Treatment of Perichondritis of the Ear
Start fluoroquinolone antibiotics immediately upon diagnosis of auricular perichondritis, as Pseudomonas aeruginosa is the predominant pathogen in 69% of cases, and delay in appropriate anti-pseudomonal coverage leads to cartilage necrosis and permanent deformity. 1
Initial Assessment and Diagnosis
Recognize the classic presentation: painful swelling, warmth, and erythema of the cartilaginous portion of the auricle that characteristically spares the earlobe (which lacks cartilage). 2, 3
Distinguish from simple cellulitis: acute tenderness when deflecting the auricular cartilage indicates deeper perichondrial infection requiring systemic antibiotics, not just superficial skin infection. 2
Identify the etiology: common causes include trauma (ear piercing, lacerations, burns), though in over 50% of cases no clear cause is identified. 1, 3
Check for modifying factors: diabetes mellitus and immunocompromised states significantly worsen prognosis and may require adjunctive therapies. 4, 1
First-Line Antibiotic Treatment
Prescribe fluoroquinolone antibiotics as initial therapy because Pseudomonas aeruginosa is isolated in 69% of culture-positive cases and is associated with more advanced clinical presentation and longer hospitalization. 1
Do not use antibiotics without anti-pseudomonal coverage (such as amoxicillin, cephalexin, or macrolides alone), as this leads to treatment failure and progression to cartilage destruction. 2, 1
Continue antibiotics for the full course even if symptoms begin improving, as premature discontinuation risks recurrence and permanent auricular deformity. 1
Surgical Intervention
Perform incision and drainage if abscess formation occurs, though recognize that good cosmetic preservation becomes difficult once purulent collection develops. 2, 5
Reserve wide cartilage and subcutaneous tissue debridement for persistent cases that fail medical management, while attempting to preserve the helical rim to minimize resulting deformity. 5
Consider continuous antibiotic irrigation with drains for severe cases, as this may avoid the need for repeated debridement procedures under general anesthesia. 6, 7
Alternative technique for localized disease: drain the infection site and irrigate with streptomycin solution, then fill the cavity with streptomycin, hyaluronidase, and triamcinolone to avoid more invasive surgical procedures. 7
Adjunctive Therapies
Add nonsteroidal anti-inflammatory drugs to control pain and inflammation alongside antibiotics. 5
Consider hyperbaric oxygen therapy in diabetic patients with recurrent or refractory perichondritis, as it promotes wound healing through regeneration of intracellular free radicals and wound-healing factors. 4
Critical Pitfalls to Avoid
Never delay treatment: 41% of patients in one series were treated inadequately prior to hospitalization for an average of only 2.5 days, yet this delay was associated with worse outcomes. 1
Never assume minor trauma is insignificant: perichondritis develops in many cases after apparent minor trauma, and the infection progresses rapidly once established. 1
Never use local anesthesia with epinephrine if surgical intervention is needed, as this compromises the already tenuous blood supply to auricular cartilage. 2
Never treat empirically without anti-pseudomonal coverage: since Pseudomonas is the predominant pathogen, initial treatment must include anti-pseudomonal antibiotics from the start. 1
Monitoring and Follow-Up
Re-examine within 48-72 hours to ensure response to antibiotics and absence of abscess formation requiring drainage. 2
Watch for progression despite antibiotics: if no improvement occurs within 2-3 days, consider surgical drainage or inadequate antibiotic coverage. 1, 5
Monitor for permanent deformity: even with successful treatment, some cartilage damage may result in "cauliflower ear" deformity, particularly if treatment was delayed or surgical debridement was required. 5, 7