Ears
OVERVIEW
The skin disorders of the ears have a close relationship to the skin disorders of the scalp. In both sexes, the external ears (pinnae), earlobes, conchae, auditory canals, and retroauricular areas are frequent places for the appearance of inflammatory disorders such as seborrheic dermatitis, atopic dermatitis, and psoriasis to occur. The diagnosis of these inflammatory conditions is usually uncomplicated and made on clinical grounds, often aided by evidence of these dermatoses elsewhere on the body.
The earlobes are subject to contact dermatitis, hypertrophic scars, and keloids from earlobe piercings and contact dermatitis from earrings. Chronic cutaneous lupus erythematosus (DLE) also occurs on the external ears, generally on the conchae. An inflammatory process that is often mistaken for an actinic keratosis is chondrodermatitis nodularis helicis, a tender, inflammatory condition of the skin and underlying cartilage of the ear.
Ears that are not protected from the sun are also common sites for the development of actinic keratoses, basal cell carcinomas, and squamous cell carcinomas. Such lesions are noted predominantly in fair-complexioned, elderly men whose hairstyles have not shielded their ears from chronic sun exposure. In contrast, women historically tend to have far fewer of these neoplasms by virtue of longer hairstyles.
HELIX AND ANTIHELIX
Chondrodermatitis Nodularis Helicis
Chondrodermatitis nodularis helicis (CNH) is a somewhat common, benign, tender, painful papule that occurs on the helix or antihelix of the ear. Clinically, CNH can be difficult to distinguish from an actinic keratosis (see below). They are noted most often in middle-aged or older men who have fair skin. In women, CNH more often appears on the antihelix. There is no tendency to malignant change.
Distinguishing Features
Spontaneously appearing tender or painful firm papule with or without a central crust or umbilication
Lesions are generally located on the lateral edge of the helix (where there is less direct sun exposure than on the superior surface) (Fig. 5-1); less commonly, CNH occurs on the antihelix (Fig. 5-2)
Figure 5-1 Chondrodermatitis nodularis helicis.
This tender lesion is commonly confused with an actinic keratosis. Note that the lesion faces laterally as opposed to that in Figure 5-3, which faces upward toward the sun.
Figure 5-2 Chondrodermatitis nodularis helicis on the antihelix.
Tender papule with underlying erythema.
Lesions are 2 to 4 mm in diameter and extremely tender
Typically wakes patient from sleep when turning in bed
Diagnosis
Clinically diagnosed; however, a shave biopsy is indicated if the diagnosis is in doubt
Management
Suggest sleeping on unaffected side using a soft pillow or a foam “donut” cut from a block of foam or a CNH Ear Protector, which can be ordered from www.delasco.com Treatment is directed at the underlying cartilage with:
Intralesional corticosteroid injections (5 to 10 mg/mL of triamcinolone acetonide solution)
Shave excision that includes some of the underlying cartilage (this may be curative)
Wedge excision if above options fail
Actinic Keratosis and Cutaneous Horn
Actinic keratoses (AKs) appear on areas of long-term sun exposure that includes the ears.
Distinguishing Features
Typically, AKs have an erythematous base covered by a white, yellowish, or brown hyperkeratotic scale (Fig. 5-3)
Generally, they are asymptomatic
AKs may gradually enlarge, thicken, become elevated, and develop into a hypertrophic AK, a cutaneous horn, or a squamous cell carcinoma
 Figure 5-3 Actinic keratosis. A scaly, hyperkeratotic papule on the upper outer rim of the ear on the sun-exposed top edge of the helix. |
Diagnosis
Palpation reveals a gritty, sandpaper-like roughness to the touch
A shave biopsy is performed when the diagnosis is in doubt or to rule out a squamous cell carcinoma
Management
Prevention begins with educating the patient to limit sun exposure by using sunscreens and wearing protective head wear that shades the ears (e.g., wearing a broad-brimmed hat)
Treatment includes methods such as the following:
Liquid nitrogen (LN2) applied to individual lesions for 3 to 5 seconds
Biopsy, followed by electrocautery of individual lesions, or electrocautery alone
Topical imiquimod, topical 5-fluorouracil (5-FU), photodynamic therapy
Cutaneous Horn
A cutaneous horn arises most frequently in elderly fair-skinned men who are age 70 or older. They are seen mostly on sun-exposed areas of the face, scalp (see Fig. 2-22), ears, nose (see Fig. 6-9), and the back of hands and forearms. The majority of these horns are derived from an underlying actinic keratosis; however, it should be kept in mind that a wart, seborrheic keratosis, an SCC in situ, or even a well-differentiated SCC may be present at its base.
Typically, a cutaneous horn evolves as follows: an actinic keratosis gradually thickens, and develops into a hypertrophic actinic keratosis, which progresses into a plate-like keratinized projection.
Distinguishing Features
Elderly male predominance
Scaly, hyperkeratotic papule that obviously sticks out
Most often located on superior edge of the helix where there is direct sun exposure (Fig. 5-4)
Diagnosis
Shave biopsy that includes the base of the lesion is generally performed
Management
Prevention and treatment for cutaneous horns is essentially the same as described above for actinic keratoses
 Figure 5-4 Cutaneous horn on the helix. A hyperkeratotic projection like a miniature horn is characteristic. At its base, an actinic keratosis, SCC, seborrheic keratosis, or a verruca may be found. |
Keratoacanthoma
A keratoacanthoma (KA) is a unique lesion with a characteristic clinical appearance. KAs occur in individuals who are generally over 65. KAs are reported in all age groups although they rarely appear before the age of 20. If ignored, KAs have been reported to regress spontaneously. There is controversy about the benign versus malignant nature of this lesion. A KA resembles an SCC histologically and is considered by some dermatologists and dermatopathologists to be a low-grade variant of an SCC.
Distinguishing Features
Affects males more than females
Lesions appear on the sun-exposed face, ears, neck, dorsa of hands, and forearms see also (Fig. 6-11)
Rapidly growing, usually taking 3 to 4 weeks to appear
Occurs as a single dome-shaped erythematous or skin-colored nodule, with a central keratin core and a central crater (Fig. 5-5)Related posts:
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