Auricular Necrotizing Wound From Brown Recluse Spider Bite

A 5-year-old white boy presented with soft-tissue cellulitis involving the soft tissue of the lower ear auricle and adjacent neck (Figs ​1a and ​1b) as a result of a brown recluse spider bite. Wound cultures gave negative results upon initial debridement. The involved area progressed from cellulitis to necrosis of the skin of the lateral neck and lower auricular cartilage (Figs 1c and 1d). The initial management consisted of intravenous antibiotics and debridement. The plastic surgery service was consulted on day 12. The wound was debrided again (Figs 2a and 2b) and cultures returned with methicillin-resistant Staphylococcus aureus sensitive to vancomycin and trimethaprim/sulfamethoxazole. Negative pressure wound therapy was started immediately following the debridement on day 12. Nanocrystalline silver mesh (Acticoat; Smith & Nephew, St. Petersburg, FL) without the absorbent layer was used as a contact layer (Figs 2c and 2d), and polyurethane foam was used as the wound filler.

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Figure 1
(a and b) Initial presentation of the wound. (c and d) Progression of the wound necrosis.
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Figure 2
(a and b) The wound after initial debridement. (c and d) A single layer of Acticoat was used as a contact layer for the negative pressure wound therapy dressing.

Because of the difficulty in maintaining a vacuum seal, the NPWT dressing was placed over the entire ear auricle. The external auditory canal was dressed with Xeroform gauze (Fig ​33a), and the auricle was incorporated into the dressing (Fig 3c). The dressing was irrigated with sterile water daily through an irrigation tube both to promote exudate clearance and to activate the silver in the dressing. The polyurethane foam was placed directly adjacent to the canal beneath the overlying occlusive dressing (Fig ​3c). The wound interface pressure was set to -80 mm Hg, and the dressing was changed and the wound debrided at 3- to 5-day intervals in the operating room. The wound bed was fully granulated after 20 days from the initial debridement and required a total of 7 days of NPWT. It was closed with a meshed, split-thickness skin graft (Figs ​4a–4b), and the patient had an uneventful recovery. The patient had a first-stage reconstruction of the ear lobule at 14 months after the injury (Fig ​4c) and will undergo 1 more procedure to complete the sulcus restoration and removal of more of the split-thickness graft.

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Figure 3
These images demonstrate the obstruction of the ear canal with Xeroform. (a) Gauze covered with an occlusive dressing. (b) The lower part of the wound is covered with a single layer of Acticoat, which serves to modulate the wound as well. (c) The entire dressing effectively controls the wound dynamics in a difficult location. Note the second catheter placed to irrigate the wound if heavy exudate is discovered.
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Figure 4
These images show the wound after negative pressure wound therapy treatment and the application of a meshed, split-thickness skin graft. The patient is awaiting ear reconstruction. (a) First stage wound closure with skin graft, (b) 1 year after wound closure, and (c) 3 months after first stage ear sulcus and lobule restoration.