Pinna Perichondritis: Causes, Diagnosis and Treatment

Perichondritis of the pinna is the name for inflammation of the perichondrial layer around the ear cartilage. The most frequent cause of perichondritis is penetrating ear trauma, such as transcartilaginous high ear piercings. Since most ear piercings are done by non-medical personnel, sterility precautions may not be followed, which increases the risk of infection.

If the infection is not treated, an abscess may develop, revascularizing the region and raising the perichondrial layer away from the cartilage. The pinna will alter its shape and get necrotic as a result. If blood builds up here, it can organize and cause hard scar tissue, giving the appearance of a cauliflower ear. If therapy is not given, the condition might get worse and turn into a systemic or soft tissue infection.

Epidemiology Of Pinna Perichondritis 

Pinna perichondritis is a rare disease. Reports show a rise in instances in England between 1990 and 1998, while the incidence remains uncertain. The surge in ear piercings among youths was attributed to this.

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Causes Of Pinna Perichondritis 

There are several reasons for pinna perichondritis. Nonetheless, the most often cited cause in the literature is penetrating trauma to the cartilaginous pinna. A rising number of writers have linked the rise in perichondritis cases over the past 10 years to transcartilaginous ear piercings, which have a greater risk of infection or abscess formation than lobule piercings.

Hot baths or freshwater exposure after surgery should be avoided since this raises the risk of infection. Less common reasons include immunosuppression, minor trauma such as scratching the ear, untreated middle or external ear infections that spread to the pinna and cartilage, and iatrogenic (post-surgery) infections. Moreover, a significant portion of cases have an unknown cause.

Pseudomonas aeruginosa is the most common causative bacteria in pinna perichondritis, and it seems to favor cartilage damage. Staphylococcus aureus and Escherichia coli are two other harmful bacteria. Perichondritis can also be brought on by a herpes zoster infection; this may be because vesicles facilitate the entry of bacteria into the body.

Pathophysiological Of Pinna Perichondritis 

The thick layer of connective tissue known as the perichondrium surrounds the cartilage. It facilitates cartilage growth and repair. Trauma can cause microfractures in the cartilage and remove pieces of cartilage from the perichondrial layer, which can cause necrosis and devascularization. 

Even with aseptic ear piercing treatments, this area is more vulnerable to infection because of its restricted blood supply. This necrosis causes a cosmetic deformity. The elevated cartilage will cause blood to collect and harden in the surrounding area, resulting in an irreversible structural deformity known as the "cauliflower ear."

 If left untreated, perichondritis may lead to an infection of the surrounding soft tissue, which may progress into pinna cellulitis or an abscess.

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Histopathology Of Pinna Perichondritis 

To find out how much cartilage was damaged by ear-piercing techniques on cadavers, Van Wijk et al. performed a histology study. They showed how puncturing caused the perichondrium to rip the cartilage, creating a pocket of detachment that might have aided in the formation of an abscess.

Diagnosis Of Pinna Perichondritis 

Pinna perichondritis is diagnosed clinically. It is consequently essential to get a focused history and a thorough physical examination. Clinical professionals should ask about relevant symptoms, such as hearing loss, otorrhea, or anomalies of the cranial nerve since they might point to a different diagnosis. 

When reviewing a patient's past medical history, particular attention should be paid to comorbid disorders like diabetes or immunosuppression that may increase the risk of infections.

A thorough physical examination should include an otoscopy, palpation, and inspection of the ears. When a patient initially arrives, their pinna is often erythematous, swollen, hot, and painful. One way to differentiate perichondritis from pinna cellulitis is that the lobule is often spared. 

This is important since different organisms cause each, and if pinna cellulitis is present, it would be prudent to note the afflicted region. A small abscess or necrosis of the soft tissue is possible. One senses the presence of a sensitive pinna. To complete the inspection mastoid technique, pain in the pre- and post-auricular regions should be assessed. A cervical swelling examination and cranial nerve test should be performed as instructed. 

Systemic symptoms, such as pyrexia or erythema beyond the pinna, suggest the infection has spread outside the external ear. A thorough otoscopy technique should begin with an evaluation of the unaffected ear. 

To identify otitis externa-related perichondritis, the doctor will often treat the condition with topical antibiotics and suction cleaning. In the external ear canal, the doctor will look for any debris or discharge, erythema, or edema. Examining the tympanic membrane for holes and air-fluid levels is also essential.

Ultimately, a patient may have recurrent polychondritis, an autoimmune disease that is mostly managed with oral steroids, if they also show signs of tracheobronchial abnormalities and inflammation of the nose, joints, and pinnae.

Routine blood tests usually aren't required in patients with simple pinna perichondritis. But suppose there is a significant area of swelling, an abscess, or necrosis. The following blood tests should be obtained: coagulation screen, urea and electrolytes, c-reactive protein, blood cultures, complete blood count, and others. 

A patient's sepsis screen should also include this if they are unstable. The affected area and any visible discharge must be sampled for microbiological. Imaging isn't advised unless there's a possibility of intracranial conditions like an abscess.

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Treatment Of Pinna Perichondritis 

Antibiotics are typically used to treat pinna perichondritis. The development of an abscess determines the management strategy. If there is an abscess, the patient has to be admitted to the hospital for the duration of their care. This entails draining the pinna and preparing the patient for surgery, including blood tests upon arrival, to remove the hematoma or pus collection. 

If there isn't an abscess, the patient has to start taking oral and topical antibiotics. Given the casual organisms, clinicians should begin a Pseudomonas aeruginosa and Staphylococcus aureus antibiotic course that provides adequate coverage. Medical professionals should follow regional guidelines for prescription antibiotics and, if in doubt, seek advice from a microbiologist.

Fluoroquinolone antibiotics are easily available in oral and topical forms and provide good staphylococcal and pseudomonal cover. Traditionally, they have been avoided in children because of the risk of tendon rupture and arthralgias. Fluoroquinolone use has not been associated with any developmental issues; a meta-analysis of its use in children found a minimal incidence of musculoskeletal side effects, all of which vanished after the medicine was stopped.

 This suggests that using a short course for a younger patient is safe. Intravenous antibiotics are not required unless the patient is unable to take antibiotics or there is a danger of an unsafe swallow since fluoroquinolone drugs have a high bioavailability and are well absorbed. However, physicians need to keep in mind that this is a painful condition, therefore they must provide appropriate analgesics.

Differential Diagnosis Of Pinna Perichondritis 

Medical professionals should be aware of the many disorders that might cause an inflamed or unpleasant external ear. An otoscopy is essential to rule out problematic otitis media during tests since children would not be able to express their symptoms as effectively as adults.

One must consider the following differential diagnoses:

• Pinna cellulitis
• Otitis external
• Otitis media
• Skin conditions like psoriasis or eczema that impact the ears.
• Malignant otitis  media
• Relapsing polychondritis

Complications Of Pinna Perichondritis

If treatment for perichondritis is not obtained, it might lead to cartilage necrosis and "cauliflower ear," a minor cosmetic deformity. There is evidence that ear deformity is more common in cases of the helix itself than in cases of perichondritis of the scapha, or the hollow part of the helix.

 Furthermore, the patient may become sick all over their body, requiring hospitalization and intravenous therapy, if the infection spreads beyond their pinna.

Prognosis Of Pinna Perichondritis

Following an early diagnosis and treatment with antibiotics, the symptoms should resolve in two to three days. However, certain symptoms, such as discomfort, may last for up to a month. The cosmetic deformity is determined by the extent of the infection and the underlying cartilage damage. 

This is especially important in cases of cartilage damage and perichondritis leading to the formation of an abscess, which necessitates surgical intervention. To promote healing without scarring, patients with an incision and drainage will need to redress and bandage the wound.

Hope you found this blog helpful for your ENT Residency Otology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs. 

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