Case Report
Surgical Excision as the Management of Keloid on the Left Ear Lobe
Presentator : dr. Muhammad Gusti Haryandi
Advisor : dr. Ramlan Sitompul, Sp. T.H.T.B.K.L., SubSp.F.P.R.(K)
Moderator : dr. Carlo Maulana Akbar, Sp. T.H.T.B.K.L., M.Ked(ORL-HNS)
Assessors : 1. Prof. Dr. dr. Farhat, Sp. T.H.T.B.K.L., SubSp.Onko.(K) , M.Ked(ORL-HNS)FICS 2. Dr. dr. Yuliani M. Lubis, Sp.T.H.T.B.K.L.
Day/ Date : Thursday, June 7th 2024 Time : 09.00-10.00 am
Place : Meeting Room ORL-HNS Department, Adam Malik Hospital
OTORHINOLARYNGOLOGY- HEAD AND NECK SURGERY DEPARTMENT
FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA
MEDAN 2024
Surgical Excision as the Management of Keloid on the Left Ear Lobe Muhammad Gusti Haryandi, Ramlan Sitompul
INTRODUCTION
When a pathological wound heals, elevated scar tissue sometimes spontaneously retracts, extending beyond the original borders. This condition is known as keloids. The four overlapping phases of cutaneous healing as inflammation, proliferation, remodeling, coagulation, and hemostasis are caused by the normal interaction of several genes and molecules (Wang et al., 2023).
Extended inflammation causes a histological imbalance that manifests as keloid formation, which is defined by an excess of dermal connective tissue deposited on the skin. Reduced collagen breakdown following dermal or subcutaneous tissue injury and enhanced collagen production in fibroblasts are the causes of this phenomenon (Betarbet & Blalock, 2020).
Although keloids may appear with unrecognized origin, this process commonly occurs in susceptible individuals after superficial or deep cutaneous trauma such as operations, ear piercing, trauma, burns and some cutaneous disorders (H. Do Kim et al., 2016).
Risk factors include younger age, pigmented skin, mobile sites with high tension and genetic predisposition. Keloids are occur in 5-15% of wounds, any traumatized region of the body including abdomen, chest, shoulder, and upper back can be a potential site for keloid appearance. However, the head and neck region, especially earlobes and the helix of the auricle are the most common sites for keloid formation. Ear lobule keloids account for 2.5% of cases which are usually secondary to ear piercing (Liu & Yuan, 2019; Mohammadi et al., 2019).
For both surgeons and patients, managing lesions associated with undesirable cosmetic deformity and psychological issues can be difficult.
Furthermore, additional keloids-related morbidities like discomfort, pruritus, ulceration, and restricted motion are frequent worries that can significantly burden the condition's largely youthful patients, particularly if they manifest in
the facial area. Since keloids usually exhibit a recurrent course and are resistant to treatment, using various modalities has been shown to significantly improve the effectiveness of treating these conditions .(S. W. Kim, 2021)
One typical way of keloids removal is surgical excision. Excision, however, creates a fresh wound and may produce a keloid that is larger or similar. Because keloids usually indicate a relapsing course after excision and that they are often resistant to treatment, a number of adjuvant therapies, such as intralesional corticosteroid injection, are recommended in order to reduce the possibility of recurrence after excision (Ojeh et al., 2020).
CASE REPORT
A 18-year-old male was admitted to Adam Malik General Hospital,Medan in February 20th 2024 with a main complaint of a lump on the left posterior auricle since 7 months ago. The lump was getting bigger gradually.
After having trauma on his ear, the patient suffered a wound on the left ear which then formed a lump which was getting bigger. The lump was itchy and is not painful. History of bleeding was denied, but the patient complains of cosmetic problems due to the lump. The patient previously had a history of ear lobe surgery 3 months ago due to keloid of the left ear auricle. The patient also previously had a Triamcinolone Acetonide (TCN) injection but the keloid size did not decrease. Maybe this is caused by improper injection technique. The patient's parents and younger siblings also had a history of keloids in wounds on the body From physical examination, vital sign was normal. On ear examination, we found a lump on the left posterior auricle. The lump consistency was round- lobulated shape, firm, smooth, with regular borders with size 3 x 2 x 2 cm (Figure 1). There was no pain on palpation. Ear canal and tympanic membrane was normal. There was no abnormality on the right ear. Nose and throat examination was normal. There are also scars on several areas of the skin of the hands and feet which form keloids too. From laboratory examination there was no abnormality, and Chest-Xray was normal.
Figure 1. The Left Posterior Auricle Mass
We diagnosed the patient with keloid on the left auricle and we planned to performed surgical excision on February 23st 2024. Patient on the supine position under general anesthesia. After disinfection with povidone iodine and alcohol 70%, we infiltrated lidocaine and epinephrine 1:100.000 compositum as local anesthesia and we performed skin marking for the site of surgery (Figure 2, 3).
Figure 2. Infiltration Figure 3. Skin marking We performed incision within the edge of the mass along the skin marking.The removal of entire mass from its origin was confirmed by palpating
the remaining cartilage of auricle, and the entire mass was dissected completely.
Bleeding was controlled. The wound were closed with 5-0 nylon after trimming to get the perfect contour (Figure 4,5,6). In order to maximize cosmetic outcomes, efforts were made to minimize tension on closure. The mass was sent to Pathological Anatomy to be analyzed (Figure 7).
Figure 4. Incision within the edge of the mass. Figure 5. Suturing the wound
Figure 6. Wound sutured Figure 7. The mass
A splint dressing consisting of sterile gauze and topical antibiotic ointment were applied for 48 hours. After 2 days patient was discharged and clinical evaluations were made 1 week post operation (Figure 8). In the first control on the outpatient clinic, we removed the stitches on the surgical wound. The patient was planned to receive a TCN injection but the patient refused.
Figure 8. Post surgery evaluation Figure 9.3 months post surgery evaluation Histopathological result for the mass: Keloid of left auricular lobe Macroscopic Auricula Lobe: Tissue with a size of 3x2x2cm which has been cleaved, looks solid, gray rubbery. Microscopic: Tissue preparation from auricular covered with stratified squamous epithelium with normal nuclear morphology.
The stroma consists of thickened fibrous connective tissue and collagen, composed of fibrocyste cells and fibroblasts with oval to spindle shaped nuclei, fine chromatin evenly distributed, cytoplasm is not clear. Blood vessels dilatation and congestion.
Three month after the procedure, the patient's wound condition was good. There were no recurrences and there were no complaints about the surgical wound (Figure 9).
DISCUSSION
Keloid is a fibroproliferative disease that happens when fibroblasts work too much, which usually happens after an accident or surgery that causes a scar to form. These abnormal growths, which can be identified by their bright red color, tend to spread beyond the original trauma site and usually stay there, with only a few cases of natural regression (Fu et al., 2024). Ear lobule keloid is simpler to diagnose than keloid in other body parts. Keloid develops considerably beyond the boundaries of the wound and appears at the site of the piercing as a solid, fibrous, pink to brown-colored nodule of varying size. In most cases, it does not spontaneously retreat. Patients often complain of discomfort and pruritus. The telangiectatic, erythematous, and sometimes hyperpigmented keloid scars (Bhat, 2014). In this case, we found a lump on the left posterior auricle. The lump consistency was round- lobulated shape, firm, smooth, with regular borders with size 3 x 2 x 2 cm. There was no pain on palpation.
The most common sites which involved are the chest, upper back, earlobes, shoulders, and arm. Keloids are caused by a pathological process (burns, varicella, acne) or trauma (surgery, burns, scalds, body piercing) (Madura et al., 2021). The keloid in this case was probably promoted by a constellation of factors, the most important were the initial ear wounding and repetitive pressure/friction on the healing wound.
Individuals of all ethnic backgrounds can form keloid and hypertrophic scars as a familial predisposition was believed to exist. Keloid formation is approximately greater in highly pigmented ethnic groups than in whites. The pathogenesis of keloid scar is complex which involves both genetic and environmental factors (Mohammadi et al., 2019). The patient's parents and younger siblings also had a history of keloids in wounds on the body.
Prior to understanding the etiology and management of keloids, it is crucial to comprehend the typical course of wound healing. Inflammatory phase, proliferative or granulation phase, and maturation or re-modeling phase are the three stages of normal wound healing. A more persistent and severe form of fibrotic illness, keloids are aberrations in the basic processes of wound healing, where there is a clear imbalance between the anabolic and catabolic phases (Shamala, 2013).
Experiments on keloids have shown that they have a long inflammatory time during which immune cells keep releasing cytokines and growth factors.
Studies of keloid tissue through histology have shown that it has a lot of inflammatory cells, such as mast cells, macrophages, lymphocytes, and neutrophils, as well as Th2 cytokines, such as interleukin (IL)-4 and IL-13, which are also involved in itching (Hawash, AA et al., 2021). This patient had complaint about feeling itch on the lump area.
For both patients and doctors, the earlobe keloid is more stressful because it looks bad and is hard to treat. It also comes back more often, which is frustrating for patients. When doctors see an ear keloid, it's usually between 1 and 3 cm in size. The earlobe keloid has only been treated by surgery excision, and about 60% of the time it comes back (Ramesh & Mohan, 2018).
Straatsma talked about cutting out the middle part of the scar, leaving about 3 mm of its edge exposed, to reduce its size and stop "normal" cells from growing into it. A different study looked back at 15 lower leg scars and compared skin graft coverage and intralesional versus extralesional excision. The extralesional method left a scar border of 3–5 mm, while the intralesional method left a scar border of 2 mm. The results showed a statistically significant difference in favor of the extralesional method (100% recurrence rate vs. 33% rate of recurrence; P = 0.011). It looks like an infiltrative, proliferating margin with tumor-like behavior was left behind after intramarginal resection (Figure 10) (Goutos, 2019). We performed incision within the edge of the mass along the skin marking. The removal of entire mass from its origin was confirmed by palpating the remaining cartilage of auricle, and the entire mass was dissected completely
Figure 10. Type of excision
Even though there is a lot of writing about the histomorphological structure of keloids, it is still hard to figure out the best way to treat patients. There isn't a set of rules that can say which of the many treatment methods for keloids are most likely to work based on a low rate of return and a good cosmetic outcome. In some cases, doctors use nonsurgical treatments along with surgical removal. This depends on where the problem is located (Mohammadi et al., 2019).
The best drug for intralesional corticosteroids is triamcinolone acetonide (TCN). There have been studies on keloids in general and on how to treat them, but the best concentration and amount of TCN for treatment have not yet been found. It has been suggested that the concentration should be between 10 mg/ml and 40 mg/ml, and the total amount should be 100 mg. The Food and Drug Administration (FDA) in the United States has only cleared TCN as a way to treat keloid. But putting it on the skin doesn't help treat keloids (Carvalhaes et al., 2015).
This patient previously had a TCN injection but the keloid size did not decrease.
Maybe this is caused by improper injection technique.
At first, the shot shouldn't go into the middle of the hard mass of the keloid or hypertrophic scar. This is because the injection fluid won't get deep enough into the tissue. When the hard mass is injected, the pressure rises, which may also hurt. It is better for the needle to go into the scar from where it meets the
(because it is softer there) or the most swollen part of the scar where the normal skin meets the scar (Figure 11) (Ogawa et al., 2019).
Figure 11. The target of injection
People who have had a keloid before or who have other risk factors should not get their bodies pierced or have other cosmetic treatments. If you don't want to miss possibly cancerous conditions, especially ones with strange symptoms, keloid scars should be sent for histopathology.
CONCLUSION
A 18-year-old male with a main complaint of a lump on the left posterior auricle since 7 months ago. We performed surgical excision with extralesion excision. We observed the patient and didn’t find any reccurences happened on the patient, and the patient had no complaint about the surgical wound.
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