Blackwell Science, LtdOxford, UKASHAnnals of the College of Surgeons of Hong Kong1028-40012004 Blackwell Publishing Asia Pty LtdAugust 200483107108Teaching

CornerManagement of perichondrial abscessFV Noronha

et al.

Ann. Coll. Surg. H.K. (2004) 8, 107108

Teaching corner

Management of perichondrial abscess following high

ear-piercing
Frederick Victor Noronha (
),* Chi-Kong Or (
Sze-Yuen Mak (
) and Man-Kwong Tung (

), Wai-Hong Wong (

),

Plastic Surgery Division, Department of Surgery, Princess Margaret Hospital, Hong Kong SAR.

Key words: ear-piercing, perichondritis, pseudomonas.

Introduction
The history of body-piercing dates back to many thousand years ago. Today it is usually a statement of
identity or being fashionable.1 The most common
body-piercing is ear-piercing which ranges from a single hole to multiple holes along the entire helix. High
ear-piercing is defined as puncturing the cartilage in
the upper third of the pinna.2
Ear-piercing can be associated with local infective
complications such as cellulitis, perichondritis and
abscess formations.1,3 The pathophysiology of complications occurs after a stud is fired from a piercing gun
and a traumatic auricular haematoma can be formed.
The stud carries bacterium from the skin into the
cartilage.4 This local sepsis of perichondritis potentially develops into an abscess.2 The usual pathogen
is Pseudomonas aeruginosa or Staphylococcus
aureus.15
These bacteria destroy the cartilage. In addition, the
nutritive supply of the relatively avascular cartilage is
dependent on the perichondrium which is dissected
off the cartilage by the abscess. The end-point cosmetic damage is a deformed5 or shrunk cartilaginous
framework. This manifests as total loss of cartilaginous
definitions or as a cauliflower ear. Both are notoriously
difficult to reconstruct surgically. Prompt surgical
treatment is warranted at the first sign of abscess
collection.2

Case report
A 17-year-old adolescent male smoker presented with
a 5-day history of painful swollen left pinna following

*Author to whom all correspondence should be addressed to.

Email: victornoronha@mail.com
Received 12 December 2003; accepted 11 March 2004.
Teaching corner

piercing at a shopping mall. Further history revealed

he had had piercings of the same pinna on seven
separate occasions in the last 9 months. On examination this patient was afebrile. There was a 4-cm fluctuant tender swelling with a bleb of necrotic skin on
the superior portion of the helix, antihelix and triangular fossa of the left pinna (Fig. 1). Hypertrophic scars
on the lateral and medial aspects of the pinna were
evident and reflected inflammations secondary to previous piercings. The tympanic membrane appeared
normal on auriscopy. Routine blood test results were
unremarkable. This patient had a perichondrial
abscess that required an incision and drainage (I &
D) procedure.

Surgical tips
To assist in a smooth surgical procedure, an operation
was organised with the theatre personnel while ordering an antitetanus toxoid injection and a hair wash with
shampoo for the patient.
In the theatre, the patients head was rested on a
silicon gel head ring and laterally rotated 30 to the
right. The operation table was adjusted to 15 head
up (above the foot side) to help reduce bleeding.
Povidone iodine was used to cleanse the left pinna
before sterile towels were draped around the operation site. The patient underwent an I & D under general
anaesthesia. This procedure could also be performed
under local anaesthesia with adequate lighting in the
operation theatre.
A 1-cm incision on the necrotic skin of the
abscess drained 15 mL of pus. The pus was sent for
microbiological studies. The necrotic bleb of skin
was excised and the abscess cavity was irrigated
with chlorhexidine 0.05%. No cartilage was excised
in order to conserve as much native tissues as
possible.

108

Fig. 1.
pinna.

FV Noronha et al.

Perichondrial abscess on the superior aspect of the left

The lateral aspect of the pinna was made up of

intervening areas of concavities and convexities.6 This
peculiar anatomy dictated that bolster dressings be
applied on these concavities to keep the skincartilage-skin envelope coapted for 1 week postoperatively. These bolster dressings were dental swabs
wrapped in paraffin gauze held by through-andthrough 3/0 monofilament sutures (Fig. 2). Our group
used 3/0 Prolene (Ethicon; Johnson and Johnson,
Somerville, New Jersey, USA) on a straight needle.
Chloramphenicol ointment was applied around the
bolster dressings. The wound was covered with light
dressing. Ciprofloxacin 500 mg b.i.d. orally was prescribed empirically.2,3 Postoperatively this patient was
nursed propped up to reduce wound oedema and
was advised against smoking. Culture results yielded
P. aeruginosa sensitive to ciprofloxacin which was
continued for 1 week.
As scar revision surgery or even full ear reconstructions might be required at a later date, referral to a

Fig. 2. Bolster dressings applied following incision and drainage with thorough irrigation of the abscess cavity.

plastic surgeon for prompt assessment should be

arranged if this had not been done so.

References
1 Widick MH, Coleman J. Perichondrial abscess resulting from
a high ear-piercing - a case report. Otolaryngol. Head Neck
Surg. 1992; 107: 8034.
2 Hanif J, Frosh A, Marnane C, Ghufoor K, Rivron R, Sandhu G.
High ear piercing and the rising incidence of perichondritis
of the pinna. BMJ. 2001; 322: 9067.
3 Staley R, Fitzgibbon JJ, Anderson C. Auricular infections
caused by high ear piercing in adolescents. Pediatrics 1997;
99: 61011.
4 More DR, Seidel JS, Bryan PA. Ear-piercing techniques as a
cause of auricular chondritis. Pediatr. Emerg. Care 1999; 15:
18992.
5 Turkletaub SH, Habal MB. Acute pseudomonas chondritis as
a sequel to ear piercing. Ann. Plast. Surg. 1990; 24: 27981.
6 Larrabee WF Jr, Sherris DA. Principles of Facial
Reconstruction. Philadelphia: Lippincott-Raven Publishers,
1995.