Piercing Your Ears? Stick to the Lobes Only

CHICAGO - Today, piercing of the upper ear cartilage is becoming increasingly popular. But done incorrectly, cartilage piercing is much riskier than ear lobe piercing and can lead to serious infection and permanent disfigurement, warn investigators who looked into an Oregon outbreak.

"Kids don't seem to realize that ear piercing is, in its own small way, an invasive procedure, and until it heals, any pierced body part is at risk for infection," said William E. Keene, Ph.D., an epidemiologist at the Oregon Department of Human Services Acute and Communicable Disease Program in Portland. Keene headed the investigation into an outbreak of ear-piercing related infections that occurred in Klamath Falls, Ore. in the summer of 2000.

At the jewelry shop that was the source of the outbreak, both lobe and cartilage piercings were being done with a spring-loaded "gun," which shoots a flat-ended stud through the ear tissue. The guns are not recommended for cartilage piercing. In some states that try to regulate the industry, including Oregon, guns are not legal for cartilage piercing.

The outbreak first came to light when an ear, nose and throat specialist called the local health department to report seeing two teenaged patients a few days apart. Both had nasty infections on the upper ear caused by a bacterium called Pseudomonas aeruginosa, and both reported getting their ears pierced at the same local shopping mall kiosk.

Health department investigators contacted local physicians to find additional cases and, using customer lists that the shop was required to maintain, surveyed customers going back over six weeks. In total, 7 of 53 people (13 percent) who had their upper ear cartilage pierced during that period were found to have Pseudomonas infections that were confirmed by cultures. None had ear lobe piercings at the same time. The people with confirmed infections ranged in age from 10 to 19; 2 were male, 5 were female. All 7 developed auricular chondritis - cartilage infection of the outer ear - within 3 days of having their ears pierced. Four were hospitalized, 1 to receive intravenous antibiotics, 2 to undergo incision and drainage of an abscess that formed at the site of the piercing and 1 for both reasons.

"Some of these kids ended up with quite serious cosmetic problems," said Keene. Three later had reconstructive surgery to try and repair their deformities.

One of the operators performing piercings at the shop admitted to spritzing the sterile ear studs with disinfectant just before injecting them. The investigators cultured Pseudomonas from the disinfectant bottle, as well as from a nearby utility sink where the disinfectant stock solutions were mixed.

"The wound caused by the piercing was getting immediately inoculated with Pseudomonas," said Keene. "The employees didn't realize that spraying a sterile earring with disinfectant was actually worse than doing nothing from an infection control point of view."

In addition to the 7 people confirmed to be infected, more than one-third of the 53 people who had cartilage piercing reported that the piercing site had drained pus for weeks. "Some of these undoubtedly were additional cases that healed on their own," said Keene.

These infections can cause the ear cartilage to erode, resulting in the outer ear tissue sagging and losing its normal shape. The shock of gun piercing is much more traumatic in cartilage than in the ear lobe, said Keene. Cartilage also takes longer to heal because there is less blood circulation than in the lobe. Signs of infection include pain, tenderness, redness and drainage of pus or blood at the piercing site.

It's important that people not take infected ear piercings lightly, said Keene. Patients with such infections should be cultured. Pseudomonas infections can be difficult to treat, and aggressive therapy often is needed, he said.

"It's a cautionary tale," he said. "Obviously the safest thing to do is not to get pierced at all. But if you are determined to have your upper ear pierced, be sure the operator uses a disposable needle, not a gun, and be sure that he or she practices good hygiene and technique. Admittedly, it can be difficult for the consumer to really be assured of that."

About 30 states have some kind of legislation regulating sanitation and hygiene of businesses that perform body piercing, according to the Association of Professional Piercers, but enforcement often is lax.

There are a handful of scattered case reports of similar infections in medical literature, but common-source outbreaks like this have not been reported previously.

"We really don't know how common these kinds of infections are," said Keene. "They are virtually never reported to the public health agencies that investigate outbreaks. We only got wind of this because two patients happened to go to the same doctor in this small town. In a big city, or if the physician hadn't thought to call the health department, it would have gone unnoticed."

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