Malignant Otitis External: Our Experience and Literature Review

Abstract

Case series Patients: Male, 74-year-old • Male, 76-year-old • Male, 77-year-old Final Diagnosis: Malignant otitis externa Symptoms: Edema • facial paralysis • hearing loss • otalgia and major otorrhea in the right ear Medication: — Clinical Procedure: ENT examination Specialty: Otolaryngology Objective: Unusual clinical course Background: Malignant external otitis (MEO) is an invasive infection that can involve the external auditory canal and the skull base up to the contiguous soft tissues. Considering the changing face of MEO, we reviewed cases of MEO treated in our Ear Nose Throat (ENT) clinic – University Federico II of Naples between 2018 and 2019 to evaluate the current epidemiology of the condition and to assess the state of art on diagnosis, therapeutic and follow-up management in our patients. Case Reports: We present the cases of three male patients with Type 2 diabetes mellitus who complained of long-lasting otorrhea and pain, with clinical suspicion of MEO. In all cases, ear swab was positive for Pseudomonas aeruginosa . All our patients received a 6-week course of intravenous ciprofloxacin, piperacillin, and tazobactam, with rapid clinical symptoms improvement and complete recovery at 1-year follow-up. Conclusions: MEO is difficult to treat due to the lack of standardized care guidelines. Patients with MEO often present with severe otalgia, edema, otorrhea, and facial nerve paralysis. Clinicians must suspect MEO in elderly diabetic and immunocompromised patients with persistent otalgia after external otitis. Imaging (computed tomography and magnetic resonance imaging) can play synergistic roles in the management of MEO. To evaluate eradication of the disease, clinicians have to assess clinical symptoms and signs as well as radiological imaging and inflammatory markers.

“Necrotising Otitis Externa: an Overview of Imaging Modalities“

“…Thus, the timely and suitable use of radiologic modalities and management protocol can lead to improved outcomes which in turn can reduce the need for surgical intervention. 15 In addition, it is worth noting, that whilst clinical presentation, diagnosis, and pathophysiology of NOE is well understood, there is still no consensus on the best use of imaging techniques. 16 The availability of latest imaging technology means that clinicians are now able to use more advanced imaging techniques in many parts of the world.…”

Effectiveness of ciprofloxacin in the treatment of Acute Otitis Media

“…In addition, no quinolone toxicity was encountered in human and animal studies (20) (23). Conversely, El-Nasr et al detected P. aeruginosa growth in 65% of the culture samples from 60 patients with malignant otitis externa and found 77% antibiotic resistance in the antibiogram (24). The antibiogram analyses in the current study revealed that 43.3% of the P. aeruginosa and 33.3% of the S. aureus were ciprofloxacin resistant.…”

Otitis externa maligna con diseminación hematógena de Pseudomonas aeruginosa resistente a carbapenémicos

“…La tomografía detecta osteomielitis del hueso temporal (1) , mientras que la resonancia magnética evalúa tejidos blandos circundantes, expansión intracraneal y edema de médula ósea (que precede a la osteítis), ambos son estudios complementarios (3)(4)(5) . El compromiso radiológico de senos paranasales o de la articulación temporomandibular debe alerta la posibilidad de etiología fúngica (12) , la que fue descartada en nuestro paciente.…”

“…Otras técnicas como la tomografía por emisión de positrones tienen una sensibilidad de 96% y especificidad de 91% para el descarte de osteomielitis de base del cráneo (2) . Tal como se hizo y a fin de evitar demora en el inicio del tratamiento, el diagnóstico de OEM podría plantearse ante la presencia de al menos 3 de los siguientes 5 hallazgos (4) : otitis externa persistente; presencia de tejido de granulación en CAE; radiología con osteomielitis en CAE, base de cráneo o compromiso de celdas mastoideas; compromiso de nervios craneales; y Pseudomonas aeruginosa aislada en cultivo de secreción de oído.…”

“…Su diagnóstico es clínico-radiológico (3) y puede presentar complicaciones como osteomielitis de base de cráneo con parálisis de nervios craneales (1) . Su principal etiología es la bacteria Pseudomonas aeruginosa (2) , su tratamiento es con antibióticos anti-pseudomónicos como fluroquinolonas y beta-lactámicos (1,4) . Muy pocos casos de resistencia a fluoroquinolonas han sido reportados y ninguno con resistencia a carbapenémicos (5,6) .…”