the auricle , which is the part of the ear exposed to the outside , is important both functionally and esthetically.1 - 3 ) the skin of the auricle has little subcutaneous tissue , with the anterior surface having less subcutaneous tissue than the posterior surface , as well as being closely attached to the cartilage . these structures are subject to frostbite , despite the presence of a relatively abundant superficial blood supply . moreover , auricular hematoma , which compresses the sensory nerves , can result in pain in response to mild inflammation . there are many clinical conditions that can occur in the auricle region , for instance , auricular anomaly , laceration , frostbite , otohematoma , perichondritis , herpeszoster otiticus and , occasionally , auricular masses . auricular tumors , including basal cell carcinoma , squamous cell carcinoma , malignant melanoma and metastatic lesions have been assessed clinically,4 ) mostly in case reports . however , there is little detailed information on auricular masses in general , such as keloids , osteomas and hemangiomas . to address this shortcoming , we retrospectively assessed the clinical characteristics of auricular masses in 63 patients , including their site , size , causes , histopathology , treatment methods and treatment results . we retrospectively identified 63 patients who visited the department of otorhinolaryngology from may 1970 to november 2009 , were diagnosed with auricular masses and underwent mass excision . we assessed the site , cause , size , patho - logy results , treatment methods and treatment results in these patients . site was assorted as the lobule , tragus , concha , crus of helix , triangular fossa , crus of antihelix , antihelix , antitragus , scapha and others . in patients who showed auricular mass recurrence after treatment , we assessed the interval from removal to recurrence , as well as the pathology , site and pattern of change in size . of the 65 patients , 30 ( 47.6% ) were male and 33 ( 52.3% ) were female . patients ranged in age from 1 - 80 years ( mean , 33.5 years ) . 33 patients ( 52.3% ) developed auricular masses in the right ear , 27 ( 42.8% ) in the left ear and 3 ( 4.7% ) in both ears . the most common site was the lobule ( n=28 , 44.4% ) , followed by the tragus ( n=13 , 20.6% ) , crus of the helix ( n=7 , 11.1% ) , triangular fossa ( n=4 , 6.3% ) , crus of the antihelix ( n=2 , 3.1% ) , antitragus ( n=2 , 3.1% ) , scapha ( n=1 , 1.5% ) and others ( n=6 , 9.5%)(table 1 ) . of the 63 patients , 49 ( 77.7% ) had auricular masses of unknown origin , whereas the causes were congenital in 8 patients ( 12.6% ) and trauma in 6 ( 9.5%)(table 2 ) . the masses had a meansd width of 15.44.32 mm , a meansd height of 12.97.65 mm and a meansd depth of 10.27.01 mm . of the 63 biopsied masses , 16 ( 25.3% ) were epidermal cysts , 8 ( 12.6 ) were hypertrophic scar , 6 ( 9.5% ) were accessory ear , 6 ( 9.5% ) were fibrous tissue , five each ( 7.9% ) were chronic inflammation and nevus , 4 ( 6.3% ) were keloid , 3 ( 4.7% ) were hemangioma , 2 ( 3.1% ) each were seborrheic keratosis and skin tag and one each ( 1% ) was leiomyoma , pilomatricoma , relapsing polychondritis , pyogenic granuloma and lymph node ( table 3 ) . among 63 cases of auricular mass , one case of hypertrophic scar was treated with biopsy and local steroid injection and one case of relapsing polychondritis was treated with biopsy , local steroid injection and systemic steroid . the one case in which a simple excision was not enough with a keloid patient . in this case , a local skin flap was needed in addition to the excision . following treatment , four patients ( 6% ; one male and three females ) experienced recurrence . pathology examination showed that the masses in three of these patients were hypertrophic scars and one was an epidermal cyst . recurrence was observed in the lobule in two patients , and in the crus of the helix and the triangular fossa in one each . the average width , height and depth were 30 mm , 27 mm and 17 mm , respectively , prior to recurrence , and 19 mm , 17 mm and 10 mm , respectively , after recurrence ( table 4 ) . of the 65 patients , 30 ( 47.6% ) were male and 33 ( 52.3% ) were female . patients ranged in age from 1 - 80 years ( mean , 33.5 years ) . 33 patients ( 52.3% ) developed auricular masses in the right ear , 27 ( 42.8% ) in the left ear and 3 ( 4.7% ) in both ears . the most common site was the lobule ( n=28 , 44.4% ) , followed by the tragus ( n=13 , 20.6% ) , crus of the helix ( n=7 , 11.1% ) , triangular fossa ( n=4 , 6.3% ) , crus of the antihelix ( n=2 , 3.1% ) , antitragus ( n=2 , 3.1% ) , scapha ( n=1 , 1.5% ) and others ( n=6 , 9.5%)(table 1 ) . of the 63 patients , 49 ( 77.7% ) had auricular masses of unknown origin , whereas the causes were congenital in 8 patients ( 12.6% ) and trauma in 6 ( 9.5%)(table 2 ) . the masses had a meansd width of 15.44.32 mm , a meansd height of 12.97.65 mm and a meansd depth of 10.27.01 mm . of the 63 biopsied masses , 16 ( 25.3% ) were epidermal cysts , 8 ( 12.6 ) were hypertrophic scar , 6 ( 9.5% ) were accessory ear , 6 ( 9.5% ) were fibrous tissue , five each ( 7.9% ) were chronic inflammation and nevus , 4 ( 6.3% ) were keloid , 3 ( 4.7% ) were hemangioma , 2 ( 3.1% ) each were seborrheic keratosis and skin tag and one each ( 1% ) was leiomyoma , pilomatricoma , relapsing polychondritis , pyogenic granuloma and lymph node ( table 3 ) . one case of hypertrophic scar was treated with biopsy and local steroid injection and one case of relapsing polychondritis was treated with biopsy , local steroid injection and systemic steroid . the one case in which a simple excision was not enough with a keloid patient . in this case , a local skin flap was needed in addition to the excision . following treatment , four patients ( 6% ; one male and three females ) experienced recurrence . pathology examination showed that the masses in three of these patients were hypertrophic scars and one was an epidermal cyst . recurrence was observed in the lobule in two patients , and in the crus of the helix and the triangular fossa in one each . the average width , height and depth were 30 mm , 27 mm and 17 mm , respectively , prior to recurrence , and 19 mm , 17 mm and 10 mm , respectively , after recurrence ( table 4 ) . the auricle is a complex skeletal system formed by thin and fine skin tissues , such that many types of techniques and approaches are used to treat auricular masses . many auricular masses , however , are difficult to diagnose by physical examination and fine needle aspiration,5 ) with most requiring diagnosis by biopsy after surgical excision . moreover , there have been few reports on auricle masses , making it difficult to obtain information . we therefore investigated the clinical aspects of auricular masses in 65 patients who underwent auricular surgery over the past 41 years . the ear lobule was the most common site of auricular masses , followed by the tragus , crus of the helix , triangular fossa , concha - crus of the antihelix and antitragus - scapha . frequent development in the lobule may be related to its being the area of the auricle with the greatest abundance of soft tissue , as well as due to the wearing of earrings and other jewelry , which may induce scars or inflammation . these cysts have been reported in the posterior surface of the lobule , mastoid skin , inferior area of the cartilagenous external auditory canal ( eac ) and posterior skin . epider - mal cysts manifest as soft , non - tender masses and , when ac - companied by inflammation , are difficult to distinguish from otofuruncles.6 ) cysts must be excised completely and dissected carefully during surgery so not to rupture the cystic wall . in contrast , the recurrence rate of keloid treated by surgery only is high ( 45 - 100% ) , making it important to differentiate keloids from hypertrophic scars in deciding treatment methods . generally , keloids show a pattern of infiltration beyond primary scars , whereas hypertrophic scars are limited.7,8 ) in addition , hypertrophic scars form within 4 weeks after injury , whereas keloids form later , an average of 30.4 months after injury.9,10 ) moreover , hypertrophic scars decrease in size within 1 year , whereas keloids maintain their size for longer than 1 year.11 ) hypertrophic scars are treated by surgery only , whereas keloids are treated by surgery followed by local injection of steroids , which decreases the expression of genes encoding collagen.12 ) due to their recurrence , long - term follow - up in patients with keloids is important . the average interval to recurrence has been reported to range from 5.5 - 12.9 months,13 ) suggesting that patients be followed - up for longer than 1 year . of our three patients with keloid recurrence , two were at 21 months and one at 10 years , suggesting the need for even longer follow - up . hemangiomas , observed in three of our patients , are congenital tumors observed most commonly in infants and usually involves the face and neck together with the auricle . capillary hemangiomas are masses composed of large capillary vessels without severe large protrusions , with large blood vessels supplying the blood in the center , from which capillary vessels branch and form a port - wine stain or spider hemangiectasia . cavernous hemangiomas are composed of endothelial cells , are filled with blood and appear as protrusions or masses.14 ) these tumors cause problems in appearance . in most patients , these masses not treated until they show a maximum decrease in size , after which they are treated by cryotherapy , radiotherapy , electrotherapy , sclerosing therapy , tattooing and other methods.15 ) basal cell carcinomas , observed in two of our patients , constitute approximately 20% of the tumors occurring in the eac and temporal bone . these skin cancers are relatively common , especially in elderly individuals , and are more prevalent in males than in females . despite being malignant histologically , these tumors show a benign progression , with metastasis being very rare . in most cases , these tumors are painless and nodular , with an ulcerative central area.16 ) although most do not show distinct borders of subcutaneous infiltration , the borders of these tumors are grossly distinct , the tumors grow slowly and distant and local metastases are rare . among the methods used to treat basal cell carcinoma are surgical excision , curettage , electrotherapy , radiotherapy , cryotherapy , laser therapy , chemical therapy , local application of cytotoxic agents and intralesion injection . treatments are chosen after considering functional aspects and cosmetic efficacy , together with complete removal of the lesion , based on patient clinical characteristics , including the extent of infiltration , histological lesion type , patient sex and age , reactions to previous treatment methods and remission rate.17 ) both of our patients with basal cell carcinoma underwent surgical excision , with no recurrences for up to 2 years after surgery . only one of our patients was diagnosed with perichondritis , which , nevertheless , should be diagnosed differentially from basal cell carcinoma . hence , patients with masses expected to be benign should undergo physical examination and biopsy of the lesion.18 ) although auricular masses are frequently encountered in outpatient clinics , few studies have investigated these conditions . hence , it is difficult to obtain information on these lesions and to design treatment plans . we found that most of the masses in the auricle were benign tumors , requiring appropriate surgery only , with good treatment outcomes and without recurrence . in rare cases , some auricular masses may be malignant tumors , requiring close observation and optimal treatment methods .