Pinna Perichondritis

RED FLAGS

  • Pinna abscess or necrosis
  • Any ear infection with central neurological signs such as low GCS

 

WHY IS THIS IMPORTANT?

Pinna perichondritis is a rare but potentially serious condition. It can either occur as a complication of acute otitis externa or as a result of trauma. 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 perichondritis and those with recent penetrating trauma and symptoms of 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

The main question is really '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 an abscess will require incision and drainage under local or general anaesthetic.

Patients with no evidence of abscess formation:

  • Microbiological swabs of the pinna, of any otitis externa and for MRSA status
  • A trial with IV and topical antibiotics would be a good starting point
    • Common causative organisms will be Staphyloccocus aureus and Pseudomonas aeruginosa; pseudomonads are invariably involved in cartilage-piercing-relating perichondritis
    • You should seek a microbiological opinion on whether to use a systemic fluoroquinolone such as ciprofloxacin to treat presumed pseudomonal infection, as usage is associated with a high rate of secondary Clostridium difficile; alternatives include co-amoxiclav, tazobactam/piperacillin or clindamycin
    • 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     

Transcartilaginous ear piercing and infectious complications: A systematic review and critical analysis of outcomes

 

 

Page last reviewed: 23 September 2016