I've spent a few shifts over the past several weeks in fast track and urgent care, churning through legions of minor injuries, runny noses, and fleeting complaints. Most emergency physicians can see and disposition these patients without too much difficulty, and they do so while knowing the true task calls for a high index of suspicion for hidden serious pathology or covert catastrophes.
An important entity to be aware of—often mistaken for otitis externa and potentially undertreated—is perichondritis. Not uncommon by any stretch (it affects hundreds of thousands of patients each year), perichondritis may be under-recognized in fast-paced emergency departments.
Perichondritis is an infection of the connective tissue of the ear that covers the cartilaginous auricle or pinna, excluding the lobule. (Ear Nose Throat J. 2014;93:E4.) The term perichondritis is a misnomer because the cartilage is almost always involved with abscess formation and cavitation. (J Laryngol Otol. 2007;121:530.) Perichondritis can be a devastating disease, and the infection can worsen into a liquefying chondritis resulting in disfigurement and loss of the external ear if left improperly treated. (J Dermatol Surg Oncol. 1989;15:633; Laryngoscope. 1976;86:664.)
Unfortunately, misdiagnosis and mistreatment are common, unacceptable shortcomings because the correct diagnosis and management can be accomplished with little more than a physical exam and a basic understanding of initial treatment. The overwhelming majority of patients presenting to a large general hospital in one small retrospective review were prescribed antibiotics without appropriate antimicrobial coverage, resulting in a significant number of patients developing a chondral deformity—cauliflower ear. (J Laryngol Otol. 2013;127:505.)
Trauma and Piercings
A number of causes of perichondritis have been identified, with one study of 85 patients suggesting the most common causes include minor trauma, burns, and ear piercing. (Am J Otolaryngol. 2005;26:1.) Notably, damage to the cartilage 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 fingernail. No significant cause can be identified in a significant percentage of cases. (J Laryngol Otol. 2007;121:530; Otolaryngol Head Neck Surg. 1995;112:493.)
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. (J Laryngol Otol. 2007;121:530; J Laryngol Otol. 2013;127:505.) The majority of perichondritis cases I've encountered have been accompanied by a high chondral piercing, and I'm always concerned about the possibility of perichondritis whenever a patient reports ear pain.
Perichondritis has also been noted to be the presenting symptom of a number of disease processes marked by immunosuppression, including HIV-associated non-Hodgkin's lymphoma, relapsing polychondritis, and, not uncommonly, diabetes. (Ear Nose Throat J. 2014;93:E4; Otolaryngol Head Neck Surg. 1995;112:493.)
The most common microorganism responsible for perichondritis is Pseudomonas aeruginosa, a gram-negative rod with intrinsic antibiotic resistance mechanisms. (Ear Nose Throat J. 2014;93:E4; Am J Clin Dermatol. 2011;12:157.) A retrospective analysis of 61 patients with perichondritis identified Pseudomonas in 95 percent of cases. Co-infection with Escherichia coli was identified in half of cases, and Staphylococcus aureus in seven percent of patients. A culture swab is recommended in all cases because of the varying antibiotic sensitivities of these causative organisms. (Am J Otolaryngol. 2005;26:1.)
Fiery Red Ear
Diagnosing perichondritis is about as simple and pure as we can ask for in emergency medicine—it's clinical, via physical exam. Patients initially experience dull pain, which gradually develops into severe otalgia with a purulent discharge. (J Dermatol Surg Oncol. 1989;15:633.) Early cases are marked by erythema, swelling, and tenderness of the auricle without notable fluctuance. (Chun R, Daramola O, . Otolaryngology for the Pediatrician; Ch. 1. Shah RK, Preciado DA, Zalzal GH, eds., Bentham Science Publishers.)
The lobule remains unaffected, helping to distinguish perichondritis from otitis externa. (Surgery. 2012;30:590; https://bit.ly/3hcUVRo.) It's really striking: Most of the time, it is a fiery red ear with a normal-appearing lobule at the bottom. Complete clinical examination should exclude tenderness or fluctuance of the mastoid process of the temporal bone as well as facial, orbital, and middle ear involvement.
Management of perichondritis includes antibiotic therapy with antipseudomonal activity and consideration of incision and drainage by ENT specialists in the case of fluctuance to remove necrotic cartilage. (Ear Nose Throat J. 2014;93:E4.) Appropriate outpatient antibiotic coverage would generally dictate oral therapy with ciprofloxacin or another fluoroquinolone, but the overall susceptibility of Pseudomonas has decreased steadily from 86 percent in 1994 to 76 percent in 2000, a result significantly correlated to the increased use of fluoroquinolones. (Am J Clin Dermatol. 2011;12:157.)
Fluoroquinolones in Children
Local antibiograms demonstrating antibiotic susceptibilities should guide empiric therapy, however. High rates of oral antibiotic treatment failure have been documented, and some patients may require a course of intravenous antibiotics or treatment in a monitored setting to ensure symptom improvement. (Arch Dis Child. 2016;101:859.) Indeed, any lesion involving the pinna can have drastic and alarming cosmetic complications, and some authors routinely recommend hospital admission for urgent specialist evaluation and parenteral therapy, particularly for children. (Am J Otolaryngol. 2005;26:1.) My practice varies depending on disease severity and patient-specific factors, but usually lands on an outpatient course of a fluoroquinolone and close follow-up with ENT. Where any of that might not be successful, I've had ENT agree several times to admission on an IV antipseudomonal agent and consideration of operative intervention.
Traditionally, fluoroquinolones have been avoided in children because of fear of arthropathy, but the newer literature suggests that the risk is abundantly low. The risk of musculoskeletal adverse events attributed to therapy was 1.6 percent, half of which were arthralgias that resolved with drug withdrawal in one meta-analysis of 16,184 children patients given systemic ciprofloxacin. (Arch Dis Child. 2011;96:874; https://bit.ly/3gcCk6G.)
Four large retrospective studies in another comprehensive literature review from 1980 to 2007 failed to identify a significant link between musculoskeletal injury and fluoroquinolone treatment. (CJEM. 2007;9:459.) Ultimately, no studies demonstrated significant growth disturbance from ciprofloxacin use, suggesting that a short course is reasonable and safe in children with appropriate monitoring and follow-up. (J Laryngol Otol. 2013;127:505.)
Share this article on Twitter and Facebook.
Access the links in EMN by reading this on our website, www.EM-News.com.
Comments? Write to us at email@example.com.
Dr. Pescatoreis the chief physician for the Delaware Division of Public Health and an emergency physician at Albert Einstein Health Network in Philadelphia. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.