Treatment of Pseudomonas aeruginosa auricular perichondritis with oral ciprofloxacin

Perichondritis: inspect the lobule

Case presentation

This is a brief report of a 57-year-old Caucasian female presented with a 4-day history of worsening left ear pain. Her symptoms began with left otalgia and otorrhea which progressed to helical erythema, prompting a visit to the emergency department. She was noted to have erythema of the left auricle and swelling of the left auditory meatus. Our otolaryngology service observed erythema of the auricle with sparing of the lobule.

Diagnosis

The diagnosis to be otitis externa with perichondritis was established, and we recommended otic ciprofloxacin-hydrocortisone, IV vancomycin, and ciprofloxacin. The patient had marked improvement and was discharged on an oral and otic fluoroquinolone. In this case, the diagnosis of perichondritis was made by a classic physical examination finding: erythema and edema with sparing of the fatty lobule. This key finding helps to distinguish perichondritis from otitis externa.

Perichondritis of the auricle: bacterial findings and clinical evaluation of different antibiotic regimens

PURPOSE

Pseudomonas aeruginosa is commonly found in suppurative perichondritis, but the significant pathogens in non-abscess perichondritis are unclarified. We aimed to explore the bacterial findings and evaluate the effectiveness of different antibiotic regimes in the treatment of patients with perichondritis.

METHODS

All patients treated for perichondritis at the two Ear-Nose-Throat Departments in Central Denmark Region (covering 20% of the Danish population) from January 1990 to October 2018 were included.

RESULTS

In total, 112 patients with (n = 12) or without (n = 100) abscess were included in the study. Potential pathogens were found in 40 of 55 cultures. P. aeruginosa was recovered in 58% of abscess cases, while Staphylococcus aureus was predominant in non-abscess infections (49%). Eighty-two percent of S. aureus recovered were isolated as heavy or moderate growth. In non-abscess cases, no significant differences in clinical progress (p = 0.65), alteration in antibiotic therapy (p = 0.31), duration of hospitalization (p = 0.65), or frequency of relapse of infection (p = 1.00) or sequelae (p = 0.38) were found between patients treated with antibiotics covering S. aureus vs. P. aeruginosa.

CONCLUSIONS

Our findings suggest that intravenous antibiotic therapy covering S. aureus is sufficient and appropriate empirical treatment in the majority of patients with non-abscess perichondritis. Antibiotic coverage should be expanded to include P. aeruginosa if the clinical response is disappointing or cultures grow P. aeruginosa. The risks and downsides to this approach seems limited as only a minority of patients suffered (minor) cosmetic sequelae and relapse of infection in our cohort of non-abscess perichondritis patients initially treated with antibiotics not covering P. aeruginosa.

Efficacy of antibiotic prophylaxis prior to tympanoplasty for contaminated cholesteatoma

OBJECTIVES

To evaluate the efficacy of combined antistaphylococcal and antipseudomonal preoperative antibiotics for preventing surgical site infections following tympanoplasty and mastoidectomy with contaminated cholesteatoma.

STUDY DESIGN

Retrospective chart review.

METHODS

Medical records of patients who underwent tympanoplasty ± mastoidectomy for cholesteatoma were reviewed. Only cases considered to have contaminated or dirty surgical fields were included. The primary outcome measure was occurrence of postoperative surgical site infections, perichondritis, pinna abscess, periotic cellulitis, or periotic abscess requiring systemic antibiotic therapy or surgical intervention.

RESULTS

The charts of 326 patients who underwent tympanoplasty ± mastoidectomy were reviewed. Of those, 195 met inclusion criteria. Preoperative antibiotics included clindamycin and ceftazidime or gentamicin. Patients treated with no perioperative antibiotics had a surgical site infection rate of 11%, and those treated with perioperative antibiotics had a rate of 1% (P = 0.02).

CONCLUSION

Administration of preoperative antibiotics to cover staphylococcal and pseudomonal species may prevent surgical site infections with tympanoplasty ± mastoidectomy for contaminated cholesteatoma.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2363-2366, 2016.

Cutaneous lesions of the external ear

Skin diseases on the external aspect of the ear are seen in a variety of medical disciplines. Dermatologists, othorhinolaryngologists, general practitioners, general and plastic surgeons are regularly consulted regarding cutaneous lesions on the ear.

This article will focus on those diseases wherefore surgery or laser therapy is considered as a possible treatment option or which are potentially subject to surgical evaluation.

Is levofloxacin necessary to prevent postoperative infections of auricular second-intention wounds?

BACKGROUND

Surgeons may prescribe oral quinolones after auricular procedures to prevent postoperative infections, especially those caused by Pseudomonas aeruginosa.

OBJECTIVE

This study compares the efficacy of levofloxacin and local wound care to local wound care alone in preventing postoperative infection of auricular second-intention wounds.

MATERIALS AND METHODS

This study was a prospective, randomized trial of 84 consecutive patients (82 in the final analysis) who underwent Mohs micrographic surgery for an auricular neoplasm and had a wound left to heal by second intention. After surgery, patients were randomly assigned to receive either local wound care or local wound care with concurrent 500 mg of levofloxacin by mouth daily.

RESULTS

Overall, 85.4% of patients had no complications. Complications included 12.2% of patients with inflammatory chondritis and 2.4% of patients with infection. No infections with P. aeruginosa were observed. No statistical significance was observed between the two treatment groups.

CONCLUSION

Levofloxacin is not necessary to prevent postoperative infections of auricular second-intention wounds after Mohs surgery.

Pseudomonas aeruginosa necrotizing chondritis complicating high helical ear piercing case report: clinical and public health perspectives

BACKGROUND

Auricular or high helical ear piercing is an increasingly widespread fashion trend that is associated with an increased risk of potentially serious post-piercing complications such as auricular perichondritis.

CASE REPORT

An 11-year-old girl developed severe auricular perichondritis following piercing of the upper helical cartilage of her ear at a hairdressing salon. Four days post piercing, she returned to the same salon for a haircut during which the pierced site was manipulated. She presented to her family physician and was treated unsuccessfully with oral cephalexin. She was then referred to an infectious diseases consultant and received antipseudomonal intravenous antibiotics with subsequent resolution. She also required debridement and removal of necrotic cartilage. Public health investigation evaluated potential sources of infection including the piercing gun, disinfectant solutions, and hair cutting spray water bottles. Final culture results of the ear helical aspirate grew Pseudomonas aeruginosa. Pseudomonas aeruginosa was also cultured from one of the water bottles used to wet her hair during the haircut.

DISCUSSION

Although the pseudomonal strains from the water bottle were different than the infecting one, this contamination presents a potential source of wound infection. Damage to the helical cartilage caused by the piercing gun may also have contributed to this infection. Initial empiric antibiotic therapy for these kinds of infection must include anti-pseudomonal coverage. Auricular or high helical ear piercing using a piercing gun is not recommended.

Gentamicin Ointment versus Petrolatum for Management of Auricular Wounds

BACKGROUND

Surgeons frequently create defects on the ear in the treatment of cutaneous malignancies. Potentially significant complications of second-intention healing on the ear are suppurative and inflammatory chondritis. Consequently, many physicians advocate the use of oral or topical prophylactic antibiotics after auricular surgery.

OBJECTIVE

The purpose of this study is to compare the efficacy of gentamicin ointment with that of petrolatum for the prevention of suppurative chondritis during second-intention healing of auricular wounds after Mohs surgery.

METHODS

One hundred forty-two patients with a total of 147 second-intention wounds were prospectively selected to receive either gentamicin ointment or petrolatum postoperatively.

RESULTS

One hundred forty-four wounds were evaluated in a follow-up examination or by telephone interview. Eight (5.56%) wounds developed suppurative chondritis. Four wounds received gentamicin and four received petrolatum, for incidences of 4.76% and 6.67%, respectively. Twelve (8.33%) other wounds developed inflammatory chondritis. Ten (11.90%) received gentamicin and two (3.33%) received petrolatum.

CONCLUSIONS

There is no statistically significant difference between the use of gentamicin ointment and petrolatum in the prevention of postoperative auricular suppurative chondritis. The data also demonstrate a disproportionate number of cases of inflammatory chondritis in the gentamicin-treated group. This study supports the cost-effective and potentially less irritating use of petrolatum for wound care in this difficult to manage area.

The incidences of chondritis and perichondritis associated with the surgical manipulation of auricular cartilage

BACKGROUND

The cartilage and soft tissues of the ear are frequently employed as donor sites for tissue used in the repair of defects of the nose and external ear after Mohs surgery. Enthusiasm for using these auricular donor sites is occasionally tempered by surgeons' concerns for the development of Pseudomonal suppurative chondritis, a complication that has been described to follow cartilage manipulation.

OBJECTIVE

To quantify the incidence of postoperative perichondritis and chondritis after Mohs reconstructions involving auricular cartilage manipulations.

METHODS

We retrospectively reviewed 341 Mohs reconstructions that involved cartilage and soft-tissue donor sites located on the ear. Procedures included full-thickness skin grafts (295) harvested from the conchal bowl and flap repairs (46) incorporating cartilage batten grafts from conchal or anthelix donor sites. When the perichondrium was compromised, patients were routinely prescribed perioperative prophylactic antibiotics with Pseudomonal coverage. Postoperative examinations were performed at 1 week and 4 to 12 weeks. Patients not seen in clinic were interviewed by telephone regarding complications.

RESULTS

Complete follow-up information was obtained in 337 of 341 (98.8%) cases. Inflammatory perichondritis was observed in 19 (5.6%) patients. There were no cases of suppurative chondritis.

CONCLUSION

The incidence of inflammatory perichondritis is low after Mohs reconstructions involving auricular cartilage manipulation. When prophylactic antibiotics and appropriate operative technique are used, the historic concern for suppurative chondritis associated with these procedures is unwarranted.

Systemic management of cutaneous bacterial infections

Cutaneous bacterial infections can be treated by a variety of modalities, although systemic antimicrobial agents usually provide the most efficacious and efficient means for treatment. Oral administration allows outpatient management, thus decreasing the overall cost of treatment. Although gram-negative organisms are increasingly implicated in dermatologic infections, the bacteria that are commonly found in skin infections include group A beta-hemolytic Streptococcus and Staphylococcus aureus, which cause many types of pyoderma or impetigo. Not every patient exhibits the common signs of bacterial skin infection, which can include redness, crusting, induration, increased local temperature, serous exudate, a purulent discharge, pustules, bullae, or a foul-smelling odor, as well as such symptoms as malaise, pain, and tenderness. Bacterial confirmation may also be difficult. Beta-lactam antibiotics, tetracycline, and erythromycin have proven useful in this setting; however, increasing resistance is problematic. The management of bacterial infections of the skin and skin structure has been expanded during the past decade with the introduction of the new fluoroquinolones--agents with a wide spectrum of antimicrobial activity and good pharmacokinetic characteristics. While the clinical efficacy of each agent must be considered in the light of risk of adverse events and potential drug interactions, ciprofloxacin, enoxacin, ofloxacin, and temafloxacin appear to be most useful for cutaneous bacterial infections.

Excision of exposed cartilage for management of Mohs surgery defects of the ear

Cartilage of the ear is often exposed during Mohs surgical procedures. Fenestration of the cartilage with a skin punch has been recommended to stimulate granulation tissue where the perichondrium has been destroyed. This article describes an alternative method--the excision of a window through the exposed cartilage, fully exposing the perichondrium on the other side of the cartilage. This promotes the rapid healing by second intention or provides a vascular bed for immediate skin grafting. Also, aggressive excision of nonviable cartilage helps prevent chondritis or perichondritis.