What is the treatment for perichondritis?

Treatment of Perichondritis

The first-line treatment for perichondritis of the ear is oral or intravenous fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) to provide coverage against Pseudomonas aeruginosa, which is the most common pathogen. 1

Clinical Presentation and Diagnosis

• Perichondritis typically presents as painful swelling, warmth, and redness of the cartilaginous portion of the ear that characteristically spares the earlobe 2, 1
• Acute tenderness on deflecting the auricular cartilage helps distinguish deeper perichondrial infection from superficial skin infection 2
• Most common pathogens include Pseudomonas aeruginosa (predominant in 69% of cases), Staphylococcus aureus, and Streptococcus pyogenes 1, 3
• It often occurs within the first month after ear piercing or trauma, especially during warm weather 1

Treatment Algorithm

First-Line Therapy

• For mild to moderate perichondritis (outpatient treatment):

  • Oral fluoroquinolones: ciprofloxacin or levofloxacin (500-750 mg once daily) 2, 1
  • Duration: 7-10 days or until clinical resolution 1
  • Pain management with acetaminophen or NSAIDs 2

• For severe perichondritis requiring hospitalization:

  • Intravenous fluoroquinolones (ciprofloxacin or levofloxacin) 1
  • Monitor for resolution of pain, swelling, and erythema 1

Alternative Treatment Options

• For patients with beta-lactam allergy or contraindications to fluoroquinolones:
  • Clindamycin may be considered, particularly if S. aureus is suspected 1

Surgical Management

• Surgical incision and drainage are necessary if an abscess is present 2, 1, 4
• Once an abscess develops, good cosmetic preservation of the auricular cartilage becomes difficult 1
• In a study of 20 patients, 80% required surgical intervention, and 28.6% of those who attended follow-up had residual deformity 4

Special Considerations

• Patients with diabetes, immunocompromised states, or history of radiotherapy require special attention as they are more susceptible to severe infections 2
• Hyperbaric oxygen therapy may be beneficial as adjunctive therapy in diabetic patients with perichondritis 5
• If perichondritis is associated with a piercing, consider temporary removal of jewelry to allow better drainage and treatment 2
• Residual deformity is associated with longer time before presentation, piercing of the cartilage, and growth of Pseudomonas 4

Monitoring and Follow-up

• Expect clinical improvement within 48-72 hours of initiating appropriate therapy 2
• If no improvement occurs within 48-72 hours, consider:
  • Treatment failure
  • Allergic reaction
  • Misdiagnosis
  • Need for surgical drainage 2
• Complete the full course of prescribed antimicrobial therapy even if symptoms improve 2

Pitfalls to Avoid

• Delaying treatment can lead to cartilage necrosis and permanent deformity 1, 6
• Failing to consider surgical drainage when an abscess has formed 1
• Using aminoglycoside-containing eardrops can cause ototoxicity if the tympanic membrane is perforated 1