Pinna perichondritis due to Pseudomonas aeruginosa after piercing in a pediatric patient: a case report with surgical debridement

Introduction

Background

Body modification practices, including tattoos and piercings, have increased significantly among teenagers and young adults in recent decades. According to the Pew Research Center, 38% of individuals aged 18 to 29 years have at least one tattoo, and 23% have piercings in areas other than the earlobe (1). This trend has raised public health concerns due to potential complications such as localized infections, bleeding, tissue laceration, hypersensitivity reactions, aesthetic issues, and, in some cases, serious infections like hepatitis B and C or tetanus (1-3). Consequently, professional organizations such as the American Academy of Pediatrics have issued guidelines emphasizing the importance of educating patients and families about risks, preventive measures, and when to seek medical attention (1).

Among body modifications, ear piercings beyond the earlobe are particularly prone to complications, with reports indicating that up to 35% of individuals experience one or more adverse events. The most common complications include localized infections (77%), allergic reactions (43%), and keloid scarring (2.5%) (2,3). Piercing-related trauma to cartilage can lead to infection, erosive chondritis, or tissue replacement by fibrocartilage, potentially progressing rapidly to tissue necrosis (4,5). Severe complications such as pinna perichondritis and perichondral abscess are especially concerned due to the risk of permanent cosmetic deformities (3-5).

Similar cases have been reported, such as an 11-year-old girl who developed severe auricular perichondritis caused by Pseudomonas aeruginosa (P. aeruginosa) after a high helical ear piercing, requiring both surgical intervention and intravenous antipseudomonal therapy (6). This highlights the potential severity of such infections and underscores the importance of addressing this issue in adolescents, a population with increasing exposure to cartilage piercings due to current fashion trends.

Objective

This report aims to present a detailed case of post-piercing perichondritis complicated by perichondral abscess and cartilage necrosis in a pediatric patient, highlighting the clinical course, therapeutic approach, and implications for early diagnosis and multidisciplinary management. This case underscores the need for increased awareness and standardized protocols to prevent severe complications associated with cartilage piercings. We present this article in accordance with the CARE reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-22/rc).

Case presentation

In June 2022, a 14-year-old Latin female patient was evaluated after presenting with a 3-week history of progressive symptoms following ear cartilage piercing on the upper portion of her right pinna. The procedure was performed at an informal establishment by non-professional personnel using non-sterile equipment. It is unknown whether any antiseptic was applied prior to the piercing. The patient had no relevant medical history, no prior antibiotic use, and no known immunodeficiencies.

She presented with erythema, heat, edema, moderate pain, and fever for the past 2 days, which led to referral to our hospital for further evaluation. Upon admission, laboratory tests showed no signs of systemic involvement, and the clinical findings were suggestive of perichondritis. Otorhinolaryngologic examination revealed significant edema, warmth, and erythema of the right pinna—specifically between the helix and antihelix—with no visible external discharge. However, localized pus accumulation was detected in the helix, with renitent consistency and crepitation on palpation (Figure 1). The otorhinolaryngology [ear, nose, and throat (ENT)] team performed needle aspiration, obtaining approximately 4 cc of purulent material along with a considerable amount of gas. A compression bandage and drain were placed, and empirical antibiotic therapy was initiated with a third-generation cephalosporin and a lincosamide to provide broad coverage, including for methicillin-resistant Staphylococcus aureus (S. aureus) and Gram-negatives (ceftriaxone 2 g every 12 hours and clindamycin 600 mg every 6 hours). Additionally, the patient received a 3-day course of intravenous hydrocortisone and a tetanus booster.

Figure 1 Clinical presentation of right auricular perichondritis with perichondral abscess secondary to transcartilaginous piercing. (A) Lateral view showing significant erythema, edema, and central necrosis over the upper helix area. (B) Posterior-lateral view highlighting diffuse swelling of the pinna and soft tissue distortion involving the helix and antihelix. (C) Oblique anterior view showing marked inflammation with epidermal desquamation and a central area of necrosis at the piercing entry site.

After 3 days of treatment, the edema subsided; however, palpation failed to identify the normal contour of the helix and antihelix, suggesting cartilage loss. Surgical exploration revealed extensive cartilage necrosis involving the helix, scaphoid fossa, and antihelix. Surgical debridement and drainage of the remaining collection were performed, and pledget sutures were placed for auricular support (Figure 2). Culture of the aspirated material identified P. aeruginosa, sensitive to multiple antibiotics, prompting adjustment of the regimen to intravenous cefepime due to its superior anti-pseudomonal efficacy (dose 2 g every 8 hours). The patient completed a 10-day course of inpatient therapy, showed favorable clinical evolution, and was discharged with outpatient follow-up by the otorhinolaryngology service (Figure 3). A graphical timeline of the case evolution is presented in Figure 4. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee(s) of Instituto Roosevelt and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s mother for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 2 Postoperative view of the right auricle following surgical drainage and debridement. (A) Immediate postoperative appearance showing mattress sutures with pledgets (arrow) and persistent edema. (B) Follow-up appearance demonstrating resolving inflammatory changes and maintained auricular contour.

Figure 3 Follow-up of the right auricle after surgical drainage of perichondritis secondary to cartilage piercing. (A,B) Postoperative week 2: resolution of acute inflammation with signs of healing and residual edema. (C,D) Postoperative week 8: complete resolution of the infectious process. Notable residual aesthetic sequelae include deformity of the auricular contour and fibrosis of the helical rim.

Figure 4 Timeline summarizing the clinical course, diagnostic interventions, and treatments of a 14-year-old female with Pseudomonas aeruginosa auricular perichondritis following upper ear cartilage piercing. ENT, ear, node, and throat.

Discussion

We report the case of a 14-year-old female with post-piercing perichondritis complicated by a perichondral abscess and cartilage necrosis caused by Pseudomonas aeruginosa, which required surgical debridement and targeted intravenous antibiotic therapy. Our patient progressed to significant esthetic deformation despite early empirical management, emphasizing the aggressive potential of Pseudomonas-related perichondritis and the need for surgical evaluation when clinical findings suggest cartilage involvement.

This case aligns with and diverges from previously reported cases in key aspects. Perichondritis typically begins 3–4 weeks after piercing with dull pain, erythema, and localized heat. In cases of progressing to perichondral abscess, patients may present fluctuating edema, crepitus, and pus collection, as in our patient (1-3). In contrast to milder cases, abscess-forming perichondritis involves deeper infection with hydrostatic compromise of vascular supply, increasing the risk of necrosis and “cauliflower ear” deformity (5,6). The ears of patients with confirmed infection were pierced with an open piercing gun in the upper ear cartilage, which increases the risk of perichondritis (7). Our patient had her ear pierced with non-sterile instruments and without documented antisepsis, consistent with those risk factors.

The most commonly isolated organism in post-piercing perichondritis is P. aeruginosa, found in up to 87% of cases (3-6). A cohort study conducted in the United States included 118 subjects whose ears had pierced in a commercial shop; 7 presented with P. aeruginosa cartilage infection, and 18 showed signs suggestive of infection, but no microbes could be isolated (8). Other agents include S. aureus, Streptococcus pyogenes, and even viral pathogens. Importantly, S. aureus tends to be more prevalent in cases without abscess formation, which has therapeutic implications (9). For patients allergic to cephalosporins or lincosamides, alternatives include aminoglycosides (e.g., gentamicin), aztreonam, or carefully monitored fluoroquinolones; however, ciprofloxacin use remains controversial in pediatrics due to the risk of cartilage toxicity (10).

What makes this case notable is the rapid evolution to cartilage necrosis requiring surgical intervention after identification of crepitus and fluctuance. Necrosis of the helix and antihelix was confirmed intraoperatively, reinforcing the role of imaging or early otolaryngologic assessment when physical findings suggest deep tissue involvement. While our patient recovered well, she had visible esthetic deformities, underscoring the psychosocial burden that can accompany facial disfigurement in adolescents.

Given the potential for severe complications and esthetic sequelae, a multipronged prevention strategy is critical. For example, standardized evaluation protocols should be implemented in primary care for any patient presenting with symptoms post-piercing. Pediatricians should routinely ask about the hygiene conditions of the piercing site, whether sterile equipment was used, and signs of local inflammation. Prompt referral to ENT specialists is warranted in any suspected case of deep perichondritis or abscess.

In parallel, community-based preventive strategies must be comprehensive. Primary care settings should promote awareness of aseptic techniques among adolescents and parents, emphasizing the importance of choosing certified professionals for body modification. Education on antiseptics is also relevant: while agents like alcohol and benzalkonium chloride are commonly used, P. aeruginosa is resistant to many of them. Iodopovidone has demonstrated superior efficacy and broader antimicrobial coverage and should be recommended prior to piercings (9,10). Educational campaigns, like infographics on infection prevention at body piercing centers, schools, and pediatric offices can help teens identify early warning signs and discourage unregulated piercings. Parental involvement is crucial for monitoring local signs of infection in the days following a piercing.

A major strength of this report lies in its detailed description of the clinical course, including the surgical management and culture-guided antibiotic adjustment, providing valuable insight into therapeutic decision-making in pediatric patients. Additionally, this case highlights the importance of early otorhinolaryngological involvement. Nevertheless, this report also has limitations worth noting, including the retrospective nature of the case description and the lack of detailed documentation about the piercing procedure, such as antiseptic use. Although the clinical evaluation and treatment were timely, early surgical intervention might have prevented further cartilage loss.

Conclusions

Cartilage piercings carry a risk of serious infections such as perichondritis, which, if not promptly recognized and treated, can lead to irreversible cosmetic deformities. This case highlights the importance of early identification, culture-guided antibiotic therapy, and timely surgical evaluation. Primary care providers play a key role in prevention through education about aseptic practices and in early detection by assessing local signs of infection. Multidisciplinary management—especially involving pediatricians and ENT—is essential to minimize complications and ensure better esthetic and psychosocial outcomes for pediatric patients.

Acknowledgments

We would like to thank the Pediatric Infectious Diseases Unit of the Instituto Roosevelt for the strict follow-up of the patient in the clinical case we present.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-22/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-22/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee(s) of Instituto Roosevelt and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s mother for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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