Aural Perichondritis Following an Unexpected Cause

Retained foreign body has been a malady to many physicians including Otorhinolaryngologist. This case report emphasizes the importance of awareness of the complications following a retained ear wick as prolonged insertion may lead to devastating outcome, as in our case perichondritis which if not detected early may have led to cartilage necrosis. We report a rare case of pinna perichondritis following a retained ear wick. The unfortunate patient was unaware of the ear wick and visited several different clinics for non-resolving ear infection. We would like to highlight the importance of awareness of the devastating complication of a retained or forgotten ear wick.


INTRODUCTION
Aural perichondritis is a common complication of a traumatised ear. The term perichondritis is considered a misnomer as the auricular cartilage is almost always involved (1). Herein, we are reporting a rare case of auricular perichondritis following a retained ear wick. Albeit a common condition, managing such cases remains a conundrum due to the possibility of a devastating outcome.

CASE REPORT
A 75-year-old male was referred to the ORL department, Hospital Selayang with left-sided otorrhea for the past 1 month. According to the patient the otorrhea was accompanied with left otalgia and pinna swelling. Further history revealed that the patient was treated by a private clinic physician 1month ago and the symptoms worsen. Apart from that, he had no facial asymmetry, no reduced hearing, tinnitus or vertigo. There was no fever or any recurrent nasal symptoms.
Upon examination, patient was comfortable, not septic looking and afebrile. Left pinna was swollen, tender, inflamed with excoriation and pus discharge seen from the external auditory meatus (Figure 1). Pinna was however not pushed medially. There was no mastoid swelling or tenderness. Otoscopic examination was not possible as the ear canal was filled with pus. Facial nerve examination was normal. Right pinna and ear canal examination was normal with an intact tympanic membrane. Oropharynx examination was unremarkable and neck nodes were not palpable. Nasoendoscopy examination was normal. All other cranial nerves were intact and no other neurological deficit was evident. Systemic examination was normal. Tuning fork test revealed left conductive hearing loss. Full blood count and electrolytes were within normal range. Examination under microscopy revealed a whitish mass embedded deeply between the narrowed ear canal which upon removal was found to be an otowick which after further investigation was noted to be inserted by the private clinic physician 1 month ago. The tympanic membrane was normal.
Patient was admitted at once and intravenous antibiotics were commenced along with daily aural toileting. Patient was discharged home after 1 week and was given an appointment upon which complete resolution of symptoms were noted (Figure 2).

DISCUSSION
Auricle perichondritis albeit a common condition may lead to devastating complication if not treated promptly. Most common factor leading to this condition includes pinna hematoma following blunt injury, penetrating injury including ear-piercing, mastoid surgery, ear infection and also as a result of burn injury have been reported. Our patient as described above developed perichondritis following retained ear wick. Having said that, perichondritis of the ear following retained ear wick although is unheard of has been reported prior to this (2).
Ear wick insertion is commonly done as a part of treatment of otitis externa and as a part of dressing post middle ear surgery (3). Dry ear wick is usually inserted under direct vision which subsequently expands after ear drops instillation (4). The ear wick serves as a reservoir of medication allowing prolonged contact with the diseased ear canal, exercises pressure on the swollen ear canal which concurrently allows distribution of medication throughout its contact (4). As for the medication to be instilled into the ear wick, multiple preparations including antibiotics, antifungal, steroid and astringent can be used (5).
As for the duration of ear wick insertion, it usually is removed within 3-5 days in the clinic setting so that re-evaluation and aural toileting can be done if indicated. Patients ought to be advised by the attending physician to return for removal of ear wick as ignorance and failure of removal may lead to calamity as pinna necrosis. As in our case, patient was not advised to return for a recheck and removal of ear wick by the physician which lead to perichondritis of the pinna.