Introduction

Perichondrites are infections of slow evolution located in the auricular cartilage that lead to laceration, contusions, surgeries or other affections.

Auricular perichondritis by piercing has been increasingly observed, particularly among youngsters. 1-4

The first signs and symptoms appear within a few days or weeks after ear piercing. Patients present intense pain, erythema, edema and hardening of the affected region.1-3,5-8

The etiological agent most frequently found in perichondritis by ear piercing is Pseudomonas aeruginosa, whose inoculation results from exposing the perichondrium and pinna cartilages to the bacteria, during or after the piercing procedure. 1,2,4-6 Other bacteria may also be associated with ear piercing complications, particularly Staphylococcus aureus.1,2,8,9

The main complications include contact dermatitis and high sensitivity to nickel.2,6,7,9-12

Investigation on the etiology of this condition is mandatory, which can be done through culture and antibiogram of the secretion1.

Treatment includes surgical drainage, antibiotic therapy and systemic antiinflammatory treatment.

The present study describes 3 cases of perichondritis by ear piercing admitted at the Otorhinolaryngology ambulatory of Cema Hospital.

Case Report

Case 1

D. M. C., 15-year-old Caucasian female with piercing placed on the right ear 14 days before being admitted to the hospital.

Local pain, erythema and progressive edema were presented by the patient 4 days after piercing the ear. Four days before arriving at our Service, she had initiated oral antibiotic therapy with Cephalexin. Two days later, her clinical status got worse, with spontaneous drainage of purulent secretion (Figure 1).

The patient was seen at our Service, where puncture and collection of the purulent secretion was performed and sent for culture and antibiogram. Following, surgical drainage with debridement of necrotic tissue and placement of Penrose drainage were performed.

Intravenous antibiotic therapy with Ciprofloxacin and steroidal antiinflammatory treatment were initiated, to which the patient responded well, leaving hospital within 48 hours. She maintained oral treatment with 500 mg Ciprofloxacin, BID, for 10 days.

In the follow-up visit, minimal scar deformity was observed. Culture result confirmed the presence of Pseudomonas aeruginosa.

Case 2

D. H., 15-year-old Caucasian female with piercing placed on the right ear 9 days before being admitted to the hospital.

The patient had presented local pain, edema and swelling of helix cartilage for 5 days, despite use of Cephalexin for the last 4 days (Figure 2).

The patient came to our Service, where puncture and collection of the purulent secretion was performed and sent for culture and antibiogram.

Afterwards, surgical drainage followed by debridement of necrotic tissue and placement of a Penrose drainage were performed. The patient stayed at the hospital and started antibiotic therapy with 500 mg Ciprofloxacin BID plus steroidal antiinflammatory treatment. She responded well to treatment, leaving the hospital within 48 hours.

Oral Ciprofloxacin treatment was maintained for 10 days.

In the follow-up visit, minimal scar deformity was observed. Culture result confirmed the presence of Pseudomonas aeruginosa.

Case 3

A. M. L., 14-year-old Caucasian female with intense edema, erythema, local pain and purulent secretion on the left ear, as a result of ear piercing 7 days before arriving at our Service (Figure 3).

Surgical drainage was performed and a sample of secretion was sent for culture and antibiogram. Oral antibiotic therapy with 500 mg Ciprofloxacin BID was initiated and maintained for 10 days.

Patient recovered well and did not show any deformities by scar.

Culture results confirmed the presence of Pseudomonas aeruginosa.

Discussion

The first case of perichondritis by Pseudomonas aeruginosa immediately after ear piercing is quite recent. It generally occurs during hot seasons (mainly Summer), when excessive body perspiration hinders healing and predisposes to infection. 2,4,10 Lack of arterial irrigation in the cartilaginous tissue favors infection perpetuation. 2-4,8 Potential complications occur within days or weeks (average time: 1 week) 2-4,7, which are as follows: local (cysts, edema, granuloma, hematoma, deformities, lipoma and abscess), or systemic (toxic shock, osteomyelitis, chondritis, diffuse acute glomerulonephritis and superficial cervical lymphadenopathy).1-3,6,9,13

Nickel seems to be the main responsible for hypersensitivity to the piercing. 7,11-13 It induces allergic reactions and leads to development of a nickel-protein complex, yielding an immunological response. 12 Several authors describe gold as the second material involved in this type of reaction. 2,6,7,12

The diagnosis is essentially clinical, while culture plus antibiogram should be performed. Generally, cultures reveal Gram-negative bacteria, among which Pseudomonas aeruginosa is the most frequently found.