In the urgent care setting, we often encounter patients with ear pain, a common yet sometimes deceptively simple complaint. However, amidst the myriad of otitis media and cellulitis cases lies a less common and easily overlooked but significantly more serious condition: perichondritis.
The first time I encountered perichondritis was the impetus for covering this topic on the podcast – and I would have missed it if a colleague hadn’t pointed it out to me!
Misidentifying or delaying the treatment of this infection can lead to devastating outcomes. Let's delve into the nuances of perichondritis, a critical condition requiring prompt recognition and intervention.
What is Perichondritis?
Perichondritis refers to the infection of the cartilage of the ear, specifically the auricle or pinna, excluding the earlobe, which lacks cartilage. This infection can present similarly to cellulitis but is distinct in its etiology and treatment requirements. The primary culprit is Pseudomonas aeruginosa, a pathogen not typically targeted by standard cellulitis treatments.
Recognizing Perichondritis: Clinical Presentation
Patients with perichondritis typically present with the following:
- Erythema and swelling: The upper ear appears red and swollen, often mistaken for cellulitis.
- Pain: Tenderness localized to the cartilage, sparing the earlobe.
- Possible fluctuance: Indicates abscess formation, necessitating immediate ENT consultation.
A thorough examination is crucial, including palpating for fluctuance and inspecting the entire ear for other potential infections such as otitis external.Another challenge in managing perichondritis is distinguishing it from similar conditions like auricular hematoma, which also involves the ear cartilage but without the infectious component. The key lies in the presence of erythema, warmth, and pain – hallmarks of an infectious process.
Who’s at Risk?
Trauma is a significant risk factor. Common causes include:
- Ear piercings: Particularly high ear piercings involving cartilage.
- Insect bites, lacerations, and burns: Minor injuries can become the nidus for infection.
- Blunt trauma: Activities like wrestling can lead to hematoma and subsequent infection.
Complications:
If untreated or inadequately treated, perichondritis can lead to:
- Abscess formation: Requiring surgical drainage
- Permanent ear deformity: Cauliflower ear, a disfiguring outcome
Treatment Decisions and Follow-Up:
The first thing to consider here is whether the patient requires transfer for surgical treatment or IV antibiotics. We have to remember to “respect the face” when it comes to these infections. Any patient with an abscess will potentially need transfer to an ED with on-call ENT or, at the very least same-day or next-day office follow-up with a specialist.
While I don’t mind draining a non-infected auricular hematoma in the urgent care setting – a perichondritis abscess is not something I am going to be tackling at the bedside. These patients will often have necrotic tissue associated with the abscess and require debridement by ENT.
Given the predominance of Pseudomonas, first-line treatment involves anti-pseudomonal antibiotics, which generally will mean ciprofloxacin or levofloxacin in the outpatient setting.
I’ve found that this can become an issue with pediatrics, as liquid ciprofloxacin can sometimes be difficult to find. In cases where I can’t ensure the patient has access to a liquid formulation, I will probably consider transferring the patient for admission to a pediatric floor for IV antibiotics – even if there isn’t an abscess present.
Take-Home Tips:
- Suspect and Diagnose Promptly: Differentiating from cellulitis and treating promptly is critical to avoid permanent ear deformation. If you don’t think about it - you’ll miss it.
- Think Pseudomonas: Always select an antibiotic that covers this, and if necessary, transfer for IV if access to PO antibiotics is not guaranteed.
- Higher Level of Care: When in doubt about abscess formation, either transfer to a center with ENT or speak directly with them to ensure the same-day or next-day follow-up.
