Pinna Perichondritis or Cellulitis
RED FLAGS
Pinna abscess or necrosis
Any ear infection with central neurological signs such as low GCS
WHY IS THIS IMPORTANT?
Pinna perichondritis or cellulitis are potentially serious conditions.
Pinna cellulitis can occur as a complication of acute otitis externa, a complication of eczema or psoriasis, or from an insect bite.
Pinna perichondritis is usually a result of penetrating trauma, including ear piercing. Left untreated, an abscess may form, lifting the perichondrial layer off the cartilage and resulting in necrosis and a cauliflower deformity. Pinna perichondritis may also progress to systemic infection or a serious soft tissue infection including necrotising fasciitis.
WHEN TO INVOLVE THE ENT REGISTRAR
Soon: Patients with pinna perichondritis should be seen by the registrar as soon as practical (post take round or emergency clinic, as applicable). For patients with a definite abscess or necrosis, while overnight surgical drainage or debridement may not be practical, discussion is advisable.
Immediately: Discuss all patients with pinna abscess, sepsis and neurological signs.
WHO TO ADMIT
Patients with a pinna abscess or tissue necrosis
Patients with an ear infection and deterioration in central neurological status
Patients who have failed to respond to oral antibiotic treatment
Immune suppressed or compromised patients eg uncontrolled diabetes mellitus, HIV AIDS, recent chemotherapy
Be cautious with patients presenting newly with five or more days of symptoms of pinna cellulitis and those with recent penetrating trauma and symptoms of pinna perichondritis
ASSESSMENT AND RECOGNITION
HISTORY
Take a focused history, including recent history of any significant trauma: piercing; acupuncture; burn; pinna haematoma; laceration and so on.
Comorbidities such as diabetes mellitus may predispose patients to perichrondritis. It is also important to take note of previous antibiotics and if there is a history of recurrent otitis externa.
EXAMINATION
Pinna perichondritis typically presents with infection of the cartilaginous pinna and sparing of the lobule (ear lobe), whereas cellulitis does not spare the lobule. This is important because the causative organisms are usually different (see below).
The main question is then, 'Is there any abscess or necrosis?' so examine the ear carefully for:
Painful erythema and induration of the pinna with loss of contours
Localised abscess formation
Necrosis of soft tissue
Primary otitis externa - perform otoscopy
Clinical hearing deficit
Spreading cellulitis of the face or scalp - please mark this
Any signs of trauma or any wounds
You must perform a lower cranial nerve examination and other general or neurological examinations as indicated.
Take note of any indwelling piercings and remove all of them, especially any in or near areas of perichondritis, cellulitis or abscess.
IMPORTANT: If the symptoms and signs are mild and involve both pinnas and the nose, you may be dealing with a relapsing POLYchondritis, which is an autoimmune condition affecting cartilage and not an infective condition.
IMMEDIATE AND OVERNIGHT MANAGEMENT
Patients with no evidence of abscess formation:
Microbiological swabs of the pinna, of any otitis externa and for MRSA status
A trial with systemic and topical antibiotics would be a good starting point
The commonest causative organism in pinna perichondritis is Pseudomonas aeruginosa; in pinna cellulitis it can be Staphylococcus aureus or other skin organisms
If you want to use a fluoroquiniolone to treat a Pseudomonal infection, seek a microbiological opinion or consult local guidelines: systemic fluoroquinolone usage is associated with a high rate of secondary Clostridium difficile; alternatives include co-amoxiclav, tazobactam/piperacillin or clindamycin
Oral fluoroquinolones and macrolides have good oral bio-availability so IV therapy is not indicated unless the patient is vomiting or drowsy
Topical fusidic acid cream may help treat staphyloccocal infection
Good analgesia
If applicable, control of blood sugars or reverse barrier nursing
If there is sepsis, then blood cultures should be taken: remember your Sepsis Six
Patients with abscess or tissue necrosis:
All of the above
Discussion with the ENT Registrar
Nil by mouth pending a decision to operate
IV access, FBC, U&E, CRP, Coag/INR
Unless there are concerns about cranial complications such as brain abscess, CT scanning is not indicated.
FURTHER MANAGEMENT
Patients who respond well to oral or intravenous antibiotics should be reviewed as outpatients. Any piercing should not be replaced until a reasonable interval has passed and there is no gross deformity. Patients should be advised that cartilaginous piercings are high risk for severe infections.
Patients who require drainage of an abscess will need to have their wound re-packed/dressed regularly as outpatients before healing by secondary intention. Cosmetic deformities may occur or remain after surgery. Sometimes, a plastic surgery referral may be required to consider reconstruction of severe deformities of the pinna.
REFERENCES
Perichondritis of the auricle: analysis of 114 cases
Page last reviewed: 15 December 2019