Problems with ear piercing

Krystal is seven going on seventeen and is brought in by her mother because she cannot take her earrings out.  She had her ears pierced a week ago.

Bottom Line

Infection due to poor hygiene is the most common complication of ear piercings.

The mainstay of treatment is removing the foreign body, not antibiotics.

Infection (often with Pseudomonas spp.) is more likely in high cartilage piercings.

What are the usual methods used for piercing high ears?

Most high street piercers (as opposed to speciality piercing/tattooists) use a gun that fires a blunt stud through the lobe.  This is then attached to a butterfly to keep the earring in place. Professional piercers use a hollow needle to form a track for the stud.

What are the potential complications of ear piercing?

Early infection is common, especially in children who may not be as fastidious as teenagers with hygiene.  Lobe piercings may become infected, leading to oedema and swelling around the retaining butterfly.  Higher piercings through the cartilage are at risk from perichondritis.  Both may lead to later piercing-related keloid formation.

Nickel alloy piercings can lead to contact dermatitis.

A piercing is also an excellent handle for bullies to grab and rip out.

Krystal has a retained butterfly. How do you go about freeing it?

The technique is essentially the same no matter what the age.  The challenge is providing adequate pain relief and/or sedation to an inflamed ear.  Younger children respond well to topical EMLA with adjunctive nitrous, whereas older children may need only some EMLA and ice.  Very occasionally, actual procedural sedation is required.

Using a sterile technique, identify the point where the back of the butterfly is nearest the surface of the skin on the back of the lobe and make a small nick.  Then, push on the front of the lobe to expose the butterfly, like shelling a pea.  You should then be able to remove the backing without difficulty.  There may be a small amount of bleeding that can be covered with a sticking plaster.

Addendum 20/4/2019

Thanks to @babydocmacski for this suggestion

What is perichondritis?

High piercings can lead to infection of the cartilage and overlying soft tissue with possible disfiguring abscess formation.  The commonest organisms involved are Pseudomonas and Staph. Aureus.

How do you treat perichondritis?

They may require IV anti-pseudomonal antibiotics (such as piperacillin/tazobactam) as well as the removal of the foreign body.

What advice would you give Krystal (and her parents) about getting her ears pierced again?

She should wait until the wound has healed and choose an alternative site, ideally done by a professional piercer. She should also be meticulous about hygiene.

Outcome

Krystal screams when you try to remove the butterfly under nitrous, so you elect to perform procedural sedation using intravenous ketamine and EMLA.  Whilst adequately sedated and no longer wriggling, you pop the butterfly out without further fuss.

Selected references

“High” ear piercing and the rising incidence of perichondritis of the pinna Junaid Hanif, Adam Frosh, C Marnane, K Ghufoor, R Rivron, G Sandhu BMJ. 2001 April 14; 322(7291): 906–907

Fijałkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol. 2011 Apr;50(4):467-9

Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008 Jan;24(1):31-3