Diagnosis Of Malignant Otitis Externa Research Articles

Surgical Treatment of Malignant Otitis Externa MOE A New Hope Although Challenging

Objective: Malignant external otitis is an aggressive inflammatory condition of the external auditory canal. Most often affects elderly patients with diabetes mellitus. This is a serious disease which spreads in the skull base associated with cranial nerve complications and high morbidity-mortality rate. Malignant otitis externa requires urgent diagnosis and treatment. The primary and most effective treatment is to control the diabetes and to fight infection with the proper antibiotic in adequate dose and duration. If medical treatment fails aggressive surgical management is the only option to save life. We present a short experience in the management of this disease. The aim of this study was to present our experience with the surgical management of malignant otitis externa. Methods: All patients' records with malignant otitis externa during the last 5 years (2007-2012) were retrieved and reviewed. Diabetes mellitus profile, erythrocyte sedimentation rate, ear swab for culture and sensitivity, computed tomography, were investigated for all patients. Results: During the last 5 years (2014-2019), 5 patients with the diagnosis of malignant otitis externa were admitted to our hospital for investigation and treatment. All between 60 and 70 years of age, with severe persistent otalgia, purulent otorrhea, granulation tissue in the external auditory canal, and diffuse external otitis, and there were 2 patients with facial nerve palsy. Patients were confirmed to have diabetes. Ear swabs for culture and sensitivity usually revealed Pseudomonas aeruginosa. One patient by systemic antibiotic and two patients were treated by Local debridement and systemic antibiotics were sufficient to control the disease. Two patients were treated by aggressive surgical debridement (skull base debridement) with 360degree Facial nerve decompression. Patients were recovered from dreadful necrotizing infection but with facial paralysis. Conclusion: Malignant otitis externa is still a serious disease associated with cranial nerve complications and high morbiditymortality rate. The primary and most effective treatment is to control the diabetes and to fight infection with the proper antibiotic in adequate dose and duration, debridement of necrotic tissue, and sometimes aggressive surgical management. Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus.

Malignant Otitis Externa and Stroke.

Malignant otitis externa (MOE) is an aggressive but benign entity which evolves into skull base osteomyelitis. An 81-year-old female patient was admitted for left hemiparesis and homonymous hemianopia. She complained of headache radiating to the right cervical area. A recent history of recurrent otitis media was present. Head and neck imaging showed an ischemic infarction (right temporo-occipital) and a parapharyngeal soft tissue mass originating in an external and medial ear infection. Culture samples revealed Pseudomonas aeruginosa infection leading to the diagnosis of Malignant otitis externa (MOE). Parenteral antibacterial therapy and hyperbaric oxygen therapy resulted in improvement.LEARNING POINTSMalignant otitis externa is an aggressive and life-threatening disease which must be identified early and treated promptly for therapeutic success.Although starting as an outer ear infection (typically caused by Pseudomonas aeruginosa) local spread can involve noble head and neck structures leading to variable signs and symptoms.Modern imaging techniques can help define structure involvement (MRI) and may help identify disease activity and prognosis (nuclear medicine).

Role of Positron Emission Tomography Scan in Complicated Ear Infection

Introduction: Malignant otitis externa (MOE) can be a potentially life threatening condition. The patient typically presents with pain in the ear with minimal clinical signs. Cranial neuropathies may be present depending upon the extent of the disease. A high index of suspicion is required to diagnose and treat MOE. MOE can be suspected clinically but is often confirmed on investigations including CT scan of temporal bone. Objective: We describe an atypical case of malignant otitis externa (MOE). Clinical and standard CT scan findings were regarded inadequate to make a definitive diagnosis. We discuss the complementary but important role of PET CT to confirm the diagnosis in the presence of equivocal finding on standard skull base CT scan. Methodology: Case report with literature review. Results: A 76 year old male presented with deep seated otalgia. Clinical findings were equivocal. He had ipsilateral hypoglossal nerve palsy. The CT scan showed opacification of the middle ear cleft. The differential included middle ear neoplasm, skull base osteomyelitis and malignant otitis externa. The PET CT showed widespread uptake of the ipsilateral skull base which led to the diagnosis of MOE. Patient was treated with 10 days of intravenous ciprofloxacin followed by oral treatment totalling 10 weeks. The pain improved with IV treatment and a review at 8 weeks revealed complete resolution of pain and hypoglossal nerve palsy. Conclusion: Standard clinical or radiological parameters may not always be adequate to make a definitive diagnosis of MOE. In such setting, we advocate the use of PET CT scan as a complementary investigation to clinch the diagnosis

Malignant Otitis Externa: An Evolving Disease

Objectives: 1) Compare the clinical presentations and outcomes of patients with MOE caused by Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). 2) Recognize the evolving trend of atypical and drug-resistant organisms causing malignant otitis externa (MOE). Methods: A retrospective review of disease course and outcome was performed of patients diagnosed with MOE at a tertiary referral center between 1995 and 2012. Results: Forty-four patients with a diagnosis of MOE were identified. Eighteen patients were excluded due to insufficient or inconsistent clinical data, leaving 26 patients for analysis. Forty-six percent of patient cultures grew Pseudomonas and 12% grew MRSA. All patients infected with Pseudomonas had diabetes mellitus, compared to 33% of MRSA-infected patients ( P < 0.05). Twenty-five percent of Pseudomonas-infected patients presented with at least one cranial nerve palsy, as compared to none of the MRSA-infected patients (ns). Duration of therapy for Pseudomonas-infected patients lasted an average of 7.2 weeks, while MRSA-infected patients lasted 10 weeks (ns). Excluding failed initial treatment courses, the average treatment durations were 5.0 and 7.7 weeks for Pseudomonas and MRSA infections, respectively. Other atypical pathogenic organisms isolated in culture include Candida, Aspergillus, and Enterococcus species. Conclusions: Increasingly, MOE is being caused by organisms other than Pseudomonas, including MRSA. Empiric treatment, without culture, can lead to delays in definitive therapy. A high index of suspicion for atypical or drug resistant organisms should be maintained in MOE patients who are not diabetic. Culture directed therapy for treatment of MOE is paramount.

Malignant Otitis Externa

Malignant external otitis is a severe infection of the external auditory canal and skull base, which most often affects elderly patients with diabetes mellitus. This disease is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. Malignant otitis externa requires urgent diagnosis and treatment. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic and debridement necrotic tissue; sometimes, aggressive surgical management is done. We present our 5-year institutional experience in the management of this disease. The aim of this study was to present our experience with the management of malignant otitis externa. All patients' records with malignant otitis externa during the last 5 years (2007-2012) were retrieved and reviewed. Diabetes mellitus profile, erythrocyte sedimentation rate, ear swab for culture and sensitivity, computed tomography, and scintigraphy using technetium 99 and gallium 67 were investigated for all patients. During the last 5 years (2007-2012), 10 patients with the diagnosis of malignant otitis externa were admitted to our clinic for investigation and treatment. There were 7 men and 3 women, all between 64 and 83 years of age, with severe persistent otalgia, purulent otorrhea, granulation tissue in the external auditory canal, and diffuse external otitis, and there were 4 patients with facial nerve palsy. Nine patients were confirmed to have a diabetes, and 4 of these 9 cases just had chronic renal failure and underwent dialysis; the remainder 1 case had no diabetes mellitus, but with chronic renal failure on dialysis. Ear swabs for culture and sensitivity usually revealed Pseudomonas aeruginosa. Local debridement and local and systemic antibiotic treatment were sufficient to control the disease. Facial nerve decompression was done in facial paralysis. Hyperbaric oxygen therapy was performed in facial nervy palsy cases. Malignant otitis externa is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic, debridement necrotic tissue, and sometimes aggressive surgical management. Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus, and improvement of computed tomography and radioisotope scanning.

Fungal Malignant Otitis Externa

Oral voriconazole is a viable alternative modality treatment to traditionally used intravenous vancomycin in the treatment of malignant otitis externa (MOE). The incidence of MOE is on the rise, more so in Saudi Arabia where diabetes mellitus is endemic. Although Pseudomonas aeruginosa is the most common offending organism, we are observing an increasing number of fungal MOE, in particular, Aspergillus species. The clinical findings in these patients can be quite different from those of the classic gram-negative bacteria. Chart review of patients with a diagnosis of MOE who underwent oral voriconazole treatment. Three cases of Aspergillus MOE are reported in detail, pointing the pitfalls in clinical findings, diagnosis, and management of this entity. Oral voriconazole proved to be an excellent alternative modality treatment in this population of patients with MOE.

Fungal Mastoiditis Masquerading as Malignant Otitis Externa and Presenting as Lateral Sinus Thrombosis

Patients/Materials and Methods: We report a case of an elderly diabetic man presenting with otalgia, facial nerve palsy, and ear discharge. Radiological investigations supported a diagnosis of malignant otitis externa. Following an initial response to treatment, he went on to develop a sixth nerve palsy and a lateral sinus thrombosis. Histology following surgical exploration identified invasive fungal mastoiditis.

Malignant otitis externa or malignancy: Report of two cases

Objectives To demonstrate the importance of detailed clinical analysis in the differential diagnosis of malignant otitis externa and to provide an update on the current diagnostic tools available. Case reports Two cases with malignancy presenting as otitis externa are reported. Both were treated initially with antibiotics; but failed to settle. CT scanning demonstrated lesions in the skull base in each case. Histology revealed two different and rare types of tumour. Conclusions Patients with unresponsive otitis externa require imaging; and clinicians should be alert to other conditions that may mimic otitis externa.

Radiological and radionuclide investigation of malignant otitis externa

This study looks at case series of malignant otitis externa, outlines detailed structural (radiological) and functional (radionuclide) investigations, and discusses their utility in the initial diagnosis, patient management and follow up of this condition. Patients were investigated by computerized tomography (CT), magnetic resonance imaging (MRI), two-phase planar and single-photon emission tomography (SPECT), technetium-99m methylenediphosphonate bone scans, gallium-67 planar and SPECT scans, and indium-111 or technetium-99m labelled WBC planar and SPECT scintigraphy. We discuss example case reports with the various radiological and scintigraphic findings and outline a protocol for rational investigation. It is concluded that CT and/or MRI should be supported by routine SPECT bone imaging for initial diagnosis of malignant otitis externa. Routine SPECT bone imaging further supplemented by gallium scintigraphy should be the investigation of choice in the follow up of these cases for assessing response to treatment and disease recurrence.

Radiological and radionuclide investigation of malignant otitis externa

Objectives: This study looks at case series of malignant otitis externa patients and outlines the detailed structural (radiological) and functional (radionuclide) investigations and discusses their utility in the initial diagnosis, patient management, and follow-up. Methods: Three case examples were scrutinized. The patients were investigated by computerized tomography (CT), magnetic resonance imaging (MRI), two-phase planar and Single Photon Emission Tomography (SPECT) technetium-99m MDP bone scans, gallium-67 planar and SPECT scans, and Indium-111 or technetium-99m labelled WBC planar and SPECT scintigraphy. Results: A CT scan should be performed to determine the anatomical extent of the disease and to look for any other pathology. The MRI should be done if there is any suspicion of skull base involvement, eg, cranial nerve palsies. SPECT technetium bone scan should be performed if the CT scan is negative but the index of suspicion remains. A technetium bone scan should be performed after the completion of the course of antibiotics. If the bone scan is still positive but the infection deemed to have resolved from clinical assessment, then a SPECT gallium scan should be done. Conclusion: It is concluded that CT and/or MRI should be supported by routine SPECT bone imaging for initial diagnosis of malignant otitis externa. Routine SPECT bone imaging further supplemented by gallium scintigraphy should be the investigation of choice in the follow-up of these cases for assessing the response to treatment and disease recurrence.

Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa.

To determine whether there has been an increase in ciprofloxacin-resistant pseudomonas malignant otitis externa, and if this has increased the morbidity of the disease. Retrospective. Tertiary referral center. Twenty-eight patients over 13 years. The records of a total of 28 patients who were admitted between 1988 and 2001 with the diagnosis of malignant otitis externa were reviewed. Seven patients had ciprofloxacin-resistant pseudomonas on their hospital culture and sensitivity test. Five of the 7 resistant cases appeared in the last 3 years, as opposed to 2 of the 7 who appeared in the 10 years before that period. In our series, there is a significant trend developing over time of pseudomonas resistant to treatment with ciprofloxacin. No increased morbidity or mortality was found in the ciprofloxacin-resistant pseudomonas group compared with the remaining patients who were sensitive to ciprofloxacin. In our series, resistance to ciprofloxacin in patients with malignant otitis externa is increasing over time. This may have an impact on the relatively successful outpatient treatment of these patients in the past decade. A return to inpatient or outpatient intravenous treatment with third-generation cephalosporins/antipseudomonal penicillins and more frequent debridement will be required in these patients.

Malignant Otitis Externa in AIDS Patients: Case Report and Review of the Literature

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.