Content uploaded by Ning-Chia Chang
Author content
All content in this area was uploaded by Ning-Chia Chang on Feb 14, 2015
Content may be subject to copyright.
Lactate dehydrogenase isoenzyme patterns in
auricular pseudocyst fluid
P-P CHEN
1
, S-M TSAI
2
, H-M WANG
3
, L-F WANG
3,4
, C-Y CHIEN
1
, N-C CHANG
5
,K-YHO
1,4
Departments of
1
Otolaryngology and
5
Preventive Medicine, Kaohsiung Medical University Hospital, Departments of
2
Public Health and
4
Otolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, and
3
Department of Otolaryngology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung,
Taiwan
Abstract
Objective: We investigated lactate dehydrogenase isoenzyme patterns in the cyst fluid of auricular pseudocysts and
autogenous blood, to assist the diagnosis of auricular pseudocyst.
Methods: Twenty patients with auricular pseudocysts participated in this study conducted in Kaohsiung Medical
University Hospital between February 2007 and June 2010. Patterns of lactate dehydrogenase in cyst fluid and
autogenous blood were analysed.
Results: Levels of lactate dehydrogenase 1 and 2 were lower in auricular pseudocysts than in autogenous blood,
whereas levels of lactate dehydrogenase 4 and 5 were higher; this difference was statistically significant ( p<0.001).
Conclusion: Lactate dehydrogenase isoenzyme patterns in auricular pseudocyst fluid indicated higher percentage
distributions of lactate dehydrogenase 4 and 5 and lower percentage distributions of lactate dehydrogenase 1 and 2.
An effective laboratory method of evaluating the different lactate dehydrogenase isoenzyme components was
developed; this method may improve the accuracy of auricular pseudocyst diagnosis.
Key words: Ear, External; L-Lactate Dehydrogenase; Pathology
Introduction
An auricular pseudocyst is a fluid-filled cavity present
within the cartilage of the ear, which is not lined by epi-
thelium.
1–4
Clinically, it is an uncommon, benign, idio-
pathic disease which typically presents as a painless,
spontaneously arising swelling on the upper anterior
surface of the auricle, and which contains sterile,
straw-coloured fluid on aspiration.
5,6
In 1966, Engel reported 17 cases in young, healthy,
Chinese men and gave the first description of the histo-
logical changes seen in auricular pseudocysts.
4
Although
these lesions can occur in both genders, all races and at
any age, they occur predominantly among males,
especially young, Asian males.
4,7–10
A hormonal influ-
ence modulating the inflammatory process has been
suggested to explain the marked male predominance of
this condition.
10
Most auricular pseudocysts are unilat-
eral, but bilateral cases have been described.
4,11–13
They are most commonly located in the concha fossa.
10
Various aetiological theories have been suggested,
including chronic minor trauma, congenital embryonic
dysplasia, autoimmune defect and circulatory disturb-
ances in the auricle; however, the exact cause remains
unclear.
3,6,14–20
In 1985, Okuma described successful treatment of an
auricular pseudocyst with needle aspiration followed
by local steroid injection.
21
Since then, many different
treatments have been employed, with varying
success.
5,7,9,14,21–28
The auricle can be the site of a variety of cystic
lesions, many of which involve potential spaces
between the auricular cartilage and the perichondrium
or within the skin and the subcutaneous tissues.
22
Therefore, it is important to properly diagnose and
treat auricular pseudocysts. If misdiagnosed and
treated inappropriately, or left untreated, permanent
deformity of the auricle may result.
In several cases of auricular pseudocysts, high levels of
lactate dehydrogenase (LDH) have been reported in the
cyst fluid.
10,14
The LDH isoenzyme patterns within cyst
fluid have been examined, and LDH-4 and LDH-5 have
been found to predominate in a small group of
patients.
6,7,14
In this study, we assessed and compared the distri-
bution of LDH isoenzymes in the cyst fluid and autoge-
nous sera of a group of patients with auricular
pseudocysts. Such an investigation has not previously
been reported. We also attempted to determine an
Presented at the 89th Annual Academic Meeting, Taiwan Otolaryngological Society, 13–14 November 2010, Taipei, Taiwan
Accepted for publication 16 July 2012
The Journal of Laryngology & Otology (2013),127,479–482.MAIN ARTICLE
© JLO (1984) Limited, 2013
doi:10.1017/S0022215113000534
accurate method with which to diagnose auricular
pseudocyst in clinically suspicious cases, in addition
to the usual clinical features.
Materials and methods
Between February 2007 and June 2010, 20 consecutive
patients diagnosed with auricular pseudocysts partici-
pated in this prospective study conducted at the otolar-
yngology department of Kaohsiung Medical
University Hospital, Taiwan. None of the patients
had received any previous treatment for their auricular
pseudocyst. All patients were initially treated with
needle aspiration of cyst fluid, followed by injection
of steroid solution (triamcinolone, 1 ml ampoule of
10 mg/ml suspension) into the pseudocyst cavity
(using a separate syringe) until it regained its original
size. Autogenous blood was drawn at the same time.
The volume of aspirated cyst fluid and blood was
measured, and the presence and percentage distribution
of LDH isoenzymes 1, 2, 3, 4 and 5 were analysed.
The study protocol was approved by the hospital
institutional review board. Statistical evaluations were
performed using the paired t-test. A pvalue of less
than 0.05 was considered statistically significant.
Results
The cohort consisted of 15 males (75 per cent) and 5
females (25 per cent) with a mean age ±standard devi-
ation (SD) of 42.05 ±13.43 years. Ten patients had
left-sided lesions and 10 had right-sided lesions. No
case of bilateral pseudocysts was seen. The pseudocyst
was located in the concha fossa in 12 patients (60 per
cent), in the scaphoid fossa in 1 patient (5 per cent)
and in the triangular fossa in 5 patients (25 per cent).
The final two patients (10 per cent) had large pseudo-
cysts, one extending over three sites (the concha
fossa, triangular fossa and scaphoid fossa) and one
extending over the triangular fossa and scaphoid fossa.
The mean ±SD and range of the percentage distri-
bution of LDH isoenzymes in cyst fluid and sera in the
20 patients are presented in Table I. In our hospital lab-
oratory, the normal reference percentage distributions of
LDH isoenzymes in sera were: LDH-1, 25–30 per cent;
LDH-2, 32–35 per cent; LDH-3, 20 –25 per cent; LDH-
4, 7–10 per cent; and LDH-5, 7–10 per cent.
All patients had fairly normal percentage distributions
of LDH isoenzymes in their serum. However, very differ-
ent LDH isoenzyme distributions were seen in the cyst
fluid (Table I), and this difference was statistically signifi-
cant ( paired t-test, p<0.001). The mean ±SD percen-
tage distributions of LDH-4 and LDH-5 in auricular
pseudocyst fluid were 30.33 ±8.12 per cent and
42.01 ±7.84 per cent, respectively; these values were
substantially higher than corresponding serum values
(Table I). In contrast, serum LDH-1 and LDH-2 had
mean ±SD percentage distributions of 21.05 ±5.05
per cent and 32.78 ±2.70 per cent, respectively; these
were substantially higher than cyst fluid values
(Table I). Plotted graphically, the overall gradient of
TABLE I
LDH ISOENZYME PATTERNS IN CYST FLUID AND SERUM
Source Pts (n) LDH-1 LDH-2 LDH-3 LDH-4 LDH-5
Mean ±SD Range Mean ±SD Range Mean ±SD Range Mean ±SD Range Mean ±SD Range
Cyst fluid 20 5.57 ±4.72 0–15.9 8.89 ±5.81 0.8–21.8 13.20 ±3.13 5–19.7 30.33 ±8.12 16.9–50.0 42.01 ±7.84 24.1–58.1
Serum 20 21.05 ±5.05 14.9–37.5 32.78 ±2.70 28.3–38.5 20.29 ±1.96 16.2–23.3 11.98 ±2.21 8.7–16.7 13.91 ±5.74 4.9–27.1
Pts =patients; LDH =lactate dehydrogenase; SD =standard deviation
P-P CHEN, S-M TSAI, H-M WANG et al.480
LDH isoenzyme percentage distribution was positive in
cyst fluid but negative in serum (Figure 1).
This pattern was also seen on an individual level, fol-
lowing analysis of initially clear, yellowish cyst fluid
from a 35-year-old, female patient with a clinical diag-
nosis of left auricular pseudocyst in the concha fossa
(Figure 2), and after analysis of dark brownish cyst
fluid from a 30-year-old, female patient with a sus-
pected auricular pseudocyst in the left scaphoid fossa
(Figure 3): the percentage distributions of LDH-4 and
LDH-5 were higher in cyst fluid than in serum, those
of LDH-1 and LDH-2 were higher in serum than in
cyst fluid (Fig 2 and 3). This confirmed the accuracy
of auricular pseudocyst diagnosis in both these cases.
Discussion
An auricular pseudocyst is a benign, asymptomatic,
fluctuant outpouching with no epithelial lining, which
is usually located on the anterior surface of the
auricle.
1–4
Some believe that these lesions arise as a
consequence of repeated minor trauma of the auricular
cartilage, for example due to sleeping on a hard pillow
or wearing stereo headphones or a motorcycle helmet;
cases have also been reported in children.
3,6,14,21,25
Several authors have described the histology of these
lesions.
1–4
Perivascular, lymphocytic infiltrates are
consistently evident in the connective tissue layer just
superficial to the anterior segment of the cartilage. In
the present study, an inflammatory response was seen
in all specimens.
Minor trauma may trigger the release of LDH in cyst
fluid; however, there is conflicting evidence on an associ-
ation with trauma.
21,29
Others have suggested aetiological
mechanisms such as lysosomal abnormalities, enzyme
leakage with subsequent cartilage degeneration, and
ischaemic necrosis secondary to repeated low-grade
trauma.
10,28
A more likely pathogenetic mechanism is
that individuals are predisposed to endochondral pseudo-
cysts during embryological development of the ears. The
complex fusion and folding of the first and second bra-
chial arches results in formation of the auricle cartilage,
but may also leave residual tissue planes within the
mesenchyme. These planes may later reopen to cause a
pseudocyst.
4,7,10,28
Studies on LDH isoenzyme patterns in auricular pseu-
docyst fluid have shown that LDH-4 and LDH-5 predo-
minate quantitatively, despite a normal serum LDH
isoenzyme pattern.
10
Lactate dehydrogenase 4 and 5
have been reported to predominate in the auricular carti-
lage of rabbits, cows and humans.
21
Ickioka et al.
theorised that, as the LDH isoenzyme pattern of auricular
pseudocyst fluid was consistent with that of cartilage, and
as histological examination of pseudocyst walls revealed
cartilage degeneration, LDH may be released from dis-
rupted auricular cartilage during pseudocyst formation.
6
•This study assessed lactate dehydrogenase
(LDH) isoenzyme patterns in auricular
pseudocyst fluid and serum
•Cyst fluid had higher proportions of LDH-4
and LDH-5 and lower proportions of LDH-1
and LDH-2, compared with serum
•A characteristic LDH isoenzyme pattern was
identified which could assist auricular
pseudocyst diagnosis
Many treatment modalities have been reported for auri-
cular pseudocyst, but the problems of recurrence and
cosmetic appearance persist. Treatments include con-
servative management and surgical intervention, and
usually address cosmetic considerations. One
FIG. 1
Percentage distribution of analysed lactate dehydrogenase (LDH)
isoenzymes in cyst fluid and autogenous serum, in 20 patients
with auricular pseudocyst.
FIG. 2
Clinical photographs showing an auricular pseudocyst in the left
concha fossa of a 35-year-old woman, and aspirated clear, yellowish
cyst fluid, together with the percentage distribution of analysed
lactate dehydrogenase (LDH) isoenzymes in this patient’scyst
fluid and serum.
FIG. 3
Clinical photographs showing an auricular pseudocyst in the left
scaphoid fossa of a 30-year-old woman, and aspirated dark brownish
cyst fluid, together with the percentage distribution of analysed
lactate dehydrogenase (LDH) isoenzymes in this patient’scyst
fluid and serum.
LACTATE DEHYDROGENASE ISOENZYME PATTERNS IN AURICULAR PSEUDOCYST FLUID 481
successful approach is local aspiration followed by
local injection of a topical steroid or sclerosing agent,
followed by application of a compression dressing to
ensure a better cosmetic appearance of the pinna. A
more aggressive treatment comprises deroofing the
anterior leaflet of the cyst and curetting the posterior
leaflet to remove granulation tissue and debris. Such
deroofing surgery is a safe, easy and reliable procedure
for auricular pseudocyst treatment, if conservative
measures fail or are declined by the patient.
5,10,26
In the present study, cyst fluid was found to have
high percentage distributions of LDH-4 and LDH-5
and low percentage distributions of LDH-1 and LDH-
2, despite fairly normal serum LDH isoenzyme pat-
terns. Plotted graphically, the percentage distribution
of LDH isoenzymes had a positive gradient in cyst
fluid but a negative gradient in serum (Figure 1).
This analytical result can be applied clinically to help
improve the accuracy of auricular pseudocyst diagnosis in
clinically suspicious cases. This is illustrated by the
patient shown in Figure 3. This patient had previously
undergone needle aspiration of her cyst twice in a local
clinic before being seen at our hospital. The percentage
values of LDH-4 and LDH-5 were higher in the cyst
fluid than the serum. The percentage distribution plot
of the various LDH isoenzymes had a positive gradient
for cyst fluid but a negative gradient for serum.
Therefore, this patient was diagnosed with auricular
pseudocyst and successfully treated, with no recurrence
at the time of writing.
Conclusion
In this study of patients with auricular pseudocysts, the
percentage distributions of various LDH isoenzymes
differed in cyst fluid compared with autogenous
serum: percentage distributions of LDH-4 and LDH-5
were higher in cyst fluid than in serum, while those
of LDH-1 and LDH-2 were higher in serum than in
cyst fluid. This result could provide a useful, labora-
tory-generated marker assisting accurate diagnosis of
auricular pseudocyst in clinically suspicious cases, in
addition to observation of the usual clinical features.
This would facilitate successful treatment of the lesion.
Acknowledgement
No funding was received for this study.
References
1 Botella-Anton R, Matos Mula M, Jimenez Martinez A, Pinazo-
Canales MI, Castells-Rodellas A, Moragon-Gordon M.
Pseudocysts of the auricle. Clinical and histological studies of
3 cases. Ann Dermatol Venereol 1984;111:919–23
2 Heffner DK, Hyams VJ. Cystic chondromalacia (endochondral
pseudocyst) of the auricle. Arch Pathol Lab Med 1986;110:740–3
3 Tuncer S, Basterzi Y, Yavuzer R. Recurrent auricular pseudo-
cyst: a new treatment recommendation with curettage and
fibrin glue. Dermatol Surg 2003;29:1080–3
4 Engel D. Pseudocysts of the auricle in Chinese. Arch
Otolaryngol 1966;83:197–202
5 Salgado CJ, Hardy JE, Mardini S, Dockery JM, Matthews MS.
Treatment of auricular pseudocyst with aspiration and local
pressure. J Plast Reconstr Aesthet Surg 2006;59:1450–2
6 Ichioka S, Yamada A, Ueda K, Harii K. Pseudocyst of the
auricle: case reports and its biochemical characteristics. Ann
Plast Surg 1993;31:471–4
7 Lim CM, Goh YH, Chao SS, Lim LH, Lim L. Pseudocyst of the
auricle: a histologic perspective. Laryngoscope 2004;114:1281–4
8 Foglia Fernandez M, Gonzalez Compta X, Arias Cuchi G,
Sandoval Puig M, Nogues Orpi J, Dicenta Sousa M. An auricu-
lar pseudocyst. A report of 4 cases [in Spanish]. An
Otorrinolaringol Ibero Am 1998;25:121–9
9 Tan BY, Hsu PP. Auricular pseudocyst in the tropics: a multi-
racial Singapore experience. J Laryngol Otol 2004;118:185–8
10 Kanotra SP, Lateef M. Pseudocyst of pinna: a recurrence-free
approach. Am J Otolaryngol 2009;30:73–9
11 Choi S, Lam KH, Chan KW, Ghadially FN, Ng AS.
Endochondral pseudocyst of the auricle in Chinese. Arch
Otolaryngol 1984;110:792–6
12 Santos AD, Kelley PE. Bilateral pseudocyst of the auricle in an
infant girl. Pediatr Dermatol 1995;12:152–5
13 Saunders MW, Jones NS, Balsitis M. Bilateral auricular pseudocyst:
a case report and discussion. J Laryngol Otol 1993;107:39–41
14 Miyamoto H, Oida M, Onuma S, Uchiyama M. Steroid injection
therapy for pseudocyst of the auricle. Acta Derm Venereol 1994;
74:140–2
15 Zhu L, Wang X. Histological examinationof the auricular cartilage
and pseudocyst of the auricle. JLaryngolOtol1992;106:103–4
16 Stankevice D, Nielsen KO. Two cases of auricular pseudocyst
[in Danish]. Ugeskr Laeger 2009;171:907
17 Chen Q, Fei Y, Zhao T, Luo D, Wu B, Yang X. Research on the
immunological cause of auricular pseudocyst [in Chinese]. Lin
Chuang Er Bi Yan Hou Ke Za Zhi 2001;15:304–5
18 Chen Q, Zhao T, Yang X. The immunological cause of auricular
pseudocyst [in Chinese]. Zhonghua Er Bi Yan Hou Ke Za Zhi
1999;34:236–7
19 Glamb R, Kim R. Pseudocyst of the auricle. J Am Acad
Dermatol 1984;11:58–63
20 Takeda M, Tomita H, Goto N. Morphological characteristics of
the auricular blood vessels related to idiopathic pseudocyst of
the auricle. Auris Nasus Larynx 1990;17:199–210
21 Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase
isozymes in and intralesional steroid injection therapy for pseu-
docyst of the auricle. Int J Dermatol 2001;40:380–4
22 Secor CP, Farrell HA, Haydon RC 3rd. Auricular endochondral
pseudocysts: diagnosis and management. Plast Reconstr Surg
1999;103:1451–7
23 Han A, Li LJ, Mirmirani P. Successful treatment of auricular
pseudocyst using a surgical bolster: a case report and review
of the literature. Cutis 2006;77:102–4
24 Goktay F, Aslan C. Successful treatment of auricular pseudocyst
with clothing button bolsters alone. J Dermatolog Treat 2011;
22:285–7
25 Kim TY, Kim DH, Yoon MS. Treatment of a recurrent auricular
pseudocyst with intralesional steroid injection and clip com-
pression dressing. Dermatol Surg 2009;35:245–7
26 Chang CH, Kuo WR, Lin CH, Wang LF, Ho KY, Tsai KB.
Deroofing surgical treatment for pseudocyst of the auricle.
J Otolaryngol 2004;33:177–80
27 Ophir D, Marshak G. Needle aspiration and pressure sutures for
auricular pseudocyst. Plast Reconstr Surg 1991;87:783–4
28 Lee JA, Panarese A. Endochondral pseudocyst of the auricle.
J Clin Pathol 1994;47:961–3
29 Lim CM, Goh YH, Chao SS, Lynne L. Pseudocyst of the
auricle. Laryngoscope 2002;112:2033–6
Address for correspondence:
Dr Kuen-Yao Ho,
Department of Otolaryngology,
Kaohsiung Medical University Hospital,
100 Tzyou 1st Road,
Kaohsiung City 807, Taiwan
E-mail: kuyaho@cc.kmu.edu.tw
Dr K-Y Ho takes responsibility for the integrity of the
content of the paper
Competing interests: None declared
P-P CHEN, S-M TSAI, H-M WANG et al.482
