CLINICAL PHOTOGRAPHS Nelson C. Goldman, MD Clinical Photographs'Edltor
Perichondrial abscess resulting from a high ear-piercing-Case report MARK H. WIDICK, MO, and JACK COLEMAN, MD, Nashville, Tennessee
A
uricular perichondritis and perichondrial abscess are recognized complications of the "fashionable high" earpiercing. 1 Other recognized causes of this condition are postoperative infections, bums, frostbite radiation, trauma, and acupuncture. The most frequently cultured organisms are Pseudomonps aeruginosa and Staphylococcus aureus. Until recently, the mainstay of therapy for perichondritis has been in-hospital intravenous antibiotics capable of having activity against Pseudomonas. Laboratory studies indicate that infections resulting from bums may be treated effectively with iontophoresis of antibiotic solutions into the cartilage? The newer class of quinolone antibiotics have nowbeen reported to have shown effectiveness in cases of perichondritis.v' We present a case of an auricular perichondrial abscess in which aggressive drainage and local and systemic antibiotics, including arninoglycosides, ceftazidime, and ciprofloxacin (Cipro, Miles Laboratories, Elkhart, Ind.), failed to control the infection, resulting in eventual debridement of the involved cartilage. CASE REPORT
A 20-year-old woman had undergone a high transcartilaginous ear-piercing aspartof herinstruction infashion school. Two weeks later, paindeveloped aboutthesiteof thepiercing and she removed the pin. On presentation to the emergency department, the ear was erythematous and had an area of fluctuance about the area of the previous piercing (Fig. 1). Treatment consisted of drainage and the administration of oral dicloxacillin. She returned 48 hours laterwith persistence of pain, swelling, and drainage. The otolaryngology service was consulted concerning her care. Examination of the pinna revealed active draining of purulent material, thickening of thesuperior rimofthe pinna, andextreme From the Department ofOtolaryngology, Vanderbilt University. This section is made possible through an educational grant from Xomed-Treace, your partners in surgical progress. Received for publication June 18, 1992; accepted June 24. 1992. Reprint requests: Mark H. Widick, MD, Department of Otolaryngology. 82100 M.C.N.• Vanderbilt University Medical Center. Nashville. TN 37232. 23/11/41102
tenderness to touch. Cultures were obtained and she was admitted for intravenous antibiotics. She was in otherwise excellent health, and the remainder of the physical examination was unremarkable. After 24 hours of therapy with ceftazidime and ciprofloxacin, she showed no clinical improvement. She was taken to the operating room and, while under general anesthesia, underwent aggressive incision and irrigation with gentamicin solution. Round drains were placed in both surfaces of the affected pinna and irrigated four times daily with a solution of gentamicin (4 mgtcc) in a normal saline solution. Cultures -subsequently grew Pseudomonas. She was continued on the treatment with ceftazidime and ciprofloxacin and had a dramatic clinical response with complete resolution of the pain and erythema. The drains were removed, and at the time of discharge she was asymptomatic except for a small area of persistent edema surrounding the original abscess cavity. Her treatment with ciprofloxacin (750 mg twice a day) was continued on an outpatient basis. Ten days after discharge she hadrecurrence of painanderythema involving the pinna. She wasreadmitted, restarted on treatment with ceftazidime, and theciprofloxacTn wascontinued. Hersymptoms persisted and she was brought to the operating room, where a segment of necrotic superior rimcartilage wasresected. A closed suction drain wasplaced, andthesubsequent cosmetic deformity was limited to flattening and loss of contour of the rim. Ceftazidime and ciproftoxacin were continued for 4 days postoperatively and the woman was discharged on ciprofloxacin. A total body pruritic rash subsequently developed and the woman was switched to treatment with a trlmethoprim/sulfamethoxasole and went on to recover uneventfully. DISCUSSION Piercing of the auricular cartilage carries with it the risk of implantation of pathogenic organisms into avascular cartilage. Even with strict aseptic technique, this procedure is prone to infection as a result of the indwelling foreign body. Occasionally, greater than usual trauma is imparted to the auricular cartilage as a result of misfiring of the piercing gun. Several reported perichondrial infections have been reported by this mechanism.' Some cosmetology schools are training in placement of the pin in the soft tissues of the auricular rim, avoiding a transcartilaginous perforation. This seems to be preferable, but it is uncertain if a peri803
OfolaryngologyHead and Neck Surgery
804 Clinical photographs
Flg.i. Perichondrial abscess resulting froma highear-piercing,
chondritis would be avoided should the pin site become infected. Perichondritis involving the auricle manifests as a painful, erythematous pinna, with loss of contours caused by edema and with sparing of the lobule. Progression to abscess will often result in necrosis of the involved cartilage and require that it be excised to control the infection. The new quinolone antibiotics have allowed the outpatient treatment of this condition because of their activity against the most common offending organisms-Pseudomonas and Staphylococcus. We attempted to avoid the need for removal of cartilage and resultant cosmetic deformity in this case by using an extended course of ciprofloxacin. Unfortunately, a nearly complete clinical response to aggressive therapy with ceftazidime, ciprofloxacin, and aggresive local measures and extended therapy with ciprofloxacin, on an outpatient basis, did not allow the preservation of the involved auricular cartilage.
This case illustrates the extreme difficulty in preserving the auricular cartilage once the infection has suppurated, even with the new quinolone antibiotics, and emphasizes the need for early recognition and aggressive treatment of abscess of the auricle to minimize the amount of cartilage that must be excised. REFERENCES
1. Crumberworth VL. Hogarth TB. Hazards of ear-piercing procedures which traverse the cartilage: a report of Pseudomonas perichondritis and review of other complications. Br J Clin Pract 1990;44:512-3. 2. Macaluso RA, Kennedy TL. Antibiotic iontophoresis in the treatment of bum perichondritis of the rabbit ear. OTOLARYNGOL HEAD NECK SURG 100:568-72. 3. Noel SB, Scallan P, Meadors MC, Meek TJ, Pankey GA. Treatment of Pseudomonas aeruginosa auricular perichondritis with oral ciprofloxacin. Dermatol Surg Oncol 1989;15:633-7. 4. Thomas JM, Swanson NA. Treatment of perichondritis with a quinolone derivative-norfloxacin. J Surg Oncol 1988;14:447-9.
Perichondrial abscess resulting from a high ear-piercing-Case report MARK H. WIDICK, MO, and JACK COLEMAN, MD, Nashville, Tennessee
A
uricular perichondritis and perichondrial abscess are recognized complications of the "fashionable high" earpiercing. 1 Other recognized causes of this condition are postoperative infections, bums, frostbite radiation, trauma, and acupuncture. The most frequently cultured organisms are Pseudomonps aeruginosa and Staphylococcus aureus. Until recently, the mainstay of therapy for perichondritis has been in-hospital intravenous antibiotics capable of having activity against Pseudomonas. Laboratory studies indicate that infections resulting from bums may be treated effectively with iontophoresis of antibiotic solutions into the cartilage? The newer class of quinolone antibiotics have nowbeen reported to have shown effectiveness in cases of perichondritis.v' We present a case of an auricular perichondrial abscess in which aggressive drainage and local and systemic antibiotics, including arninoglycosides, ceftazidime, and ciprofloxacin (Cipro, Miles Laboratories, Elkhart, Ind.), failed to control the infection, resulting in eventual debridement of the involved cartilage. CASE REPORT
A 20-year-old woman had undergone a high transcartilaginous ear-piercing aspartof herinstruction infashion school. Two weeks later, paindeveloped aboutthesiteof thepiercing and she removed the pin. On presentation to the emergency department, the ear was erythematous and had an area of fluctuance about the area of the previous piercing (Fig. 1). Treatment consisted of drainage and the administration of oral dicloxacillin. She returned 48 hours laterwith persistence of pain, swelling, and drainage. The otolaryngology service was consulted concerning her care. Examination of the pinna revealed active draining of purulent material, thickening of thesuperior rimofthe pinna, andextreme From the Department ofOtolaryngology, Vanderbilt University. This section is made possible through an educational grant from Xomed-Treace, your partners in surgical progress. Received for publication June 18, 1992; accepted June 24. 1992. Reprint requests: Mark H. Widick, MD, Department of Otolaryngology. 82100 M.C.N.• Vanderbilt University Medical Center. Nashville. TN 37232. 23/11/41102
tenderness to touch. Cultures were obtained and she was admitted for intravenous antibiotics. She was in otherwise excellent health, and the remainder of the physical examination was unremarkable. After 24 hours of therapy with ceftazidime and ciprofloxacin, she showed no clinical improvement. She was taken to the operating room and, while under general anesthesia, underwent aggressive incision and irrigation with gentamicin solution. Round drains were placed in both surfaces of the affected pinna and irrigated four times daily with a solution of gentamicin (4 mgtcc) in a normal saline solution. Cultures -subsequently grew Pseudomonas. She was continued on the treatment with ceftazidime and ciprofloxacin and had a dramatic clinical response with complete resolution of the pain and erythema. The drains were removed, and at the time of discharge she was asymptomatic except for a small area of persistent edema surrounding the original abscess cavity. Her treatment with ciprofloxacin (750 mg twice a day) was continued on an outpatient basis. Ten days after discharge she hadrecurrence of painanderythema involving the pinna. She wasreadmitted, restarted on treatment with ceftazidime, and theciprofloxacTn wascontinued. Hersymptoms persisted and she was brought to the operating room, where a segment of necrotic superior rimcartilage wasresected. A closed suction drain wasplaced, andthesubsequent cosmetic deformity was limited to flattening and loss of contour of the rim. Ceftazidime and ciproftoxacin were continued for 4 days postoperatively and the woman was discharged on ciprofloxacin. A total body pruritic rash subsequently developed and the woman was switched to treatment with a trlmethoprim/sulfamethoxasole and went on to recover uneventfully. DISCUSSION Piercing of the auricular cartilage carries with it the risk of implantation of pathogenic organisms into avascular cartilage. Even with strict aseptic technique, this procedure is prone to infection as a result of the indwelling foreign body. Occasionally, greater than usual trauma is imparted to the auricular cartilage as a result of misfiring of the piercing gun. Several reported perichondrial infections have been reported by this mechanism.' Some cosmetology schools are training in placement of the pin in the soft tissues of the auricular rim, avoiding a transcartilaginous perforation. This seems to be preferable, but it is uncertain if a peri803
OfolaryngologyHead and Neck Surgery
804 Clinical photographs
Flg.i. Perichondrial abscess resulting froma highear-piercing,
chondritis would be avoided should the pin site become infected. Perichondritis involving the auricle manifests as a painful, erythematous pinna, with loss of contours caused by edema and with sparing of the lobule. Progression to abscess will often result in necrosis of the involved cartilage and require that it be excised to control the infection. The new quinolone antibiotics have allowed the outpatient treatment of this condition because of their activity against the most common offending organisms-Pseudomonas and Staphylococcus. We attempted to avoid the need for removal of cartilage and resultant cosmetic deformity in this case by using an extended course of ciprofloxacin. Unfortunately, a nearly complete clinical response to aggressive therapy with ceftazidime, ciprofloxacin, and aggresive local measures and extended therapy with ciprofloxacin, on an outpatient basis, did not allow the preservation of the involved auricular cartilage.
This case illustrates the extreme difficulty in preserving the auricular cartilage once the infection has suppurated, even with the new quinolone antibiotics, and emphasizes the need for early recognition and aggressive treatment of abscess of the auricle to minimize the amount of cartilage that must be excised. REFERENCES
1. Crumberworth VL. Hogarth TB. Hazards of ear-piercing procedures which traverse the cartilage: a report of Pseudomonas perichondritis and review of other complications. Br J Clin Pract 1990;44:512-3. 2. Macaluso RA, Kennedy TL. Antibiotic iontophoresis in the treatment of bum perichondritis of the rabbit ear. OTOLARYNGOL HEAD NECK SURG 100:568-72. 3. Noel SB, Scallan P, Meadors MC, Meek TJ, Pankey GA. Treatment of Pseudomonas aeruginosa auricular perichondritis with oral ciprofloxacin. Dermatol Surg Oncol 1989;15:633-7. 4. Thomas JM, Swanson NA. Treatment of perichondritis with a quinolone derivative-norfloxacin. J Surg Oncol 1988;14:447-9.
