Ori gi nal Art i cl e

Ob je ct ive s :
To analyse the aetiological factors responsible for perichondritis of pinna and to see the role of antibiotic
and surgical treatment in the outcome of disease

Ma t e r i a l s a n d Me t h o d s :
A prospective study involving 49 patients who were admitted with perichondritis of pinna during June
2012 to June 2014. Analysis of their demographic details, medical history, current illness, etiology,
pathogens and treatments was carried out.

Re s u l t s :
The patients mean age was 21 years. In 9 patients (18.36%), the etiology could not be determined.
Pseudomonas aeruginosa was found to be the predominant organism (62.06 %) and was associated
with a more advanced clinical presentation and longer hospitalization. 29 patients (59.18 %) required
surgical intervention.

Co n c l u s i o n :
Perichondritis of pinna can develop after apparent minor trauma. Since Pseudomonas aeruginosa is
probably the predominant pathogen, initial treatment should include anti-pseudomonal antibiotics.

Ke y Wo r d s : Perichondritis, Pseudomonas aeruginosa

I N TRO D U CTI O N : The aim of this present study was to analyse the aetiological factors
Perichondritis of pinna is a serious complication of the traumatized responsible for the disease and to see the role of antibiotic and
ear that can lead to residual deformity.1 Two types of inflammatory surgical treatment in the outcome of disease.
conditions are seen in the auricular cartilage: suppurative perichondritis
and relapsing polychondritis. Relapsing polychondritis is a rare disease, M ATERI ALS AN D M ETH O D S :
with an autoimmune cause, featured by an episodic and progressive This prospective study of patients presenting with perichondritis to
course that involves the cartilaginous tissue of the nose, ears and the the Department of Otolaryngology - Head and Neck surgery at
laryngo- tracheo-bronchial tree.2 B.P.Koirala Institute of Health Sciences was conducted over a two-
year period from June 2012-June 2014. Patients were classified based
Blunt injury with haematoma and infection acts as the most common on the severity of the disease. Stage one involves patients with early
cause of perichondritis,3 although penetrating injuries such as ear- perichondritis without fluctuant abscess; stage two involves patients
piercing 4 and acupuncture 5 can also introduce infection directly. with perichondritis with fluctuant abscess but no cartilage destruction;
Suppurative perichondritis has also been seen following mastoid and stage three involves patients with perichondritis with fluctuant
surgery 6 and as a complication of a burns injury. In uncomplicated abscess and cartilage destruction. Factors like demographic details,
cases, only a limited portion of the cartilage is usually involved, where medical history (diabetes mellitus, recurrent otitis), recent medical
as in serious cases the cartilage damage is more generalised.1 history related to current illness (any recent surgical intervention on
The infection usually starts as a dull pain accompanied by redness, the ear), possible predisposing event (e.g., trauma, acupuncture) were
warmth and swelling. It usually starts from the helix and anti-helix also taken into consideration.
but may involve the whole cartilage if treatment is withheld.1 The
most common microbiological agent implicated is thought to be In case of early disease the patients were treated with intravenous
Pseudomonas aeruginosa,1 which seems to have a special affinity for antibiotics alone. Ciprofloxacin was initially given in all cases. Antibiotics
the damaged cartilage.7,8 The other organisms commonly seen are were subsequently changed depending on the bacterial culture and
Proteus species,6 Staphylococcus aureus1 and Escherichia coli.9 sensitivity reports obtained. If there was a clinical suggestion of abscess
P. aeruginosa is often found in the external auditory canal, particularly formation incision and drainage was performed. In all cases, this was
under moist conditions. Traumatic injury introduce this pathogen performed under local anaesthesia with aseptic precautions. After
into the cartilaginous layer and the underlying soft tissue culminating making the incision, a swab was taken for culture and sensitivity. The
in perichondritis.10 cartilage was then inspected and, if found to be normal, a pressure
bandage was applied. In cases of persistent fluctuance in the same
area, or appearance of fluctuance in any other area, the procedure
was repeated. In cases of cartilage necrosis, the necrosed cartilage
was removed and a window was created. The margins of the remaining
cartilage was freshened and the skin flap repositioned. A firm pressure
bandage was applied in all cases.

RES U LTS :
Altogether 49 patients were included in the study. The mean age of
the patients was 21 years (median age 18 , range 8-65years) and 34
(69.38%) were females. 6 patients (12.24%) had diabetes mellitus. The
most common aetiological factor observed was trauma, which was
present in 24 cases (48.97%), 4 cases (8.16%) after mastoid surgery,
3 cases (6.12%) were secondary to chronic aural discharge, and 3 cases
Fig. 1 showing subperichondrial Fig. 2 showing perichondritis (6.12%) were due to a burn. In 9 cases (18.36%), no significant cause
abscess secondary to piercing of due to burn injury co u ld b e d e t e rm in e d . Th e re su lt s are d e p ict e d in Tab le I.
pinna
Society of Otorhinolaryngologists of Nepal (SOL Nepal) Vol. 4, No. 2, Issue 2 (July-Dec 2013) Nepalese Journal of ENT Head & Neck Surgery 5
P o k h a r e l A, P a u d e l D: P e r i c h o n d r i t i s o f P i n n a
Table 1. Showing aetiological factor of perichondritis.
D I S CU S S I O N :
Aetiology Cases Percentage Perichondritis of the auricle can lead to external ear deformity, and
Post-traumatic 24 48.97 it is a difficult condition to treat. Like other previous studies, in our
Post- operative 4 8.16 study the main aetiological causes for this disease were found to be
Post- infective 3 6.12 traumatic, iatrogenic (postoperative),6,7,11 burns,1,12 ear-piercing 4,
allergy and insect bite. In 8 cases, infection developed on a background
Burns 3 6.12 of middle-ear and external ear infections, the latter varying from otitis
Furunculosis 2 4.08 externa to diffuse lesions following herpes zoster and infection in
Herpes Zoster 2 4.08 diabetic patients. This shows that cartilage damage is not necessary
prerequisite condition for perichondritis; the cartilage can clearly
Insect Bite 1 2.04 become infected if the overlying infected meatal skin is subjected to
Allergy 1 2.04 only minimal trauma, such as follows instrumentation or scratching
Unknown 9 18.36 with an infected fingernail. In a significant percentage of cases, no
significant cause could be determined.
20 patients (40.81%) fell into stage one , 20 patients (40.81%) fell into
stage two and 9 patients (18.36%) fell into stage three. Fever Although many surgical modalities have been described in the past,
( 38°C) and lymphadenopathy were each found in 24 patients all authors have agreed that parenteral antibiotics are of paramount
(48.97%). Although the white blood cell count and ESR levels in the importance in the treatment of this condition. Analysis of pus in 29
stage three group were higher, they were not significantly different patients with perichondritis showed that Pseudomonas aeruginosa
(WBC 9.6 x 103 vs. 9.8 x 103 vs. 10.1x103 cell/mm3 for stage 1, Stage was present in the majority of cases (62.06 %). However, the antibiotic
2 and stage 3 group respectively; average ESR 36.4 vs. 37.2 vs. 39.4 sensitivity of this organism did vary, and this highlights the need to
mm/ hr for stag e 1, stag e 2 and stag e 3 g roup re sp e ctive ly). obtain a swab in all cases. Patients with positive ear cultures for P.
P. aeruginosa was found to be the predominant organism (n= 18, aeruginosa presented with a more severe disease. These patients had
62.06% of isolates) followed by staphylococcus aureus (n=4, 13.79%). a longer hospital stay. In light of these findings, it is justifiable to
The distribution of causative pathogens is depicted in Table 2. recommend empiric treatment with anti-pseudomonal antimicrobials
Infections caused by P. aeruginosa were associated with a more for outpatients as well as for hospitalized patients. A prospective study
advanced clinical presentation and involved a lengthier hospitalization could answer the question whether initial treatment in the community
(Table 3). 8(44.44%) isolates of P. aeruginosa showed resistance to at with antipseudomonal antibiotics (e.g., fluoroquinolone) could
least one antibiotic, while 4 (22.22%) were found to be resistant to minimize the number of hospitalizations and significantly raise the
three or more drugs. 6 (33.33%) isolates were sensitive to all anti- su cce ss ra t e s o f o u t p a t ie n t t re a t m e n t o f p e rich o n d rit is.
pseudomonals tested. Drugs like Amikacin, Carbenicillin, Ceftazidime,
Pipracillin, Tobramycin, Ciprofloxacin and Meropenem were used to CO N CLU S I O N :
test antibiotic sensitivity. Perichondritis develops in many cases after apparent minor trauma.
Since P. aeruginosa is probably the predominant pathogen, initial
Table2. Distribution
Pathogen Isolates of pathogens
Number Percentage t re a t m e n t sh o u ld in clu d e a n t i-p se u d o m o n a l a n t ib io t ics.
Pseudomonas aeruginosa 18 62.06 REF EREN CES :
Staphylococcus aureus 4 13.79 1. Martin R, Yonkers AJ, Yarington CT Jr. Perichondritis of the ear.
Escherichia coli 3 10.34 Laryngoscope 1976; 86: 664-73.
2. Rapini RP, Warner NB. Relapsing polychondritis. Clin Dermatol
Klebsiella pneumoniae 2 6.89 2006; 24: 482-5.
Acinetobacter species 2 6.89 3. Caruso VG, Meyerhoff WL. Trauma and infections of the external
ear. In: Paparella MM, Shumrick DA, eds. Otolaryngology, 3rd edn.
The hospital stay was significantly longer in Stage 3 group (14 days Philadelphia: WB Saunders, 1991;1227–35
vs.7days vs. 3 days). 29 patients (59.18%) needed surgical intervention, 4. Hanif J, Frosh A, Marnane C, Ghufoor K, Rivron R, Sanchu G. “High”
20 patients needed incision and drainage and 9 patients required ear piercing and the rising incidence of perichondritis of the pinna.
debridement of soft tissue and excision of necrotic cartilage. All BMJ 2001;322:906–7
patients in this study were treated with intravenous antibiotics. Patients 5. Davis O, Powell W. Auricular p erichondritis secondary to
with Pseudomonas infections demonstrated longer hospitalization acupuncture. Arch Otolaryngol 1985;111:770–1.
time than those with non-Pseudomonas infections (mean 7.2±2.8 vs. 6. Stroud MH. A simple treatment for suppurative perichondritis.
5.9±2.1 days respectively ). Laryngoscope 1963;73:556–63.
7. Stevenson EW. Bacillus pyocyaneus perichondritis of the ear.
Table 3. Clinical features of perichondritis caused by P. aeruginosa vs. Laryngoscope 1964;74:255–9
other organisms 8. Austin DF. Diseases of the external ear. In: Ballenger JJ, Snow JB,
Pseud omonas Non-Pseud omonas e d s. Otolaryn g olog y: He ad an d Ne ck Surg e ry, 15th e d n .
(n=18) (n=11) Philadelphia: Williams & Wilkins, 1996;974–88
Diabetes mellitus 4 2 9. Bassiouny A. Perichond ritis of the auricle. Laryngoscop e
Post-surgical 1 3 1981;91:422–31.
10. Christopher AO, Pollack M. Infections due to Pseudomonas species
Post-infective and related organisms. In: Braunwals E, Fauci AS, Kasper DL, et al.,
(Chronic Ear Discharge) 1 2 eds. Harrison’s Principles of Internal Medicine. Vol. 1,15th edn.
Stage 1 No culture No culture New York: McGraw-Hill, 2001: 963-5.
Stage 2 9 11 11. Wanamaker HH. Suppurative perichondritis of the auricle. Trans
Stage 3 9 0
Am Aca d Op h t h a lm o l Ot o la ryn g o l 1972;76:1289–91
12. Dowling JA, Foley FD, Moncrief JA. Chondritis of the burned ear.
Fever 15 9 Plast Reconstr Surg 1968;42:115–22
White Blood Cells 10.1±2.4 9.4±2.7P value
Count (*103/mm3) 0.47. Insignificant
Maximum ESR (mm/hr) 38.6±10 36.4±12P value
0.59. Insignificant
Required surgery 18 11
Number of days of 7.2±2.8 5.9±2.1P value
hospital stay 0.19. Insignicant
ESR = erythrocyte sedimentation rate

6 Society of Otorhinolaryngologists of Nepal (SOL Nepal) Vol. 4, No. 2, Issue 2 (July-Dec 2013) Nepalese Journal of ENT Head & Neck Surgery