The Frequency of Underlying Causes and Required Surgical Interventions in Patients withExternal Ear Chondritis in south west of Iran

Perichondritis is acute inflammation of the skin and perichondrium, but the changes do not proceed beyond the ear cartilage border. In case of cartilage involvement, chondritis will occur. Clinical signs include severe pain, discharge, erythema, swelling and tenderness. Previous surgical manipulation of the ear, diabetes, and burns are the most important underlying etiologies of this disease. If not treated properly, permanent destruction of cartilage and deformity of the ear is created. This study was designed to study the disease thoroughly in relation to its epidemiologic situation. This retrospective chart review of patients with external ear chondritis, referring to ear, nose, and throat (ENT) ward of Imam Khomeini hospital, Ahvaz, during the years 2002 to 2013was conducted through a checklist. The information included epidemiologic and treatment data of 130 patients suffering fromchondritis. The mean age of patients was 29.8 years. 66.2% were male and 33.8% were female. History of previous surgery was the most common etiology with 52.3% and 53.8% of patients needed surgery during hospitalization. The mean duration of hospitalization was almost 10 days. The most common antibiotic prescribed was ceftazidime in 84.6% of patients. This disease has a significant association with age and sex of the patients. There is also a significant association between underlying etiologies and external earchondritis. More than half of patients required surgical intervention during hospitalization.


INTRODUCTION
Perichondritis is acute inflammation of the skin and perichondrium that involves the cartilage of the ear stems.The changes are limitedand do not proceed beyond the ear cartilage border.In case of cartilage involvement, chondritis will occur 1 .Earhas a very special anatomy and its skin is directly connected to perichondrium and the cartilage is very vulnerable to injuries 6,16,17 .Common organisms include Staphylococcus aureus and Pseudomonasstrains.Less common causes of poisoning includetoxic allergic or autoimmune causes 1 .In cases of blunt trauma, a hematoma can be formed in the external surface of the ear in the beginning due to infection, such as wrestlers.
Penetrating trauma may be due to different injuries, including ear piercing, needle, bites, wounds without a reason (unknown), thermal or chemical burns, and after some surgeries (Mastoidectomy).Diabetes andexternal otitis are among other predisposing factors for this disease [5][6][7][8][15][16][17] 5,9 .Epidemiologic studies on the diagnosis and treatment of diseases and management strategies play the prime rolethat lead to accomplishing age, gender, ethnic, economic, and cultural patterns of the disease in the region andfocuses the mindsonspecifictarget groupsin order toreducedisability andeconomic coststhrough adetailedplanfor screening, diagnosis,and early treatment. Regardingthe fact that external ear chondritis is considered a disease with high physical complications and that the ear is the second prominent organ in the face after the nose, it is more susceptible to damage and regarding the cartilage structure of the ear, chondritis can cause deformity by the mentioned underlying causes and due to the special ring structure of cartilage and its being doubled,concordance and symmetry between both organs should be preserved, which makes the remedy difficult 10 .
Thus, the importance of this issue has provoked us to assess the frequency, etiologies and underlying causes, hospitalization duration, and cases needed surgical intervention in a descriptive epidemiologic study in patients suffering from external ear chondritis referring to training hospital of Imam Khomeini, Ahvaz.

METHODS
This study is a descriptive epidemiologic study based on hospital data.The charts, available in the archives of the ear, nose, and throat (ENT) ward of Imam Khomeini Hospital,Ahvaz,were studied and finally 130 cases of external ear chondritissince 2002 to 2013 were reviewed.After reading the cases, a checklist was designed, including age, sex, duration of hospitalization, the need for surgery, antibiotics prescribed duringhospitalization, etiologies of the disease, including diabetes, burns, external otitis, blunt trauma, immune deficiency, and history of previous surgeries, including mastoidectomy, piercingtheearcartilage, laceration,and suturing theears and informationwas recordedinchecklists andfor analysis, descriptive statistical methods, including frequency tables, graphs, and numerical indicators were used to describe variables and then chi-square test and logistic regression were usedfor the association between variables.Thesignificant level was considered 0.05 and SPSS software was used for data analysis.

RESULTS
The mean age of patients was 29.8 years.53.7% of patients were in the age range of 11-30 years.66.2% of the patients were men and 33.8% women.The frequency of the underlying etiology of was as follows: 52.3% previous surgeries and ear manipulation, 29.2%burn, 15.3% diabetes, 6.1% external otitis,and 4.6% blunt trauma.Among the hospitalized patients, 72 cases (53.8%) required surgical intervention and underwent incision and debridement.Of those, 54 cases (41.5%) underwent surgery onceduring hospitalization, 8 (6.2%) twice, 4 (3.1%) three times, four patients (3.1%) four times, and 2 patients (1.5%) five times.Among the injectable antibiotics prescribed, ceftazidime had the highest rate with 84.6%, gentamicin with60%, ciprofloxacin 29.2%, cefazolin with 16.9%, and clindamycin with 7.7%, respectively.52.3% of patients were treated concurrently with the injectable and topical antibiotics.The mean duration of hospitalization was 10.1 days.The mean duration of hospitalization in patients with underlying etiology of diabetes was 13.1 days,burns 12.8 days, previous surgeries and manipulation 9.5 days, trauma 7.6 days, and external otitis 7 days.There was a significant relationship between each of the factors of age (P=0.04),sex (P=0.01), and the underlying etiology (P=0.02) with external ear chondritis.There was also a significant association between the duration of hospitalization of patients and their underlying etiology(P=0.01).

DISCUSSION
The mean age of patients in this study was almost 30 years and most patients (27.6%) were in age range of20-30 years, and26.1% in the range of 10-20 years.Therefore, this disease has a high prevalence at young age due to the listed risk factors and the incidence of the disease decreases with increasing age.These results are similar tostudy of Weissler JM [2] and Davidi E [3]; they concluded that the prevalence of the disease is higher in young people.
In this study, 66.2% of patients were male and 33.8% female.So, the male to female ratio is higher in this disease and the disease is more common in men, whichis similarto Prasad, HKC's study [20].
In this study, among the listed causes, the majority of patients (52.3%) had a recent history of previous surgery or manipulation of the ear.This suggests that any previous surgery on the ear is a common cause for the occurrence of external earchondritis in patients.Burns (29.2%), diabetes (15.3%), external otitis (6.1%), and blunt trauma (4.6%), respectively, were the other causes of diseases.This result is consistent withPrasad HKC's study 20 , in whichtrauma was the most common underlying etiology with 46%.Respecting the significant association of underlying etiologies with external ear chondritis, any previous surgery, and manipulation, including mastoidectomy, piercingtheearcartilage, laceration due to trauma,and suturing plays a major role in the incidence of disease in these patients.Thus, the occurrence ofsuch casesshould be prevented orat leastdrastically reduced through giving detailed information about the importance of sterility ofanysurgical procedureonthe external ear, andgiving health-medicaladvice, and emphasizing the fact that patients should visitadoctorquickly iflisted symptoms occur.
In this study, 72 patients (53.8%) required surgical procedure during theirhospitalization and were admitted to the operating room and underwent incision and debridement.These results are contradictory to studyof Davidi E 3 and Prasad HKC 20 , in which no relationship was found between the external earchondritis and cases who needed surgery.
In this study, among the prescribed injectable antibiotic, ceftazidime had the highest frequency (84.6%), and gentamicin was in the second place (60%).
The hospitalization duration were 1-34 days, with mean length of 10 days and 30.7% of patients were treated in 6-8 days of their hospitalization.These results are dissimilar to Sosin M's study 2 , where the average length of hospital stay was 6.1±4.1 days and no significant relationship was found between the duration of hospitalization and external earchondritis.
Duration of hospitalization was highest in diabetic patients and lowest in patients with otitis media.Regarding the significant association of hospital length of stay and underlying etiology, it can be concluded that reducing thelength of stay,and probablecomplications, andimproving thequality of lifeof these patientsshould be accomplished by acceleratingthe diagnosis ofdiabetic patientswithinfectious complicationsof external earchondritis and implementing more complete and effectivehealthmeasures.