Perichondritis as an Associated Complication Affecting the Surgical Outcome of Interpositional Arthroplasty: A Case Report

Perichondritis is a distressing complication of external ear leading to secondary deformity [1, 2]. Most common etiology stated for this condition is repeated trauma or penetrating injury to auricular cartilage [3]. It might also occur as a result of spread of infection from nearby foci [4]. The pinna has lesser soft tissue adherent to the underlying avascular cartilage, making it more vulnerable to necrosis [5]. Affected ear has been termed as “cauliflower ear” [6]. Perichondritis is most commonly seen following direct injury to auricle or chronic ear infection, uncommonly seen associated with TMJ surgeries. This condition adversely affects younger age group for whom it may be of concern due to cosmetic outcome [7]. The purpose of this paper is to highlight the possibility of such condition following interpositional arthroplasty of temporomandibular joint. It requires particular attention if encountered [5].

Case Report

A 22-year-old male patient was referred to maxillofacial surgery clinics with complaint of inability to open mouth since 19 months. Gradually, over the period of 11 months, his mouth opening reduced significantly and reached almost nil. Based on history, clinical examination and computed tomographic scans, diagnosis of post-traumatic right side TMJ ankylosis was made (Fig. 1). Patient was planned for gap arthroplasty followed by temporalis muscle interposition. Standard modified Al-Kayat Bramley incision was used for joint exposure. Planned surgery was carried out. Intra-op mouth opening of 39 mm was achieved. Postoperative physiotherapy was started and patient was discharged on the fourth post-op day. Patient reported back for follow-up after 1 week with mouth opening of 38 mm. After 2 weeks, patient again reported with reduced passive mouth opening of 32 mm and swelling on the external ear associated with pain (Fig. 2). Swelling was fluctuant, erythematous and tender. Patient has voluntarily restricted mouth opening due to pain, but active mouth opening was still 35 mm. Surgical wound site was healthy. Based on the above findings and ENT consultation, diagnosis of auricular perichondritis was made and planned for incision and drainage under antibiotic coverage. Cartilage destruction of around 0.5 cm was noted (Fig. 3). Culture and sensitivity reports revealed Pseudomonas species sensitive to cefuroxime and ciprofloxacin. Injection of cefuroxime plus sulbactam 1.5 gm IV was started twice a day. Patient was reviewed after 3 days, antibiotics were continued for 1 week, and swelling was subsided.

Fig. 1.

Computed tomography (coronal section) showing TMJ ankylosis right side

Fig. 2.

Perichondrial abscess in right auricle

Fig. 3.

Mild defect after abscess drainage

Discussion

Perichondrial infection of pinna is related to major morbidity that can cause potential long-term cosmetic deformity [8]. Perichondritis has varied etiologies and predisposing events. Previous studies revealed multiple factors responsible for its occurrence like iatrogenic trauma, burns, piercing and acupuncture, chronic otitis media, insect bites, etc. [2]. In a case reported by Al-Zahrani et al. [5], female patient suffered from severe postoperative wound infection, leading to auricular perichondritis after TMJ gap arthroplasty. In our case when patient presented with perichondritis after 2 weeks of surgery, we presumed it to be due to cartilage injury during arthroplasty.

Pathophysiology suggested behind this rare occurrence was inadvertent injury to the cartilaginous anterior wall of the meatus. This resulted due to deep posterior dissection in preauricular approach and severing anterior wall of meatus, making it prone to infection [9]. This, if infected, leads to rapid necrosis of avascular cartilage, resulting in considerable morbidity and severe deformity of the ear. Pseudomonas aeruginosa is implicated as the major pathogen of perichondritis, but can be polymicrobial [10]. In advanced cases, treatment suggested is incision and drainage, prolonged hospitalization and intravenous administration of antibiotic and deformity correction in later stages.

In the present case, as the diagnosis was prompt followed by immediate drainage with proper antibiotic support, the resultant cartilage loss was fortunately insignificant to cause aesthetic deformity as noted in another case report stated previously [5, 6].

Conclusion

It is a rare clinical situation especially after TMJ surgery, if standard surgical procedure is not followed. It is advisable that patient should be kept on regular follow-up and to be reinforced about the postoperative wound care and mouth opening exercises. In our case, patient has stopped mouth opening exercises due to auricular infection, which is the most important postoperative aspect. The prognosis of auricular perichondritis varies according to the stage of disease. An attempt must be made to preserve cartilage, since the final outcome depends on the extent of cartilage damage.

Funding

No source of funding.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed written consent was obtained from the patient. Additional consent was obtained from the patient for whom identifying information is included in this article.