What are the diagnosis and treatment options for perichondritis?

Perichondritis: Diagnosis and Treatment

Diagnosis

Auricular perichondritis presents as painful swelling, warmth, and redness affecting the cartilaginous portion of the auricle while characteristically sparing the earlobe. 1

Clinical Presentation

• Acute tenderness on deflecting the auricular cartilage is the key distinguishing feature that differentiates deeper perichondrial infection from superficial skin infection 1
• Pain, swelling, and potentially purulent discharge from the external ear 2
• Typically occurs within the first month after ear piercing, especially during warm-weather months 1
• May progress from minor infection to perichondritis, abscess formation, and necrosis with or without systemic symptoms 1

Diagnostic Workup

• Culture and sensitivity testing should be obtained to identify the causative organism 3, 4
• Consider patient risk factors including diabetes mellitus, which may aggravate the condition 2
• Assess for history of trauma (the main cause in 46% of cases) or recent ear piercing 5

Treatment

Initial Antibiotic Therapy

For non-abscess perichondritis, initiate intravenous antibiotics covering Staphylococcus aureus as first-line empirical therapy, as S. aureus is the predominant pathogen (49% of cases) in non-abscess infections. 4

• Staphylococcus aureus was found in 49% of non-abscess perichondritis cases with heavy or moderate growth in 82% of isolates 4
• Pseudomonas aeruginosa is the predominant organism in abscess-forming perichondritis (58% of abscess cases) and overall represents 69% of available isolates 3, 4
• For abscess-forming or severe perichondritis, fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) provide excellent anti-pseudomonal coverage 1, 6

Treatment Algorithm by Severity

Stage 1 (Early, Non-Abscess):

• Conservative management with intravenous antibiotics covering S. aureus 4, 5
• No residual deformity expected with early treatment 5
• Expand coverage to include P. aeruginosa if clinical response is disappointing or cultures grow P. aeruginosa 4

Stage 2 (Abscess Formation):

• Surgical incision and drainage is necessary when abscess develops 1, 5
• Continue anti-pseudomonal antibiotics (fluoroquinolones preferred) 1, 3
• Minor residual deformity occurs in approximately 50% of cases requiring drainage 5

Stage 3 (Advanced with Cartilage Necrosis):

• Surgical debridement is required for extensive cartilage involvement 5
• Good cosmetic preservation of auricular cartilage is difficult once abscess develops 1
• Gross residual deformity occurs in 29% and minor deformity in 71% of cases requiring debridement 5

Alternative Treatment Options

Oral ciprofloxacin can be used for outpatient management of P. aeruginosa perichondritis in selected cases, avoiding prolonged hospitalization 6

Hyperbaric oxygen therapy may be considered as adjunctive therapy in diabetic patients with recurrent perichondritis, though this remains investigational 2

Common Pitfalls

• Avoid delaying treatment: 41% of patients in one series were treated inadequately prior to hospitalization for an average of 2.5 days, potentially worsening outcomes 3
• Do not assume P. aeruginosa in all cases: Recent evidence shows S. aureus predominates in non-abscess infections, and empirical anti-pseudomonal coverage may be unnecessary initially 4
• Recognize progression risk: P. aeruginosa infection is associated with more advanced clinical presentation and longer hospitalization 3
• Monitor closely: Once abscess formation occurs, cosmetic outcomes are significantly compromised regardless of treatment 1, 5