Endgames Case Review

The swollen pinna

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5073 (Published 16 November 2017) Cite this as: BMJ 2017;359:j5073
  1. E Warner, ST3 ENT registrar,,
  2. C Weston, ENT foundation year doctor,,
  3. N Barclay-Klingle, ENT foundation year doctor,,
  4. R Corbridge, consultant ENT surgeon
  1. Royal Berkshire Hospital, Reading, UK
  1. Correspondence to Elinor Warner Elinor.warner{at}nhs.net

A 65 year old man presented to his general practitioner with a one month history of pain and swelling of his left ear. His only comorbidity was a renal transplant 14 years earlier for immunoglobulin A nephropathy. His symptoms started with a small spot in the left external auditory canal and worsened after ear syringing. He was initially treated with two courses of oral antibiotics (co-amoxiclav). His symptoms failed to improve and he was admitted to hospital for intravenous antibiotics (tazocin and framycetin/gramicidin ear drops). On examination, the pinna was erythematous, warm, and swollen, without evidence of a discrete pus collection. Palpation of the neck revealed firm pre and post auricular nodes. He had no joint pains, respiratory, or eye symptoms, and was not diabetic. His inflammatory markers were not raised and he was discharged after 24 hours of intravenous antibiotics. The symptoms persisted and, after a further course of oral antibiotics in the community, he was again admitted (with increasing pain). The pinna was more painful, swollen, and erythematous on this admission (fig 1). He was managed with intravenous antibiotics, microsuction, and insertion of a pope wick. Swabs revealed no growth, and the appearance of the pinna did not improve with antibiotic treatment.

Fig 1 Clinical appearance of the pinna following re-admission to hospital

Questions

  • 1. What are the differential diagnoses?

  • 2. How should you investigate this patient’s symptoms?

  • 3. How will you manage this case?

Answers

1. What are the differential diagnoses?

Short answer

Perichondritis, relapsing perichondritis, necrotising otitis externa, malignancy (eg, Merkel’s cell carcinoma).

Discussion

Perichondritis is an infection of the ear cartilage most commonly caused by Pseudomonas aeruginosa. Infection can occur after …

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