How to manage a painful epidermal inclusion cyst behind the ear?

Management of Painful Epidermal Inclusion Cyst Behind the Ear

Complete surgical excision is the definitive treatment for painful epidermal inclusion cysts behind the ear to prevent recurrence, infection, and rare malignant transformation. 1

Initial Assessment

• Evaluate for signs of infection: erythema, warmth, tenderness, fluctuance
• Assess size, location relative to auricular cartilage, and mobility of the cyst
• Determine if the cyst is attached to underlying structures
• Check for fistula formation or ulceration which may indicate complications

Management Algorithm

For Non-Infected Cysts:

1. Primary Treatment: Complete Surgical Excision

   • Excise the entire cyst including the wall to prevent recurrence
   • Use marker sutures for proper specimen orientation 2
   • Consider minimally invasive techniques if preservation of normal tissue is critical 2
   • Send the entire specimen for histopathological examination to rule out malignancy 1, 3

2. Surgical Approach

   • Local anesthesia without epinephrine
   • Careful dissection to avoid rupturing the cyst
   • Complete removal of cyst wall
   • Primary closure if possible
   • Consider appropriate wound management based on location 2

For Infected/Inflamed Cysts:

1. Initial Management

   • Incision and drainage if fluctuant
   • Culture the contents (note: 47% of inflamed cysts show no bacterial growth or normal flora) 4
   • Consider atraumatic cleaning with aural suctioning under microscopic guidance if near ear canal 5

2. Antibiotic Therapy

   • For culture-positive infections: targeted antibiotics based on sensitivity
   • For presumed infection: topical antibiotic drops if near ear canal 5
   • For significant surrounding cellulitis: consider oral antibiotics covering Staphylococcus aureus

3. Definitive Treatment

   • Schedule complete excision after resolution of acute inflammation
   • Ensure complete removal of cyst wall to prevent recurrence 3

Pain Management

• For mild to moderate pain: acetaminophen or NSAIDs (ibuprofen)
• For severe pain: consider short-term opioid combination therapy
• Administer analgesics at regular intervals rather than as needed for better pain control 5

Special Considerations for Retroauricular Location

• Proximity to auricular cartilage increases risk of auricular perichondritis if infected 2
• If perichondritis develops, treat with fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) 2
• Surgical drainage is necessary if abscess forms 2
• Keep the ear dry during treatment period 5

Follow-up and Monitoring

• Monitor for signs of recurrence
• Histopathological examination is mandatory to rule out malignant transformation 1, 3
• Any cyst that grows rapidly, reaches large size, ulcerates, develops a fistula, or recurs after treatment should raise suspicion for possible malignancy 1

Important Caveats

• Complete excision is superior to incision and drainage alone, which often leads to recurrence
• Incomplete removal of the cyst wall is the most common cause of recurrence
• Although rare, malignant transformation to squamous cell carcinoma has been reported 1
• Aesthetic considerations are important given the visible location behind the ear 3

By following this approach, painful epidermal inclusion cysts behind the ear can be effectively managed with minimal risk of recurrence and optimal cosmetic outcomes.