CASE REPORT
relapsing polychor~ritis
Relapsing Polychondritis: An Unusual Cause of Painful Auricular Swelling From the Emergency Medicine
Marco Coppola, DO, CPT, MC*
Residency, Darnall Army
Donald M Yealy, MD, FACEP**
Community Hospital, Fort Hood, Texas;* Division of Emergency Medicine, Texas A&M University College of Medicine;* and Department of Emergeney Medicine, Scott and White Hospital, Temple, Texas.* Receivedfor publication January 8, 1991. Acceptedfor publication April 4, I991.
Auricular pain, redness, and swelling are usually the result of infectious cellulitis. However, relapsing polychondritis is another cause of this symptom complex and is the result of an autoimmune phenomenon. It presents with inflammation and destruction of both articular and nonarticular cartilage, with the external ear and joint cartilage most often involved. Although usually indolent with multiple acute exacerbations, relapsing polychondritis can be rapidly fatal if the airway or cardiovascular system is involved. We present a case of relapsing polychondritis initially mistaken for auricular cellulitis. The clinical manifestations and course of relapsing polychondritis are reviewed, along with the emergency department management. [Coppola M, Yealy DM: Relapsing polychondritis: An unusual cause of painful auricular swelling. Ann Emerg Meal January 1992; 21:81-85.]
Opinions or assertions contained herein are the private views of
INTRODUCTION
the authors and should not be
The differential diagnosis of acute nontraumatic auricular swelling and pain includes both infectious and noninfectious etiologies. Infectious cellulitis is the most common cause of a warm, swollen, and painful auricle. Early treatment of auricular celluiitis is mandatory to prevent permanent cosmetic deformity. These concerns may prompt the emergency physician to treat all patients with painful auricular swelling with systemic antibiotics. However, this approach may result in delayed diagnosis and treatment of the less common noninfectious causes. One syndrome associated with noninfectious auricular swelling is termed "relapsing polychrondritis" (RP). Initially described in 1923,1 RP is characterized by recurrent destructive inflammatory lesions involving various cartilaginous structures, especially the auricle, auricular surfaces, nose, larynx, and tracheaJ -7 We present the case of a patient presenting to the emergency department with acute unilateral auricular swelling and pain. The differential diagnosis of this complaint along with the pathophysiology, clinical manifestations, and treatment of RP are reviewed.
construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
JANUARY1992
21:1 ANNALS 0F EMERGENCY MEDICINE
81/109
RELAPSING POLYCHONDRITIS Coppola & Yealy
CASE REPORT A 62-year-old woman presented to the ED at approximately 6:00 AM complaining of left external ear pain and swelling. Her symptoms began the evening before presentation and progressed throughout the night. The patient denied any trauma to the area and had not worn earrings for 48 hours before the onset of symptoms. She denied fever, chills, night sweats, vertigo, and subjective decreased auditory or visual acuity. Similarly, she denied photophobia, headache, lightheadedness, or back pain. There was no history of rash, muscular weakness, or acute joint swelling. However, the patient had been treated intermittently for ten years with nonsteroidal anti-inflammatory agents for presumed osteoarthritis, primarily involving the hips and knees, and she reported an increase in her pain for one week. There were no other neurologic, gastrointestinal, or genitourinary complaints. Otherwise, the patient's medical history included hypertension and menopause, and she was taking ibuprofen, triamterene/hydrochlorothiazid, and estrogen. She had no allergies. Physical examination revealed a pleasant, wellnourished woman appearing her stated age and in no obvious distress. Her initial vital signs were blood pressure of 160/84 mm Hg; pulse, 88;
110/82
I
respirations, 20; and oral temperature, 37.7 C. The left pinna was diffusely swollen and erythematous without any obvious integument disruption, drainage, or fluctuance (Figure). The left earlobe was minimally erythematous, and tenderness was elicited primarily along the pinna. The otoseopic examination revealed no abnormalities. The Rinne and Weber tests did not suggest a conductive or sensorineural hearing deficit, and the bedside auditory acuity was normal. The mastoid area was nontender and without erythema or swelling, and there was no preauricular and postauricular or cervical adenopathy. The right ear, scalp, oral, and ocular examinations were normal. No joint swelling, tenderness, or deformities were found, and the neurologic examination was normal. No rashes were present, and the remainder of the physical examination was unremarkable. Figure. Initial appearance of the auricle.
No laboratory tests were ordered, and a presumptive clinical diagnosis of early auricular cellulitis was made. IV cefazolin 2 g was given in the ED, and oral cephalexin 2 g per day and acetaminopherdoxycodone 325 mg/5 mg per tablet every four to six hours as needed were prescribed. The patient was instructed to return in 24 hours or sooner if increased pain, redness, or swelling occurred or fever or rigor was noted. On her return the next day, the patient continued to deny fever, chills, headache, vertigo, or decreased subjective hearing, but her pain persisted. During this second visit, the patient recalled that a similar episode had occurred involving her right ear approximately eight years earlier and had resolved over two weeks with the use of her "arthritis medicines." The examination of the left external ear and head was
unchanged, and oral temperature was 36.6 C. A CBC count revealed a hematocrit of 38.7%, a hemoglobin concentration of 13.2 g/dL, and a WBC count of 10,100 with 50% segmented neutrophils, 9% bands, 24% lymphocytes, and 15% monocytes. The Zeta erythrocyte sedimentation rate was moderately elevated at 66% (normal,
relapsing polychor~ritis
Relapsing Polychondritis: An Unusual Cause of Painful Auricular Swelling From the Emergency Medicine
Marco Coppola, DO, CPT, MC*
Residency, Darnall Army
Donald M Yealy, MD, FACEP**
Community Hospital, Fort Hood, Texas;* Division of Emergency Medicine, Texas A&M University College of Medicine;* and Department of Emergeney Medicine, Scott and White Hospital, Temple, Texas.* Receivedfor publication January 8, 1991. Acceptedfor publication April 4, I991.
Auricular pain, redness, and swelling are usually the result of infectious cellulitis. However, relapsing polychondritis is another cause of this symptom complex and is the result of an autoimmune phenomenon. It presents with inflammation and destruction of both articular and nonarticular cartilage, with the external ear and joint cartilage most often involved. Although usually indolent with multiple acute exacerbations, relapsing polychondritis can be rapidly fatal if the airway or cardiovascular system is involved. We present a case of relapsing polychondritis initially mistaken for auricular cellulitis. The clinical manifestations and course of relapsing polychondritis are reviewed, along with the emergency department management. [Coppola M, Yealy DM: Relapsing polychondritis: An unusual cause of painful auricular swelling. Ann Emerg Meal January 1992; 21:81-85.]
Opinions or assertions contained herein are the private views of
INTRODUCTION
the authors and should not be
The differential diagnosis of acute nontraumatic auricular swelling and pain includes both infectious and noninfectious etiologies. Infectious cellulitis is the most common cause of a warm, swollen, and painful auricle. Early treatment of auricular celluiitis is mandatory to prevent permanent cosmetic deformity. These concerns may prompt the emergency physician to treat all patients with painful auricular swelling with systemic antibiotics. However, this approach may result in delayed diagnosis and treatment of the less common noninfectious causes. One syndrome associated with noninfectious auricular swelling is termed "relapsing polychrondritis" (RP). Initially described in 1923,1 RP is characterized by recurrent destructive inflammatory lesions involving various cartilaginous structures, especially the auricle, auricular surfaces, nose, larynx, and tracheaJ -7 We present the case of a patient presenting to the emergency department with acute unilateral auricular swelling and pain. The differential diagnosis of this complaint along with the pathophysiology, clinical manifestations, and treatment of RP are reviewed.
construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
JANUARY1992
21:1 ANNALS 0F EMERGENCY MEDICINE
81/109
RELAPSING POLYCHONDRITIS Coppola & Yealy
CASE REPORT A 62-year-old woman presented to the ED at approximately 6:00 AM complaining of left external ear pain and swelling. Her symptoms began the evening before presentation and progressed throughout the night. The patient denied any trauma to the area and had not worn earrings for 48 hours before the onset of symptoms. She denied fever, chills, night sweats, vertigo, and subjective decreased auditory or visual acuity. Similarly, she denied photophobia, headache, lightheadedness, or back pain. There was no history of rash, muscular weakness, or acute joint swelling. However, the patient had been treated intermittently for ten years with nonsteroidal anti-inflammatory agents for presumed osteoarthritis, primarily involving the hips and knees, and she reported an increase in her pain for one week. There were no other neurologic, gastrointestinal, or genitourinary complaints. Otherwise, the patient's medical history included hypertension and menopause, and she was taking ibuprofen, triamterene/hydrochlorothiazid, and estrogen. She had no allergies. Physical examination revealed a pleasant, wellnourished woman appearing her stated age and in no obvious distress. Her initial vital signs were blood pressure of 160/84 mm Hg; pulse, 88;
110/82
I
respirations, 20; and oral temperature, 37.7 C. The left pinna was diffusely swollen and erythematous without any obvious integument disruption, drainage, or fluctuance (Figure). The left earlobe was minimally erythematous, and tenderness was elicited primarily along the pinna. The otoseopic examination revealed no abnormalities. The Rinne and Weber tests did not suggest a conductive or sensorineural hearing deficit, and the bedside auditory acuity was normal. The mastoid area was nontender and without erythema or swelling, and there was no preauricular and postauricular or cervical adenopathy. The right ear, scalp, oral, and ocular examinations were normal. No joint swelling, tenderness, or deformities were found, and the neurologic examination was normal. No rashes were present, and the remainder of the physical examination was unremarkable. Figure. Initial appearance of the auricle.
No laboratory tests were ordered, and a presumptive clinical diagnosis of early auricular cellulitis was made. IV cefazolin 2 g was given in the ED, and oral cephalexin 2 g per day and acetaminopherdoxycodone 325 mg/5 mg per tablet every four to six hours as needed were prescribed. The patient was instructed to return in 24 hours or sooner if increased pain, redness, or swelling occurred or fever or rigor was noted. On her return the next day, the patient continued to deny fever, chills, headache, vertigo, or decreased subjective hearing, but her pain persisted. During this second visit, the patient recalled that a similar episode had occurred involving her right ear approximately eight years earlier and had resolved over two weeks with the use of her "arthritis medicines." The examination of the left external ear and head was
unchanged, and oral temperature was 36.6 C. A CBC count revealed a hematocrit of 38.7%, a hemoglobin concentration of 13.2 g/dL, and a WBC count of 10,100 with 50% segmented neutrophils, 9% bands, 24% lymphocytes, and 15% monocytes. The Zeta erythrocyte sedimentation rate was moderately elevated at 66% (normal,
