What is the treatment for perichondritis?

Treatment of Perichondritis

For auricular perichondritis, initiate oral fluoroquinolones (ciprofloxacin or levofloxacin) as first-line therapy for outpatient cases, targeting Pseudomonas aeruginosa, with surgical drainage reserved for abscess formation. 1

Antibiotic Selection

First-Line Treatment

• Oral fluoroquinolones are the recommended first-line therapy for mild to moderate perichondritis, specifically ciprofloxacin or levofloxacin 1
• Levofloxacin dosing: 500-750 mg orally once daily 1
• This recommendation is based on Pseudomonas aeruginosa being the predominant pathogen in severe cases (69% of isolates in hospitalized patients) 2
• For severe cases requiring hospitalization, switch to intravenous fluoroquinolones 1

Alternative Considerations Based on Recent Evidence

• A 2019 study challenges the universal need for anti-pseudomonal coverage in non-abscess perichondritis, finding Staphylococcus aureus predominant (49%) in these cases, while P. aeruginosa was more common (58%) only when abscess was present 3
• In non-abscess cases, antibiotics covering S. aureus showed no significant difference in clinical outcomes compared to anti-pseudomonal coverage 3
• For patients with beta-lactam allergy or fluoroquinolone contraindications, clindamycin may be considered if S. aureus is suspected 1

Practical Algorithm for Antibiotic Selection

• If abscess present: Use anti-pseudomonal coverage (fluoroquinolones) from the start 1, 3
• If no abscess: Consider starting with S. aureus coverage, expanding to P. aeruginosa if clinical response is poor 3
• However, given the serious consequences of inadequate treatment (cartilage necrosis, permanent deformity), the safer approach remains starting with fluoroquinolones 1, 2

Treatment Duration and Monitoring

• Continue antibiotics for 7-10 days or until clinical resolution 1
• Monitor specifically for resolution of pain, swelling, and erythema 1
• Delaying treatment risks cartilage necrosis and permanent auricular deformity 1

Surgical Management

• Surgical incision and drainage are mandatory if abscess develops 1
• Once abscess forms, preserving good cosmetic appearance of the auricular cartilage becomes difficult 1
• Historical data supports tubal drainage over excision techniques, as excision resulted in marked deformity and protracted treatment 4
• Tubes retained for 2-4 weeks maintain perichondrial elevation and allow local antibiotic delivery 4

Clinical Recognition

• Perichondritis presents with painful swelling, warmth, and redness of the auricle that characteristically spares the earlobe 1
• Acute tenderness on deflecting the auricular cartilage distinguishes it from superficial cellulitis 1
• Often occurs within the first month after ear piercing or trauma, particularly in warm weather 1
• In over half of cases, no clear etiology can be determined 2

Critical Pitfalls to Avoid

• Never delay treatment - cartilage necrosis can occur rapidly 1
• Do not miss abscess formation - requires immediate surgical drainage 1
• Avoid aminoglycoside-containing eardrops if tympanic membrane perforation is possible - risk of ototoxicity 1
• Do not use inadequate antibiotic duration - 41% of patients in one series had received prior inadequate treatment before hospitalization 2

Special Populations

• In diabetic patients with recurrent or refractory perichondritis, hyperbaric oxygen therapy may be considered as adjunctive treatment, though evidence is limited to case reports 5
• Patients with diabetes mellitus may have more complicated courses requiring longer treatment 5

Key Distinction

• Distinguish auricular perichondritis from relapsing polychondritis - the latter requires steroid therapy, not surgical intervention 4