Chondrodermatitis Nodularis Helicis

What is it?

Chondrodermatitis nodularis helicis is a painful inflammatory condition affecting the ear. Chondrodermatitis nodularis helicis is inflamed cartilage of the ear with small, intensely painful nodules on the rim or border of the helix of the ear. Chondrodermatitis nodularis helicis (CNH) is most often seen in middle-aged men and results in a benign tender lump in the cartilaginous portion of the ear. Although not a rare condition in females, women account for approximately 10% of the cases. Blacks as well as whites may be afflicted. The affected area may only be a few millimeters wide but to lie on it causes exquisite discomfort. There is often a tiny central core which may discharge a small amount of scaly material. The cause appears to be pressure between the head and the pillow at night. CNH occurs in people who sleep predominantly on one side. There is no correlation with occupation, season, or geography, except that local repeated trauma to the ear may be a factor in telephone operators, and in nurses or physicians using a stethoscope. Hearing protectors can also contribute to chondrodermatitis. It can be precipitated by minor trauma, such as tight headgear or a telephone headset, or by exposure to cold. Reduction in the local blood supply of the ear with aging prevents adequate healing. 

What causes it?

Several anatomic features of the ear appear to predispose it to this distinctive clinical picture. First, the ear's exposed position subjects the ear to constant mechanical trauma. Environmental trauma from sun, wind, and extremes of temperature also has an effect. Trauma leads to thinning of skin, thinning of cartilage, loss of elastic tissue, and severe degenerative vascular and connective tissue changes. These changes multiply the ear's vulnerability to injury. Second, there is no subcutaneous tissue padding the external ear to insulate it. Third, only small dermal blood vessels supply nourishment to the skin of the ear and elastic cartilage below. Fourth, cartilaginous aberrations common in the area of the human ear where the painful nodule localizes. It seems probable that minor trauma often precipitates focal dermal inflammation, edema, and cartilage necrosis to initiate the disease. Inadequate circulation prevents tissue repair and leads to secondary cartilage inflammation (perichondritis) and epidermal damage.

How does it progress?

An intensely painful, small, firm nodule on the helix of the ear is typical only of the injured and inflamed cartilage of chondrodermatitis nodularis helicis. Characteristic histopathology under the microscope establishes the diagnosis in the doubtful lesion. Typical lesions are firm, non-mobile, round to oval, with sloping margins, either embedded in the ear's skin or elevated several millimeters. Chondrodermatitis nodularis helicis nodules of the ear appear spontaneously, enlarge quickly to maximum size, and can then remain stationary unless altered by infection or trauma. Pain or tenderness is almost always the initial presenting complaint. Pain or tenderness of the ear may occur spontaneously, or may be intensified by pressure or cold. Intense pain and stabbing sensations lasting several hours can be common. Removal of the crust may relieve the pain. A history of ulceration or drainage frequently obtained. Because of the location, chondrodermatitis nodularis helicis may be associated with precancers and cancers of the ear. The chondrodermatitis nodularis helicis is not cancerous, but sunexposed ears in and of themselves are often at high risk for skin cancer. No significant relation with any systemic disease has been found. Spontaneous disappearance has been noted but is rare. Remissions of months to years may occur, but the disease generally continues to be active indefinitely unless adequately treated.

How is it treated?

It is important to avoid sleeping on the affected ear. Check that your pillow is soft and consider fashioning a "hole" in it so there is no pressure on the painful spot. Try to sleep evenly on both sides, but it is best not to sleep on your ears.  Wear a warm hat over the ears when outside in the cold and wind.  If the CNH is ulcerated, apply an antibiotic ointment under a light dressing.  Dr. Jacobs may treat the lesion with a cortisone injection or freeze it with liquid nitrogen. High-potency topical corticosteroids are occasionally effective and should be tried first. Single or multiple intralesional injections of corticosteroids will often cause lesions to regress or disappear (triamcinolone acetonide 10 to 40 mg/ml). Cryosurgical, chemical, or electrosurgical ablation is often helpful. The definitive treatment, excisional surgery, eliminates the mechanical squeezing of the dermis by removing the pathologic tissue. Excision relieves the pain by cutting the nerves, and reduces the amount of projecting rim of helical cartilage. Unfortunately, even excision, recurrence rates of 18% and 31% have been reported. Because chondrodermatitis nodularis helicis is caused by repeated trauma, the most important point in treatment is to stop the offending trauma. This means, that the patient must do something about the hard telephone against the ear. Suggestion: Use a phone pad. This also means that the patient should avoid sleeping on the affected ear. A special pillow made for patients with chondrodermatitis nodularis helicis is available by calling: 800-255-7487 or 915-675-5452. This pillow is shaped like a donut with a hole in the middle. The address: CNH Pillow, Inc. P.O. Box 1247  Abilene, Texas  79604 Toll Free: (800) 255-7487