What is the appropriate evaluation and treatment for a patient with a persistent lump in the ear lobe for several months?

Evaluation and Management of a Persistent Earlobe Lump

A persistent lump in the earlobe for several months is most likely an epidermoid (epidermal inclusion) cyst and should be evaluated with physical examination to assess size, mobility, and concerning features, followed by complete surgical excision with histopathological examination to confirm the diagnosis and exclude malignancy. 1, 2

Initial Clinical Assessment

Examine the lump for specific characteristics:

• Location within the earlobe – the lobule is the most common site for benign auricular masses (44.4% of cases) 2
• Size and growth pattern – document dimensions and ask about rate of enlargement 1, 3
• Mobility and attachment – benign epidermoid cysts are typically mobile and not fixed to underlying structures 1, 3
• Skin changes – look for a central punctum (characteristic of epidermoid cysts), erythema, or ulceration 1, 3
• Pain or tenderness – typically absent in uncomplicated epidermoid cysts but may indicate infection or other pathology 3
• History of prior ear surgery – previous middle ear procedures can lead to epidermal inclusion cysts that may present years later 4

Differential Diagnosis to Consider

The most common pathologies for earlobe masses include:

• Epidermoid cysts (25.3% of auricular masses) – the most frequent diagnosis 2
• Hypertrophic scar or keloid (18.9% combined) – particularly with history of ear piercing 2
• Fibrous tissue or accessory ear (9.5%) 2
• Chronic inflammation or nevus (7.9%) 2
• Hemangioma (4.7%) 2
• Rare entities – cylindroma, though typically in the external auditory canal rather than lobule 5

Definitive Management

Complete surgical excision is the treatment of choice:

• All earlobe masses should be completely excised rather than observed, given the several-month duration of this lesion 1, 2
• Excision technique – remove the entire cyst with intact capsule to prevent recurrence; the wound can typically be closed primarily with simple sutures 1
• Histopathological examination is mandatory – despite clinical suspicion of benign disease, all excised masses must be sent for pathology to exclude malignancy, as rare malignant transformation can occur in epidermoid cysts 1, 3

Critical Pitfalls to Avoid

• Do not rely on clinical diagnosis alone – always obtain histopathological confirmation, as malignancy can occasionally develop in what appears to be a benign cyst 1
• Do not perform incomplete excision – partial removal or simple drainage leads to high recurrence rates 1
• Do not dismiss the possibility of extension from deeper structures – in patients with prior ear surgery, consider that the mass could represent extension of pathology from the middle ear or mastoid 4
• Do not delay excision – masses present for several months are unlikely to resolve spontaneously and warrant definitive treatment 1, 2

Follow-Up

• Post-excision surveillance – examine the surgical site at 6 months to assess for recurrence 1
• Review pathology results – ensure histology confirms the presumptive diagnosis and shows clear margins 1
• If pathology reveals unexpected findings (atypical features, malignancy), refer to appropriate specialist for further management 3