Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Ciprofloxacin for empiric therapy of presumed S. aureus infection
- Martin Cormican (13 April 2001)
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"High" ear piercing and the rising incidence of perichondritis of the pinna
- Stephen E Kent (11 May 2001)
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Cauliflower ear and keloid scars
- Philip Gilbert (15 May 2001)
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Cauliflower ear pathogenesis
- Silvia Cicchetti (2 August 2001)
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Martin Cormican, Professor of Bacteriology/Consultant Microbiologist NUI, Galway and UCH, Galway Ireland
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I found this paper by Haniff and colleagues very valuable but have some reservation about the use of ciprofloxacin alone for empirical therapy of infection in which S. aureus is considered a likely pathogen. While I accept that most strains of S. aureus are susceptible to ciprofloxacin in vitro (with an MIC 90 of the order of 0.5ug/ml)I believe that there is much greater clinical experience of efficacy with the penicillinase resistant penicillins such as cloxacillin and flucloxacillin. In a site in which rapid control of infection is critical and blood supply may be limmited I believe it may be preferrable to include an anti-staphylococcal penicillin from the outset with possible subsequent modification based on results obtained on microbiological examination of tissue or pus removed at surgery. |
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Stephen E Kent, Consultant Otolaryngologist Warrington Hospital NHS Trust
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Dear Sir Hanif et al highlight the rising incidence of perichondritis of the pinna after "high" ear piercing (1). Our own experience adds further information. We found an incidence of ten cases over the period of July 1998 to October 1999 in a population of 320,000. Nine patients were female, one male and all were under twenty years of age. The auricular abscess took two to four weeks to develop after "high" ear piercing. On aerobic culture six cases grew pseudomonas aeruginosa and four cases were sterile. Inappropriate antibiotics were prescribed by General Practitioners, the most popular being Flucloxacillin (four cases) and Erythromycin (two cases). We agree with Hanif et al (1) that this is a case where Ciprofloxacin is the antibiotic of choice in children despite reports of quinolone causing arthropathy in weight bearing joints of immature animals (2). Our enquiries at local beauty salons etc found a sterile prepacked "gun" designed for piercing the lobule is used for "high" ear piercing. This is inappropriate as the "piston" crushes the auricular cartilage allowing subsequent infection with pseudomonas. We have found that spiration of incision and drainage alone is not adequate treatment. Incision, drainage and splinting as described by Nahl et al (3) for auricular haematomata is required. Although Hanif et al (1) state that no statutory regulations exist on body piercing, the Vocational Training Charitable Trust produce an Industry Code of Practice for Hygiene in salons and clinics and there is a Local Government Act 1982 covering byelaws for the business of ear piercing. We have argued that Local Authorities should require persons performing "high" ear piercing to warn customers of the possibility of abscess formation and the resulting permanent deformity of the auricle. Stephen E Kent MB ChB(Hons) FRCS(Otol) Eng
Ashok V Rokade MS FRCS DLO
Koppada Premraj MS DLO
Christine Butcher RGN
(1) 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: 906-907 (2) British National Formulary March 2000: 39: 280 (3) Nahl SS, Kent SE, Curry AR. Treatment of auricular haematoma by silicone rubber splints. J. Laryngol Otol 1989; 103: 1146-1149 THERE IS NO COMPETING INTEREST |
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Philip Gilbert, consultant plastic surgeon & burns unit director Queen Victoria Hospital, East Grinstead
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Dear Sir, We read with interest the article by Hanif et al. (1) highlighting the problems of high ear piercing and the rising incidence of perichondritis of the pinna. We would like however to raise the following issues. Cauliflower ear caused by trauma or infection occurs because the cartilage splits creating a space between the layers of perichondrium, which then heals by fibrosis and distortion.(2) It would seem logical to treat the infected ear in the same way as the severely traumatized ear if a cauliflower ear deformity is to be avoided. This necessitates removal of a full thickness window of cartilage to allow adequate drainage. Case 3 I in Hanif et al. report also caused us considerable concern as the ear is a common site for development of keloid scars. From the illustration the swellings on this patient’s ear are most likely to be keloids. Direct excision of these lesions can result in a cociderable worsening of the condition rather than an improvement so before such surgery is undertaken there needs to be a full discussion with the patient regarding the possibility of an adverse result. Ali Pirayesh Philip Gilbert Department of Plastic & Reconstructive Surgery,
The Queen Victoria Hospital,
Holtye Road , East Grinstead,
West Sussex RH19 3 DZ
1 Hanif J, Frosh A, Marnane C, Ghufoor K, Rivron R, Sandhu S. “High “ ear piercing and the rising incidence of perichondritis of the pinna. BMJ 2001;322:906-7 2 Davis P.K.B.. An operation for haematoma auris. BJPS 1971;24:277. |
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Silvia Cicchetti, Resident in Plastic and Reconstructive Surgery Cattedra di Chirurgia Plastica e Ricostruttiva- Università degli Studi- Genova- Italy
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Dear Sirs, I have read with much interest your article entitled "High ear piercing and the rising incidence of perichondritis of the pinna", published on the 14th April 2001 issue of BMJ. Ear piercing is indeed an increasingly popular fashion and early treatment of complications is of great importance, in order to prevent serious deformities. Chondritis and perichondritis cause destruction of the cartilagineous pinna, leaving the ear with a crumpled appearance. However, the resultant deformity cannot be termed "cauliflower ear", which is rather caused by a subperichondrial hematoma: this is progressively invaded by condroblasts, giving rise to a new tissue which changes into more mature cartilage. The separated perichondrium retracts and the original cartilage buckles over the hematic collection(1). Auricular hematomas and, consequently, cauliflower ears are very common among wrestlers, are usually recurrent and may cause significant pain and discomfort to patients. Early intervention in such cases is strongly advocated. Treatment options range from simple aspiration and the use of a compression bandage, to total excision of the new fibroneocartilage(2- 4). Ear deformities after upper ear piercing can be so psychologically distressing, especially for the youngs, to require a demanding reconstruction, which is still possible with the use of autologous costal cartilage (5). 1. Ohlsen L, Skoog T, Sohn SA. The pathogenesis of cauliflower ear. An experimental study in rabbits. Scand J Plast Reconstr Surg 1975; 9 (1): 34- 39. 2. Giffin CS. Wrestler's ear: pathophysiology and treatment. Ann Plast Surg 1992; 28 (2): 131- 139. 3.Gross CG. Treating "cauliflower ear" with silicone mold. Am J Sports Med 1978; 6 (1): 4- 5. 4. Vogelin E, Grobbelaar AO, Chana JS, Gault DT. Surgical correction of the cauliflower ear. Br J Plast Surg 1998; 51 (5): 359- 362. 5. Harris PA, Ladhani K, Das- Gupta R, Gault DT. Reconstruction of acquired sub- total ear defects with autologous costal cartilage. Br J plast Surg 1999; 52 (4): 268- 275. |
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