Perichondritis - Not Just Simple Cellulitis - REBEL EM - Emergency Medicine Blog

4/13/2019 Perichondritis: Not Just Simple Cellulitis - REBEL EM - Emergency Medicine Blog
JULY 20, 2017
Perichondritis: Not Just Simple Cellulitis

Written by Rick Pescatore 
REBEL EM 
Medical Category: Infectious
Disease 
1 Comment
Background: Perichondritis is an infection of the connective tissue of the ear that

covers the cartilaginous auricle or pinna, excluding the lobule (Caruso 2014). The
term perichondritis is itself a misnomer, as the cartilage is almost always
involved, with abscess formation and cavitation (Prasad 2007). Perichondritis can
be a devastating disease, and if left improperly treated, the infection can worsen
into a liquefying chondritis resulting in dis gurement and/or loss of the external
ear (Noel 1989) (Martin 1976). Unfortunately, misdiagnosis and mistreatment is
common. In one small retrospective review, the overwhelming majority of
patients presenting to a large general hospital were prescribed antibiotics
without appropriate antimicrobial coverage, resulting in a signi cant number of
patients developing chondral deformities or “cauli ower ear” (Liu 2013).

Causes: A number of causes of perichondritis have been identi ed, with one
study of 85 patients suggesting the most common causes including minor
trauma, burns, and ear piercing (Prasad 2005). Notably, damage to the cartilage
https://rebelem.com/perichondritis-not-just-simple-cellulitis/ 1/8
, , p g 5 y, g g
is not a necessary prerequisite—infection can occur if the overlying meatal skin is
subjected to even trivial trauma, such as a scratch with an infected ngernail. In a
signi cant percentage of cases, no signi cant cause can be identi ed (Prasad
2007) (Levin 1995). Nonetheless, several authors postulate that a growing
incidence of perichondritis may be associated with the rising popularity of high
chondral ear piercing, which causes stripping of the perichondrium and
microfracture of the avascular cartilage while directly introducing infection
(Prasad 2007) (Liu 2013). Perichondritis has been noted to be the presenting
symptom of a number of disease processes marked by immunosuppression,
including HIV-associated Non-Hodkin’s Lymphoma, relapsing polychondritis, and
—not uncommonly—diabetes (Caruso 2014) (Levin 1995).
The most common microorganism responsible for perichondritis is

Pseudomonas Aeruginosa, a gram-negative rod with intrinsic antibiotic
resistance mechanisms (Caruso 2014) (Wu 2011). In one retrospective analysis of
61 patients with perichondritis, Pseudomonas was identi ed in 95% of cases. Co-
infection with E. Coli was identi ed in half of cases, and Staph Aureus in 7% of
patients. Because of the varying antibiotic sensitivities of these causative
organisms, culture swab is recommended in all cases (Prasad 2005).
Diagnosis and Management: The diagnosis of perichondritis is clinical via

physical exam. Patients initially experience dull pain, which gradually develops
into severe otalgia with a purulent discharge (Noel 1989). Early cases are marked
by erythema, swelling, and tenderness of the auricle without notable uctuance
(Chun 2013). The lobule remains una ected, helping to distinguish perichondritis
from otitis externa (Kullar 2012). A nidus of infection may be able to be identi ed
within the superior fossae, though often will be absent. Complete clinical
examination should exclude tenderness or uctuance of the mastoid process of
the temporal bone, as well as facial, orbital, or middle ear involvement.
Perichondritis in an 8-year-old boy.

No traumatic etiology was
identi ed.
Management of perichondritis includes antibiotic therapy with anti-

pseudomonal activity and consideration of incision and drainage by ENT
specialists in the case of uctuance in order to remove necrotic cartilage (Caruso
2014). Generally, appropriate outpatient antibiotic coverage would dictate oral
therapy with cipro oxacin or another uoroquinolone, however the overall
susceptibility of Pseudomonas has decreased steadily from 86% in 1994 to 76%
in 2000, a result that has been signi cantly correlated to the increased use of
uoroquinolones (Wu 2011). Local antibiograms demonstrating antibiotic
susceptibilities should guide empiric therapy, however. As high rates of oral
antibiotic treatment failure have been documented, some patients may require a
course of intravenous antibiotics or treatment in a monitored setting in order to
ensure symptom improvement (Rees 2016). Indeed, as any lesion involving the
pinna can have drastic and alarming cosmetic complications, some authors
routinely recommend hospital admission for urgent specialist evaluation and
parenteral therapy, particularly among pediatric patients (Prasad 2005).

Perichondritis in a 16-year-old girl.
An infected high chondral piercing
is visible near the scaphoid fossa.
is visible near the scaphoid fossa.
Traditionally, uoroquinolones have been avoided in pediatric patients due to

fears of arthropathy, however recent literature suggests that risk is abundantly
low. In one meta-analysis of 16,184 pediatric patients given systemic
cipro oxacin, the risk of musculoskeletal adverse events attributed to therapy
was 1.6%, half of which were arthralgias which resolved upon drug withdrawal
(Adefurin 2011). In another comprehensive review of the literature from 1980 to
2007, four large retrospective studies failed to identify a signi cant link between
musculoskeletal injury and uoroquinolone treatment (Forsythe 2007).
Ultimately, there are no studies demonstrating signi cant growth disturbance
due to cipro oxacin use, suggesting that a short course in reasonable and safe in
pediatric populations in the context of appropriate monitoring and follow-up (Liu
2013).
Take-Home Points:
Perichondritis is a pseudomonal infection of the outer ear marked by

tenderness and erythema and distinguished by a spared lobule.
Misdiagnosis or mistreatment can result in devastating patient outcomes.
Treatment of perichondritis includes a foundation of anti-pseudomonal
antibiotic therapy with or without surgical intervention.
Urgent specialist evaluation and hospital admission should be considered
when abscess or necrosis are suspected or patient follow-up may be
challenging.
Fluoroquinolone therapy appears safe in pediatric populations in the
context of appropriate monitoring and follow-up.
References:
1. Caruso, Andria M., Macario Camacho Jr, and Scott Brietzke. “Recurrent
auricular perichondritis in a child as the initial manifestation of insulin-
dependent diabetes mellitus: A case report.” ENT: Ear, Nose & Throat
Journal 93.2 (2014). (PMID: 24526489)
2. Prasad, H. Kishore C., et al. “Perichondritis of the auricle and its
management.” The Journal of Laryngology & Otology 121.6 (2007): 530-534.
(PMID: 17319983) 
3. Noel, Stella Boustany, et al. “Treatment of Pseudomonas aeruginosa
auricular perichondritis with oral cipro oxacin.” The Journal of dermatologic
surgery and oncology. 15.6 (1989): 633-637. (PMID: 2723226)
g y gy 5 9 9 33 37 7 3
4. Martin, A.J. Yonkers, C.T. Yarington. Perichondritis of the ear
Laryngoscope, 86 (1976), pp. 664-673 (PMID: 933656)
5. Liu, Z. W., and P. Chokkalingam. “Piercing associated perichondritis of the
pinna: are we treating it correctly?.” The Journal of Laryngology & Otology 127.5
(2013): 505-508. (PMID 23442437)
6. Levin, Roger J., David H. Henick, and Alan F. Cohen. “Human
immunode ciency virus-associated non-Hodgkin’s lymphoma presenting as
an auricular perichondritis.” Otolaryngology–Head and Neck Surgery 112.3
(1995): 493-495. (PMID: 7870459)
7. Wu, Douglas C., et al. “Pseudomonas skin infection.” American journal of
clinical dermatology 12.3 (2011): 157-169. (PMID: 21469761)
8. Prasad KC, Karthik S, Prasad SC. A comprehensive study on lesions
9. of the pinna. Am J Otolaryngol 2005;26(1):1-6. (PMID: 15635573)
10. Chun, Robert, and Opeyemi Daramola. “Clinical Anatomy for the
Pediatrician.” Otolaryngology for the Pediatrician 1 (2013): 3.
11. Kullar, Peter, and Philip D. Yates. “Infections and foreign bodies in
ENT.” Surgery (Oxford) 30.11 (2012): 590-596. (PMID: 27057069)
12. Rees, Chris A., Daniel M. Rubalcava, and Corrie E. Chumpitazi. “A child with a
painful swollen ear.” Archives of disease in childhood 101.9 (2016): 859. (PMID:
27102760)
13. Adefurin A, Sammons H, Jacqz-Aigrain E, Choonara I. Cipro oxacin safety in
paediatrics: a systematic review. Arch Dis Child 2011;96:874–80 (PMID:
27185119)
14. Forsythe, Clinton T., and Michael E. Ernst. “Do uoroquinolones commonly
cause arthropathy in children?.” Canadian journal of emergency medicine 9.6
(2007): 459-462. (PMID: 18072993)
Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)
Cite this article as: Rick Pescatore, "Perichondritis: Not Just Simple Cellulitis",
REBEL EM blog, July 20, 2017. Available at: https://rebelem.com/perichondritis-
not-just-simple-cellulitis/.
Bio Latest Posts 

Rick Pescatore
Director of Clinical Research, Department of Emergency
M di i C
https://rebelem.com/perichondritis-not-just-simple-cellulitis/
K t H lth Ch t PA 5/8
Medicine Crozer-Keystone Healthcare Chester, PA
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PERIKONDRIT – ÖMMANDE YTTERÖRA – MIND

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4/13/2019 Perichondritis: Not Just Simple Cellulitis - REBEL EM - Emergency Medicine Blog

JULY 20, 2017

Perichondritis: Not Just Simple Cellulitis

Background: Perichondritis is an infection of the connective tissue of the ear that

The most common microorganism responsible for perichondritis is

Diagnosis and Management: The diagnosis of perichondritis is clinical via

Perichondritis in an 8-year-old boy.

Management of perichondritis includes antibiotic therapy with anti-

Traditionally, uoroquinolones have been avoided in pediatric patients due to

Perichondritis is a pseudomonal infection of the outer ear marked by

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

Bio Latest Posts 

PERIKONDRIT – ÖMMANDE YTTERÖRA – MIND

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