What are the next steps for a patient with persistent swelling, redness, and tenderness at a periauricle tag removal site 2 weeks post-operatively?

Management of Persistent Periauricular Tag Removal Site Infection at 2 Weeks

This patient requires immediate initiation of systemic antibiotics targeting Pseudomonas aeruginosa and Staphylococcus aureus, with fluoroquinolone therapy (ciprofloxacin or levofloxacin) as first-line treatment, along with urgent wound inspection to rule out perichondritis or abscess formation. 1

Clinical Assessment and Diagnosis

At 2 weeks post-operatively, persistent swelling, redness, and tenderness represents a true surgical site infection rather than normal postoperative inflammation, which typically resolves within 2-3 days. 2 The key diagnostic considerations include:

• Auricular perichondritis: This serious complication typically occurs within the first month after auricular procedures and presents with painful swelling, warmth, and redness that often spares the earlobe. 1 Acute tenderness on deflecting the auricular cartilage helps distinguish this deeper perichondrial infection from superficial skin infection. 1

• Superficial surgical site infection: Characterized by purulent drainage, local pain, swelling, and erythema at the incision site. 1

• Abscess formation: If fluctuance is present, this indicates progression to abscess requiring surgical drainage. 1

Immediate Management Algorithm

Step 1: Wound Examination

• Inspect for purulent drainage, measure extent of erythema from wound edge, assess for fluctuance, and test for cartilage tenderness by deflecting the auricle. 1
• If erythema extends >5 cm from the wound edge with induration, or any tissue necrosis is present, this mandates immediate antibiotic therapy. 1, 3

Step 2: Culture and Antibiotic Initiation

• Obtain Gram stain and culture of any purulent drainage before starting antibiotics, but do not delay treatment. 1, 3
• Start empiric fluoroquinolone therapy immediately: Ciprofloxacin or levofloxacin are the antibiotics of choice because Pseudomonas aeruginosa is the predominant pathogen (69% of auricular perichondritis cases), followed by Staphylococcus aureus and Streptococcus pyogenes. 1, 4
• Alternative regimens for hospitalized patients or severe cases include clindamycin, ceftazidime, or cefepime. 1

Step 3: Assess for Abscess

• If fluctuance or abscess is present, surgical incision and drainage is necessary. 1 Once an abscess develops, good cosmetic preservation of auricular cartilage is difficult to maintain, making early intervention critical. 1
• The primary therapy for surgical site infection with abscess is opening the incision and evacuating infected material, with continued dressing changes until healing by secondary intention. 1

Step 4: Determine Need for Hospitalization

• Consider admission if the patient has systemic signs including temperature ≥38.5°C, heart rate ≥110 beats/minute, or evidence of spreading infection. 3
• Pseudomonas aeruginosa infection is associated with more advanced clinical presentation and longer hospitalization. 4

Critical Pitfalls to Avoid

• Do not delay antibiotic treatment: At 2 weeks post-operatively with persistent symptoms, this is not benign postoperative inflammation. Early postoperative fever (first 48-72 hours) is typically non-infectious, but by day 4 and beyond, infection becomes increasingly likely. 2

• Do not use inadequate antibiotic coverage: Standard anti-staphylococcal antibiotics alone (such as cefazolin) are insufficient for auricular infections, which require anti-pseudomonal coverage. 1, 4

• Do not miss perichondritis: Minor superficial infections can progress to perichondritis, abscess formation, and cartilage necrosis with permanent deformity if not treated aggressively. 1

• Do not rely on antibiotics alone if abscess is present: Studies of subcutaneous abscesses found no benefit for antibiotic therapy when combined with drainage, and drainage is the primary treatment. 1

Follow-up and Monitoring

• Reassess the wound within 24-48 hours for clinical improvement. 3
• If symptoms persist beyond 3 weeks despite appropriate antibiotic therapy, consider imaging (CT scan) to evaluate for deeper infection or retained foreign material. 1
• The ear can be repierced 6-8 weeks after complete resolution of local swelling and tenderness. 1