Chondrodermatitis Nodularis

Synonyms: chondrodermatitis nodularis helicis (or antihelicis – depending on site of lesion), chondrodermatitis nodularis chronica helicis, ear pressure sore, painful nodule of the ear, Winkler's disease

This is a painful, inflamed nodule of the ear, involving the cartilage and skin of the pinna. It is usually located at the apex of the helix.

• It is probably caused mainly by pressure, combined with the anatomy of the pinna and its blood supply:
  • The initial damage may be triggered by inflammation, oedema, and necrosis from trauma, cold, actinic damage or pressure.
  • The pinna has relatively little subcutaneous tissue for insulation and padding. Only small dermal blood vessels supply the epidermis, dermis, perichondrium and cartilage. These features may prevent adequate healing and lead to secondary perichondritis.
• Possibly, perichondrial arteriolar changes may be involved.²

There are no reliable figures for its incidence or prevalence but it is probably a relatively common condition.

It is most common in older men with white, sun-damaged skin, but can affect people of all ages, gender and pigmentation. The use of apparatus that puts pressure on the external ear, such as headphones, may precipitate the condition, as may a tendency always to sleep on the same side.

Symptoms

History:

• Presents as a painful nodule on the helix or antihelix of the ear.
• It appears spontaneously, then usually enlarges rapidly to its maximum size and remains stable. Onset may be precipitated by pressure, trauma or cold.

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Signs

There is usually only one nodule - most often on the outer side of the helix, commonly at its apex:

• The nodule is firm, tender and well-demarcated.
• Size range is 3-20 mm diameter - usually about 6 mm diameter.
• It is round or oval, slightly raised and firmly stuck to the underlying cartilage.
• It may appear inflamed.
• The surface appears scaly or crusty. If the crust is removed, a small raw area or core may be visible centrally.

• Basal cell carcinoma
• Squamous cell carcinoma
• Keratoacanthoma
• Actinic keratosis
• Elastotic nodules of the ears
• Cystic chondromalacia

Biopsy is needed if the diagnosis is uncertain, particularly to exclude basal cell carcinoma or squamous cell carcinoma.

The condition is benign and traditionally not thought to be related to any systemic illness.¹ One study suggested an association with immune-mediated vascular compromise and necrobiotic collagenous disease such as granuloma annulare, especially in younger patients.⁴

The lesion rarely resolves spontaneously and so will usually need some form of treatment if it is causing discomfort or annoyance. A trial of conservative therapy for all patients is suggested.^5,6

Conservative management^1,3

The aim of treatment is to reduce pressure on the site of the lesion; for example by:

• Altering the way headphones or telephone receivers are held to the ear.
• Sleeping on the opposite side, if possible.
• Using a soft pillow, or modifying the pillow with a hole where the nodule is in contact. A doughnut-shaped pillow was effective in one study.⁶
• Using a corn plaster.
• A pressure-relieving device can be made by cutting a hole from the center of a bath sponge, which is held in place with a headband.
• A protective made-to-measure silicone splint may be used.⁷

In addition:

• Avoid excessive exposure to the cold and the sun.
• Topical antibiotics for secondary infections or ulceration. Petroleum jelly may also help if the lesion is ulcerated.⁷

Further management¹

• Topical and intralesional steroids may relieve discomfort.
• Collagen injections may bring relief by providing cushioning between the skin and cartilage.
• Cryotherapy has been used.
• Surgery:
  • There are a range of surgical techniques used to achieve excision of the affected cartilage with reconstruction of the overlying skin.
  • Excision of the damaged area of cartilage is usually successful, but recurrence can occur at the edge of the excised area.
  • A technique of narrow elliptical excision of the skin lesion with shaving of the underlying cartilage appears to be as effective, less invasive and to have similar recurrence rates (around 13.5% after 4 years or so).⁸
  • A newer technique is excision by punch biopsy, with full thickness skin grafting (the 'punch and graft' technique).^7,9

• The prognosis is excellent, with the lesion usually progressing no further.¹
• Small studies suggest that many, or most, cases respond to conservative treatment.^5,6
• The condition may recur after surgery. Recurrence rates are about 10-30%.⁷