Case Report: Infected ear cartilage piercing

EDITOR’S KEY POINTS.

• Ear cartilage piercing is common and can lead to infection.

• While most of us consider Staphylococcus aureus to be the primary infecting agent, it is not uncommon for cartilaginous ear piercing to become infected with Pseudomonas aeruginosa.

• Ciprofloxacin is considered the drug of choice for infected high ear piercing pending culture and sensitivity; however, the possibility of resistant strains needs to be considered in any infections that do not promptly respond to antibiotics.

• Despite prompt and appropriate treatment, deformities of the cartilage can still appear.

POINTS DE REPÈRE DU RÉDACTEUR.

• De nombreuses personnes se font percer le cartilage de l’oreille, et cela peut entraîner des infections.

• La majorité d’entre nous considèrent que le principal agent infectieux de ces lésions est le Staphylocoque doré, mais il n’est pas rare que le Pseudomonas aeruginosa soit aussi en cause.

• La ciprofloxacine est considérée comme le médicament de choix pour les lésions du piercing du haute de l’oreille, en attendant les résultats de la culture et de la sensibilité; il faut toutefois penser à la possibilité de souches résistantes dans toute infection qui ne répond pas rapidement aux antibiotiques.

• Même avec un traitement rapide et approprié, des déformations du cartilage peuvent survenir.

Ear cartilage piercing is becoming common; hence family physicians will be encountering problems with this fad. It is important that we determine the best approach to deal with infections resulting from ear cartilage piercings. While most of us consider Staphylococcus aureus to be the primary infecting agent, it is not uncommon for cartilaginous ear piercings to become infected with Pseudomonas aeruginosa.¹ Special consideration should be given to these infections to minimize or avoid serious auricular chondritis, which can contribute to deformation of the external ear.

Case description

While in Thailand, a 21-year-old woman had her left upper ear cartilage pierced by a professional piercer. It was done in a sanitary environment in Koh Pha Ngan, Thailand, near the beach of Hat Rin. The ear was swabbed with an unknown solution and local anesthetic was injected with a syringe before piercing. The patient presumed the curved stainless steel needle used to pierce the ear to be sterile because it was removed from packaging. A titanium earring was inserted at the time of the piercing. The patient resumed swimming 1 week after the piercing. She swam in the Gulf of Thailand, just off the coast of Koh Pha Ngan, and then went swimming again in Lac La Ronge, Sask.

Two weeks after the piercing, after the patient swam in Thailand but before she swam in Saskatchewan, the ear became painful. The patient visited a physician in Canada 3 weeks after the piercing, with erythema and purulent discharge. The earring was removed and a 7-day course of cephalexin (500 mg 4 times daily) was prescribed on the presumption that S aureus was the most likely pathogen. A specimen was obtained for culture and susceptibility testing.

Despite these interventions, the discomfort in the left ear intensified. Yet the patient remained afebrile and the erythema had not increased. She was reassessed on an urgent basis 2 days after the initial visit. On examination a serosanguineous discharge was noted despite no obvious abscess and no cervical lymphadenopathy. The ear was exquisitely tender to palpation. A preliminary report revealed Gram-negative bacilli; levofloxacin (500 mg daily) was prescribed in addition to the cephalexin. Pseudomonas aeruginosa was subsequently identified and found to be sensitive to ciprofloxacin, ceftazidime, gentamicin, piperacillin, and tobramycin. The patient was informed of the culture results and ciprofloxacin (500 mg twice daily) was substituted for the levofloxacin even though her condition had improved. Five days after the previous visit and 3.5 days after having received ciprofloxacin, the erythema in the left ear had decreased; however, localized swelling was noted on the medial aspect of the left ear. Local incision and drainage was attempted, but only blood-tinged serous fluid with a small amount of pus was obtained; the swelling remained.

Concern about the viability of the underlying cartilage was raised, and specialists in infectious disease and otolaryngology were consulted. After débridement, the ear was splinted with gauze sewn onto the cartilage to appose the skin to the cartilage. When the patient was reevaluated 1 week later, the splint was removed. The ear was no longer erythematous and healed without serious deformity. The patient received ciprofloxacin for 17 days.

Discussion

A PubMed literature review spanning 1992 to 2004 with no limitations and using the search terms auricular cartilage piercing produced 15 articles. Ovid MEDLINE from 1966 to August 2005 was also searched using the search terms ear piercing, ear cartilages, infection control, infection, wound infection, surgical wound infection, and methicillin-resistant S aureus. Skin and soft tissue infections of the ear have been documented after piercing. The most common pathogens are S aureus and P aeruginosa in high piercing of the ear involving the cartilage.^1,2

Many factors contribute to P aeruginosa infections. Swimming in lakes or stagnant water can increase the risk of Pseudomonas species contamination,¹ and contaminated water used to clean or disinfect the ear can contribute to infections.² A disinfectant contaminated with P aeruginosa was reported as one contributing cause of an outbreak of infected ear cartilage piercings,² and contaminated benzalkonium chloride has been a source of Pseudomonas species infection in hospitals.^3,4 The technique used to pierce the ear can also cause problems. Some piercing guns cause trauma and predispose to infection; these should be avoided.^1,2 One literature review and survey of ear-piercing businesses recommended that benzalkonium chloride should never be used as an antiseptic preparation and that the ear should be scrubbed multiple times with either an ethyl or isopropyl alcohol (70%) solution or an iodine solution.⁵ To minimize problems, Health Canada developed guidelines for personal services, including piercing and tattooing; they suggest using iodine or a 70% alcohol solution on the skin as an antiseptic.⁶

Ciprofloxacin is the drug of choice for piercing-related infections of the high ear, pending culture and sensitivity testing.^7,8 Ciprofloxacin is active against S aureus; unfortunately the incidence of cases infected with resistant pathogens is unknown. One retrospective study at an army community hospital in the United States found the incidence of methicillin-resistant S aureus increased from 12% to 43% between 1998 and 2004.⁹ Of these infections, 14% were resistant to ciprofloxacin. Another study in Australian teaching hospitals demonstrated an increase in resistance to ciprofloxacin among methicillin-resistant S aureus of 4.9% to 75.9% between 1989 and 1999.¹⁰ Thus the possibility of resistant strains needs to be considered if any infections do not promptly respond to antibiotics.

Infections with P aeruginosa have been said to occur within 2 to 4 weeks of piercing.^1,2,7 Exquisite tenderness upon flexing the cartilage has been described and is thought to be caused by inflammation of the perichondrium. Less pain is associated with more superficial infections that involve only the skin.¹ Unfortunately it is not uncommon to develop deformities of the cartilage, or “cauliflower ear,” after infections involving the cartilage.^1,2,7 Aggressive treatment is required to preserve the cartilage. Despite prompt incision, drainage, and splinting, some deformity could still occur.⁷

Conclusion

Ear cartilage piercing is popular, and the site can become infected with S aureus and P aeruginosa. Infections generally manifest within 2 to 4 weeks of piercing. Exquisite tenderness is often associated with infections involving the cartilage. Treatment should include removing the foreign body (earring), submitting a swab of the infected site for culture and sensitivity, and using an antibiotic, such as ciprofloxacin, that is effective against S aureus and P aeruginosa. The ear should be monitored for abscess development, and if an abscess appears, débridement is appropriate. Despite prompt and appropriate treatment, deformities of the cartilage can still occur.

Biographies

Dr Manca practises at the Grey Nuns Family Medicine Centre, is an Assistant Professor in the Department of Family Medicine at the University of Alberta, and is Clinical Director of the Alberta Family Practice Research Network in Edmonton.

Dr Levy practises at the Grey Nuns Family Medicine Centre and is an Assistant Professor in the Department of Family Medicine at the University of Alberta.

Dr Tariq is an international medical graduate who practised medicine in Pakistan before moving to Canada. She is a first-year family medicine resident at the Grey Nuns Family Medicine Centre.