Cutaneous lesions of the external ear
© Sand et al; licensee BioMed Central Ltd. 2008
Received: 27 September 2007
Accepted: 08 February 2008
Published: 08 February 2008
Skin diseases on the external aspect of the ear are seen in a variety of medical disciplines. Dermatologists, othorhinolaryngologists, general practitioners, general and plastic surgeons are regularly consulted regarding cutaneous lesions on the ear.
This article will focus on those diseases wherefore surgery or laser therapy is considered as a possible treatment option or which are potentially subject to surgical evaluation.
When evaluating skin lesions on the ear, specific anatomical peculiarities should be considered. The outer ear consists of the skin bearing external ear canal and the auricle. Both are of elastic cartilage covered with skin. It is attached to the periost and poorly vascularised. The epidermis on the concave aspect lies on a very thin subcutis which is strongly attached to the auricular cartilage. In contrast the convex aspect of the outer ear has a thicker subcutis with a stronger layer of subcutaneous fat which causes a certain laxity and displaceability compared to the concave side. An additional anatomical uniqueness is the high concentration of holocrine ceruminal glands in the skin of the external ear canal. The cerumen may mask existing diseases of the skin in the entrance of the external ear canal. In case of a ceruminal obstruction, an adequate assessment of the external auditory meatus should be done only after cleaning, which may demask existing dermatosis. The auricle is susceptible to environmental influences and trauma. Because of its exposed localization, the ear is particularly liable to the effects of ultraviolet (UV) light and, consequently, to pre-neoplastic and neoplastic skin lesions. Further, it has a sound-transmitting function and is located at a visible, esthetically obvious site, drawing considerable attention from the patient. Depending on the localization, lesions on the external ear which lead the patient to seek professional help are noticed by the patient himself or by a relative or friend.
When hidden areas of the outer ear are affected, consultation may be delayed until very late in the disease process. This is especially true for malignant tumors which may often present at an invasive stage, due to the minimal thickness of the skin compared to other parts of the body. In many cases, optimal medical care for patients with skin diseases of the external ear requires an interdisciplinary approach dermatological, ear-nose-throat and surgical collaboration. Below, the most important and frequent skin diseases of the ear which are potentially subject to surgical or laser therapy are described. Because of the large number of different diagnosis a description of all pathologic conditions of the external ear seems to be impossible. Hence, we limited our description to the diseases which are frequent or call for special attention because of their prognosis.
Epithelial tumors of the external ear
Seborrhoic keratosis (Syn.: seborrhoic wart, senile wart, and basal cell papilloma)
Atheroma (Syn.: sebaceous cyst, atheroma, steatoma, keratinous cyst)
Atheroma is a benign tumor which is mostly located at the back of the earlobe. On clinical exam, it appears as a 5 – 25 mm firm, displaceable nodule and may show signs of secondary infection. Sometimes, a pinpoint depression at the surface of the cyst corresponds to the infundibulum of a pre-existing hair follicle. The high density of sebaceous glands over the earlobe predisposes the ear for this lesion. Therapy consists of spindle-shaped excision to prevent recurrence. Other techniques of removal include punch biopsy aspiration followed by curettage and avulsion of the cyst wall. Cysts removed from the back of the ears have the highest recurrence rates (13% and 13.8%) . Regardless of the chosen treatment, thorough removal of the cyst wall seems therefore to be essential for reducing the high recurrence rates.
Granuloma fissuratum (Syn.: acanthoma fissuratum)
Actinic keratoses (Syn.: solar keratoses or senile keratoses)
Actinic keratoses is a UV light-induced lesion which is often located on the ear, especially on the helical rim. Its frequency increases with age and can progress to invasive squamous cell carcinoma in 20%, a malignant transformation which treatment can prevent . Its prevalence is higher in individuals with fair complexion. Mostly, a well-defined patch with a rough texture, 3–8 mm in diameter, and typical erythematous base is visible, accompanied by occasional hyperkeratosis. However the lesion may grow to large hyperkeratotic plaques with several centimeters in diameter. Signs of inflammation may occur. In the case of a persistent, recurrent, or isolated lesion, a biopsy is recommended to confirm the diagnosis . Effective treatment options are curettage, photodynamic therapy, laser therapy, topical 5-floururacil (5-FU), diclofenac, colchicine, imiquimod and retinoid application [10–13].
Cutaneous Horn (Syn.: cornu cutaneum)
Cutaneous Horn is not a pathological diagnosis. A variety of primary underlying processes, benign, premalignant or malignant, can cause this lesion [14–17]. It presents a mostly asymptomatic, variably sized, keratotic mass arising from the superficial layers of the skin or deeply from the cutis . It generally occurs on sites, which are subjected to actinic radiation, with the upper part of the face and the ears being the most common area . In a case series of 643 cutaneous horns, 40% were derived from malignant or premalignant epidermal lesions (squamos cell carcinoma, actinic keratosis), and 60% from benign lesions . The important issue when dealing with this lesion is accurate determination of the nature of the processes at its base. An underlying lesion with malignant or premalignant potential at the base of a cutaneous horn is a common finding wherefore we recommend excision and histology.
Basal cell carcinoma (Syn,: basalioma, basal cell epitelioma)
The most successful therapy for basal cell carcinoma is micrographic-controlled surgery (two stage operation). Five-year recurrence rates by micrographic-controlled surgery are reported to be between 1 and 5.6% [21, 22]. Nevertheless, BCC found in the middle of the face (so-called H-zone), followed by those on the auricular and preauricular area have the highest rate of recurrence following treatment by excisional surgery, radiation, cryosurgery, curettage or electrodessication – all alternative forms of treatment [23–25]. Several theories attempt to explain the high rate of relapse. The ear has a complex anatomy which can confuse the assessment of tumor boundaries . Further an unusual horizontal growth phase makes this tumor prone to incomplete excision . As mentioned above, the skin on the concave aspect of the outer ear is very thin and close to the perichondrium. This encourages subclinical spread  as skin cancers grow both radially and vertically. Additionally numerous embryonic fusion planes in the auricular skin have been suggested that may contribute to the spread of the tumor . Pensak has described cartilaginous fissures (Santorini) in the lateral floor of the ear canal and a bony dehiscence (Huschke's Foramen) in the medial floor of the ear canal to provide pathways for intracranial tumor spread which also have to be considered . In cases of growth into the parotid gland, a lateral parotidectomy with monitoring of the facial nerve has to be performed. Closure of skin defects can be achieved by local flaps in most patients.
Bowens disease (Syn.: Morbus Bowen, carcinoma in situ, squamous intraepidermoid neoplasia)
Bowens disease is an intraepidermal carcinoma in situ, presenting the preinvasive form of squamous cell carcinoma. It is strongly associated with sun exposure and lesions are in up to 83% infected with human papillomavirus (HPV) type 16 . The lesions are erythematous, scaly patches or plaques with irregular borders which can occur anywhere on the skin. They can become hyperkeratotic, crusted, fissured, or ulcerated and generally occur in sun-exposed areas. On the ear, they are most frequently found on the helical rim or the external side of the auricle. Although the size is variable, Nordin et al. describe a mean size on the ear of 18 mm (range 5–70 mm) . Bowens disease is a carcinoma in situ of the epidermis and therefore potentially malignant. Progression to invasive SCC is noted in approximately 10% of Bowen's lesions. It should therefore be completely excised when possible by means of micrographic guided surgery.
Histological the atypical and disordered keratinocytes in bowens disease extend down the follicular epithelium. Superficial, topical treatment is therefore associated with an increased probability of recurrence.
Topical imiquimod, 5-FU, cryotherapy, photodynamic therapy, x-ray and grenz-ray radiation, cauterization or diathermy coagulation therapy are described to be effective but lack mircrographic control [31–33]. The latter forms of treatment can be considered for large lesions which are sometimes spread over the whole ear or for patients who refuse surgery.
Squamous cell carcinoma
SCC lesions on the nose and ear have the highest rates of recurrence which might be due to an association with embryonic fusion planes . Therapy should therefore be aggressive as tendency of recurrence is high . A complete excision by means of micrographic surgery with tumor free margins is necessary for a successful outcome and should be attempted whenever possible. Although this tumor tends to grow in a vertical fashion it is less likely to respect the barriers of cartilage and bone than BCC. Consequently intratemporal spread with involvement of the external auditory canal is possible and can lead to conductive hearing loss. With further deep extension facial nerve palsy due to destruction of the facial nerve along its vertical or tympanic segment may evolve, and finally a further advancement into the internal auditory canal and cerebellopontine angle may cause dizziness and/or sensorineural hearing loss.
Additionally it is important to investigate for possible regional lymph node metastases which portends poor prognosis. Locoregional metastases follow the lymphatic drainage patterns which include the parotid and upper cervical nodes [38, 39]. Nodal involvement is reported to be present in 1–12.5% of all cases [40–42]. Therapy for locoregional metastases is regional lymphadenectomy (Neck-dissection level I-V), followed by postoperative irradiation. It has been suggested that with evidence of lymphovascular or perineural spread in the primary specimen the nearest "sentinel node" should be examined. In cases of histologically aggressive malignancy prophylactic lymphadenectomy and/or regional irradiation should be considered [43, 44]. However large multi-institutional studies are missing, therefore the role of sentinel lymph node biopsy for SCC of the head and face region can not be determined so far.
Non-epithelial tumors of the external ear
Lentigo maligna (Syn.: Hutchinson's freckle)
Lentigo maligna (LM) is a slow-growing, non-invasive melanoma in situ. Little attention is paid to this insidious lesion which can potentially become an invasive lentigo maligna melanoma with a conversion rate of 33–50% . The estimated lifetime risk of LM progressing to LM melanoma is 5% . The lesion begins as an unevenly pigmented and irregularly bordered, brown to black macule which slowly extends in the course of time. The lesions size can sometimes obtain several centimetres. It begins as a tan macule which extends peripherally within the course of several years. Non-surgical therapy such as cryosurgery, radiotherapy, electrodessication and curettage, laser surgery, and topical medications with a recurrence rate ranging from 20 to 100% at 5 years have been described in the literature. Recurrence following standard therapies is common because histologic evaluation can be difficult due to the widespread atypical melanocytes that are present in the background of long-standing sun damage . Whenever excision by means of micrographic-controlled or MOHS surgery is possible it should be the preferred method of treatment as it shows the lowest recurrence rate (4–5%) and the best form of margin control among all described forms of therapy. As this lesion occurs more frequently in an elderly patient population, alternative forms of treatment, such as radiotherapy, have to be considered when patients present with very large lesions that are not subject to reconstructive surgery.
Melanoma (Syn.: malignant melanoma)
Approximately twenty percent of all primary melanomas are located at the head and neck, of which 7–14% are located at the ear's helix and antihelix. Peripheral parts of the ear are more frequently affected. Interestingly the left ear is more often affected than the right ear. The most accepted theory for this phenomenon is the asymetric UV-dosage in anglo-saxon countries with left-hand driven cars. Further, a male predisposition of 61.5–90.5% is reported in the literature with a predisposition for fair-skinned individuals [61–66]. It can be explained with different hair styles which correlate with UV exposition. With the exception of young children this disease affects all age groups. The average age is 50 years.
The available data for sentinel node sampling do not permit definitive conclusions regarding a prognostic or even therapeutic impact of sentinel lymph node biopsy (SLNB) in patients with melanoma of the ear. Patients with tumours thicker than 1 mm are currently undergoing SLNB and should be included in large multicenter studies. In special cases where surgical removal of a lentigo maligna melanoma is not possible, radiation therapy should be considered as an alternative with good results . Unfortunately this tumor is aggressive, with a tendency for spreading to both regional lymph nodes and distant sites. One third of all patients presenting with auricular melanoma have cervical lymph node involvement. As the correlation between melanoma location and drainage is inconsistent lymphoscintigraphy with sentinel node sampling seems to be the primary method of identifying nodal disease [70, 71]. However a final evaluation is not possible. Adjuvant therapy includes chemotherapy, immunotherapy, and radiation.
Winkler Disease (Syn.: Chondrodermatitis Nodularis Chronica Helicis)
Lymphocytoma (Syn.: Lymphadenosis cutis benigna)
Infectious lesions of the external ear are rarely subject to surgical intervention. Nevertheless drainage of the subperichondral space and surgical removal of necrotic ear tissue following infectious diseases of the external ear are sometimes necessary.
Cylindroma (Syn.: Cylindroma, Spiegler's Tumor, Turban Tumor)
Adnexal Tumours (Syn.: Sweat gland tumours)
As the skin of the external auditory canal shows a high concentration of ceruminal glands it is susceptible for this already very rare type of benign and malignant tumours. Benign adnexal tumours include ceruminous adenomas and pleomorphic adenoma which are best treated by wide local excision . Malignant adnexal tumours include adenoidcystic-, mucinous-, cylindro-, poro-, spiradeno and adenocarcinoma [79–81]. They should be treated by an initial aggressive wide en bloc surgical resection with a primary lateral or subtotal temporal bone resection stage dependent combined with a parotidectomy and neck dissection. Even in T1 tumours local resection is described to be not sufficient . However due to their rarity, a further discussion of these individual tumors is beyond the scope of this article.
Blue Nevus (Syn.: Naevus bleu, Tieche's Nevus)
The outer ear with the auricle and ear canal can be affected by a variety of different skin lesions and dermatologic conditions. They can be either solitary lesions which are locally limited to the ear or are part of a generalized dermatologic condition. They can afflict skin, cartilage, glands, vessels and hair follicles of the outer ear.
The outer ear itself plays a functional role in audition by collecting and transmitting sound. Additionally it has an important effect on facial appearance and therefore on the individual psychological disposition. Although the auricles skin macroscopically shares the anatomy and physiology of the bodys skin it shows some histological differences compared to the rest of the bodys skin. This specific anatomical peculiarities should be considered when treating skin lesions on the ear.
In cloncusion, the authors suggest that an interdisciplinary approach that combines surgery, dermatology and otolaryngology can provide optimal care for the patient. The most common skin diseases of the outer ear which are potentially subject of surgical or laser therapy have been described briefly in this review.
The written consent was obtained from the patients.
- Konishi E, Nakashima Y, Manabe T, Mazaki T, Wada Y: Irritated seborrheic keratosis of the external ear canal. Pathol Int. 2003, 53: 622-6. 10.1046/j.1440-1827.2003.01524.x.View ArticlePubMedGoogle Scholar
- Rigopoulos D, Rallis E, Toumbis-Ioannou E: Seborrhoeic keratosis or occult malignant neoplasm of the skin?. Eur Acad Derm Venereol. 2002, 16: 168-170. 10.1046/j.1468-3083.2002.00396.x.View ArticleGoogle Scholar
- Murphy GF, Elder DE: Seborrheic keratosis. Atlas of Tumor Pathology. Non-Melanocytic Tumors of the Skin, 3rd series. Edited by: Rosai J. 1991, Washington DC: AFIP, 13-19.Google Scholar
- Mehrabi D, Leonhardt JM, Brodell RT: Removal of keratinous and pilar cysts with the punch incision technique: analysis of surgical outcomes. Dermatol Surg. 2002, 28: 673-7. 10.1046/j.1524-4725.2002.02020.x.PubMedGoogle Scholar
- Dorn M, Plewig G: Acanthoma fissuratum cutis. Hautarzt. 1981, 32: 145-8.PubMedGoogle Scholar
- Benedetto AV, Bergfeld WF: Acanthoma fissuratum. Histopathology and review of the literature. Cutis. 1979, 24: 225-9.PubMedGoogle Scholar
- Rist TE, Marks JG: Granuloma fissuratum masquerading as a skin tumor. Cutis. 1980, 25: 663-PubMedGoogle Scholar
- Lever WF, Schaumburg-Lever G: Histopathology of the skin. 1983, Philadelphia: J.B. Lippincott, 42-46.Google Scholar
- Emmett AJ, Broadbent GD: Shave excision of superficial solar skin lesions. Plast Reconstr Surg. 1987, 80: 47-54. 10.1097/00006534-198707000-00007.View ArticlePubMedGoogle Scholar
- Smith SR, Morhenn VB, Piacquadio DJ: Bilateral comparison of the efficacy and tolerability of 3% diclofenac sodium gel and 5% 5-fluorouracil cream in the treatment of actinic keratoses of the face and scalp. J Drugs Dermatol. 2006, 5: 156-9.PubMedGoogle Scholar
- Smit JV, de Sevaux RG, Blokx WA, van de Kerkhof PC, Hoitsma AJ, de Jong EM: Acitretin treatment in (pre)malignant skin disorders of renal transplant recipients: Histologic and immunohistochemical effects. J Am Acad Dermatol. 2004, 50: 189-196. 10.1016/S0190-9622(03)01837-1.View ArticlePubMedGoogle Scholar
- Alexiades-Armenakas MR, Geronemus RG: Laser-mediated photodynamic therapy of actinic keratoses. Arch Dermatol. 2003, 139: 1313-20. 10.1001/archderm.139.10.1313.View ArticlePubMedGoogle Scholar
- Newman MD, Weinberg JM: Topical therapy in the treatment of actinic keratosis and basal cell carcinoma. Cutis. 2007, 79: 18-28.PubMedGoogle Scholar
- Bart RS, Andrade R, Kopf AW: Cutaneous horns. A clinical and histopathologic study. Acta Derm Venereol. 1968, 48: 507-15.PubMedGoogle Scholar
- Baruchin A, Sagi A, Lupo L, Hauben DJ: Cutaneous horn (Cornu cutaneum). Int J Tissue React. 1984, 6: 355-7.PubMedGoogle Scholar
- Mehregan AH: Cutaneous horn: a clinicopathological study. Dermatol Dig. 1965, 4: 45-54.Google Scholar
- Yu RC, Pryce DW, Macfarlane AW, Stewart TW: A histopathological study of 643 cutaneous horns. Br J Dermatol. 1991, 124: 449-52. 10.1111/j.1365-2133.1991.tb00624.x.View ArticlePubMedGoogle Scholar
- MacKie RM: Epidermal skin tumours. Rook and Wilkinson and Ebling's Textbook of Dermatology. Edited by: Champion RH, Burton JL, Burns DA, Breathnach SM. 1998, Oxford: Blackwell Science, 1673-4. sixthGoogle Scholar
- Kastanioudakis I, Skevas A, Assimakopoulos D, Daneilidis B: Cutaneous horn of the auricle. Otolaryngol Head Neck Surg. 1998, 735-10.1016/S0194-5998(98)70256-6.Google Scholar
- Hyams VJ, Batsakis JG, Michaels L: Tumors of the upper respiratory tract and ear. Atlas of tumour pathology. Edited by: Hartmann WH, Sobin LH. 1988, Washington, DC: Armed Forces Institute of Pathology, 25: 343-Google Scholar
- Rowe DE, Carroll RJ, Day CL: Long-term recurrence rates in previously untreated basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989, 15: 315-328.View ArticlePubMedGoogle Scholar
- Rowe DE, Raymond JC, Day CL: Mohs' surgery is the treatment of choice for recurrent basal cell carcinoma. J Dermatol Surg Oncol. 1989, 15: 424-431.View ArticlePubMedGoogle Scholar
- Levine HL, Bailin PL: Basal cell carcinoma of the head and neck: identification of the high risk patient. Laryngoscope. 1980, 90: 955-61. 10.1288/00005537-198007000-00022.View ArticlePubMedGoogle Scholar
- Bailin PL, Levine HL, Wood BG, Tucker HM: Cutaneous carcinoma of the auricular and periauricular region. Arch Otolaryngol. 1980, 106: 692-696.View ArticlePubMedGoogle Scholar
- Caloglu M, Yurut-Caloglu V, Kocak Z, Uzal C: Metastatic giant basal cell carcinoma and radiotherapy. J Plast Reconstr Aesthet Surg. 2006, 59: 783-4. 10.1016/j.bjps.2005.12.015.View ArticlePubMedGoogle Scholar
- Niparko JK, Swanson NA, Baker SR, Telian SA, Sullivan MJ, Kemink JL: Local control of auricular, periauricular, and external canal cutaneous malignancies with Mohs surgery. Laryngoscope. 1990, 100: 1047-51. 10.1288/00005537-199010000-00004.View ArticlePubMedGoogle Scholar
- Robbins P, Nix M: Analysis of persistant disease on the Ear following Mohs' surgery. Head Neck Surg. 1984, 6: 998-1006. 10.1002/hed.2890060604.View ArticleGoogle Scholar
- Pensak ML: Skull Base surgery. Surgery of the ear. Edited by: Glasscock ME, Shambaugh GE. 1990, Philadelphia: WB Saunders, 530-33. 4Google Scholar
- Clavel CE, Huu VP, Durlach AP, Birembaut PL, Bernard PM, Derancourt CG: Mucosal oncogenic human papillomaviruses and extragenital Bowen disease. Cancer. 1999, 86: 282-7. 10.1002/(SICI)1097-0142(19990715)86:2<282::AID-CNCR12>3.0.CO;2-C.View ArticlePubMedGoogle Scholar
- Nordin P: Curettage-cryosurgery for non-melanoma skin cancer of the external ear: excellent 5-year results. Br J Dermatol. 1999, 140: 291-3. 10.1046/j.1365-2133.1999.02665.x.View ArticlePubMedGoogle Scholar
- Heising RA: Treatment of Bowen's disease of the ear by the combined use of cryosurgery and topical 5-fluorouracil. Cutis. 1979, 24: 271-5.PubMedGoogle Scholar
- Rosen T, Harting M, Gibson M: Treatment of Bowen's disease with topical 5% imiquimod cream: retrospective study. Dermatol Surg. 2007, 33: 427-31. 10.1111/j.1524-4725.2007.33089.x.PubMedGoogle Scholar
- Cox NH, Eedy DJ, Morton CA: Guidelines for management of Bowen's disease: 2006 update. Br J Dermatol. 2007, 156: 11-21. 10.1111/j.1365-2133.2006.07610.x.View ArticlePubMedGoogle Scholar
- Nindl I, Gottschling M, Stockfleth E: Human papillomaviruses and non-melanoma skin cancer: Basic virology and clinical manifestations. Dis Markers. 2007, 23: 247-59.View ArticlePubMedPubMed CentralGoogle Scholar
- Molho-Pessach V, Lotem M: Viral carcinogenesis in skin cancer. Curr Probl Dermatol. 2007, 35: 39-51.View ArticlePubMedGoogle Scholar
- Panje WR, Ceilley RI: The influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope. 1979, 89: 1914-20. 10.1288/00005537-197912000-00003.View ArticlePubMedGoogle Scholar
- Yoon M, Chougule P, Dufresne R, Wanebo HJ: Localized carcinoma of the external ear is an unrecognized aggressive disease with a high propensity for local regional recurrence. Am J Surg. 1992, 164: 574-7. 10.1016/S0002-9610(05)80709-3.View ArticlePubMedGoogle Scholar
- Khurana VG, Mentis DH, O'Brien CJ, Hurst TL, Stevens GN, Packham NA: Parotid and neck metastases from cutaneous squamous cell carcinoma of the head and neck. Am J Surg. 1995, 170: 446-50. 10.1016/S0002-9610(99)80326-2.View ArticlePubMedGoogle Scholar
- Brown RO, Osguthorpe JD: Management of the neck in nonmelanocytic cutaneous carcinomas. Otolaryngol Clin North Am. 1998, 31: 841-56. 10.1016/S0030-6665(05)70092-X.View ArticlePubMedGoogle Scholar
- Kraus DH, Carew JF, Harrison LB: Regional lymph node metastasis from cutaneous squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998, 124: 582-7.View ArticlePubMedGoogle Scholar
- Dinehart SM, Pollack SV: Metastases from squamous cell carcinoma of the skin and lip. J Am Acad Dermatol. 1989, 21: 241-7.View ArticlePubMedGoogle Scholar
- Cherpelis BS, Marcusen C, Lang PG: Prognostic factors for metastasis in squamous cell carcinoma of the skin. Dermatol Surg. 2002, 28: 268-73. 10.1046/j.1524-4725.2002.01169.x.PubMedGoogle Scholar
- Rowe DE, Carroll RJ, Day CL: Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. J Am Acad Dermatol. 1992, 26: 976-90.View ArticlePubMedGoogle Scholar
- Osguthorpe JD, Abel CG, Lang P, Hochman M: Neurotropic cutaneous tumors of the head and neck. Arch Otolaryngol Head Neck Surg. 1997, 123: 871-6.View ArticlePubMedGoogle Scholar
- Wilkins RH: Neurosurgical Classic. XVII.: Edwin Smith Surgical Papyrus. J Neurosurg. 1964, 21: 240-4.View ArticlePubMedGoogle Scholar
- Retz N: Traite des Maladies de la Peau et de celles de l'Esprit. 1790, Mequignon, Paris, 155-3Google Scholar
- Alibert JL: Note sur la chéloïde. Journal universel des sciences médicales. 1816, 2: 207-216.Google Scholar
- Simplot TC, Hoffman HT: Comparison between cartilage and soft tissue ear piercing complications. Am J Otolaryngol. 1998, 19: 305-10. 10.1016/S0196-0709(98)90003-5.View ArticlePubMedGoogle Scholar
- Sand M, Sand D, Boorboor P, Mann B, Altmeyer P, Hoffmann K, Bechara FG: Combination of surgical excision and custom designed silicon pressure splint therapy for keloids on the helical rim. Head Face Med. 2007, 12;3 (1): 14-10.1186/1746-160X-3-14.View ArticleGoogle Scholar
- Kauh YC, Rouda S, Mondragon G, Tokarek R, diLeonardo M, Tuan RS, Tan EM: Major suppression of pro-alpha1(I) type I collagen gene expression in the dermis after keloid excision and immediate intrawound injection of triamcinolone acetonide. J Am Acad Dermatol. 1997, 37: 586-9. 10.1016/S0190-9622(97)70176-2.View ArticlePubMedGoogle Scholar
- Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T: Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003, 111: 547-53. 10.1097/01.PRS.0000040466.55214.35.View ArticlePubMedGoogle Scholar
- Naeini FF, Najafian J, Ahmadpour K: Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars. Dermatol Surg. 2006, 32: 1023-9. 10.1111/j.1524-4725.2006.32225.x.PubMedGoogle Scholar
- Maarouf M, Schleicher U, Schmachtenberg A, Ammon J: Radiotherapy in the management of keloids. Clinical experience with electron beam irradiation and comparison with X-ray therapy. Strahlenther Onkol. 2002, 178: 330-5. 10.1007/s00066-002-0935-6.View ArticlePubMedGoogle Scholar
- Rusciani L, Rossi G, Bono R: Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol. 1993, 19: 529-34.View ArticlePubMedGoogle Scholar
- Berman B, Kaufman J: Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. J Am Acad Dermatol. 2002, 47: 209-11. 10.1067/mjd.2002.126585.View ArticleGoogle Scholar
- Ahn ST, Monafo WW, Mustoe TA: Topical silicone gel: A new treatment for hypertrophic scars. Surgery. 1989, 106: 781-6.PubMedGoogle Scholar
- Sproat JE, Dalcin A, Weitauer N, Roberts RS: Hypertrophic sternal scars: Silicone gel sheet versus Kenalog injection treatment. Plast Reconstr Surg. 1992, 90: 988-92. 10.1097/00006534-199212000-00008.View ArticlePubMedGoogle Scholar
- Fulton JE: Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars. Dermatol Surg. 1995, 21: 947-51. 10.1016/1076-0512(95)00389-4.PubMedGoogle Scholar
- Weinstock MA, Sober AJ: The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol. 1987, 116: 303-10. 10.1111/j.1365-2133.1987.tb05843.x.View ArticlePubMedGoogle Scholar
- McKenna JK, Florell SR, Goldman GD, Bowen GM: Lentigo maligna/lentigo maligna melanoma: current state of diagnosis and treatment. Dermatol Surg. 2006, 32: 493-504. 10.1111/j.1524-4725.2006.32102.x.PubMedGoogle Scholar
- Byers RM, Smith JL, Russell N, Rosenberg V: Malignant melanoma of the external ear. Review of 102 cases. Am J Surg. 1980, 140: 518-21. 10.1016/0002-9610(80)90203-2.View ArticlePubMedGoogle Scholar
- Davidsson A, Hellquist HB, Villman K, Westman G: Malignant melanoma of the ear. J Laryngol Otol. 1993, 107: 798-802. 10.1017/S0022215100124466.View ArticlePubMedGoogle Scholar
- Arons MS, Savin RC: Auricular cancer. Some surgical and pathologic considerations. Am J Surg. 1971, 122: 770-6. 10.1016/0002-9610(71)90443-0.View ArticlePubMedGoogle Scholar
- Pockaj BA, Jaroszewski DE, Dicaudo DJ: Changing surgical therapy for melanoma of the external ear. Ann Surg Oncol. 2003, 10: 689-96. 10.1245/ASO.2003.09.017.View ArticlePubMedGoogle Scholar
- Narayan D, Ariyan S: Surgical considerations in the management of malignant melanoma of the ear. Plast Reconstr Surg. 2001, 107: 20-4. 10.1097/00006534-200101000-00004.View ArticlePubMedGoogle Scholar
- Dost P, Lehnerdt G, Kling R, Wagner SN: Surgical therapy of malignant melanoma of the external ear. HNO. 2004, 52: 33-7. 10.1007/s00106-003-0852-8.View ArticlePubMedGoogle Scholar
- Koh HK, Michalik E, Sober AJ: Lentigo maligna melanoma has no better prognosis than other types of melanoma. J Clin Oncol. 1984, 2: 994-1001.PubMedGoogle Scholar
- Jahn V, Breuninger H, Garbe C, Moehrle M: Melanoma of the ear: prognostic factors and surgical strategies. Br J Dermatol. 2006, 154: 310-8. 10.1111/j.1365-2133.2005.07065.x.View ArticlePubMedGoogle Scholar
- Stevenson O, Ahmed I: Lentigo maligna: prognosis and treatment options. Am J Clin Dermatol. 2005, 6: 151-64. 10.2165/00128071-200506030-00002.View ArticlePubMedGoogle Scholar
- Cole MD, Jakowatz J, Evans GR: Evaluation of nodal patterns for melanoma of the ear. Plast Reconstr Surg. 2003, 112: 50-6. 10.1097/01.PRS.0000065913.11455.15.View ArticlePubMedGoogle Scholar
- Wagner JD, Park HM, Coleman JJ, Love C, Hayes JT: Cervical sentinel lymph node biopsy for melanomas of the head and neck and upper thorax. Arch Otolaryngol Head Neck Surg. 2000, 126: 313-21.View ArticlePubMedGoogle Scholar
- Rickli H, Hardmeier T: Winkler's chondrodermatitis nodularis chronica helices. Pathologe. 1988, 9: 25-9.PubMedGoogle Scholar
- Munnoch DA, Herbert KJ, Morris AM: Chondrodermatitis nodularis chronica helicis et antihelicis. Br J Plast Surg. 1996, 49: 473-6. 10.1016/S0007-1226(96)90035-1.View ArticlePubMedGoogle Scholar
- More DR, Seidel JS, Bryan PA: Ear piercing techniques as a cause of auricular chondritis. Pediatr Emerg Care. 1999, 15: 189-192. 10.1097/00006565-199906000-00007.View ArticlePubMedGoogle Scholar
- Martin R, Yonkers AJ, Yarington CT: Perichondritis of the ear. Laryngoscope. 1976, 86: 664-673. 10.1288/00005537-197605000-00006.View ArticlePubMedGoogle Scholar
- Noel SB, Scallan P, Meadors MC, Meek TJ, Pankey GA: Treatment of Pseudomonas aeruginosa auricular perichondritis with oral ciprofloxacin. J Dermatol Surg Oncol. 1989, 15: 633-7.View ArticlePubMedGoogle Scholar
- Lotem M, Trattner A, Kahanovich S, Rotem A, Sandbank M: Multiple dermal cylindroma undergoing a malignant transformation. Int J Dermatol. 1992, 31: 642-644. 10.1111/j.1365-4362.1992.tb03985.x.View ArticlePubMedGoogle Scholar
- Hicks GW: Tumors arising from the glandular structures of the external auditory canal. Laryngoscope. 1983, 93: 326-40.PubMedGoogle Scholar
- Meyer TK, Rhee JS, Smith MM, Cruz MJ, Osipov VO, Wackym PA: External auditory canal eccrine spiradenocarcinoma: a case report and review of literature. Head Neck. 2003, 25: 505-10. 10.1002/hed.10216.View ArticlePubMedGoogle Scholar
- Klenzner T, Arapakis I, Kayser G, Boedeker CC: Eccrine porocarcinoma of the ear mimicking basaloid squamous cell carcinoma. Otolaryngol Head Neck Surg. 2006, 135: 158-60. 10.1016/j.otohns.2005.03.041.View ArticlePubMedGoogle Scholar
- Völter C, Baier G, Schwager K, Müller JG, Rose C: Cylindrocarcinoma in a patient with Brooke-Spiegler syndrome. Laryngorhinootologie. 2002, 81: 243-6. 10.1055/s-2002-25034.View ArticlePubMedGoogle Scholar
- Kollert M, Draf W, Minovi A, Hofmann E, Bockmühl U: Carcinoma of the external auditory canal and middle ear: therapeutic strategy and follow up. Laryngorhinootologie. 2004, 83: 818-23. 10.1055/s-2004-825804.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.