To understand perichondritis, it helps to break down the medical term: peri- means “around,” -chondr- refers to cartilage, and the suffix -itis means inflammation. Therefore, perichondritis is, quite literally, the inflammation of the perichondrium.

The perichondrium is a thin but dense layer of connective tissue surrounding cartilage throughout the body. In the ear, its role is absolutely vital. The cartilage that gives your outer ear (the pinna or auricle) its distinctive shape has no direct blood supply of its own. It relies completely on the tightly attached perichondrium for its delivery of oxygen and nutrients.

A helpful analogy is to think of the ear cartilage as a delicate coral reef and the perichondrium as the thin layer of nutrient-rich ocean water that constantly flows over it, providing everything it needs to live. In perichondritis, an infection causes inflammation and often a collection of pus to form in the space between the perichondrium and the cartilage. This barrier of pus effectively lifts the “ocean water” away from the “coral reef.” Starved of its essential blood supply, the cartilage can quickly begin to die, a process called necrosis. This death of the cartilage is what leads to the collapse and deformity of the ear’s structure.

It is important to note that perichondritis affects the cartilaginous parts of the ear, the firm, flexible areas that make up the helix, antihelix, and tragus. It characteristically spares the earlobe, because the earlobe does not contain cartilage. This is a key diagnostic clue.

In my experience, when someone comes in with an intensely painful, red ear but the earlobe looks fine, I immediately think of perichondritis. Lack of earlobe involvement is a classic sign.

Perichondritis is caused by bacterial infection that takes hold in the perichondrium. When the skin of the ear is broken, bacteria from the environment or from the skin’s surface can be introduced into the deeper tissues.

The Primary Bacterial Culprit: The most common bacterium responsible for causing perichondritis is Pseudomonas aeruginosa. This organism is widespread in the environment and is particularly well-known for thriving in water and soil. Its association with perichondritis is very strong, especially in cases related to ear piercings (American Academy of Otolaryngology, Head and Neck Surgery, 2018).

Other Bacteria Staphylococcus aureus: (Staph) is another common bacterium that can cause perichondritis. In some cases, the infection can be polymicrobial, meaning several different types of bacteria are involved.

It’s not always from obvious trauma. Sometimes, even a small scratch or bug bite behind the ear leads to severe perichondritis in a few days if not cleaned and treated early.

You develop perichondritis when the skin overlying cartilage is breached, allowing bacteria to enter and cause infection in the perichondrium. While any trauma to the ear can be a cause, some events carry a much higher risk than others.

The most common ways to get perichondritis include:

• High Ear Piercings: This is now considered the leading cause of perichondritis, especially in adolescents and young adults. Piercing the cartilage of the upper ear (the helix or “rim”) is far riskier than piercing the fleshy earlobe. The poor blood supply of the cartilage makes it much harder for the body’s immune system to fight off an infection in this area. The risk is significantly increased if the piercing is done in unhygienic conditions or with non-sterile equipment.
• Trauma or Injury: Any direct blow to the ear can create a small cut or a collection of blood (a hematoma) that can become secondarily infected. This includes:
  • Contact sports injuries (wrestling, boxing, rugby).
  • Accidents or falls.
  • Human bites or even animal scratches.
• Burns: Both thermal and chemical burns to the ear can destroy the protective skin barrier and lead to a deep infection.
• Insect Bites: An infected insect bites the ear cartilage.
• Acupuncture: If non-sterile needles are used for acupuncture on the outer ear.
• Ear Surgery: Perichondritis can be a rare complication of ear surgery.
• Spreading Skin Infections: A simple skin infection or boil on the ear that is not treated properly can spread deeper to involve the perichondrium.

I’ve often seen this after upper ear piercings done in non-medical settings. Poor hygiene and trauma give bacteria a chance to invade, and the thin skin over cartilage makes infection spread fast.

Perichondritis symptoms typically appear within 24–72 hours after trauma or infection and may worsen rapidly. The condition can be extremely painful.

The key signs and symptoms to watch for include:

• Severe pain in the affected part of the ear.
• Redness that spreads to involve most of the outer ear structure.
• Swelling and thickening of the ear, causing the normal contours and ridges to be lost.
• Extreme tenderness: The ear is often so painful that the person cannot sleep on that side.
• The affected ear feels warm or hot to the touch.
• A key diagnostic sign is that the earlobe is typically not red or swollen, as it lacks cartilage.

As the infection progresses, an abscess (a collection of pus) may form between the cartilage and the perichondrium. This may be felt as a soft, fluctuant (fluid-filled) area. In some cases, the abscess may rupture and drain pus. A fever may also develop as the infection becomes more severe.

If I can press the earlobe without pain, but the upper ear is swollen and hot, I’m almost certain it’s perichondritis. Acting quickly here prevents irreversible ear damage.

Diagnosis is typically clinical, based on history and physical examination. Lab or imaging studies are rarely needed unless complications are suspected.

• Medical History: The doctor will ask about any recent injuries, piercings, insect bites, or other skin problems.
• Physical Examination: The diagnosis is strongly suggested by the classic appearance of a red, tender, swollen outer ear that characteristically spares the earlobe.
• Wound Culture: If there is any pus or drainage, the doctor will take a swab and send it to the laboratory for a culture. This test can identify the specific bacterium causing the infection and, importantly, determine which antibiotics will be most effective at killing it.

I don’t usually need fancy tools to diagnose this, just a good look and a gentle press. But if I see pus or signs of spreading, I culture it and start treatment fast.

Treatment of perichondritis must be started promptly and aggressively to prevent the most serious complications. The goal is to eradicate the bacterial infection before it can lead to the death of the underlying cartilage.

1. Antibiotics

This is the mainstay of treatment. Because Pseudomonas aeruginosa is such a common cause, the doctor will choose an antibiotic that is known to be effective against this particular bacterium.

• Oral Antibiotics: For early or mild infections, a course of a strong oral antibiotic from the fluoroquinolone class (such as ciprofloxacin) is typically prescribed for at least 10 to 14 days.
• Intravenous (IV) Antibiotics: If the infection is severe, if the person has a fever, or if they have other medical problems, they will likely be admitted to the hospital for treatment with IV antibiotics.

I stress the importance of completing the antibiotic course, even if symptoms improve early. Relapses can lead to cartilage breakdown, and restoring the ear shape later is much harder.

2. Surgical Intervention

If an abscess has formed, antibiotics alone are not enough. The pus collection must be surgically drained.

• Incision and Drainage (I&D): A surgeon (usually an ENT specialist) will numb the ear with local anesthesia and make a small incision to drain the pus completely.
• Debridement: The surgeon may also need to remove any pieces of cartilage that have already died.
• Suture-Through-and-Through Stitches: Sometimes, after drainage, special stitches are placed through the entire ear to hold the perichondrium back down against the cartilage, ensuring its blood supply is restored.

Complications of Untreated Perichondritis

If treatment is delayed or inadequate, the consequences can be severe and permanent.

• Cartilage Necrosis: The cartilage, starved of its blood supply, dies.
• “Cauliflower Ear” (Auricular Deformity): This is the most feared and devastating complication. Once the cartilage framework dies and is absorbed by the body, the ear loses its structural support. It shrivels and collapses into a misshapen, lumpy form that resembles a cauliflower. This deformity is permanent and very difficult to correct surgically.

Perichondritis is a serious bacterial infection of the tissue that nourishes the ear cartilage. While often triggered by a seemingly minor event like a high ear piercing, it can rapidly progress, causing severe pain and threatening the structural integrity of the ear. The key to a successful outcome is immediate medical evaluation at the first sign of a red, painful, swollen ear. Prompt and aggressive treatment with the correct antibiotics, combined with surgical drainage if an abscess has formed, is the only way to cure the infection and, most importantly, to prevent the permanent and disfiguring collapse of the ear known as cauliflower ear.

American Academy of Otolaryngology, Head and Neck Surgery. (2018). Piercings. Retrieved from https://www.enthealth.org/be_ent_smart/piercings/

Merck Manual Professional Version. (2023). Perichondritis. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/external-ear-disorders/perichondritis Cleveland Clinic. (2022). Perichondritis. Retrieved from