Chondrodermatitis nodularis chronica helicis H61.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Chondrodermatitis nodularis helicis; CNCH; Ear corn; Ear nodules painful; Painful ear nodule; Winkler's disease

History
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Winkler 1915

Definition
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Chronic, benign nodule on the free edge of the auricle, which is very painful under pressure. The clinical picture usually persists for 10-15 months before the medical consultation.

Occurrence/Epidemiology
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Prevalence data are not available. Men are mainly affected (>60%).

Etiopathogenesis
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Unknown. Probably pressure necrosis due to increasing hardening of the ear cartilage with advancing age and firm sleeping habits (e.g. sleeping only possible on one side) or due to permanent trauma caused by wearing a helmet or headphones etc. Furthermore, most patients report intensive UV exposure (in a larger study group of almost 100 patients, this figure was found in almost 60%).

Manifestation
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Occurring in middle to old age (average age 58-72 years - average 65 years), only very few cases in children are described.

Localization
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On the right side slightly more frequently than on the left side; very rarely bilateral (6-10%). Mostly upper external auricle margin above the Darwin hump; clearly more rarely anthelix, scapha and concha are involved.

Clinical features
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On pressure or firm palpation, moderate (about 20%), very strong (60%) to no longer bearable (20%) pain, spontaneously occurring, rapidly growing, coarse, skin-coloured or whitish, often centrally ulcerated or encrusted, coarse nodules (rarely knot formation), which usually cannot be moved on its support.

About 60% of patients report a very intense stabbing, sometimes spontaneously shooting pain, which can last for minutes or even several hours; a characteristic feature is the patients' statement that they could no longer sleep in this ear.

The size is usually 0.4-0.7 cm in diameter; the maximum extension is about 2.0 cm in diameter.

The atypically (not at the helix) localized CNCH can impress as a flat painful ulcer or as flat keratotic papules or plaque.

Histology
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Acanthosis with hyper-, sometimes parakeratosis, possibly epidermal defect with fibrin deposits at the base. In the dermis granulomatous inflammation, possibly with giant cells. In addition mostly signs of actinic elastosis. The cartilage shows inflammatory (perichondritis) and degenerative changes with perichondral fibrosis.

Differential diagnosis
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Basal cell carcinoma: Lack of pain; ulceration possible; in these cases smooth "basal cellcarcinoma typical" margins.

Gout tophi: Rarely as a single finding; usually multiple; at first soft, yellowish, later increasingly coarse, mostly painless nodules due to deposition of precipitated uric acid salts in the skin.

Keratosis actinica: Usually flat, firmly adhering scaling; a slight painfulness may be present, but no intense pain.

Keratoacanthoma: Rapidly growing red lump, no pain.

Squamous cell carcinoma: Important DD; clinically not always definable although the typical pain of CNCH is missing. Histology is conclusive. .

Therapy
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Surgical procedures:

  • The safest therapy is the complete surgical removal of the painful nodules by means of wedge excision, as recurrences can only be prevented if the removal is sufficiently generous.
  • The so-called "punch and graft procedure" represents a surgical therapy variant. In this technique, the lesional skin with the underlying cartilage is punched out and the defect is covered with full skin.

Alternatively, intralesional glucocorticoid injections with triamcinolone (e.g. Volon A crystal suspension diluted 1:5 with LA like lidocaine 1%). Initial success is good, with prompt pain relief. Continuous success is doubtful.

Alternative: Therapy with electrocautery and curettage for superficial changes can be considered.

Alternative: Laser ablation withCO2-, or Erbium-YAG-laser.

Alternative: Topical glucocorticoids (Remark: only moderate success in chronic conditions).

Alternative: Pressure relief by individually adapted ear protection bandage. Possibly pillow with auricular recess.

Literature
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  1. Greenbaum SS (1991) The treatment of chondrodermatitis nodularis chronica helicis with injectable collagen. Int J Dermatol 30: 291-294
  2. Hesse G et al (1994) Argon laser therapy of chondrodermatitis nodularis chronica helicis. dermatologist 45: 222-224
  3. Khurana U et al (2015) A man with painful nodules on both ears. Chondrodermatitis nodularis chronica helicis. JAMA Otolaryngol Head Neck Surg 141:481-482
  4. Nadaud B et al (2014) Chondrodermatitis nodularis helicis. Ann Dermatol Venereol 141:306-307
  5. Oelzner S et al (2003) Bilateral chondrodermatitis nodularis chronica helicis on the free border of the helix in a woman. J Am Acad Dermatol 49: 720-722
  6. Rajan N et al (2007) The punch and graft technique: a novel method of surgical treatment for chondrodermatits nodularis helicis. Br J Dermatol 157: 744-747
  7. Taylor MB (1991) Chondrodermatitis nodularis chronica helicis. Successful treatment with the carbon dioxide laser. J Dermatol Surg Oncol 17: 862-864
  8. Wagner G et al (2011) Clinical forms, differential diagnosis and therapeutic options of chondrodermatitis nodularis chronica helicis Winkler. JDDG 9: 287-291
  9. Wettlé C et al(2013) Chondrodermatitis nodularis chronica helicis: a descriptive study of 99 patients. Ann Dermatol Venereol 140:687-962
  10. Winkler M (1915) Chondrodermatitis nodularis chronica helicis. Arch Dermatol Syphilol 121: 278

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020