What is the recommended management for perichondritis?

Management of Perichondritis

The recommended first-line treatment for perichondritis of the ear is fluoroquinolone antibiotics (oral and/or topical) due to the high prevalence of Pseudomonas aeruginosa infection, with surgical drainage indicated for abscess formation or treatment failure. 1

Diagnosis and Pathogen Identification

• Key diagnostic finding: Erythema and edema of the auricle with sparing of the fatty lobule (a classic physical examination finding that distinguishes perichondritis from otitis externa) 2
• Predominant pathogens:
  • Pseudomonas aeruginosa: Most common in abscess cases (58-69% of isolates) 3, 4
  • Staphylococcus aureus: Predominant in non-abscess infections (49%) 4

Treatment Algorithm

Initial Antibiotic Therapy

1. For mild to moderate cases:

   • Oral fluoroquinolones (e.g., ciprofloxacin) with or without topical fluoroquinolones 1
   • Duration: 10-14 days 1
   • Note: For non-abscess perichondritis, antibiotics covering S. aureus may be sufficient as initial therapy 4

2. For severe cases:

   • Hospitalization for IV antibiotics 1
   • Options include:
     • IV anti-pseudomonal antibiotics (e.g., piperacillin-tazobactam, ceftazidime)
     • Combination therapy with IV fluoroquinolones plus an aminoglycoside for severe infections
   • Duration: 2-4 weeks 1

Surgical Management

• Surgical drainage is indicated for:
  • Abscess formation
  • Treatment failure with antibiotics alone 1
  • Note: Only 7-8% of patients require surgical intervention 3

Adjunctive Measures

• Pain management:

  • Acetaminophen or NSAIDs for mild to moderate pain
  • Regular dosing rather than as-needed for better pain control 1

• Local care:

  • Avoid inserting anything into the ear canal
  • Keep the area dry
  • Apply warm compresses to improve circulation and reduce pain 1

Special Considerations

Diabetic Patients

• Consider more aggressive treatment in diabetic patients
• Hyperbaric oxygen therapy may be beneficial as adjunctive therapy in diabetic patients with recurrent perichondritis 5

Recurrent Perichondritis

• Consider relapsing polychondritis (an autoimmune disorder) in cases of recurrent perichondritis without clear infectious etiology
• Treatment for autoimmune etiology includes corticosteroids and immunosuppressants 1

Follow-up and Monitoring

• Reassess within 48-72 hours if symptoms persist despite treatment 1
• Patients should expect improvement within 48-72 hours of appropriate antibiotic therapy 1
• If clinical response is disappointing or cultures grow P. aeruginosa in patients initially treated with S. aureus coverage, expand antibiotic coverage to include P. aeruginosa 4

Prevention of Complications

• Early recognition and appropriate antibiotic therapy are essential to prevent cartilage destruction and subsequent auricular deformity
• Delayed treatment can lead to cartilage destruction and permanent deformity 1
• Common pitfalls leading to poor outcomes:
  • Inadequate antibiotic coverage
  • Failure to drain abscesses
  • Misdiagnosis 1