What is the initial lab workup and treatment for a patient with ear chondritis (inflammation of the ear cartilage)?

Ear Chondritis: Laboratory Workup and Initial Management

Clinical Diagnosis

Ear chondritis (perichondritis) is primarily a clinical diagnosis that does not require routine laboratory testing, but when systemic involvement or relapsing polychondritis is suspected, targeted workup becomes essential.

The diagnosis is made by recognizing painful swelling, warmth, and erythema of the cartilaginous portion of the auricle that characteristically spares the earlobe 1. A key distinguishing feature is acute tenderness when deflecting the auricular cartilage, which indicates deeper perichondrial infection requiring systemic antibiotics rather than simple cellulitis 1.

Laboratory Workup

When to Order Labs

• Routine laboratory tests are NOT indicated for isolated, uncomplicated ear chondritis following trauma or piercing 1, 2
• Labs become essential when systemic disease is suspected, particularly relapsing polychondritis, which presents with recurrent episodes affecting multiple cartilaginous sites 3

Specific Laboratory Tests for Suspected Relapsing Polychondritis

When patients present with:

• Bilateral ear involvement
• Recurrent episodes (86% have relapsing course) 3
• Associated arthralgias (81% of cases) 3
• Respiratory symptoms (cough, wheezing, stridor, dyspnea) 3

Order the following workup:

• Inflammatory markers: ESR and CRP to assess systemic inflammation 3
• Autoimmune panel: ANA, RF, anti-CCP to evaluate for associated autoimmune conditions 3
• Complete blood count: to assess for anemia of chronic disease and leukocytosis 3

Microbiological Testing

• Culture and sensitivity testing is critical when surgical drainage or debridement is performed 2, 4
• Pseudomonas aeruginosa is isolated in 69% of culture-positive cases, followed by Staphylococcus aureus 1, 2
• In one series, polymicrobial infection was found in 3 of 4 chronic cases 4

Imaging Studies

For Isolated Ear Chondritis

• No imaging is required for straightforward perichondritis 1

For Suspected Relapsing Polychondritis with Respiratory Involvement

Pulmonary function tests with inspiratory and expiratory flow-volume curves should be performed to identify clinically subtle airway involvement 3

CT scanning of the chest may reveal:

• Thickening and stenosis of the tracheobronchial wall 3
• Collapse and calcification of cartilage 3
• Bronchiectasis in late-stage disease 3

Chest radiographs are usually unhelpful in diagnosis 3

Bronchoscopy is not always required but may show inflammation, collapse, and stenosis of the larynx, trachea, and/or bronchi 3

Initial Treatment

First-Line Antibiotic Therapy

Fluoroquinolone antibiotics should be prescribed as initial therapy because Pseudomonas aeruginosa is the predominant pathogen 1. This represents the most critical treatment decision.

Dual antibiotic coverage targeting both P. aeruginosa and S. aureus is recommended:

• Intravenous dual therapy for median duration of 6 days, followed by oral therapy for median 15 days (total ~16 days) 2
• Oral monotherapy may be appropriate for less severe cases, typically for 10 days 2

Surgical Management

• Immediate earring removal should be performed in 18 of 21 cases in one series 2
• Re-examination within 48-72 hours is mandatory to ensure antibiotic response and absence of abscess formation requiring drainage 1
• Aggressive surgical debridement with excision of infected cartilage is indicated for treatment-refractory cases or when abscess formation occurs 5, 6, 4
• Surgical excision of diseased cartilage should be considered in chronic cases refractory to antibiotics and incision/drainage, potentially offering definitive cure 4

Critical Pitfall to Avoid

Never use local anesthesia with epinephrine if surgical intervention is needed, as this compromises the already tenuous blood supply to auricular cartilage 1.

Treatment for Relapsing Polychondritis

• Salicylates and NSAIDs for milder cases 3
• Systemic corticosteroids and immunosuppressants (cytotoxic agents) for more severe disease, particularly with respiratory involvement 3
• Long-term immunosuppression is usually required for respiratory involvement 3

Follow-Up and Monitoring

• Mandatory re-examination at 48-72 hours to assess treatment response 1
• Early aggressive treatment prevents complete destruction of the external ear and minimizes residual deformity 5
• No ear deformity or general complications were reported when early appropriate antibiotic therapy was administered 2