What is the treatment for infected ear cartilage (perichondritis) in a patient with a history of ear infections, trauma, or immune system disorders?

Treatment of Infected Ear Cartilage (Perichondritis)

Start systemic fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) immediately for any suspected auricular perichondritis, as Pseudomonas aeruginosa is the predominant pathogen and delays in appropriate treatment lead to cartilage necrosis and permanent ear deformity. 1, 2

Immediate Recognition and Diagnosis

• Distinguish perichondritis from simple skin infection by checking for acute tenderness when deflecting the auricular cartilage—this indicates deep perichondrial infection requiring systemic antibiotics. 1, 3
• Look for painful swelling, warmth, and redness involving the cartilaginous portion of the ear that characteristically spares the earlobe, as this distribution pattern is pathognomonic for perichondritis rather than cellulitis. 4, 1, 3
• Most cases occur within the first month after trauma (piercing, laceration, or other injury), with highest incidence during warm-weather months. 4, 1, 3

First-Line Antibiotic Treatment

• Prescribe oral fluoroquinolones (ciprofloxacin or levofloxacin) as first-line therapy because Pseudomonas aeruginosa accounts for 69% of culture-positive cases and is associated with more severe clinical presentation. 1, 2
• Never use antibiotics that don't cover Pseudomonas aeruginosa, as this leads to treatment failure and permanent cosmetic deformity. 1, 3
• Staphylococcus aureus and Streptococcus pyogenes are also common pathogens, but fluoroquinolones provide adequate coverage for these organisms as well. 1, 3

Essential Concurrent Interventions

• Remove any piercing jewelry immediately, as removal is fundamental for treatment success and prevents ongoing foreign body reaction. 1, 3
• If an abscess has formed, perform surgical incision and drainage urgently—delay leads to cartilage necrosis and makes good cosmetic preservation difficult or impossible. 4, 1, 3
• Consider tubal drainage for 2-4 weeks rather than wide cartilage excision, as this maintains perichondrial elevation and allows homogeneous new cartilage formation with superior aesthetic results. 5

High-Risk Populations Requiring Aggressive Management

• Diabetic and immunocompromised patients require special attention with more aggressive systemic antibiotic therapy, as they have greater susceptibility to treatment failure and progression to necrotizing infection. 1, 6
• Avoid ear canal irrigation in these patients, as it can predispose to necrotizing otitis externa. 1
• Consider adjunctive hyperbaric oxygen therapy for diabetic patients with recurrent or refractory perichondritis, as it promotes wound healing through regeneration of intracellular free radicals. 6

Mandatory Re-evaluation Timeline

• Re-examine the patient at 48-72 hours—if symptoms have not improved, obtain cultures of ear drainage to identify resistant bacteria or unusual pathogens. 1, 3
• Do not continue the same antibiotic regimen beyond 48-72 hours without clinical improvement; this represents treatment failure requiring culture-directed therapy. 1
• Consider fungal infection (otomycosis) after prolonged antibiotic therapy, particularly in immunocompromised patients. 1

Surgical Intervention Criteria

• Perform incision and drainage when fluctuance or abscess formation is present, as antibiotics alone cannot penetrate organized purulent collections. 1, 7
• For persistent infection despite appropriate antibiotics and drainage, wide cartilage and subcutaneous tissue debridement with preservation of the helical rim minimizes resulting auricular deformity. 7
• Surgery should be considered a last resort after medical management has failed, as it inevitably results in some degree of cosmetic deformity. 7

Critical Pitfalls to Avoid

• Never prescribe only topical antibiotics for perichondritis—the infection involves deep cartilage structures that topical agents cannot penetrate. 1
• Do not delay treatment while awaiting culture results; empiric anti-pseudomonal coverage must be started immediately based on clinical diagnosis. 2
• Never use local anesthesia containing epinephrine for any ear procedures, as it compromises the already tenuous blood supply to auricular cartilage. 4
• Avoid treating suspected perichondritis as simple otitis externa or cellulitis, as inadequate antibiotic coverage leads to progression and permanent deformity. 8

Special Considerations for Pediatric Patients

• Fluoroquinolone use in children is warranted for perichondritis despite traditional concerns about cartilage toxicity, as the risk of permanent ear deformity from untreated Pseudomonas infection far outweighs theoretical musculoskeletal risks. 8
• The latest evidence supports fluoroquinolone safety in this specific clinical scenario where alternative antibiotics lack adequate Pseudomonas coverage. 8

Prevention of Recurrence

• After complete resolution, wait at least 6-8 weeks before considering repiercing in an unscarred area. 3
• Educate patients that in over half of perichondritis cases, no clear etiology can be determined despite apparent minor trauma. 2
• Average pre-hospitalization treatment duration of 2.5 days with inadequate antibiotics is associated with worse outcomes and longer hospitalization. 2