Symptoms

CNH patients typically present with the complaint of a spontaneously appearing painful nodule on the helix or antihelix of the pinna. CNH is mainly located on the ear of the usual sleeping side, predominantly the right one. CNH classically presents unilaterally. Nevertheless, bilateral ear involvement may also be observed. Previously mentioned predisposing factors usually precipitate onset. The nodule grows rapidly and then stabilizes after attainment of maximum size. Nocturnal pain is the most frequent symptom with only a few cases presenting with daytime pain, occurring with touching.

Physical Examination

Physical examination reveals a single oval or round shaped nodule with raised, rolled edges and an ulcer or crust in its center. The lesion has a diameter of 4 mm to 6 mm and is typically surrounded by an erythematous area. The most common site is the apex of the helix. The nodule is firm, tender and usually fixed to the auricular cartilage on palpation. Removal of the central crust reveals a small channel. Other associated features include bleeding and exudate on the removal of the crust. Distribution on the antihelix is more common among females than among males. Location on rare sites like the external auditory canal and posterior part of the pinna has been reported.

Diagnosis of CNH can begin with a clinical examination. Histopathological confirmation by skin biopsy is the substitute method of diagnosis. Some recommend investigations to rule out systemic illness like scleroderma, thyroid disease, and other collagen vascular diseases especially in young adults presenting under 40 years of age.

There are several therapeutic options for the management of CNH. These can be broadly divided into conservative treatment and surgical excision.

Conservative Treatment

1. Pressure-relieving prosthesis/padding is a cost-effective and inexpensive method. The primary goal of this prosthesis is to relieve or eliminate pressure on the lesion. These are available in various forms like foam sponge that is self-adhering to the postauricular area, foam bandages attached to the head and doughnut pillows for sleeping. The cure rate achieved by this method varies among different studies, mainly depending on patient compliance.
2. Some institutes have used topical and intralesional steroids; however, the cure rate achieved with steroid use is unsatisfactory.
3. Local collagen injection may provide relief by offering cushioning and insulation (like subcutaneous tissue).
4. Photodynamic therapy has been found promising; however, a disadvantage is the requirement for multiple treatment sessions.
5. Carbon dioxide/argon laser is another treatment modality. The patient is treated with laser, and later the wound is allowed to heal by secondary intention.
6. Topical application with 2% nitroglycerine twice daily has been shown to relieve both symptoms and appearance. Nitroglycerine patches may be used as a substitute.
7. Some also recommend cryosurgery. 
8. Electrocauterization/ curettage is another treatment modality.

Surgery

Many techniques have emerged over the years for surgical excision of CNH. These include large excision followed by ear reconstruction using skin grafts or local flaps, removal of the lesional skin and cartilage, as well as techniques of cartilage-only removal with skin-sparing. Most of the studies agree that the simple approach with primary excision and meticulous trimming of cartilage is preferred as the method of choice.

CNH may be confused with a malignant skin condition like basal cell carcinoma due to its nodular appearance and central crusting. Larger and inflamed lesions may mimic squamous cell carcinoma. Gouty tophi is another differential diagnosis; however, unlike CNH,  tophi are multiple and occur on other sites like finger and toes.

Keratoacanthoma grows much faster than CNH, and classical resolution after a few months is the characteristic feature which helps to differentiate this condition. CNH lesions with predominant keratosis may resemble seborrheic or keratotic dermatitis.

CNH has a good prognosis, although long-term morbidity is common. Spontaneous resolution is extremely rare. Remission is commonly seen among inadequately treated cases.

CNH is best managed by an interprofessional team including ENT nurses. CNH is a relatively common disorder which is not well recognized. It is believed to be due to pressure on the ear from a variety of causes. The basic feature is a painful ear, usually at the pinna. Over the years, many treatments have been devised for this condition including surgery. To improve outcomes. clinicians should first try pressure offloading remedies first. Surgery to remove any obvious lesion should be the last resort. Because of the lack of trials, there is no consensus on which treatment works; hence one should educate the patient on avoiding ear pressure first, which does appear to provide symptom relief.