1. Introduction
he pinna projects at a variable angle as a fan-like formation from the side of the head and perform the collecting of sound. The unique pattern of it is comparable with fingerprint and can allow the identification of persons on the physiognomy of their auricles [1]. The body of the pinna is formed of a single piece of yellow elastic fibro-cartilage and is a continuous plate except for a narrow gap between the tragus and the helix. The cartilage of the auricle covers with perichondrium from which it derives its supply of nutrients, as cartilage itself is avascular. High ear piercing, accident or assault makes injury of the pinna, and stripping of perichondrium, which causes hematoma may lead to necrosis of cartilage with crumpled up 'boxer's ear, pugilistic or cauliflower ear [2]. The sequelae of inflammation of the pinna described by James W. Loock into four stages: 1. Erysipelas, 2. Cellulitis, 3. Perichondritis, 4. Chondritis [3]. Perichondritis is mainly traumatic, which includes lacerations of the pinna, surgery of external auditory canal, frost bite, insect bite, burns, infected hematoma Auris, incision, or aspiration for hematoma of the pinna, and in recent years high ear piercing for wearing fashional ornaments [4]. In the process of perichondritis, various types of bacterial invasion occur. The most common organisms were Pseudomonas aeruginosa (69%) [5], Polymicrobial (22%), Streptococcus spp. (22%), Staphylococcus aureus (20%), and other Gramnegative organisms include Proteus, Enterococcus, and Escherichia coli [6], [7]. Body piercing is popular after 1990, which was done by well known singer Michael Jackson, Madonna, and so many Hollywood stars. The teenager and young adult following them piercing the Tongue, Lips, Eyebrows, Nose, Nipple, Umbilicus, and Genitalia [8], [9], [10]. Body piercing is one of the religious or rituals of mysticism to God in some countries of Asia and Latin America from teenager to adulthood. The procedure usually did by an untrained person; as a consequence, healing of the wound various from one month to one year [11]. The pathological process of perichondrium of pinna following hyperplasia of skin, thickened subcutaneous tissue, thickening of perichondrium by infiltration, and destruction of cartilage by phagocytes [12]. The classical presentation of the perichondrium of the pinna is severe earache, erysipelas, cellulitis, and auricular abscess, so diagnosis is clinical and special investigation aren't required routinely [3]. Some systemic disease related to perichondritis which includes Relapsing Perichondritis [13], non-Hodgkin lymphoma of pinna with or without immunodeficiency state [14], [15]. Different types of management options described by the surgeons depending on the staging of perichondritis. Stage of erysipelas and early cellulitis adequately managed by the use of a topical, and high doses of oral and parental antibiotics may halt the progression of disease due to Pseudomonas aeruginosa [16]. Some surgeons practiced minimum invasive procedures like aspiration of infected edematous fluid, syringing the cavity two to three times daily with streptomycin solution [17]. It is difficult to decide how much cartilage to excise, and frequent consecutive debridement to prevent the deformity of the pinna. Many surgeons suggested aggressive excision of necrotic cartilage, including overlying skin and subcutaneous tissue [18] [19]. In severe cases, James W. Look, and Dowling et al. practiced total cordectomy via an incision in the helical margin, the ear splits in bivalve fashion, the necrotic cartilage removed, and a layer of fine mesh gauze placed between the flap and changed daily [3], [20]. Another group of surgeons applied fenestrated polyethylene tubes placed in subperiosteal tunnels on either side of the cartilage and aminoglycoside/cortisone solution used to irrigate these twice daily [21], [22]. Aggressive surgery, while it may, at times be necessary, may aggravate the ultimate deformity [3].
This study finds out the relative incidence, frequency, presentation, and complications of perichondritis of the pinna and the best management option for it.
2. Methods and Materials
It is a cohort retrospective study of 63 cases in the two tertiary care Hospitals from 01 July to 31 June 2019. During three years period, ENT casualty patient was 7295. We divided the 63 patients into two categories depending on the James W. Cook's classification [3]. added pain killer, anti-ulcer, local drop, and ointment whichever were needed. Accordingly, they came to consult with us and exhibited 90% improvement. We converted the parental antibiotic into oral form like Tab Moxifloxacillin (400mg), Cap Clindamycin (300mg), and Tab Metronidazole (400mg) for another ten days. They were disease-free since the last follow-up.
The rest 36 patients were category two, who produced symptoms auricular abscess, perichondritis, and chondritis. They need immediate surgical exploration and got admitted to the hospital. We started parental intravenous combined broad-spectrum systemic antibiotics without any delay like category one. We did incision and drainage 22 patients and regular surgical dressing with EUSOL pack (Edinburg solution of lime). We gave incision along the helical margin up to maximum fluctuate point and split the ear bivalve fashion. Through the splitting line, we placed the EUSOL pack and gave pressure bandage by maintaining the auricular shape. The 13 patients of category two need exploration, debridement, and extensive scooping and curettage. We gave helical incision from the upper The category one patients produced mild to moderate symptoms like erysipelas, induration, and early cellulitis. They were twenty-seven and treated conservatively through out-patient department service. We discussed with the patient about the fatal out of the disease to maintain the proper treatment. We started parental intravenous combined systemic broadspectrum like Injection Meropenem, Clindamycin, and Metronidazole to combat both aerobic and anaerobic bacteria especially Pseudomonas aeroginosa. We advised them to admit in the Upazilla Health Complex, which is the secondary care hospital, and near their homes to maintain the intravenous course properly for seven to ten days according to the condition of the attachment of auricle up to the lobule (Figure -11) and split the ear bivalve fashion, debridement, scooping and curettage of all dead tissue and cartilage, and placing the EUSOL pack and regular dressing as before. We did the surgery of the children and uncooperative patients under general anesthesia and cooperative patients under local anesthesia when the infection was overcome and growing of granulation tissue, the bivalve ear attached by button method for ten to fourteen days 13).
One patient did mastoidectomy operation. He cleared his ear by street ear cleaner like a hawker. Afterward he developed perichondritis with mastoiditis. Perichondritis treatment continued, but he complained the sever earache need narcotic analgesic. CT scan showed osteomyelitis change in the mastoid bone. After mastoidectomy, the patient cured of symptoms.
We followed-up the patient fifteen days interval for one month and the last follow-up after three months. We referred the major deformed patients to the Plastic and Reconstruction department for further consultation. The following data collected about the patient: Sex, age, laterality, personal history, presenting features, investigation, treatment, post-operative follow-up, complication, and hospital stay. Statistical software SAS used to calculate all data.
3. III.
4. Results
The incidence of perichondritis of pinna, out of ENT casualty, was 0.86%. The etiological factors explored , post-traumatic was 18 (28.57%) in which high ear piercing 11 (17.46%), accident and assault 07(11.11%), furunculosis 12 (19.05%), post-infective 09 (14.29%), allergy due to hair color 06 (9.53%), Herpes Zostus Oticus 04 (6.35%), Malignant otitis externa 03 (4.76%), post-operative 02 (3.17%), insect bite( honey bees) 02 (3.17%), burn 02 (3.17%), and unknown 05(7.94%). Of them, the female was 30 (47.62%), and the male 33(52.58%), children (according to UNICEF and WHO children age up to 18 years) were 27 (42.86%), and adult 36 (57.14%) in which lowest age 02 years, highest age 76, mean age 21.952, and the standard deviation 16.676, and all patients had a unilateral ear. Personal history revealed diabetic was 08 (12.70%), and non-diabetic 55 (87.30%), smoker 09 (14.29%), and non-smoker 54 (85.71%). Presenting features exhibited moderate to severe earache was 61 (96.83%), red, hotness, and stiffness of pinna 59 (93.65%), auricular abscess 36 (57.14%). Bacteriology showed Pseudomonas aeruginosa was 21 (58.33%), Staphylococcus aureus 15 (41.67%), Streptococcus pyogenes 13 (36.11%), and gram-negative Bacillus Proteus, Enterococcus faecalis, Escherichia coli 11(30.56%). Regarding the treatment of the patient, 27 (42.86%) treated by conservative medical through outpatient department service, and 36 (57.14%) surgical through indoor service in which incision and drainage did 22 (61.11%), exploration, debridement, scooping, and curettage of auricular cartilage 13 (36.11%), and mastoidectomy 01(2.78%). After four months of followup, complications revealed minor deformity was 15 (23.81%), major deformity 07 (11.11%), and rest 41 (65.08%) normal. The treatment response was variable depending on the condition of the patient and prolonged the hospital stay. 17 IV.
5. Discussion
Perichondritis of the pinna is a fatal infection and deformed the second identity of the body after fingerprint [1]. The incidence of perichondritis in the present study, out of ENT casualty (7295) was 0.86%. There was no available data to compare it.
Regarding the etiology, post-traumatic was the common cause (28.57%) which included high ear piercing 11 (17.46%) usually found during Eid festival, and accident and assaulted 07 (11.11%) supported by Cicchetti S et al. and Prasad HK study [23], [16]. Other factors were furunculosis 19.05%, post-infective 14.29%, allergy due to hair color 9.53%, Herpes zostus oticus 6.35%, malignant otitis externa 4.76%, post-operative, insect bite and burn all three were 3.17%, and unknown 7.94%, persistence with Hanif J, Prasad HK and Gautam D et al. series [4], [16], [24].
In gender epidemiology, males were 52.58%, and females 47.62%, almost equal in my work in opposition to Gautam D et al. series, revealed male 38 (76%), female 12 (24%), Prasad KC also exhibited male preponderance [24], [25]. It may be due to high ear piercing and furunculosis of external auditory canal patients; all or maximum were females in my paper.
Concerning the age, children were 42.86%, and adults 57.14% in the present study, against Gautam D et al. reported 76% was 30-50 years. Still, Fernandez ADP et al. series showed maximums were a teenager in favor of my observation [24], [26].
Personal history revealed diabetic was 12.70% and smoker 14.29% in my research causes delayed wound healing persistence with Fernandes LF work, recorded insulin depended on diabetic patient treated by hyperbaric oxygen after proper controlling of DM [27]. To control this type of fatal infection, the patient should stop smoking and diabetes should be normal through consultation with the Endocrinologist.
Presenting features exhibited earache was 96.83%, erythematous and indurated pinna 93.65%, and auricular abscess 57.14% in this paper, kept up by all others study like Prasad HK, Cicchetti C, Gautam D and Davis O et al. series [16], [23], [24], [28].
Culture and sensitivity report in my study, Pseudomonas aeruginosa was 58.33%, Staphylococcus aureus 41.67%, Streptococcus pyogenes 36.11%, and Gram-negative 30.56%, near to James W. Loock, Prasad HK and Gautam D papers [3], [16], [24]. James W. Loock observation also near to my report [29], [30].
Regarding treatment, we treated 42.86% patient conservative medical treatment supported by Prasad HK and Gautam D, though the number of patients fewer than me. They treated 19% and 24% patient accordingly conservative alone [16], [24]. Surgical treatment included incision and drainage was 61.11%, exploration, debridement, scooping and curettage 36.11%, and mastoidectomy 2.78% in this paper, near Prasad HK percentage of the patient but the difference the method of surgery [16]. He presented incision and drainage was 31%, cartilage and wound debridement 31%, and mastoidectomy 07%. But my method of surgery kept up by James W. Loock, Dowling JA, Kent SE, and Widick MH et al. series [3], [20], [31], [32].
Post-operative follow-up presented minor deformity was 23.81%, extensive deformity 11.11%, and retain architecture 65.08% near to Gautam D et al. displayed partial deformity was 50%, total deformity 18%, and no deformity 32% [24]. Salem W and Scoog T et al. report also support our findings [33], [34].
Regarding hospital stay, conservatively treated 42.86% of patient received their treatment through outpatient department service. Surgically treated, 57.14% patients had got admitted to the hospital. Among them, 42.22% stayed in the hospital up to two weeks, 16.67% three to four weeks, and 36.11% five weeks and above-, consistent with Prasad HK, Gautam D, and Fernandez ADP works [16], [24], [26].
V.
6. Conclusion
Perichondritis of the pinna is one of the dreadful diseases which can commonly strike teenagers, young, and diabetic persons. Teenagers and females are doing high ear piercing for wearing ornaments, which increases their fashion and smartness. It is necessary to develop their awareness to do high ear piercing a trained medical personnel. Development of realization about the ear infection and care to the people is essential through local health authority. Truculent surgical treatment without undue delay and the latest parental broad-spectrum antibiotic may restrain the disease and mitigate the hospital stay outstanding.
