Treatment and Management of Perichondritis
Immediate Antibiotic Therapy
Start fluoroquinolone antibiotics immediately as first-line therapy for perichondritis, as Pseudomonas aeruginosa is isolated in 69% of culture-positive cases and is the predominant pathogen. 1, 2
- Fluoroquinolones are specifically recommended by the American Academy of Pediatrics as initial therapy due to their anti-pseudomonal coverage 1
- The microbiology consistently shows P. aeruginosa as the dominant organism, and its presence correlates with more advanced clinical presentation and longer hospitalization 2
- While fluoroquinolone use in pediatrics has historically raised concerns, the severity of perichondritis and risk of permanent cartilage destruction justifies their use in this specific indication 3
Clinical Recognition and Diagnosis
Recognize perichondritis by the classic triad: painful swelling, warmth, and erythema of the cartilaginous auricle that characteristically spares the earlobe. 1
- Check for acute tenderness when deflecting the auricular cartilage, which distinguishes deeper perichondrial infection from simple cellulitis 1
- This finding indicates the need for systemic antibiotics rather than topical therapy alone 1
- In more than half of cases, no clear etiology can be determined, though trauma (including minor trauma from piercings) accounts for 46% of identifiable causes 2, 4
Mandatory Early Follow-Up
Re-examine all patients within 48-72 hours to ensure antibiotic response and rule out abscess formation requiring surgical drainage. 1
- Early follow-up is critical because delays in treatment lead to devastating focal cartilage necrosis and permanent ear deformities 3
- Patients treated prior to hospitalization average 2.5 days of inadequate therapy before appropriate treatment 2
Surgical Intervention When Needed
If surgical drainage becomes necessary, avoid local anesthesia with epinephrine, as this compromises the already tenuous blood supply to auricular cartilage. 1
- Approximately 7-8% of patients require surgical intervention 2
- For cases requiring drainage, tubal drainage methods are superior to excision techniques, which result in marked deformity and protracted treatment 5
- Tubes should be retained 2-4 weeks to maintain perichondrial elevation and allow homogeneous cartilage reformation 5
- Debridement is reserved for advanced cases with significant cartilage involvement, though this results in residual deformity in all cases (29% gross, 71% minor) 4
Treatment Stratification by Severity
The management approach depends on disease stage at presentation:
- Stage 1 (Early): Antibiotics alone achieve complete resolution without residual deformity in 31% of cases 4
- Stage 2 (Moderate): Incision and drainage plus antibiotics result in minor residual deformity in 50% of cases 4
- Stage 3 (Advanced): Debridement is required, with residual deformity expected in all cases 4
Special Populations
In diabetic or immunocompromised patients with severe otalgia, consider necrotizing (malignant) otitis externa as a differential diagnosis requiring more aggressive management. 6
- Hyperbaric oxygen therapy may serve as beneficial adjunctive therapy in diabetic patients with recurrent perichondritis 7
- Six patients with perichondritis secondary to malignant otitis externa required wound debridement via post-auricular approach, all resulting in minor residual deformities 4
Critical Pitfall to Avoid
Do not confuse perichondritis with relapsing polychondritis, as the latter requires steroid therapy rather than antibiotics and surgical intervention. 5