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.
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.
Patients with perichondritis typically present with the following:
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.
Trauma is a significant risk factor. Common causes include:
If untreated or inadequately treated, perichondritis can lead to:
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.