Management of Perichondritis in Children
Fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) should be prescribed as first-line therapy for perichondritis in children, despite traditional concerns about fluoroquinolone use in pediatrics, because Pseudomonas aeruginosa is the predominant pathogen in severe cases and delays in appropriate treatment lead to cartilage necrosis and permanent auricular deformity. 1, 2
Clinical Recognition and Diagnosis
Key diagnostic features to identify:
- Painful swelling, warmth, and erythema of the cartilaginous auricle that characteristically spares the earlobe 1, 2
- Acute tenderness when deflecting the auricular cartilage, which distinguishes perichondritis from superficial cellulitis 1, 2
- History of ear piercing or trauma within the preceding month, particularly during warm weather 1
Antibiotic Selection Based on Severity
Mild to Moderate Cases (Outpatient Treatment)
Oral fluoroquinolones are recommended as first-line therapy: 1
- Ciprofloxacin (oral dosing per pediatric guidelines) 1
- Levofloxacin 500-750 mg orally once daily (adjust for pediatric weight-based dosing) 1
The rationale for fluoroquinolones is compelling: Pseudomonas aeruginosa is isolated in 69% of culture-positive cases and is the predominant organism in severe perichondritis requiring hospitalization. 2, 3 While recent research suggests Staphylococcus aureus predominates in non-abscess cases (49% of isolates), 4 the American Academy of Pediatrics guidelines prioritize anti-pseudomonal coverage given the devastating consequences of treatment failure. 1, 2
Severe Cases Requiring Hospitalization
Intravenous fluoroquinolones (ciprofloxacin or levofloxacin) are indicated for severe perichondritis with extensive involvement or systemic signs. 1
Alternative Therapy
Clindamycin may be considered for patients with contraindications to fluoroquinolones or when S. aureus is strongly suspected, though this provides inadequate Pseudomonas coverage. 1 If clindamycin is chosen initially and clinical response is disappointing within 48-72 hours, coverage must be expanded to include P. aeruginosa. 4
Treatment Duration and Monitoring
- Continue antibiotics for 7-10 days or until complete clinical resolution of pain, swelling, and erythema 1
- Re-examine within 48-72 hours to ensure response to antibiotics and absence of abscess formation 2
- Monitor specifically for resolution of tenderness on cartilage deflection 1
Surgical Intervention
Immediate surgical incision and drainage are necessary if abscess develops. 1, 5 Once abscess formation occurs, good cosmetic preservation becomes difficult despite intervention. 1 Wide debridement of necrotic cartilage and subcutaneous tissue with preservation of the helical rim minimizes resulting deformity. 5
Critical Pitfalls to Avoid
- Never delay treatment while awaiting culture results—cartilage necrosis can occur rapidly and causes permanent deformity 1, 6
- Do not use local anesthesia with epinephrine if surgical intervention is needed, as this further compromises the already tenuous blood supply to auricular cartilage 2
- Avoid aminoglycoside-containing eardrops as they cause ototoxicity if the tympanic membrane is perforated 1
- Do not treat as simple cellulitis—failure to use anti-pseudomonal antibiotics leads to treatment failure in the majority of severe cases 3
Addressing the Fluoroquinolone Controversy in Pediatrics
While fluoroquinolones traditionally carry concerns about musculoskeletal adverse effects in children, the American Academy of Pediatrics specifically recommends their use for perichondritis because the risk of permanent auricular deformity from inadequate treatment outweighs theoretical musculoskeletal risks. 1, 2 This represents one of the accepted indications for fluoroquinolone use in pediatric patients. 6 The successful outpatient treatment of P. aeruginosa perichondritis with oral ciprofloxacin has been well-documented, avoiding prolonged hospitalization and intravenous therapy. 7