What is the treatment for ear cellulitis vs perichondritis?

Treatment of Ear Cellulitis vs Perichondritis

For ear cellulitis, treat with oral cephalexin, dicloxacillin, or amoxicillin-clavulanate; for auricular perichondritis, fluoroquinolones (ciprofloxacin or levofloxacin) are the first-line treatment due to Pseudomonas coverage, with surgical drainage necessary if an abscess develops. 1, 2

Distinguishing Between the Conditions

Ear Cellulitis

• Affects the soft tissue of the ear, including the earlobe
• Common causative organisms: Streptococcus and Staphylococcus aureus
• Presents with redness, swelling, warmth, and pain
• Typically involves the earlobe (which lacks cartilage)

Auricular Perichondritis

• Infection of the cartilage of the external ear
• Spares the earlobe and tragus (which lack cartilage)
• Presents with painful swelling, warmth, and redness of the auricle
• Acute tenderness on deflecting the auricular cartilage (key diagnostic finding)
• Most common pathogens: Pseudomonas aeruginosa, S. aureus, and S. pyogenes
• Often occurs within first month after ear piercing, especially in warm weather 1

Treatment Algorithm

For Ear Cellulitis (Non-purulent):

1. First-line antibiotics (7-10 days):

   • Cephalexin 500 mg orally four times daily, OR
   • Dicloxacillin 500 mg orally four times daily, OR
   • Amoxicillin-clavulanate 875/125 mg orally twice daily 2

2. For penicillin-allergic patients:

   • Clindamycin 300-450 mg orally three times daily 2

3. Supportive measures:

   • Elevation of affected area to reduce edema
   • Analgesics for pain control
   • Daily monitoring until improvement 2

For Auricular Perichondritis:

1. First-line antibiotics:

   • Fluoroquinolone treatment (ciprofloxacin or levofloxacin) 1, 3, 4
   • Ciprofloxacin is particularly effective against Pseudomonas aeruginosa

2. Alternative options for hospitalization (based on pathogen):

   • Clindamycin
   • Ceftazidime
   • Cefepime 1

3. Surgical intervention:

   • Incision and drainage if abscess is present
   • Note: Once an abscess develops, good cosmetic preservation of the auricular cartilage is difficult to maintain 1, 5

4. For severe cases:

   • Consider hospitalization for IV antibiotics
   • In diabetic patients, hyperbaric oxygen therapy may be beneficial as adjunctive therapy 6

Special Considerations

Risk Factors for Perichondritis:

• Recent ear piercing (especially cartilage)
• Trauma to the ear
• Swimming in contaminated water
• Diabetes mellitus or immunocompromised state 1, 6

Pediatric Dosing:

• For cellulitis: Amoxicillin-clavulanate 40 mg/kg/day divided into two doses, not exceeding 875/125 mg twice daily 2
• For perichondritis in children: Fluoroquinolones are generally avoided but may be warranted given the risk of cartilage destruction and permanent deformity 7

Follow-up and Prevention:

• Monitor daily until improvement
• Remove any embedded earrings or foreign bodies
• For piercing-related infections, the ear can be repierced 6-8 weeks after resolution of swelling and tenderness 1
• Address predisposing factors to prevent recurrence 2

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to distinguish between cellulitis (soft tissue infection) and perichondritis (cartilage infection) leads to inappropriate antibiotic selection 1

2. Inadequate Pseudomonas coverage: For perichondritis, failure to cover Pseudomonas with appropriate antibiotics (fluoroquinolones) can lead to cartilage destruction 1, 3

3. Delayed surgical intervention: When an abscess is present in perichondritis, delaying surgical drainage can lead to cartilage necrosis and permanent deformity 1, 5

4. Inadequate follow-up: Both conditions require close monitoring until clinical improvement is observed 2

5. Overlooking underlying conditions: Diabetes and immunocompromised states may require more aggressive management 6