British Journal of Dermatology 1996; 135; 550-554.

Weathering nodules of the ear: a clinicopathological study

G.M.KAVANAGH.* J.W.B.BRADFIELD.* CM.P.COLLINS AND C.T.C.KENNEDY

University Departments of Dennatology and 'Pathology. Bristol Hoyal Infirmary. Bristol. U.K.

Accepted for publication 19 February 1996

S u m m a r y Twenty-five cases of distinctive ear noduies on the helices of the ears in elderly males are presented.We believe the clinicopathological features of these lesions allow them to he defined as a distinctentity. They are probably more common than is currently recognized. Histologieaily. a typical nodulecomprises a spur of fibrous tissue with a focus of cartilage metaplasia. While the pathogenesis ofweathering nodules remains unclear, there is an association with age and chronic UV exposure.

A nodule on the ear rarely escapes attention. Evenwhen asymptomatic, discovery is usually made eitherby the patient who is worried about cancer, or by thephysician for whom the nodule may identify anotherdisease. Our attention was drawn to these distinctivenodules on the helices of the ear, on referral of twopatients for diagnosis. While recognized anecdotally bysome of our dermatologists and ENT specialists as'degenerative' lesions not infrequently seen in elderlypatients, a review of the literature failed to reveal aclinical or histopathological description. The aim of ourstudy was to define these nodules clinically andhistologically.

Materials and methods

Of the 25 patients studied, four were referred primarilyfor diagnosis of ear nodules. The remainder were seenfor other dermatological conditions and the nodulesnoted as additional clinical findings. Eight underwenta wedge excision biopsy of a nodule, after informedconsent. A concomitant chondrodermatitis nodularishelicis (CNH) lesion was also excised from one patientto provide a histologieal comparison. Biopsies were fixedin formalin, sectioned at multiple levels and stainedwith a variety of stains including haematoxylin andeosin, van Gieson (collagen). Miller's stain (elastic tissue),mucin stains and a variety of immunohistochemical stains.

Clinical findings

All 2 3 patients were male and Caucasian. The medianage was 79, with a range of 44-91 years. Similar

Correspondence: Dr G.M.Kavanagh, Department of Dennatology, TheRoyal Infirmary of Edinburgh NHS Trust. Lauriston Building.Edinburgh EH J 9YW, U.K.

nodules have not so far been observed in females.Twenty patients had an outdoor occupation, the otherfive each had a hobby which involved spendingprolonged periods of time outdoors. All nodules hadbeen present for a least 1 year and typically wereasymptomatic. There was no history of infiammationat any stage. Frevious clinical diagnoses involving thehead and neck area included actinic keratoses (10patients). CNH (five patients), squamous cell carcinoma(four patientsVand basal cell carcinoma (two patients).Two patients who experienced pain precipitated by cold.also suffered from chilblains of the hands. Two patientshad had several nodules treated previously with cryother-apy prior to referral, with no local recurrence.

In 20 patients, the nodules were bilateral. All werelocated on the free margin of the helix. Loss of theoverhang with marked thinning of the helical rim wasnoted in several cases. Multiple nodules were present in18 of 2 5, forming a chain to produce a scallopedappearance of the helix (Fig. 1). Individual lesionswere white or skin coloured and non-tender. Theymeasured 2-3mm in diameter and 1-2mm inheight, had a smooth surface with occasional scaling.and a gritty texture suggestive of cartilage (Eig. 2).Significant actinic damage on other exposed sites wasnoted in 18 patients.

To study the prevalence of weathering nodules (WN)in the general population from a similar catchment areato that of our subjects. 100 geriatric male inpatients(median age 73, range 65-9 3) were examined. Fourpatients were identified with identical asymptomaticnodules, three of whom had had outdoor occupation.s.

We also identified 40 patients with a diagnosis ofCNH from our diagnostic index and reviewed theirelinical details, paying particular attention to theiroccupation and sex. Interestingly, despite previous

550 © 1996 British Association of Dermatologists

WEATHERING NODULES OF THE EAR 551

1. Mullipk' ivhilisii nodules on the upper helix.

reports of this condition occurring predominantly inmale subjects, there was an equal sex incidence amongthese patients and only five subjects had an outdooroccupation.

Histological findiniis

The nodule which was palpable clinically appeared tocomprise a focus of cartilage overlying the edge of thepinna cartilage (Fig. 3). By serially sectioning some ofthe samples it was possible to show that this was not aseparate nodule of cartilage, but comprised cartilagemetaplasia within a spur of fibrous tissue extending upfrom disrupted perichondrlum of the underlying pinnacartilage (Fig. 4). In some cases, the fibrous tissueextended almost up to the epidermis (Fig. 5). In othersamples, by cutting sections en face, the spur of carti-lage was clearly seen to arise from the underlying pinnacartilage (Fig. A). In most cases, the fibrous tissue wasrelatively acellular, but in some specimens there were

Figure 2. Typical weathering nodules, with a consistency suggestive ofcartilage.

numerous cells with spindle-shaped nuclei. These cellswere vimentin positive, had large amounts of fibronec-tin in association (Fig. 7). but were negative for SlOOprotein and factor XI 11a. The results of the immuno-peroxidase findings are summarized in Tabfe 1.

In contrast to CNH. there was no cellular inflamma-tion and no uiceration. However, solar elastotic degen-eration of collagen, atrophy and telangiectasia.indicative of sun damage, were universal. Epidermaldysplasia. adjacent to a solar keratosis. was noted in onebiopsy only. Although the solar change was often verymarked (Fig. 3). this did not seem to correspond withthe bulk ol' the nodule felt clinically.

Discussion

Nodules, predominantly occurring on the antihelix butalso involving the helix of the ear. and typically occur-ring in white elderly males living in tropical climates.

r 1996 British Association of Dermatologists. British journal ofDermatolotjy. t 55. 550-554

552 G.M.KAVANAGH etal.

N

Figure 4. Triinsverse section across the pinna. The spur of collagen(rt'dl extends from within the disrupted tip of ihe main cartilage of thepinna (C): the fibrous edge of the nodule (N) is just visible in thissection. (Miller's and van Gieson. xf>5.)

Figure 3. Transverse section across the pinna. There is an overlyingilake of hyperkeratosis (K) and solar elastic degeneration in the upperdermis (Kl. A nodule of cartilage (N) is present, apparently separatefrom Ihe main cartilage of ihc pinna iC), (Hiiematoxyliri andeosin. x6().l

have previously been attributed to masses of abnormalelastic tissue. In 19S,S, Kocsard ct »/.' surveyed 250geriatric in-patictits. to document 'senile'changes in iheskin olthe average Australian male. A high incidence ofpainless yellow nodules was identified on the antihelixof the ear. Although (he location and colour of thenodules diflered from the WN we describe, they arecomparable in several respects. They had a consistencysimilar to cartilage on palpation, and histological exam-ination of post-mortem nodules revealed elastosis. dila-tation of blood vessels in the overlying dermis. and a

marked absence of inflammatory cells. The specimensexamined also included cartilage which showed degen-eration of the clastic tissue with an increase in theintercellular tissue around the site of the nodule. Aningrowth of fibrous tissue and deposition of fresh elasticfibres were observed at later stages.

Elastotic nodules involving the anterior crus andantihelix of the ear were subsequently described byCarter cl al. in 1969." These nodules were found in14 of 145 Caucasian male patients examined (averageage 61 years), but in none of the 91 black patients. Theclinical description of 'bilateral, semi-transluscentaggregates of pink-white material, wilh an orange-peel-like surface' differs significantly to the WN wehave observed. The histological appearances also dif-fered with disorganized thick collagen fibres replacingmuch of the dermis. The biopsies were not deep enoughto allow adequate evaluation of the underlying carti-lage.

Weedon also reported asymptomatic elastoticnodules occurring on the untlhelix (six patients).rather than the helix (two patients) of elderly males.^Histologica! examination showed the nodules to

© 194f-i British Association of Dermatologists. British journal of Dennatolofiy. 1 J 5 . 5 5 0 - 5 5 4

WEATHERING NODULES OF THE EAR 553

N

Figure 5. I'riinsvcrst' st'ftion across the pinriii. Tht' spur ol colltigen(red) exleiids from the main carlilaye of ihe pinnii (O almosl lo theepidermis |Ep|. I Miller's, alcian blue I acidic proteoglycan.s incartilage ^ blue) and van Giesnn. x75.)

comprise marked dermal actinic elastosis with course,irregular elastotic fibres forininy; larger masses. Weconsider the nodules reported by the authors above tobe histologically and clinically distinct from the lesionswe describe. Other diagnoses considered included rheu-matoid nodules, gout and calcinusis cutis. but charac-terizing features of these conditions were not present.

The frequent coexistence of weathering nodules andCNH noduies in our patients raised the possibility thatthese asymptomatic WN may represent either an earlyor late burnt out phase of CNH. There are, however,several clinical and histological features which differ-entiate WN from CNH. The lesions of CNH are typicallypainful, pink or greyish, often with a central crust-likescale or uiceration. In contrast. WN are invariablyasymptomatic, they are skin coloured or white, andhave little scaling. The patients do not describe anyprevious painful or inflammatory phase. While there isa male preponderance in CNH. they are nol exclusivelyaffected, as observed in WN to date. Weatheringnodules also tend to affect an older age group thanCNH. which suggests degeneration of tissue may be animportant factor. The observed absence of inilammation

Tigurc 6. hii tace seclion of Ihe pinna. In this plane the cartilagenodule IN) is seen within a fibrous spur in continuity with theperichondrium of the main pinna cartilage. Solar elastosis (K) is notwell developed. (Miller's and van Giesiin x JO.)

at any stage also argues against WN representing aburnt out phase of CNH.

Histologically. CNH is distinguished from WN by thecharacteristic nodular hyperplasia of the epidermis.tibrinoid alteration of dermal collagen, proliferation ofrichly vascularized granulation tissue, and a prominentinflammatory infiltrate . ln contrast, a marked absenceof inflammatory cells was noted in all sections in ourstudy, i-urthermore, while solar elastosis was a univer-sal linding in the WN. histological evidence of actinicdamage in CNH is variable.

The frequent iinditig of aetinic keratoses (a recognizedindicator oi" chronic actinic exposure), a consistent

Table I. Inirniinohislnchemistrv

Primary antibody

CD45Factor XlilaMac 1,S7SlOOA245M()72S

Specificity

bone marrow cellsdermal dendrocytes

macrophagesl.aiijierhans cefls

vimentinlibroiiectiii

Supplier

DakoBehring

DakoDakoDakoDako

Result

riej;alivenegativenegativenegativenegativepositive

l*-)96 Hritish Association of Dermalologisls. Hritisli Joiirnii! of i. 1 JS. 150-554

554 G.M.KAVANAGH etal.

Figure 7. Immunoperoxidase stain using anti-fibrcnectin antibody,showing large amounts of fihronectin in association with spindle cellsin the dermis. Epidermis is seen (Kp). (x J40.I

clinical history of an outdoor occupation in this group ofpatients, and histologically universal solar-inducedchanges supports a role for UV radiation in thepathogenesis of WN. Thermal injury, resulting fromoccupational cold exposure, could also be a contribu-tory factor in producing the nodular growth of WN. andlocal anatomical peculiarities of the helical region (lackof subcutaneous tissue leading to an inadequate cush-ioning effect and poor local blood supply) may beimportant. Fibronectin is thought to be important in

cell replication, mobility and difTerentiation.^ We are, asyet unsure of the significance of its presence in largeamounts in the dermis in our study. Increased fibro-nectin production by fibroblasts has been reported inmorphoea, and it was suggested that this connectivetissue glycoprotein may act as a collagenase inhibitor.''It is conceivable that fibronectin may account for thelocalized accumulation of collagen seen in our samples.Alternatively, the increased fibronectin production maybe a consequence of wound healing.'

Our clinicopathological correlation study confirmsthe clinical impression that these lesions are predomi-nantly comprised of cartilage. The triggering factor forcartilage metaplasia in these patients remains unclear,but chronic weathering seems a likely stimulus. We alsosuspect that WN are more common than is currentlyrecognized.

References1 Kocsard E. Ofner F, Coles fL, Turner B. Senile changes in the skin

and visible mucous membranes of the Australian male. Austral JD<Tmm(j/19S8: 4: 216-22.

2 Carter VH, Constantine VS, Poole WL. Elastotic nodules of theantihelix. Arch Dermatol 1969: 100: 282-5 ,

i Weedon D. Elastotic nodules of the ear. ; Cutan Pathol 198t: 8:4 2 9 - J } .

4 Bard |. Cliondrodermatitis nodularis chronica helicis. Dermatologica1981: U)i: 376-84.

5 Ruoslati E. Pierschbacher EE, Oldberg A et al. Molecular andbiological interaction of fibronectin. / Invest Dermatal 1982: 79:65-8S.

6 VuorioT, Makela|K. VuorioE. Activation of type I collagen genes incultured scleroderma Kbroblasts. Arch Dermatol Res 1987: 279:154-60.

7 Nagata H. l!eki H. Moriguchi T. Fibronectin. Localisation in normalhuman skin, granulation tissue, hypertrophic scar, mature scar,progressive systemic sclerotic skin, and other tibrosing dermatoses.Arch Dermatol 1985; I2t: 995-9.

1996 British Association of Dermatologists. Rritisli Jounial of Derwatoloiju. 155. 550-554