are seen in the right outer auricle of the patient before and immediately after the operation

Chondrodermatitis nodularis helicis is clinically characterized by a small tender nodule on the helix or antihelix of the ear, it is not resolved with treatment, may make physicians think that it is a local aggressive skin tumo. may make physicians mistakenly think that it is a local aggressive skin tumor. The skin and underlying cartilage may be affected by the ischemic process. Some cases are a consequence of excess external pressure, such as sleeping on one side or extended telephone use. A case of bilateral chondrodermatitis nodularis helicis associated with systemic sclerosis has been published >> Bilateral chondrodermatitis nodularis helicis associated with systemic sclerosis

Since Chondrodermatitis nodularis helicis is an inflammatory process affecting the skin and cartilage of the ear, it is written that it can be named as "chondrodermatitis nodularis auricularis" in some sources since it is usually seen in the auricle.

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photograph above, the lesion excision area and biopsy material are seen in the right outer auricle of the patient before and immediately after the operation

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photograph above, the lesion excision area and biopsy material are seen in the right outer auricle of the patient before and immediately after the operation

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photograph above, the area where the free skin graft was placed in the right auricle is seen immediately after the operation

Chondrodermatitis Nodularis Helicis, CNH, Auricle lesion, Small tender nodule on the auricle
In the photo above, the patient's surgical field image after 3 weeks is available. Almost complete healing of the areas other than the dark crusted part can be seen

Chondrodermatitis Nodularis Helicis Symptoms

It is characterized by lesions called papules or nodules, which usually involve the auricle in patients with chondrodermatitis nodularis helicis, and turn into painful and sensitive areas in some patients. This lesion is usually seen in the helix or antihelix. Although nodular lesion usually occurs spontaneously; some patients may mention local traumas such as mechanical trauma, sunburn or frostbite in this area prior to the lesion. Some patients may experience severe pain and bleeding when they apply pressure to the lesion, such as squeezing a pimple with their own hands.

Chondrodermatitis Nodularis Helicis Causes - Etiology

In this lesion, mainly factors that cause decreased circulation, namely ischemic causes, are blamed, but the exact cause is unknown. According to the articles, mechanical traumas (such as lying on the ear, using headphones for a long time, wrapping a bandana or a headscarf that covers the ear), cold stroke, and silver burns, which may cause decreased circulation or thinning of the skin, are blamed. There is not much blood flow under the skin at the outer edge of the auricle. In cold regions, freezing areas generally cover the auricle and fingertips. The easy occurrence of ischemia in the auricle makes it more prone to develop pressure sores. Chondrodermatitis nodularis helicis usually occurs in the auricle in areas exposed to pressure. Apart from these, CNH is also linked to autoimmune disorders and connective tissue disorders in young women. In the paragraphs above, I shared an incident presentation that mentioned that there may be a relationship between systemic sclerosis and CNH. Upile et al. described the perichondrial vasculitis theory, according to this theory, the lesion occurs due to ischemia resulting from chronic sleeping on the auricle or applying long-term pressure on the auricle (source link >> Advances in the understanding of chondrodermatitis nodularis chronica helices: the perichondrial vasculitis theory).

Chondrodermatitis Nodularis Helicis Diagnosis

Diagnosis is made by the presence of clinical distinguishing features such as typical localization of chondrodermatitis nodularis helicis and being painful, and by histoparological evaluation after excisional deep biopsy. Cutaneous tumors in the differential diagnosis are usually painless, even when ulcerated. Histopathological evaluation is essential for definitive diagnosis.

Chondrodermatitis Nodularis Helicis Differential Diagnosis

The differential diagnosis of chondrodermatitis nodularis helicis depends on the clinical picture of the patient. However, the typical localization of the lesion and its painful tenderness help to distinguish CNH from other diagnoses. 

Differential diagnosis may include the following diagnoses:
  • Squamous cell carcinoma (SCC)
  • Keratoacanthoma
  • Gouty tophus
  • Calcinosis cutis
  • Basal cell carcinoma (bcc)
  • Actinic or seborrheic keratosis
  • Viral wart
When these lesions are present not only in the ear but also in more than one region, for example, more than one lesion in the fingers and toes, gout may be suspected. As in this patient, nodular appearance with central ulceration can be confused with basal cell carcinoma, which is a progressive and locally aggressive skin tumor; larger and more inflamed lesions may look like squamous cell carcinoma, one of the most common misdiagnoses of CNH. Keratoacanthoma usually grows much faster. When keratosis is the predominant clinical feature, actinic or seborrheic keratosis may be suspected. However, histopathological examination of a deep biopsy material can guarantee the diagnosis and definitively rule out malignancy.

Chondrodermatitis Nodularis Helicis Treatment

Different procedures have been described in the treatment of chondrodermatitis nodularis helicis, these are:
  • wedge excision
  • curettage
  • electrocauterization
  • photodynamic therapy
  • carbon dioxide laser ablation
  • includes skin and cartilage excision (in our patient, whom I shared with you here, an excisional biopsy operation involving skin and cartilage was performed for both diagnosis and treatment purposes, it can also be used in full-thickness skin grafting to repair the surgical defect)

Precautions for Chondrodermatitis Nodularis Helicis

In order to reduce the mechanical pressure on the auricle, it is useful to sleep with a soft pillow, not to sleep on its side, to use ear protectors, and to use products that keep the ear warm in cold weather.

You can check the link to read the articles about auricle on this website >> https://www.ent-istanbul.com/search?q=auricle


Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
E-Mail: muratenoz@gmail.com 
Mobile phone: +90 533 6550199
Fax: +90 212 542 74 47



  
 


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