What is the treatment for a painful bump on the helix and behind the ear?

Treatment of Painful Bump on Helix and Behind Ear

The most likely diagnosis is chondrodermatitis nodularis helicis (CNH), which should be treated initially with topical nitroglycerin 0.2% applied to the lesion for 1-2 months, with surgical excision reserved for treatment failures or when malignancy cannot be excluded. 1, 2

Initial Clinical Assessment

Distinguish between three primary conditions based on location and characteristics:

• CNH presents as a painful nodule or ulcer specifically on the helix or antihelix, typically measuring a few millimeters, with pain out of proportion to the size of the lesion 3, 4
• External otitis (behind ear involvement) presents with ear canal pain, tenderness, and possible discharge, with pain worsening when the pinna is manipulated 5, 6
• Perichondritis presents as painful swelling and warmth that spares the earlobe, often following trauma or piercing, with acute tenderness when deflecting the auricular cartilage 7

First-Line Treatment for CNH (Helix Bump)

Start with conservative medical management:

• Apply topical nitroglycerin 0.2% directly to the lesion, which achieves 93% clinical improvement with mean treatment duration of 1.8 months and excellent tolerance 1
• Eliminate pressure sources on the affected ear during sleep by using specialized pillows or changing sleep position, as trauma and pressure are key contributing factors 3, 1
• Reassess at 6-8 weeks to determine response, as most responders show improvement within this timeframe 1

Important Caveat for CNH

• Excisional biopsy is mandatory if malignancy cannot be excluded clinically, as CNH can mimic basal cell or squamous cell carcinoma, particularly in patients over 50 years old 4, 8
• Surgical excision should include undermining between skin and cartilage at the ellipse ends and trimming cartilage spikes to create smooth transition and minimize recurrence at excision tips 2

Treatment for External Otitis (Behind Ear)

If the pain extends behind the ear with ear canal involvement:

• Use topical antimicrobial drops as first-line therapy, which deliver concentrations 100-1000 times higher than oral antibiotics and target Pseudomonas aeruginosa and Staphylococcus aureus 6
• Administer drops with patient lying affected-ear-up for 3-5 minutes to ensure adequate canal penetration, using tragal pumping to eliminate trapped air 6
• Avoid neomycin-containing preparations if tympanic membrane integrity is uncertain, as neomycin causes ototoxicity with non-intact membranes and contact sensitivity in 13-30% of chronic cases 6
• Expect improvement within 48-72 hours; if no improvement occurs, consider treatment failure, fungal co-infection, or misdiagnosis 6

Treatment for Perichondritis

If cartilage infection is suspected (painful swelling sparing earlobe):

• Start fluoroquinolone antibiotics immediately to cover Pseudomonas, as this is the predominant pathogen in perichondritis and delays lead to permanent cartilage deformity 7
• Perform incision and drainage if abscess forms, though cosmetic outcomes are compromised once this stage is reached 7
• Monitor closely during the first month, particularly in warm weather when infection risk peaks 7

Critical Pitfalls to Avoid

• Never dismiss a persistent painful nodule on the helix without considering malignancy, especially in older patients or those with sun-damaged skin, as CNH mimics skin cancer 4, 8
• Do not prescribe oral antibiotics for uncomplicated external otitis, as they add cost without improving outcomes and topical therapy is vastly superior 6
• Avoid treating suspected cartilage infections without Pseudomonas coverage, as inadequate antibiotic selection leads to treatment failure and permanent deformity 7
• Never use epinephrine-containing local anesthesia on the ear, as it compromises the already tenuous blood supply 7

When to Escalate Care

• Refer for biopsy if the lesion does not respond to 2 months of conservative therapy or if clinical features suggest malignancy 1, 2
• Escalate to systemic antibiotics if external otitis extends beyond the ear canal or if the patient is immunocompromised or diabetic 5, 6
• Consider necrotizing otitis externa in elderly, diabetic, or immunocompromised patients with severe pain and granulation tissue at the bony-cartilaginous junction, requiring imaging and aggressive systemic therapy 9, 5