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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 169-171

Clavicular skin-colored nodule


1 Medical Student, Medical School UNAM, Mexico City, Mexico
2 Dermatopathology Fellow, General Hospital Dr. Manuel Gea González, Mexico City, Mexico
3 Dermatology Resident, General Hospital Dr. Manuel Gea González, Mexico City, Mexico
4 Department of Dermatopathology, General Hospital Dr. Manuel Gea González, Mexico City, Mexico

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. Sonia Toussaint-Caire
Hospital General Dr. Manuel Gea González, Av. Calzada De Tlalpan 4800, Sección XVI, 14 Tlalpan, Mexico City
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_14_18

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  Abstract 


An accessory tragus (AT) is a congenital flesh-colored nodule occasionally covered with vellus hair. It can arise anywhere along the line from the preauricular area to the corner of the mouth. It can also be found on the glabella or suprasternal region. The tragus is derived from the first branchial arch, which also develops into the mandible and mouth. The rest of the external ear develops from the second branchial arch. AT may occur as an isolated defect or in chromosomal first branchial arch syndromes with ear anomalies, cleft lip and palate, and mandibular hypoplasia.

Keywords: Accessory tragus, congenital nodule, heterotopic tragus


How to cite this article:
Manriquez-Robles A, Franco AM, Castañeda-Zarraga A, Lopez-Ornelas AF, Toussaint-Caire S, Vega-Memije ME. Clavicular skin-colored nodule. Indian J Paediatr Dermatol 2019;20:169-71

How to cite this URL:
Manriquez-Robles A, Franco AM, Castañeda-Zarraga A, Lopez-Ornelas AF, Toussaint-Caire S, Vega-Memije ME. Clavicular skin-colored nodule. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Apr 25];20:169-71. Available from: http://www.ijpd.in/text.asp?2019/20/2/169/255195




  Introduction Top


Accessory tragus (AT) is a rare benign congenital anomaly of the external ear that presents as a small elevation of the skin that is made up of the skin, subcutaneous fat, and elastic cartilage. It is located most commonly just anterior to the tragus, which is the fleshy prominence in front of the opening of the ear. They can also occur on the cheek, lateral part of the neck, in the middle ear, or between the eyebrows.[1],[2]


  Case Report Top


A 16-year-old male patient presented with a congenital nodule on his right clavicular region. The lesion was asymptomatic.

On examination, 0.3 cm × 0.3 cm × 0.8 cm pedunculated exophytic nodule was present on the upper clavicular region. The lesion had a firm consistency; it was well demercated, skin colored, nontender on palpation, and non-adherant to deep tissues [Figure 1].
Figure 1: Single nodule in the right clavicular region

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A soft-tissue ultrasound was performed which reported a solid skin-dependent mass. An excisional biopsy of the lesion was performed.

Histopathological examination of the lesion revealed a dome-shaped nodule covered by thin, rugated epidermis with an orthokeratotic stratum corneum. In the superficial and medium reticular dermis, the presence of numerous vellus hair folicles, sebaceous glands, and lobes of mature adipose tissue. In the deep dermis, a fragment of cartilage surrounded by perichondrium was observed [Figure 2]a and [Figure 2]b.
Figure 2: (a) Histopathology shows thin stratum corneum and epidermis with numerous irregularly spaced vellus hair follicles (H and E, ×10). (b) Mature adipose tissue and central plate of elastic cartilage (arrow) (H and E, ×40)

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  Discussion Top


The AT is a congenital abnormality of the external ear, and the approximate prevalence is 1.7: 1000 and 9–10: 10,000 for unilateral and bilateral lesions, respectively.[1]

It originates from the abnormal embryonic development of the first and second branchial arches from 4th to 6th week of intrauterine life.[1],[2] Initially, the tragus begins its development at the base of the neck and with the development of the mandible migrates to its usual anatomical position near week 20, which explains its location along the migratory line.[3],[4]

Being a malformative process is always present from birth, although it can go unnoticed. As to its origin, it may be hereditary (especially in cases associated with other malformations) or exclusively embryopathic.[1],[4]

There are different designations for it such as poliotia, accessory external ear, heterotopic tragus, accessory atrium, and supernumerary tragus.[4]

It was first described in 1958 by Birket.[4],[5]

It is clinically identified as a nodule or papule of skin color, of variable size that may be unilateral or bilateral, sessile or pedunculated, with or without vellus follicles, and with a soft or firm consistency depending on the presence or absence of cartilage.[1],[5] The most common site of localization is the preauricular region, although it may be found on cheeks, lateral borders of the neck, upper clavicular region, nasal vestibule, and glabella. It is usually present from birth; however, it may be underdiagnosed for a long time.[2],[6]

The diagnosis of an AT is based on the clinical and histological features that include a thin layer of stratum corneum with anfractuous epidermis. In addition, there are generally eccrine glands and vellus hair follicles accompanied by sebaceous glands.

The differential diagnosis include acrochordons, epidermoid cysts, atrial fistulas, branchial cysts, fibroepithelial polyps, and thyroglossal cysts.[1],[3]

Although genetically related to minor anomalies, defined as atypical morphological features with no serious cosmetic or functional significance to the patient, there are some associations that require our consideration, especially if the lesions are multiple, bilateral, or >1 cm. The most frequent is Goldenhar syndrome, which is an autosomal recessive syndrome that causes hemifacial microsomia. The AT is also associated, although less frequently to other syndromes such as Townes-Brocks syndrome,  Treacher Collins syndrome More Details, Delleman syndrome, Noonan syndrome, VACTERL association, and Wolf-Hirschhorn syndrome [Table 1].[1],[4],[6]
Table 1: Associated syndromes

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Due to its characteristics, the AT is a lesion of benign evolution that does not require immediate treatment but can be performed for esthetic purposes.[4],[6]

The usual treatment consists of surgical removal, which usually has good results with null recurrence and in general does not cause complications.[2],[4],[6] However, during the incision in atypical locations, there may be damage to structures such as facial nerves, parotid gland and parotid ducts.

The underlying cartilage of the lesion located in the deep subcutis should be removed for optimal results.[7]

Slow healing of the wound occurs when the underlying cartilaginous fragments are completely removed, as the cartilaginous structures may be deep in the preauricular tissue.[7],[8]

In conclusion, the AT is a rare congenital anomaly, usually presented as an asymptomatic lesion and benign course; however, its presence requires a multidisciplinary approach, so ophthalmological, otorhinolaryngological, and oral and spinal examinations should be performed to rule out association with congenital syndromes such as those already mentioned.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Larson KN, O'Shea P, Zedek DC, Morrell DS. Hair follicle nevus located on the chin of an infant: Case report and review of literature. Pediatr Dermatol 2016;33:e106-8.  Back to cited text no. 1
    
2.
Jansen T, Romiti R, Altmeyer P. Accessory tragus: Report of two cases and review of the literature. Pediatr Dermatol 2000;17:391-4.  Back to cited text no. 2
    
3.
Lowry TR. Cervical accessory tragus: An unusual pediatric neck mass. Ear Nose Throat J 2014;93:22.  Back to cited text no. 3
    
4.
Bahrani B, Khachemoune A. Review of accessory tragus with highlights of its associated syndromes. Int J Dermatol 2014;53:1442-6.  Back to cited text no. 4
    
5.
Shin MS, Choi YJ, Lee JY, Lee SH, Ahn JY, Park MY, et al. Acase of accessory tragus on the nasal vestibule. Ann Dermatol 2010;22:61-2.  Back to cited text no. 5
    
6.
Pan B, Qie S, Zhao Y, Tang X, Lin L, Yang Q, et al. Surgical management of polyotia. J Plast Reconstr Aesthet Surg 2010;63:1283-8.  Back to cited text no. 6
    
7.
Asahina A, Mitomi H, Sakurai N, Fujita H. Multiple accessory tragi without cartilage: Relationship with hair follicle naevi? Acta Derm Venereol 2009;89:316-7.  Back to cited text no. 7
    
8.
Moon IY, Oh KS. Surgical correction of an accessory auricle, polyotia. Arch Plast Surg 2014;41:427-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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