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ORIGINAL ARTICLE
Post-piercing Perichondritis of Pinna - Our Experience at
Lyari General Hospital, Karachi
Ismail Hirani, Ashok Kumar, M. Shuja Farrukh, Ashfaque Ahmed Shaikh, Shaheen Malik

Shaheed Mohtarma
Benazir Bhutto Medical
College, Lyari, Karachi
I Hirani
A Kumar
AA Shaikh
Dow University of Health
Sciences, Karachi.
MS Farrukh
Baqai Medical University,
Karachi.
S Malik
Correspondence:
Dr. Ismail Hirani
Associate Professor of
ENT Head & Neck
Surgery, Shaheed
Mohtarma Benazir Bhutto
Medical College Lyari,
Karachi.
Email: Ismail_hirani@
hotmail.com
Cell: 0333-3355882

Abstract:
Objective: To determine cosmetic results of auricle after different modes of treatment in
post-piercing perichondritis.
Study Design: Descriptive, prospective and interventional study.
Place and Duration of Study: This study was conducted at E.N.T department of Shaheed
Mohtarma Benazir Bhutto Medical College & Lyari General Hospital, Karachi which include
large number of Baloch population of District West where ear piercing is the most common
custom. The duration of study was 3 years from Jan, 2010 to Dec, 2012.
Subject and Method: It is study of 56 patients who visited in our department with the history
of post-piercing perichondritis / abscess, including their demographic details, along with
complete medical history. All patient with Post piercing perichondritis of pinna were managed
either conservatively or surgically by incision drainage with placement of drain or with placement of splints.
Results: Out of 56 patients, 52 were female with common age group were between 18-30years.
Commonest lesion was post-piercing perichondritis, cellulitis, fluid draining from lesions. In
15 patients we perform incision and drainage and removal of necrotic tissue and placement of
drain tube and another 15 patients after incision and drainage and removal of Necrotic tissue
we placed splints on both sides of pinna. we found good cosmetic results of the patients with
placement of splints.
Conclusion: Ear piercing by an authorized and trained personal with all aseptic measures is
essential for prevention of this complication. Avoid high ear piercing as it causes more complication as compare to lobule piercing. Use of drip bottle pieces as splints after incision and
drainage provide better cosmetic result as compare to simple incision and drainage only.
Keywords: Ear piercing, perichondritis, perichondritic abscess
Introduction:
The custom of ear piercing not new, it was found
in oldest mummy (around at 5,300 years old) in
also documented in the Holy Bible1. Multiple
ear piercing becomes very much popular especially in our Baloch population living in district
West of Karachi. Perichondritis is very common
in high piercing which require puncture through
the cartilage and they can even occur due to
blunt trauma, laceration, insect bite and other
infection.
Infection of auricle results in auricular perichon-

dritis. Cartilage of auricle is covered by a thin

layer of tissue around it called perichondrium.
This covering provides nutrients to the cartilage
but the sub periosteal abscess associated with
perichondritis often leads to loss of cartilage and
to an unsightly deformity known as cauliflower
ear2, which has poor chance of good reconstruction. This complication is usually seen in trans
cartilaginous ear piercing. The aggressive management is desirable at the earliest stage to prevent complication. The most common organism
found is pseudomonas aeruginosa followed by
staphylococcus, streptococcus and methicilPak J Surg 2013; 29(2):105-109

Post-piercing Perichondritis of Pinna - Our Experience at Lyari General Hospital, Karachi

lin resistant S. aureus. The majority of piercing

are performed by non-medical practitioners,
such as jewelers, beauty parlor and community
professional persons etc. Low literacy rate and
socioeconomic status lead to this ear piercing
from the areas where these practitioners have no
idea of complication of cartilage damage resulting from high piercing and non sterilized techniques. The use of ear ring devoid of nickel may
be less irritating3.
A painful red ear is the most common symptom
initially looks like as skin infection (cellulitis)
but rapidly progress to involve perichondrium
(Figure 1), and redness usually surrounds the
site of piercing. There may also be fever, changes
in the normal shape of ear, or it may look swollen or fluid draining from wound.
Treatment consists of antibiotic either oral or intravenous. If there is trapped collection of secretion or pus, surgery may be necessary to drain
the fluid and remove any dead skin or cartilage.
Patients and Methods:
This is a descriptive, prospective and interventional community based study conducted at
E.N.T department of SMBBMC & Lyari General Hospital, Karachi, during January 2010 to December 2012. This hospital is located at district
West of Karachi having a large population of
Baloch community heaving common tradition
of the ear piercing especially multiple high ear
piercing. We include all the cases of post piercing auricle infection and we excluded the case
of post traumatic, skin allergy and herpes zoster
type of lesion.

Figure 1: (a)Skin infection (cellulitis) involving perichondrium; (b) Lesion excised; (c) Postoperative appearance
Pak J Surg 2013; 29(2): 105-109

106
It is the study of 56 patients who were visited
our department with the history of post-piercing perichondritis/abscess included in this
study along with there demographic detail, and
complete medical history.
Results:
Total no. of patients were 56 out of which
52(92.85%) patients were female and 04(7.15%)
were male (Figure 2). Male female ratios were
13:1. Age ranges from 12-42 years with commonest age group between 18-30 years. Commonest lesion were post-piercing perichondritis/cellulitis/ fluid draining from wound found
in 26 patients & perichondrial abscess in 30
patients (Figure 3). Out of this we perform incision and drainage and removing necrotic tissue
and place drainage tube in 15 patients. Incision
and drainage + removal of necrotic tissue and
stitching drip sets splints on both sides of pinna,
where the skin is intact done in 15 patients (Figure 4). The surgical procedures in both groups
were performed in operation theater with all
aseptic measures under general anesthesia. Patients with the history of diabetes mellitus or
immuno-compromised were excluded from this
study. We were able to send pus for culture and
sensitivity in only 27 patients due to financial
and other reasons and found pseudomonas aeruginosa the commonest organism followed by
staph aureus.
We divided the patients in three groups. In group
A we included those patients who have postpiercing perichondritis/cellulitis/fluid draining
from wound, number of cases in this group were
26. In group B we included those patients who
presented with perichondrial abscess in whom
we performed incision and drainage, removable
of necrotic tissue and we placed draining tube.
In this group numbers of patients were 15. In
group C we included those patients who have
perichondrial abscess and where we performed
incision and drainage, removal of necrotic tissue
and then we place splint made of plastic drip to
the both sides of helix. Both surgically treated
patients were kept in close follow up and remove
drainage tube around 5 days and splint around
10 days as per condition of wound.

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I Hirani, A Kumar, MS Farrukh, AA Shaikh, S Malik

7.15%

35

Female

30

31

30

Male

25

25

47%

25
20

20

15

15

26.5%

26.5%

I/D with drainage

tube placement

I/D with
splint placement

10

10

92.85%

5
0

Figure 2: Gender Distribution n=56

Cellulitis

Perichondrial abscess

Figure 3: Disease Pattern

In group A patients who were presented to us

with auricular perichondritis/cellulitis or fluid
draining from the site of wound were managed
conservatively either as out patient or in patient
with oral or injectable antibiotic usually 3rd generation cephalosporins or quinolones, most of
these patients improve with medical treatment
the cosmetic result of auricle were acceptable.
In Group B patients who were treated by incision and drainage + removal of necrotic tissue
and placement of drainage tube, in our observation 09 patients develop seroma/haematoma
and due to residual infection could not achieve
acceptable cosmetic results, where 6 patients
have un-eventful and acceptable recovery.
In group C who were treated by incision and
drainage + removal of necrotic tissue and placement of plastic drip set splints have good cosmetic results in 11 patients and while 04 patients
have unacceptable cosmetic results.
Discussion:
Ear Piercing is an established fashion and cultural tradition of all contemporary or primitive
society. In our country it is especially very common in our Baloch population of district West
of Karachi. In last many years multiple piercing
in the many parts of body increasing particularly
multiple high piercing of auricle is also markedly
increased. This is especially true in developed
countries where up to 51% of general population may have body piercing4 and the number
of individuals with piercing continues to rise5. It
is particular common in adolescents. Sexual behaviors, Sadism, Cosmetics, Mysticism or pure
rebelliousness are some of the reasons given by
people who have piercing implant in their bod-

Conservative

Figure 4: Treatment offered to the Patients

ies6. Infection is among the most commonly reported complication of ear piercing occurring in
up to 35% of cases7.
In our study males were (7.15%) and female
(92.85%) and male: female were 13:1 and age
group ranges from 12-42 years with common
age group between 18 to 30 years. In literature
mean age from 20-41 years8.
It usually happens in warm months when body
sweating is excessive, impairing healing and pre
disposing the site to infection. Where air moisture and skin moisture faster the proliferation of
the most common causative agents. This risk of
developing an infection is higher in the ear cartilage than it is in the ear lobe 9, Same Observation
seen in our study.
The available literature also Suggest that the increased prevalence of high ear piercing has led
to an increased risk of morbidity associated with
these piercing including higher incidences of
auricular perichondritis, abscess formation and
cosmetic deformity10.
Anatomic variation such as blood Supply to the
site can contribute to an increased risk of infection after piercing. While piercing sites in the ear
lobe heal in approximately six weeks11, cartilage
and tragus piercing can take up to one year to
heal12.
The cosmetic sequelae such as Cauliflower ear
may be considerable. A case of endotoxic shock
arising from ear piercing has been reported13,
several other reports of complication after high
cartilaginous piercing have been published14.

Pak J Surg 2013; 29(2): 105-109

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Post-piercing Perichondritis of Pinna - Our Experience at Lyari General Hospital, Karachi

Ear have been pierced for hundreds of years now

and the literature have always reported ear lobe
complication caused by staphylococcus aureus
infection The first twist case of pseudomonas
causing perichondritis was described about 15
years ago, which reflect this new trend among
young people15. In our study the most common
organism is also pseudomonas aeruginosa, it
is also most common organism isolated in the
large serious of 114 cases from Haifa Israel. In
our study commonest lesion was post-piercing
perichondritis, cellulitis, fluid draining from the
wound was found in 26 patients, the literature
review also shows the same results16.
30 patients were presented with perichondrial
abscess, out of this we perform incision and
drainage and removing of necrotic tissue and
place drainage tube for around 05 days as per requirement in 15 cases. This procedure is usually
practice in many centers in the World and they
claim better cosmetic results.
In our study along with this procedure of incision and drainage and removing of necrotic
tissue, we use plastic drip bottle and cut it according to helix shape and stitched to its both
ventral and dorsal surfaces. In 15 cases, we used
incision and drainage and removed the necrotic
debris and used piece of dripset bottle as splint
for support, although number of cases in our
study is less but when we compare our results of
group B and group C we found that the use of
splint after incision and drainage and removal of
necrotic debris give more better cosmetic result
as compare to simple incision and drainage and
removal of necrotic tissue and drain placement.
Multi centre large study will give us better idea
of cosmetic result after the use of this type of
splint.
Prevention is key in terms of piercing site infection and anatomic issues should be discussed
with the patients for high ear piercing. Also only
trained professionals who are more likely to be
aware of risk factor should perform ear piercing
and in particular high ear piercing.
Piercing guns should be avoided especially for
Pak J Surg 2013; 29(2): 105-109

cartilaginous piercings17; it is thought to be related to additional blunt trauma and the associated shear forces deleterious to the perichondrium and the blood supply of the cartilage18.
Further more due to documented season element to infection risk, ear piercing should be
avoided in summer months. Finally importance
of after care should be stressed, such as touching
the jewellary only when necessary and only after
thoroughly washing their hands.
Conclusion:
Ear piercing by an authorized and trained personal with all aseptic measures are essential for
prevention of this complication. Avoid high ear
piercing as it causes more complication as compare to lobule piercing. Use of drip bottle pieces
as splints after incision and drainage provide
better cosmetic result as compare to simple incision and drainage only.
References:
1. Marie Lyons, Joanna Stephens, Joseph Wasson. High ear-piercing: an increasingly popular procedure with serious complication. Is good Clinical practice exercised? Eur Arch Otorhinolaryngol, 2012; 269: 1041-1045.
2. Hanif J, Frosh A, Marnane C, et al. Lessons of the Week: High
ear piercing and the rising incidence of perichondritis of the
pinna. BMJ, 2001; 322: 906-7.
3. M. Umar Farooq, M. Ahsan Ansari, M. Jameel Bhojani. A comparative study in the management of perichondritis auricle: a
prospective study of 28 cases at Lyari General Hospital Karachi. Medical Channel, Jan- March 2008, Vol.14, No.1: 48-51.
4. Antoszewski B, Szychta P, Fijalkowska M. Are we aware of all
complications following body piercing procedures? Int J Dermatol, 2009; 48(4): 422-5.
5. Mayers LB, Judelson DA, Moriarty BW, Rundell, KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications.
Mayo Clinic Proc, 2002; 77: 29-34.
6. Andre de Paula Fernandaz, Ivan de Castro Neto, Christiane Ribeiro Anias. Case report-post-piercing perichondritis. Brazilian Journal of Otorhino[aryngology, 2008:74(6): 933-7.
7. Stirn A. Body piercing: Medical consequences and psychological motivations. Lancet, 2003; 361(9364): 1205-15.
8. Davidi E, Paz A, Duchman H. Perichondritis of the auricle:
Analysis of 114 Cases, IMAJ, Vol- 13 January 2011: 21-24.
9. Keene WE, Markum AC, Samadpour M. Outbreak of pseudomonas aeruginosa infections caused by commercial piercing
of upper ear cartilage. JAMA, 2004; 29: 981-5.
10. Fernandez A de P, Castro Neto I, Anias CR, et al. Post-piercing
perichondritis. Rev Bras Otorrinolaringol, 2008; 74(6): 933-7.
11. Meltzer D. Complications of body piercing. Am Fam Physician,
2005; 72(10): 2029-34.
12. Gunter T, McDowell B. Body piercing: issues in adolescent
health. J Spec Pediatr Nurs, 2004; 9(2): 67-9.
13. McCarthy VP, Peoples WM. Toxic shock syndrome after ear
piercing. Pediatr Infect Dis J, 1988: 7: 741-2.
14. Turkeltaub SH, Habal MB. Acute pseudomonas chondritis as a
sequel to ear piercing. Ann Plast Surg, 1990: 24: 279-82.
15. Hanif J, Frosh A, Marnane C, et al. Lessons of the Week: High

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I Hirani, A Kumar, MS Farrukh, AA Shaikh, S Malik

ear piercing and the rising incidence of perichondritis of the
pinna. BMJ, 2001; 322: 906-7.
16. Cicchetti S, Skillman J, Gault DT. Piercing the upper ear: a
simple infection, a difficult reconstruction. Br J Plast Surg,
2002; 55(3): 194-7.
17. Keene WE, Markum AC, Samadpour M. Outbreak of pseudo-

monas aeruginosa infections caused by commercial piercing

of upper ear cartilage. J Am Med Assoc, 2004; 291(8): 981-5.
18. Folz BJ, Lippert BM, Keulkens C, Werner JA. Hazards of piercing and facial body art: a report of three patients and literature review. Ann Plast Surg, 2000; 45(4): 374-81.

Pak J Surg 2013; 29(2): 105-109