What is the recommended management for perichondritis?

Management of Perichondritis

Perichondritis of the ear should be treated with fluoroquinolone antibiotics (oral and/or topical) as first-line therapy due to the high prevalence of Pseudomonas aeruginosa infection, with surgical drainage indicated for abscess formation or treatment failure. 1, 2, 3

Clinical Identification

• Key diagnostic feature: Erythema and edema of the auricle with sparing of the earlobe (which lacks cartilage) 4
• Common symptoms: Pain, swelling, warmth, and redness of the affected cartilaginous area
• Risk factors: Trauma, ear piercings (especially through cartilage), burns, surgery, or other injuries to cartilage

Microbiology

• Primary pathogens:
  • Pseudomonas aeruginosa (predominant in abscess cases - 58-69% of isolates) 2, 3
  • Staphylococcus aureus (predominant in non-abscess infections - 49%) 3

Treatment Algorithm

Initial Management

1. Antibiotic therapy:

   • First-line: Fluoroquinolones (ciprofloxacin or levofloxacin) 1, 5
     • Oral ciprofloxacin 500-750 mg twice daily
     • Consider adding topical fluoroquinolone drops (ciprofloxacin or ofloxacin) if external ear canal is involved
   • Alternative for non-abscess cases: Anti-staphylococcal antibiotics (e.g., dicloxacillin, cephalexin) 3

2. Pain management:

   • Acetaminophen or NSAIDs for mild to moderate pain 6
   • Regular dosing rather than as-needed for better pain control

3. Local care:

   • Avoid inserting anything into the ear canal 6
   • Keep the area dry (avoid swimming, use ear protection during showering) 6
   • Apply warm compresses to improve circulation and reduce pain

For Severe Cases or Treatment Failure

1. Hospitalization and IV antibiotics:

   • Consider IV anti-pseudomonal antibiotics (e.g., piperacillin-tazobactam, ceftazidime) 1
   • For severe infections: combination therapy with IV fluoroquinolones plus an aminoglycoside

2. Surgical intervention (indicated in ~7% of cases) 2:

   • Incision and drainage for abscess formation
   • Debridement of necrotic cartilage
   • Consider surgical consultation early if rapid progression or poor response to antibiotics

Monitoring and Follow-up

• Expected response: Improvement within 48-72 hours of appropriate antibiotic therapy 6
• Duration of therapy: 10-14 days for mild cases; 2-4 weeks for severe cases
• Follow-up: Reassessment within 48-72 hours if symptoms persist despite treatment 6

Special Considerations

• Relapsing polychondritis: Consider this autoimmune disorder in cases of recurrent perichondritis without clear infectious etiology; treatment includes corticosteroids and immunosuppressants 1
• Cosmetic sequelae: Cartilage necrosis can lead to permanent deformity ("cauliflower ear"); early and aggressive treatment reduces this risk

Pitfalls to Avoid

1. Delayed treatment: Can lead to cartilage destruction and permanent deformity
2. Inadequate antibiotic coverage: Initial therapy should cover Pseudomonas in abscess cases or when high suspicion exists
3. Failure to drain abscesses: Antibiotics alone may be insufficient if purulent collections are present
4. Misdiagnosis: Distinguishing from simple cellulitis (look for earlobe sparing) 4
5. Inadequate duration of therapy: Premature discontinuation can lead to recurrence

Early recognition and appropriate antibiotic therapy targeting the most likely pathogens are essential to prevent cartilage destruction and subsequent auricular deformity.