Perichondritis is an inflammation of the suprachondria. It can be primary (in acute or chronic cartilage injuries) or secondary (in general infectious diseases and direct microbial damage). Most often occurs in the area of rib cartilage, laryngeal cartilage and auricle. It is manifested by pain and swelling of the affected area. With suppuration, it is possible to melt the tissue with the formation of a fistula. The diagnosis is made on the basis of clinical symptoms, ultrasound and fistulography (with purulent processes). Treatment of perichondritis can be conservative or operative.
ICD 10
M94.8 Other specified cartilage lesions
Causes
Damage to the rib cartilage, as a rule, develops after injuries. Damage to the auricle can be observed with injuries and purulent processes in the area of the outer and middle ear. Perichondritis of the laryngeal cartilage is usually a complication of intubation or radiation therapy for laryngeal cancer. In addition, cartilage damage can develop due to a common infectious disease (malaria, influenza). Very rarely, specific tuberculous and syphilitic perichondrites occur.
Pathanatomy
In its functions, the supracondrium is similar to the periosteum. However, pathological processes in the periosteum and the suprachondrium proceed differently and have different consequences, due to differences in the structure and nutrition of bone and cartilage. The bone is equipped with its own blood vessels, it receives nutrition not only from the outside (from the periosteum), but also from the inside (from the bone marrow). Cartilage has no blood vessels, and the cartilage is the only source of nutrients for it. Therefore, with periostitis, bone necrosis does not always occur, while destruction or detachment of the cartilage inevitably entails necrosis of the entire layer of the underlying cartilage.
The periosteum has pronounced proliferative and plastic properties, which allows it to participate in the formation of a callus in the fracture zone. The same property of the periosteum explains the proliferation of bone tissue in chronic (ossifying) periostitis. Unlike the periosteum, the proliferative properties of the periosteum are insignificant, so excess cartilage does not form as a result of inflammation.
Classification
There are two main forms of perichondritis: aseptic and purulent. With aseptic perichondritis, as a rule, there is a gradual regression of symptoms, with purulent – destruction of cartilage and the formation of fistulas. With aseptic perichondritis, conservative therapy is carried out, with purulent surgical operations are performed. Treatment of perichondritis, depending on the etiology and localization, can be carried out by orthopedic traumatologists, otolaryngologists or oncologists.
Types of perichondritis
Purulent perichondritis of the ribs
Purulent perichondritis of the ribs usually occurs as a result of open trauma with damage to the rib cartilage and /or crushing of the surrounding soft tissues or due to contact spread of infection (with mediastinitis, pleural empyema, osteomyelitis of the sternum and ribs). Less often, complications after chest surgery become the cause of perichondritis. As pathogens, as a rule, streptococci or staphylococci act, less often – E. coli, proteus, Pseudomonas aeruginosa and other bacteria.
Rib perichondritis is manifested by pain along the course of the ribs, which increases with movements and deep breathing. The general condition in the absence of other purulent processes usually remains satisfactory. An infiltrate is formed in the affected area. After a while, the center of compaction softens, fluctuation appears. If the costal arch is involved in the process, the inflammation can spread to the entire lower part of the chest and the upper part of the anterior abdominal wall. The formed abscess breaks through the skin or through the posterior cartilage. In the first case, a fistula is formed, in the second case, there are congestion in the soft tissues.
The period of acute inflammation in perichondritis of the ribs can last up to 3 months. At this time, foci of destruction form in the area of the suprachondrium, from which microbes penetrate into the central zone of the cartilage. Chondritis develops, spreading beyond the primary purulent focus. From the central areas of the cartilage, the infection gets to the unchanged suprachondria. The features of the spread of the purulent process cause damage to the cartilage for a considerable period. After 3 months, the phenomena of perichondritis subside, while regenerative processes are combined with ongoing necrosis of cartilage tissue. Usually, the destroyed cartilage is gradually replaced by scar tissue, less often by bone tissue. The restoration of cartilage is very rare.
The diagnosis of perichondritis is made on the basis of the clinical picture, CT and MRI data. With fistulas, fistulography is performed. The most effective method of treatment is the complete removal of the affected cartilage. When the process spreads to the bone (osteomyelitis of the rib), 2-3 cm of bone tissue is additionally removed. In the postoperative period, antibiotics and painkillers are prescribed. The outcome of rib perichondritis is usually favorable.
Titze syndrome
Titze syndrome is an aseptic perichondritis in the area of attachment of rib cartilage to the sternum. The etiology is not fully clarified, there are theories about the connection of the disease with previous injuries, metabolic disorders and decreased immunity. The patient complains of pain on the side of the sternum (usually on one side, more often on the left). The pain increases with sneezing, coughing, movements and turns of the body. On palpation , a tumor – like formation with a size of 2-5 cm is determined . The skin above it is usually unchanged, 10% of patients have minor edema, local hyperthermia and hyperemia.
In the early stages, the diagnosis of perichondritis is clarified by CT or cartilage biopsy. After 2-3 months, corresponding changes appear on the radiographs of the ribs: calcification of cartilage, narrowing of the intercostal space and thickening of the anterior part of the bone rib. Conservative therapy includes taking NSAIDs (ibuprofen, diclofenac, voltaren) and mild manual exposure. With severe pain, blockades with hydrocortisone are performed. Surgical treatment consists in resection of the affected cartilage.
Perichondritis of the larynx
The cause of the development of laryngeal perichondritis is most often measles necrosis, radiation therapy for laryngeal cancer and bedsores caused by intubation. Less often, laryngeal cartilage is affected by tuberculosis and syphilis. Inflammation is always purulent in nature due to the contamination of the affected area with pathogens penetrating from the upper respiratory tract. As a rule, perichondritis begins in the deep layers of the suprachondria. Pus exfoliates the perichondria from the cartilage, the corresponding area of cartilage tissue necrotizes and gradually melts. After a while, the abscess opens into the larynx, esophagus or pharynx, less often – out through the skin.
The diagnosis of perichondritis is made on the basis of clinical signs and laryngoscopy data. The course of the disease is long, the prognosis is unfavorable. Due to the weak regenerative ability of the cartilage, the resulting defect is filled poorly, granulations are formed weakly and sluggishly. Many patients with laryngeal perichondritis die from pneumonia or sepsis. Even with a favorable outcome, a deforming scar forms in the area of the lesion, which affects the voice, makes breathing difficult or (with the formation of large cicatricial usures in the area of the entrance to the larynx) it causes frequent ingestion of food into the respiratory tract.
Perichondritis of the auricle
The cause of the development of perichondritis of the auricle can be any, even a minor injury to the ear. Sometimes the infection penetrates into the cartilage through inconspicuous abrasions of the ear or the external auditory canal. In addition, perichondritis can occur with frostbite, burns, eczema, inflammation of the outer (otitis externa) and middle (otitis media) ear. As the causative agent of perichondritis of the auricle, Pseudomonas aeruginosa most often acts.
A characteristic feature of perichondritis is diffuse inflammation. The auricle is edematous, tense, bluish-red. Its surface is uneven, bumpy. After the formation of ulcers in different places of the auricle, areas of fluctuation are felt. Body temperature is elevated. Like other forms of inflammation of the cartilage, perichondritis of the auricle has a tendency to a long, persistent course. The duration of the disease ranges from several weeks to several months. During this time, the cartilage deprived of the cartilage gradually melts, the auricle shrinks and deforms, in severe cases turning into a soft shapeless formation. The auditory canal narrows.
To clarify the diagnosis of perichondritis, diaphanoscopy is used. Treatment includes compresses with boric acid, analgesics and antibiotics. When foci of fluctuation appear, surgical intervention is indicated. Purulent cavities are widely opened, sequesters are removed, granulations are scraped out, after which tamponade is performed with iodoform gauze. Tight tampons are used to prevent narrowing of the auditory canal. A patient with perichondritis is referred for UHF, UV irradiation or microwave. The prognosis for perichondritis of the auricle is favorable for life, however, the outcome almost always becomes a more or less pronounced cosmetic defect.