Indian Journal of Dermatology
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Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 473-474
A purple retro auricular nodule


1 From the Department of Dermatology, Fattouma Bourguiba University Hospital, Research Laboratory LR20SP03A, University of Monastir, Monastir, Tunisia
2 Departments of Anatomopathology, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
3 Department of Otorhinolaryngology, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
4 Department of Anatomopathology, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia

Date of Web Publication2-Nov-2022

Correspondence Address:
Nesrine Ben Salah
Department of Dermatology, Fattouma Bourguiba University Hospital, Research Laboratory LR20SP03A, University of Monastir, Monastir
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_814_21

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How to cite this article:
Salah NB, Lahouel I, Zili I, Bellallah A, Rouatbi J, Koubaa J, Zakhama A, Zili J. A purple retro auricular nodule. Indian J Dermatol 2022;67:473-4

How to cite this URL:
Salah NB, Lahouel I, Zili I, Bellallah A, Rouatbi J, Koubaa J, Zakhama A, Zili J. A purple retro auricular nodule. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 4];67:473-4. Available from: https://www.e-ijd.org/text.asp?2022/67/4/473/360356




Clinical and histopathological findings

A 68-year old man presented with a 3-year history of a slow-growing and painful nodule in the right retro auricular region. There was no history of trauma or infection. Physical examination revealed a small, purple, firm and mobile subcutaneous nodule, measuring approximately 1.5 cm in diameter [Figure 1]. Telangiectasia was scattered diffusely over the lesion. There was neither thrill nor bruit observed over the nodule. Dermoscopic examination revealed a symmetric lesion with a purple appearance. It was composed of a central white pattern with chrysalis structures in addition to a vascular pattern with dotted and fine linear vessels. These vessels crossed the spaces within the lesion and formed complete or incomplete polygons [Figure 2]. The nodule was completely excised. Its histopathologicalexamination revealed a well-encapsulated lesion composed of vascular channels in a collagenized connective tissue and spindle-shaped smooth muscle cells [Figure 3]a and [Figure 3]b. The vessels were principally venous. The smooth muscle cells showed minimal nuclear atypia with no mitosis [Figure 3]c. There was no evidence of inflammatory infiltrate, granulation tissue, or haemorrhage. The lesion was also free of adipose tissue. In the immunohistochemical examination, the perivascular smooth muscle cells and the muscular wall of thick blood vessels showed immunoreactivity for the smooth muscle antigen (SMA) [Figure 3]d. The endothelial cells were stained with a CD34 antibody. There was no recurrence during the postsurgical period.
Figure 1: A small purple subcutaneous nodule in the right retro auricular region

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Figure 2: Dermoscopic findings: A symmetric lesion with purple appearance composed of central white pattern, chrysalis structures and vascular pattern with dotted and fine linear vessels

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Figure 3: (a) A well limited proliferation composed of fascicles of smooth muscle cells admixed with vessels (HE × 40) (b) Tumor cells appear to originate and radiate from the vessel walls (HE × 100) (c) Smooth muscle cells show minimal nuclear atypia with no mitosis (HE × 400) (d) Diffuse and strong positivity of tumor cells with Smooth muscle actin (SML)

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Diagnosis

Venous type angioleiomyoma.


   Discussion Top


Angioleiomyomas, a subtype of leiomyomas, are rare, benign, smooth muscle tumors that arise from the tunica media of vessels.[1] They are slow-growing tumors that appear in the third to fifth decade of life but have been described also in children. Their typical clinical manifestation is a skin-colored, firm and solitary subcutaneous nodule. It has been suggested that angioleiomyoma may be a form of hamartoma, a vascular malformation, or an intermediate lesion occurring during the progression of haemangioma to a leiomyoma.[2] Several etiologies for angioleiomyoma have been proposed, including local infection, hormonal influences, and venous stasis.[2] The majority of these tumors involve the lower extremities, with fewer than 10% of lesions involving the head and neck.[3] Although isolated cases have been reported in the gastrointestinal tract, inferior turbinate, larynx, and submandibular region, fewer than a dozen cases involving the ear specifically have been described.[4] The tumor was located over the helix, pinna, and lobule in these reports.[4] To our knowledge, its localization in the retro auricular region like in our case has not been previously described. Painful nodular lesion on the ear requires the exclusion of differential diagnosis that includes venous malformation, hemangioma, glomus tumor, angiomyolipoma, and angioleiomyosarcoma. In our case, the presence of a white pattern with dotted and fine linear vessels with chrysalis structure are nonspecific dermoscopic features.[3] However, the appearance of the tumor on dermoscopy as a purple nodule dotted with vessels was typically described as angioleiomyoma of the auricle.[3] These dermoscopic findings are mainly related to the unique anatomical structure of the auricle. The diagnosis of angioleiomyoma and its classification into capillary or solid, cavernous and venous are usually made with a histopathological examination.[1] Complete surgical excision is the mainstay of treatment and is curative. Recurrence after complete excision is rare.[1] Malignant degenerations have been reported in recurrent tumors.[5] There is only one case report that described an occurrence of an angioleiomyoma in association with a leiomyosarcoma.[5]

Learning points

  • Angioleiomyoma is rarely found in the ear.
  • Angioleiomyoma of the auricle is typically painless and purple in colour.
  • The purple appearance of the tumor on dermoscopy seems to be characteristic of the angioleiomyoma of the auricle. This dermoscopic finding is related to the unique anatomical structure of the auricle.
  • Complete surgical excision is the mainstay of treatment.
  • Recurrence is rare and malignant degeneration is exceptional.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hachisuga T, Hashimoto H, Enjoji M. Angioleiomyoma: A clinicopathologic reappraisal of 562 cases. Cancer 1984;54:126-30.  Back to cited text no. 1
    
2.
Wang CP, Chang YL, Sheen TS. Vascular leiomyoma of the head and neck. Laryngoscope 2004;114:661-5.  Back to cited text no. 2
    
3.
Kimura R, Sugita K, Goto H, Yamamoto O. A small nodule on the auricle. Clin Exp Dermatol 2019;44:203-5.  Back to cited text no. 3
    
4.
Kim HI, Roh SG, Lee NH, Yang KM, Park HS. Angioleiomyoma of the auricle. Arch Plast Surg 2013;40:68-9.  Back to cited text no. 4
    
5.
Nishio J, Iwasaki H, Ohjimi Y, Ishiguro M, Kobayashi K, Nabeshima K, et al. Chromosomal imbalances in angioleiomyomas by comparative genomic hybridization. Int J Mol Med 2004;13:13-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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