| Malignant external otitis.
Laryngorhinootologie.
2006 Oct;85(10):763-9
Malignant external otitis or skull base osteomyelitis and
osteoradionecrosis of the skull base and the skull are potentially
life-threatening conditions. The standard methods of treatment involve
the use of antibiotics, local treatment and, where necessary, surgical
excision of necrotic tissue. These approaches do not provide a
complete cure in many cases. Severe functional deficits and even death
can occur in advanced stages. We conducted a long-term retrospective
follow-up study and report on a multimodal approach that we have been
using with great success since 1987. The four cornerstones of this
treatment are surgical debridement, combinations of antibiotics,
specific immunoglobulins, and adjunctive hyperbaric oxygen therapy.
This multimodal treatment approach has proved to be highly effective
in improving the survival and quality of life of the patients
concerned. These excellent outcomes justify the high costs that this
therapy admittedly involves.
Necrotizing external otitis in a
patient caused by Klebsiella pneumoniae.Eur Arch Otorhinolaryngol. 2006 Apr;263(4):344-6.
Necrotizing external otitis is a potentially
life-threatening infection involving the temporal and adjacent bones.
The most frequent pathogen is attributed to Pseudomonas aeruginosa,
but is rarely caused by Klebsiella pneumoniae. Recently, we
encountered a 47-year-old diabetic man with a swollen obliterated
external ear canal with granulation tissue on the right ear. Image
study demonstrated skull base osteomyelitis, epidural abscess and
cerebral venous sinus thrombi. It was later proved to be necrotizing
external otitis caused by Klebsiella pneumoniae. He then underwent
craniotomy for drainage of the epidural abscess, followed by
intravenous ciprofloxacin and metronidazole for 2 consecutive weeks
until both pus and blood cultures depicted no growth of pathogens.
Based on this case, synergistic antibiotic therapy using a
third-generation cephalosporin or quinolone (ciprofloxacin),
accompanied by metronidazole, and even a short-term aminoglycoside is
recommended for the treatment of severe Klebsiella-induced necrotizing
external otitis. Surgical intervention should be limited without
shedding of the pathogens.
The changing face
of malignant (necrotising) external otitis: clinical, radiological,
and anatomic correlations.Lancet
Infect Dis. 2004;4(1):34-9.
Malignant (necrotising) external otitis is an
invasive infection of the external auditory canal. Although elderly
patients with diabetes remain the population most commonly affected,
immunosuppressed individuals (eg, from HIV infection, chemotherapy,
etc) are also susceptible to malignant external otitis. Pseudomonas
aeruginosa is isolated from the aural drainage in more than 90% of
cases. The pathophysiology is incompletely understood although aural
water exposure (eg, irrigation for cerumen impaction) has been
reported as a potential iatrogenic factor. The typical patient
presents with exquisitely painful otorrhoea. If untreated, cranial
neuropathies (most commonly of the facial nerve) can develop due to
subtemporal extension of the infection. The diagnosis of malignant
external otitis is based on a combination of clinical findings, an
increased erythrocyte sedimentation rate, and radiographic evidence of
soft tissue with or without bone erosion in the external canal and
infratemporal fossa. Treatment consists of prolonged administration
(6-8 weeks) of an antipseudomonal agent (typically an orally
administered quinolone). With the introduction and widespread use of
both oral and topical quinolones, there are reports of less severe
presentation of malignant external otitis and even the emergence of
ciprofloxacin resistance. Reservation of systemic quinolones for the
treatment of invasive ear infections is recommended.
Necrotizing (malignant) external
otitis.
Am Fam Physician. 2003 Jul
15;68(2):309-12.
Necrotizing (malignant) external otitis, an infection involving the
temporal and adjacent bones, is a relatively rare complication of
external otitis. It occurs primarily in immunocompromised persons,
especially older persons with diabetes mellitus, and is often
initiated by self-inflicted or iatrogenic trauma to the external
auditory canal. The most frequent pathogen is Pseudomonas aeruginosa.
Patients with necrotizing external otitis complain of severe otalgia
that worsens at night, and otorrhea. Clinical findings include
granulation tissue in the external auditory canal, especially at the
bone-cartilage junction. Facial and other cranial nerve palsies
indicate a poor prognosis; intracranial complications are the most
frequent cause of death. Diagnosis requires culture of ear secretions
and pathologic examination of granulation tissue from the infection
site. Imaging studies may include computed tomographic scanning,
technetium Tc 99m medronate bone scanning, and gallium citrate Ga 67
scintigraphy. Treatment includes correction of immunosuppression (when
possible), local treatment of the auditory canal, long-term systemic
antibiotic therapy and, in selected patients, surgery. Family
physicians and others who provide medical care for immunocompromised
patients should be alert to the possibility of necrotizing external
otitis in patients who complain of otalgia, particularly if they have
diabetes mellitus and external otitis that has been refractory to
standard therapy. Susceptible patients should be educated to avoid
manipulation of the ear canal (i.e., they should not use cotton swabs
to clean their ears) and to minimize exposure of the ear canal to
water with a high chloride concentration. Appropriate patients should
be referred to an otolaryngologist.
Malignant otitis externa: a review.Pac
Health Dialog. 2002 Mar;9(1):64-7.
Malignant otitis externa is a rare but potentially fatal disease of
the external auditory canal seen mostly among elderly, diabetic or
immunocompramised patients. The causative organism is mainly
Pseudomonas aeruginosa. The disease spreads rapidly, invading
surrounding soft tissues, cartilage and bones causing their necrosis
and even spreading to the cranial nerves. The disease can be fatal if
treatment is not aggressive and timely, especially if it spreads
outside the auditory canal with involvement of the cranial nerves.
Treatment is mainly medical with antipseudomonal drugs like the third
generation cephalosporin and the fluoroquinolones and local
debridement. With aggressive treatment the mortality rate from this
disease, which used to be 50% in the past has now been reduced to
10-20%. The pathophysiology of the disease, clinical presentation,
diagnosis, treatment and the outcome has been discussed and reviewed.
Malignant or necrotizing otitis externa:
experience in 22 cases.
Ann Otolaryngol Chir Cervicofac. 2000 Nov;117(5):291.
Malignant or progressive necrotizing otitis extrema is an uncommon but
severe infectious condition of the external auditory canal. Over a
period of four years, we treated 22 patients: 60% had diabetes (1/4
insulin dependent) and 13% were immunodepressed. The causal germ was
Pseudomonas aeruginosa in 87% of cases. The pretherapeutic work-up
included a computed tomography scan and a technetium scintigraphy to
confirm diagnosis and assess extension. Repeated scintigraphies with
gallium were used to follow the course under treatment. Medical
treatment was used in most cases (16/22) with parenteral antibiotic
therapy using a third-generation cephalosporin (ceftazidime or
ceftriaxone) and a fluoroquinolone (ciprofloxacin or ofloxacin) and,
if there was no contraindication, hyperbaric oxygen. Surgery is not
indicated in malignant otitis externa. We had a 95% cure rate with
only 10% recurrence. We reviewed the data in the literature on
malignant otitis externa and present the important diagnostic, imaging
and therapeutic aspects.
Necrotizing external otitis
caused by Aspergillus fumigatus: computed tomography and high
resolution magnetic resonance imaging in an AIDS patient.J
Laryngol Otol. 1998 Jan;112(1):98-102.
Most necrotizing (malignant) external otitis (NEO) occurs in diabetic
patients and is commonly caused by Pseudomonas aeruginosa. We report
an acquired immunodeficiency syndrome (AIDS) patient with NEO caused
by Aspergillus fumigatus in which computed tomography (CT) showed
destructive petrous bone involvement and magnetic resonance imaging (MRI)
of the ear discovered extensive soft tissue and facial nerve
involvement. Dedicated MRI studies of the ear in this type of
pathology provide new insights relating to nerve dysfunction, that
cannot be obtained with CT.
Necrotizing external otitis in
patients with AIDS.Laryngoscope.
1997 Apr;107(4):456-60.
In a retrospective review of seven patients with AIDS who were
diagnosed with necrotizing external otitis between 1990 and 1995, it
was found that the presentation of necrotizing external otitis in
patients with AIDS differed from the classic description of malignant
external otitis in several respects. The patient population was
significantly younger and nondiabetic. Granulation tissue was usually
absent from the external auditory canal and Pseudomonas aeruginosa was
not the predominant pathologic organism. Also, outcome was found to be
significantly worse. Thus a high index of suspicion must be
entertained and vigorous local and systemic treatment initiated early
in the course of disease to achieve a satisfactory outcome.
Malignant external otitis: a case
report and review. Am
Fam Physician. 1994 Feb 1;49(2):427-31.
Malignant external otitis is an unusual but serious and potentially
fatal condition that has only recently been described. It is an
invasive pseudomonal infection of the external auditory canal and deep
periauricular tissues that characteristically involves the bone and
adjacent cartilaginous structures, and it may lead to osteomyelitis of
the base of the skull. It typically occurs in elderly diabetic
patients. Malignant external otitis can cause severe pain, necrosis of
the external auditory canal and progressive palsies of the facial and
cranial nerves. Treatment consists of debridement of external auditory
canal granulation tissue and long-term therapy with an antipseudomonal
cephalosporin or an antipseudomonal penicillin plus an aminoglycoside.
Malignant otitis externa in AIDS
patients: case report and review of the literature.Ear
Nose Throat J. 1994 Oct;73(10):772-4,
777-8.
Malignant otitis externa is a necrotizing infection of the external
ear canal and surrounding soft tissue and bone, usually caused by
Pseudomonas aeruginosa. The infection classically occurs in diabetic
patients, however recently, several patients with the acquired
immunodeficiency syndrome (AIDS) have been reported to have malignant
otitis externa. A patient with AIDS who had malignant otitis externa
with skull base osteomyelitis is presented and reported cases in
patients with AIDS are reviewed. Predisposing factors include
immunologic abnormalities (notably neutropenia), dermatitis,
medications, neoplasm, and iatrogenic procedures, e.g., ear lavage.
Treatment of malignant otitis externa has traditionally included anti-pseudomonal
cephalosporins/penicillins and aminoglycosides for prolonged
durations. Recently, ciprofloxacin has been shown to be effective as
an oral regimen. With the increasing number of patients with AIDS
being seen in the outpatient clinics, the diagnosis of malignant
otitis externa should be considered in any patient with persistent ear
pain or otorrhea who does not respond to conventional treatment for
external otitis.
Adjuvant hyperbaric oxygen in malignant
external otitis.Arch
Otolaryngol Head Neck Surg. 1992 Jan;118(1):89-93.
Necrotizing invasive pseudomonal infection of the external auditory
canal (malignant external otitis) is an uncommon but important
disorder in the elderly. The high morbidity, and even mortality, of
this disorder has been reduced by the early and intensive use of
combination antipseudomonal antibiotics. However, in severely
immunocompromised patients or in infection involving the base of the
skull, multiple cranial nerves, or the meninges, conventional therapy
has been prolonged, intensive, and relatively ineffective. We treated
16 patients with malignant external otitis with adjuvant hyperbaric
oxygen therapy. In six patients, infection was in advanced stages,
infections were recurrences after previous treatment, and repeated
treatment with antipseudomonal antibiotics had failed. All 16 cases
responded promptly when a 30-day course of hyperbaric oxygen was added
to the antibiotic regimen, and all patients remained free of infection
or neurologic deficit during 1 to 4 years of follow-up. No
complications of this treatment modality were noted. Hyperbaric oxygen
therapy reverses tissue hypoxia, which enhances phagocytic killing of
aerobic microorganisms, and stimulates neomicroangiogenesis. In
addition, hyperbaric oxygen augments the action of aminoglycoside
antibiotics. Adjuvant hyperbaric oxygen therapy should be considered
in advanced or recurrent cases of malignant external otitis.
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