What is the recommended management for a patient with perichondritis, considering their underlying medical conditions and potential allergies?

Management of Perichondritis

Start oral fluoroquinolones (ciprofloxacin or levofloxacin) immediately as first-line therapy for perichondritis, as Pseudomonas aeruginosa is the predominant pathogen in 69% of culture-positive cases. 1, 2, 3

Initial Assessment and Diagnosis

Recognize the classic presentation: painful swelling, warmth, and erythema of the cartilaginous auricle that characteristically spares the earlobe. 1, 2

• Distinguish from simple cellulitis by checking for acute tenderness when deflecting the auricular cartilage—this indicates deeper perichondrial infection requiring systemic antibiotics rather than topical therapy alone. 2
• Most cases occur within the first month after ear piercing or trauma, especially during warm weather. 1
• Assess for abscess formation, which requires surgical drainage in addition to antibiotics. 1, 2

Antibiotic Treatment

First-Line Therapy (Outpatient)

Oral fluoroquinolones are the recommended first-line treatment because Pseudomonas aeruginosa is isolated in 69% of culture-positive cases and is associated with more advanced clinical presentation and longer hospitalization. 1, 2, 3

• Levofloxacin 500-750 mg orally once daily 1
• Ciprofloxacin (standard dosing) 1, 2
• Continue treatment for 7-10 days or until clinical resolution 1

Severe Cases Requiring Hospitalization

• Use intravenous fluoroquinolones (ciprofloxacin or levofloxacin) for severe perichondritis. 1
• Hospitalization is typically required for only 2 days with appropriate drainage procedures. 4

Alternative Therapy

• For patients with fluoroquinolone contraindications or beta-lactam allergy, consider clindamycin, particularly if Staphylococcus aureus is suspected. 1
• Other less common pathogens include Streptococcus pyogenes. 1

Surgical Management

Perform incision and drainage immediately if abscess is present—this is non-negotiable as medical therapy alone will fail. 1, 5

• Avoid local anesthesia with epinephrine as this compromises the already tenuous blood supply to auricular cartilage and increases risk of necrosis. 2
• Use tubal drainage (tubes retained 2-4 weeks) rather than Stroud's excision technique, as the latter results in marked deformity and protracted treatment. 4
• Tubes should be retained to maintain elevation of the perichondrium from remaining cartilage, ensuring homogeneous cartilage formation and providing local antibiotic delivery. 4
• Wide cartilage and subcutaneous tissue debridement with preservation of the helical rim minimizes resulting auricular deformity when extensive surgery is necessary. 5

Monitoring and Follow-Up

Re-examine patients within 48-72 hours to ensure response to antibiotics and absence of abscess formation requiring drainage. 2

• Monitor for resolution of pain, swelling, and erythema. 1
• Patients treated with antibiotics alone (31% in one series) had no residual deformity at follow-up when caught early. 6
• Those requiring incision and drainage (31%) had minor residual deformity in half of cases. 6
• Patients requiring debridement had either gross (29%) or minor (71%) residual deformities. 6

Critical Pitfalls to Avoid

• Delaying treatment leads to cartilage necrosis and permanent deformity—this is the most important complication to prevent. 1
• Do not use aminoglycoside-containing eardrops if tympanic membrane perforation is present, as this causes ototoxicity. 1
• Do not fail to consider surgical drainage when an abscess has formed—once developed, good cosmetic preservation of auricular cartilage is difficult to maintain. 1
• In more than half of cases, no clear etiology can be determined, so maintain high clinical suspicion even without obvious trauma history. 3
• Pseudomonas aeruginosa infections are associated with more advanced clinical presentation, so empiric anti-pseudomonal coverage is essential from the start. 3

Special Considerations

• For diabetic patients with recurrent perichondritis, hyperbaric oxygen therapy may be considered as adjunctive therapy, though this is based on limited case report evidence. 7
• Distinguish auricular perichondritis from relapsing polychondritis, as the latter requires steroid treatment rather than surgical intervention. 4