What is the treatment for auricle perichondritis?

Treatment of Auricle Perichondritis

Start immediate systemic fluoroquinolone antibiotics (such as ciprofloxacin) targeting Pseudomonas aeruginosa, as this organism causes 69% of cases and delays in treatment lead to irreversible cartilage necrosis and permanent ear deformity. 1

Immediate Antibiotic Management

• Initiate anti-pseudomonal fluoroquinolone therapy immediately upon clinical diagnosis without waiting for culture results, as Pseudomonas aeruginosa is the predominant pathogen and is associated with more advanced clinical presentation and longer hospitalization 1
• Ciprofloxacin is the fluoroquinolone of choice, providing excellent coverage against both Pseudomonas aeruginosa and Staphylococcus aureus 2, 1
• Even in pediatric patients, fluoroquinolone use is warranted given the devastating consequences of untreated perichondritis, including permanent cartilage deformity 3

Clinical Recognition

• Perichondritis presents with painful swelling, warmth, and redness that characteristically spares the earlobe (which lacks cartilage), distinguishing it from simple cellulitis 4
• Acute tenderness when deflecting the auricular cartilage indicates deeper perichondrial infection requiring systemic antibiotics 4
• The infection involves the perichondrium and underlying cartilage of the external ear, sparing the lobule and tragus 5

Etiology and Risk Factors

• In more than half of cases, no clear etiology can be determined, though many develop after apparent minor trauma 1
• Common precipitating factors include ear piercing, trauma, burns, and prior ear surgery 4, 1, 6
• Infection risk is highest during warm weather months 4

Surgical Intervention: When and How

• Reserve surgical drainage for cases with abscess formation or treatment failure after 48-72 hours of appropriate antibiotic therapy 1, 5
• Only 7% of patients require surgical intervention when treated promptly with appropriate antibiotics 1
• If surgery becomes necessary, use tubal drainage with continuous antibiotic administration rather than cartilage excision, as excision results in marked deformity, repeated debridement, and protracted treatment 7
• Maintain drainage tubes for 2-4 weeks to elevate perichondrium from remaining cartilage, ensuring homogeneous cartilage reformation and providing local antibiotic treatment 7
• Wide cartilage and subcutaneous tissue debridement with preservation of the helical rim minimizes resulting auricular deformity when extensive surgery is unavoidable 5

Monitoring and Follow-Up

• Re-examine within 48-72 hours to assess treatment response, as patients with Pseudomonas infection have longer hospitalizations and more advanced presentations 4, 1
• Watch for signs of progression including increased swelling, fluctuance suggesting abscess formation, or systemic symptoms 3, 5
• Patients treated prior to hospitalization averaged 2.5 days of inadequate therapy before appropriate treatment, emphasizing the importance of early correct antibiotic selection 1

Critical Pitfalls to Avoid

• Never treat suspected perichondritis with antibiotics lacking anti-pseudomonal coverage (such as amoxicillin, cephalexin, or macrolides), as this leads to treatment failure and permanent deformity 4, 1
• Do not confuse perichondritis with simple otitis externa—perichondritis involves the cartilaginous structures and spares the lobule, while otitis externa affects the ear canal 3
• Avoid the outdated Stroud excision technique, which results in marked deformity and protracted treatment; tubal drainage should be the method of choice even in gram-negative infections 7
• Do not delay treatment waiting for culture results, as cartilage necrosis can occur rapidly 1, 3

Duration of Therapy

• Continue systemic antibiotics until complete resolution of inflammation, typically requiring hospitalization for initial management 1
• The mean hospitalization in one large series was significantly longer for Pseudomonas infections, underscoring the severity of this pathogen 1