What are the treatment options for a painful small bump on the ear?

Treatment of a Painful Small Bump on the Ear

For a painful small bump on the ear, the most likely diagnosis is auricular perichondritis (if involving cartilage) or a localized infection such as furunculosis, and treatment requires topical or systemic fluoroquinolone antibiotics targeting Pseudomonas aeruginosa and Staphylococcus aureus, along with appropriate pain management. 1, 2

Initial Assessment and Diagnosis

The location and characteristics of the bump determine the diagnosis and treatment approach:

• Auricular perichondritis presents as painful swelling, warmth, and redness in the cartilaginous portion of the auricle that typically spares the earlobe (which lacks cartilage). 1
• Acute tenderness when deflecting the auricular cartilage distinguishes deeper perichondrial infection from superficial skin infection. 1
• Furunculosis (infected hair follicle) occurs in the outer third of the ear canal and presents with localized tenderness, focal swelling, and pustular lesions. 2
• Perichondritis typically occurs within the first month after ear piercing, especially during warm-weather months. 1

First-Line Treatment for Auricular Perichondritis

Systemic fluoroquinolone antibiotics are the definitive treatment because the most common pathogens are Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pyogenes:

• Adults: Ciprofloxacin or levofloxacin for 7-10 days. 1
• Children: Despite traditional concerns about fluoroquinolone use in pediatrics, recent evidence supports their use for auricular perichondritis given the risk of devastating cartilage necrosis and permanent ear deformity if inadequately treated. 3, 4
• Alternative antibiotics (clindamycin, ceftazidime, cefepime) may be considered for hospitalized patients depending on pathogen identification. 1

Critical pitfall: Minor infections can rapidly progress to perichondritis, abscess formation, and cartilage necrosis with or without systemic symptoms. 1 Once an abscess develops, good cosmetic preservation of auricular cartilage is difficult to maintain. 1

Surgical Intervention

• If an abscess is present (fluctuant collection), surgical incision and drainage is necessary in addition to antibiotics. 1
• Biopsy may be necessary if neoplasia is suspected or response to therapy is incomplete. 1

Treatment for Furunculosis

If the bump is a furuncle (localized to outer ear canal):

• Warm compresses and topical antibiotics may suffice for small lesions. 2
• Incision and drainage under local anesthesia may be required for larger furuncles. 1
• Systemic antibiotics targeting Staphylococcus aureus if cellulitis extends beyond the localized area. 2

Pain Management

Pain relief is essential and should be addressed immediately:

• Mild to moderate pain: Ibuprofen 400 mg every 4-6 hours as needed (doses greater than 400 mg are no more effective). 5
• Severe pain: Consider short-term opioid therapy for the initial 48-72 hours while antibiotics take effect. 6
• Pain typically improves within 48-72 hours of starting appropriate antibiotic therapy. 7

When to Reassess or Escalate Care

• Reassess within 48-72 hours if no improvement is seen. 7
• Consider imaging (CT or MRI) if necrotizing infection is suspected, particularly in diabetic or immunocompromised patients. 1
• Elevated erythrocyte sedimentation rate plus abnormal imaging confirms necrotizing otitis externa, which requires surgical debridement and prolonged systemic antibiotics. 1

Important Differential Diagnoses to Consider

• Contact dermatitis from nickel or other metals in earrings presents with itching, redness, and swelling; treatment involves removing the offending jewelry and applying topical corticosteroids. 1
• Embedded earring in the earlobe requires removal under local anesthesia if gentle probing fails. 1
• Keloid formation (2.5% of ear piercings) presents as a firm, raised scar extending beyond the original piercing site. 1
• Herpes zoster oticus (Ramsay Hunt syndrome) presents with vesicles on the external ear canal and posterior auricle, requiring antiviral therapy. 2

Critical Pitfalls to Avoid

• Do not delay antibiotic treatment for suspected perichondritis—cartilage necrosis can occur rapidly and cause permanent "cauliflower ear" deformity. 1, 3
• Do not use aminoglycoside-containing drops (like neomycin) if tympanic membrane integrity is uncertain, as they are ototoxic. 7
• Do not dismiss pain in high-risk patients (age >50, smokers, alcohol users, diabetics) without considering malignancy or temporal arteritis. 8, 9
• Do not confuse perichondritis with simple otitis externa—perichondritis involves the cartilage and requires systemic antibiotics, not just topical therapy. 1, 2

Patient Education

• Remove jewelry from the affected ear during treatment. 1
• Avoid trauma or pressure to the ear. 1
• Complete the full antibiotic course even if symptoms improve. 7
• Return immediately if swelling worsens, fever develops, or the ear becomes more deformed. 1
• Ear can be repierced in an unscarred area after 6-8 weeks of complete resolution. 1