Chapter 22: Infections of the Temporal Bone

Chondritis, Perichondritis, and Cellulitis of the Auricle

• Spectrum of disease from mild superficial skin infection to chondritis.

• Cellulitis is an infection of the skin of the auricle.

• Perichondritis and chondritis are infections of the auricular perichondrium and cartilage, respectively.

• Bacterial infections typically result from blunt or penetrating trauma, or extension of infectious otitis externa (OE).

• Superficial infections commonly related to Staphylococcus and Streptococcus.

• Deeper infections often involve Pseudomonas.

Etiology

• Trauma—most common cause

• Blunt trauma (assault, wrestling) resulting in hematoma and secondary infection

• Penetrating trauma—bites, knives, foreign, body, firearms

• Ear piercing—transcartilagenous piercings

• Iatrogenic—otologic surgery

• Extension of OE

• Extension of subperiosteal abscess

• Rule out:

  1. Relapsing perichondritis—autoimmune condition that involves the cartilage and spares the lobule from inflammation

  2. Cutaneous lymphoma

  3. Gouty tophus

Physical Examination

• Pain and erythema common in cellulitis, perichondritis, and chondritis.

• Induration and edema typical for chondritis and perichondritis.

• Induration usually not seen with cellulitis.

• Hematoma with or without abscess formation—fluctuation present with abscess.

• Cartilage deformity (“cauliflower ear”) in chronic or recurrent infections and in advanced or untreated cases.

• Fever, chills, and elevated white blood cell count can be seen.

Diagnosis and Pathogens

• Diagnosis made on clinical grounds

• Cellulitis of the auricle typically due to Staphylococcus spp

• Pseudomonas spp most common cause of perichondritis and chondritis

  1. Most commonly cultured organism from auricular abscess

• Incision and drainage with culture when possible

• Other rare bacteria—Escherichia coli and Proteus spp

• Erysipelas caused by beta-hemolytic Streptococcus

  1. Auricle typically erythematous, indurated, and painful

  2. Infection typically follows a well-demarcated border

Treatment

• Mild infections

  1. Oral anti-staphylococcal and anti-streptococcal antibiotics

• Severe infection or immunocompromised patient

  1. IV anti-staphylococcal, anti-streptococcal, and anti-pseudomonal antibiotics

• Perichondritis or chondritis

  1. Involvement of cartilage with inflammation or abscess can result in cosmetic deformity (cauliflower ear)

  2. Goal of treatment: rapid diagnosis and initiation of therapy, maximize aesthetic outcome

  3. No abscess—oral antibiotics with anti-pseudomonal coverage (fluoroquinolone)

  4. Abscess—incision and drainage with cartilage debridement as needed

  5. Antibiotic therapy for 2 to 4 weeks

  6. Placement of bolsters as needed

Viral Processes of the Auricle

Herpes Zoster

Etiology

• Thought to occur following viral reactivation within ganglion nerve cells

• Can result following insult due to direct trauma, dental work, or upper respiratory infection (URI)

• Most commonly seen in the elderly and immunocompromised

Signs and Symptoms

• Often includes prodrome of otalgia which precedes vesicular eruption.

• Vesicles in the external auditory canal (EAC) and conchal bowl.

• May included tinnitus, hearing loss, vertigo, decreased lacrimation (associated ganglion).

• Facial paralysis with Herpes Zoster Oticus is known as Ramsay Hunt Syndrome.

• Other cranial neuropathies (V, IX, X, XI, XII) can be seen.

Diagnosis and Pathogens

• Tzanck smear to look for multinucleated giant cells ...