Severe Otalgia Research Articles

Facial nerve paralysis as first sign of metastatic breast cancer to the temporal bone

Introduction. Facial nerve paralysis originates from various factors, although in most cases etiology is idiopathic. Temporal bone metastases are quite rare, but should still be suspected in cases when congenital disorders, inflammatory disease, infection or trauma are excluded as cause of facial palsy. We present an unusual case of facial nerve paralysis as the initial sign of temporal bone metastasis of breast carcinoma and discuss diagnostic pitfalls. Case outline. A 70-year-old patient presented with facial nerve palsy, severe otalgia, hearing loss and vertigo. Patient underwent steroid treatment 6 months earlier due to peripheral facial palsy with complete neurological resolution. CT scan revealed osteolytic lesion of the right temporal bone with extension into the parietal bone and soft-tissue. Additional examination confirmed ductal breast carcinoma and osteolysis of the ribs and vertebrae. After four months, the patient with metastatic breast carcinoma to the temporal bone died despite chemotherapy. Conclusion. Temporal bone metastasis of breast cancer is very rare condition with poor prognosis. Late diagnosis and inadequate management of breast cancer are factors that contribute to the temporal bone metastasis formation. Temporal bone metastasis should be excluded in elderly patients, both with and without any history of malignancy, especially in cases of peripheral facial palsy refractory to treatment.

Intractable Methicillin-Resistant Staphylococcus Aureus Otorrhea with Silicone Impression in the Middle Ear.

We report a case of methicillin-resistant Staphylococcus aureus (MRSA) otorrhea with impression material of hearing aid in the middle ear. The patient had chronic otitis media in the right ear with sensorineural hearing loss in both ears. The silicone flowed into the middle ear through a tympanic membrane perforation during the process of making an ear mold. Several days after hearing aid fitting, the patient had severe otalgia, intractable otorrhea, aggravated hearing loss, and dizziness. The pus culture and sensitivity test revealed MRSA. After topical treatment using diluted vinegar irrigation and ototopical vancomycin solution, intractable otorrhea was controlled. The infected silicone impression was removed by canal wall-up mastoidectomy, and hearing was saved. We present here a review of the literature regarding silicone impression in the middle ear after hearing aid mold fitting.

Necrotizing Otitis Externa: A Disease Barely Known to Neurosurgeons

AbstractNecrotizing otitis externa (NOE), also known as malignant otitis externa (MOE), is a severe and rare infectious disease of the external auditory canal (EAC). Without treatment, it may progress to skull base involvement. The bacteria Pseudomonas aeruginosa is the most common causative agent (∼ 90% of the cases), and affects immunocompromised subjects, particularly diabetic patients. Severe chronic otalgia, otorrhea, and cranial nerve palsy are the most common clinical presentations. Patients with NOE are frequently referred to neurosurgery because of the neurological impairment and skull base compromise. The definitive diagnosis is frequently elusive, requiring a high index of suspicion. Several laboratorial tests, imaging modalities, and the histologic exclusion of malignancy may be required. An early diagnosis and aggressive treatment reduce morbidity and mortality. We present four NOE cases to illustrate the spectrum of clinical presentation and complementary exams. According to the literature, more effort for early diagnosis and treatment is required, and neurosurgeons play an important role in this task.

A case of herpes zoster oticus with multiple cranial nerve palsy

Herpes zoster oticus (HZO) otherwise called as Ramsay Hunt syndrome is a rare complication due to reactivation of the herpes zoster virus in the geniculate ganglion of facial nerve presenting with vesicular eruptions over external ear along with severe otalgia and LMN type of 7th cranial nerve palsy. This syndrome often misdiagnosed because of absence of these symptoms. About 12% of all peripheral facial nerve palsies are caused by varicella zoster virus. The occurrence rate of associated cranial polyneuropathy has been reported to be 1.8-3.2% and cranial nerves VII, VIII, IX and X are the ones most commonly affected. Here, we present a case of Ramsay Hunt syndrome with cranial polyneuropathy. The patient was treated with antiviral and oral steroid and the symptoms were improved.

Management of acute otitis media in children six months of age and older.

Acute otitis media (AOM) continues to be a common infection in young children. Milder disease, usually due to viruses or less virulent bacteria, resolves equally quickly with or without antibiotics. A bulging tympanic membrane, especially if yellow or hemorrhagic, has a high sensitivity for AOM that is likely to be bacterial in origin and is a major diagnostic criterion for AOM. Perforation of the tympanic membrane with purulent discharge similarly indicates a bacterial cause. Immediate antibiotic treatment is recommended for children who are highly febrile (≥39°C), moderately to severely systemically ill or who have very severe otalgia, or have already been significantly ill for 48 h. For all other cases, parents can be provided with a prescription for antibiotics to fill if the child does not improve in 48 h or the child can be reassessed if this occurs. Amoxicillin remains the clear drug of choice. Ten days of therapy is appropriate for children <2 years of age, whereas older children can be treated for five days.

Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner.

.On the basis of research evidence, a recommended strategy for improving the care of middle ear infections is to identify the subset of patients least likely to benefit from antibiotic therapy. They include children ages 6 months to 23 months with unilateral disease without severe signs and symptoms (moderate or severe otalgia, otalgia lasting more than 48 hours,or temperature of 39°C [102.2°F]), and those older than 2 years ofage with unilateral or bilateral disease who have mild signs andsymptoms.(9) On the basis of research evidence, the initial treatment of otitis media with effusion is watchful observation. There is little harm in observing a child who is not at risk for speech, language, or learning difficulties compared to medical or surgical intervention.(4) On the basis of research evidence, administration of the annual influenza vaccine and the conjugated pneumococcal vaccination has been shown to have a small but statistically significant impact on the frequency of middle ear disease. (7)(8) On the basis of expert opinion, optimal outcomes depend oncommunication between clinicians and parents. At a minimum , primary care clinicians should state their reasons for their own clinical judgment about appropriate management and for referral to otolaryngology if necessary.

Skull Base Osteomyelitis Presenting with Facial Paralysis, Low Cranial Nerve Palsies and Bilateral Carotid Involvement: A Case Report

Ad dress for Cor res pon den ce/Ya z›fl ma Ad re si: Murat Mert Atmaca MD, Istanbul University Faculty Of Medicine, Department Of Neurology, Istanbul, Turkey Phone: +90 212 414 20 00-32578 E-mail: drmuratmertatmaca@hotmail.com Re cei ved/Ge lifl Ta ri hi: 27.09.2013 Ac cep ted/Ka bul Ta ri hi: 16.05.2014 Skull base osteomyelitis (SBO) typically presents with severe otalgia and unilateral otorrhea in immune-compromised, particularly in elderly diabetic patients. Skull base osteomyelitis usually presents with external otitis but it can also occur as a complication of acute otitis media and mastoiditis. Complications of SBO are venous sinus thrombosis, meningitis, abscess, cranial neuropathies and carotid invasion with or without ischemic stroke. Here we report a case with SBO presenting with facial paralysis, lower cranial nerve palsies and bilateral carotid involvement which occurred following sore throat and bilateral otalgia. (Turkish Journal of Neurology 2015; 21:27-30)

Surgical Resection of a Small Cell Carcinoma Primary Tumor of the Parotid Gland with Perineural and Skull Base Involvement

Background: One of the rarest tumors of the parotid gland is a Small Cell Carcinoma (SmCC) of neuroendocrine or ductal origin. These lesions tend to be aggressive, often invading bone and nerve and carry a grave prognosis for the patient. Presently there is no standardized treatment protocol and no consensus to tumor management. Case Report: This case report is of a 70 year-old male with a right-sided facial mass, facial pain, severe otalgia, weight loss, and right-sided facial paralysis. Subsequent imaging and Fine Needle Aspiration (FNA) revealed T4aN2bM0 SmCC of the parotid gland with facial nerve enhancement and skull base erosion. The patient underwent major extirpative surgery including radical neck dissection, total parotidectomy with facial nerve resection and cable graft, and partial temporal bone resection as the initial step in a combined modality therapy The patient has done very well post-operatively. Conclusion: This case report describes the successful, aggressive surgical management of locally and regionally advanced SmCC of the parotid gland. Although the prognosis for patients with SmCC of the parotid gland is typically grave, the absence of distant metastatic disease in the presented case provided the rationale for an aggressive surgical approach with a curative, rather than palliative, focus.

Air travellers' awareness of the preventability of otic barotrauma.

Otic barotrauma is common among air travellers and can cause severe otalgia, perforation of the tympanic membrane and hearing loss. Many prevention measures exist, with varying evidence to support their use. There are no data to establish if air travellers are aware of them or indeed use them. We aimed to establish air travellers' knowledge of such prevention measures. We surveyed air travellers at two UK airports by means of a questionnaire. Answers to the questionnaire were collected over a two-week period. Overall, 179 air travellers with a mean age of 28 years (range: 15-72 years) completed the questionnaire. There were 66 female and 113 male air travellers. The majority (84 per cent) complained of symptoms while flying and 30 per cent were not aware of any prevention measures. Barotrauma-related symptoms were reported in 25 per cent of air travellers who were unaware of any prevention measures. Nearly all air travellers (86 per cent) indicated that more information regarding prevention measures would be useful. Air travellers are often not aware of prevention measures to avoid otic barotrauma, and the majority suffer as a result. Increasing public awareness of simple prevention measures would have a significant impact on air travellers.

Acute Otitis Media

Two-thirds of all children have an episode of acute otitis media (AOM) before their third birthday. Antibiotic treatment is often given immediately, even though adequate scientific evidence for this practice is lacking. This review is based on a selective literature search including previously published evidence-based recommendations, particularly those of the current American guidelines. A purulent tympanic effusion, possibly associated with inflammation of the tympanic membrane, is indicative of AOM. Only some patients with AOM need immediate antibiotic treatment: children with severe otalgia and/or fever of 39.0°C or above, infants under 6 months of age, and children with certain specific risk factors, including immune deficiency and Down syndrome. In other cases, symptomatic treatment is appropriate. Antibiotic therapy (preferably with amoxicillin) should be initiated only if the symptoms and signs do not improve within two to three days. As the currently available data are not fully consistent, there is still a need for controlled trials with well-defined endpoints to determine the relative benefits of immediate antibiotic treatment versus two to three days of watchful waiting.

Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study

Objective To document whether elements of a structured history and examination predict adverse outcome of acute sore throat.Design Prospective clinical cohort.Setting Primary care.Participants 14 610 adults with acute sore throat...

Carcinoma Middle Ear with Facial Nerve Palsy and Temporal Lobe Abscess

Carcinoma of middle ear is very rare condition being one in 20,000 new patients. The commonest primary middle ear malignancy is usually squamous cell carcinoma. A 36-year-male presented with right sided severe earache with blood stained aural discharge, associated with headache and deviation of angle of the mouth to the opposite side. He had ear discharge since childhood. On examination he had bleeding polypoidal mass in the right external auditory canal &amp; tympanic membrane was not visualized. He also had features of facial nerve palsy. CT scan of brain finding was chronic right mastoiditis &amp; right temporal lobe abscess causing significant mass effect. The patient was undergone Burr-hole operation. After 2 weeks right radical mastoidectomy was done. There was huge granulation tissue involving middle ear, attic &amp; mastoid antrum and ossicles was eroded. Histopathology report revealed infiltrating squamous cell carcinoma grade-I. The patient was sent for radiotherapy &amp; asked for follow up monthly. In long standing chronic suppurative otitis media with blood stained discharge &amp; facial nerve palsy, middle ear malignancy should be suspected. Anwer Khan Modern Medical College Journal Vol. 4, No. 2: July 2013, Pages 49-51 DOI: http://dx.doi.org/10.3329/akmmcj.v4i2.16943

Bullous myringitis: A cause of hearing loss

Bullous myringitis is defined by the presence of blisters on the tympanic membrane which has generally a severe otalgia as a first symptom of presentation. This clinical picture sometimes may be accompanied by sensori-neural hearing loss. In this study, we aimed to share visual content of a patient with Bullous myringitis admitted to the emergency department. A 24-year-old male patient complained of a right severe pain in the right ear and hearing loss was admitted to the emergency department. On physical examination the right tympanic membrane was oedematous, hyperaemic and blisters were seen. The patient was referred to ENT department for evaluation of hearing loss. Bullous myringitis with sensori-neural hearing loss in the right ear was diagnosed. For treatment, pain control and warm compression was recommended. Antibiotic therapy has been also planned for middle ear infection. ENT follow-up were planned for the assessment of hearing loss. Many microorganisms, especially viruses, m.pneumoniae, chlamydia may cause Bullous myringitis. In the literature bullous myringitis cases that admitted to ED with sensori-neural hearing loss have been reported. Diagnosis is made by clinical examination. Pain control and mild compression may be sufficient for treatment. If concomitant otitis media is present, antibiotics should be added to treatment.

Skull base osteomyelitis following a mastoidectomy

Skull base osteomyelitis is a rare but life-threatening condition that is characterized by osteitis of the temporal bone and skull base. Although skull base osteomyelitis is recognized as a rare complication of malignant external otitis or middle ear infection, it may also occur following a mastoidectomy. We present a case of an 81-year-old woman who suffered severe otalgia with normal-looking EAC and tympanic membrane that developed six weeks following a canal wall up mastoidectomy. Otalgia was the only abnormal feature to suspect occurrence of skull base osteomyelitis.

Middle Ear Carcinoma Masquerading as an Aural Polyp

Objective: To present a case of middle ear carcinoma masquerading as an aural polyp and describe our experience with the clinical presentation, management and outcome of an elderly patient with this pathology.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Public Hospital&#x0D; Patients: One&#x0D; Result: A 63-year-old female presented with an aural polyp and preceding symptoms of inner ear disturbances followed by otorrhea and otalgia. CT scans revealed an erosive lesion occupying the entire middle ear cleft, external ear canal and mastoid cavity with involvement of inner structures. A repeat biopsy subsequently revealed malignancy leading to a diagnosis of middle ear carcinoma. The patient was offered surgical treatment but opted for radiotherapy and subsequently defaulted follow-up.&#x0D; Conclusion: Middle ear carcinoma is rare and can masquerade as a benign aural polyp. Symptoms of severe otalgia and inner ear disturbances are indicators of possible malignancy, as are recent-onset symptoms of otitis media developing over a relatively short course later in life. A high index of suspicion is needed to avoid late diagnosis. Repeat deeper aural tissue biopsy is needed to exclude malignancy. Computed tomography imaging is indispensable in delineating tumor extent and aids in tumor staging as well as prognostication. Surgical resection with clear tumor margins, followed by postoperative radiotherapy, is the preferred choice of treatment. Sole radiotherapy is reserved for tumors of small volume as well as in cases where surgery is not feasible.&#x0D; Keywords: Middle ear carcinoma; aural polyp; temporal bone carcinoma&#x0D;

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.

Skull base osteomyelitis: current microbiology and management

Skull base osteomyelitis typically presents in an immunocompromised patient with severe otalgia and otorrhoea. Pseudomonas aeruginosa is the commonest pathogenic micro-organism, and reports of resistance to fluoroquinolones are now emerging, complicating management. We reviewed our experience of this condition, and of the local pathogenic organisms. A retrospective review from 2004 to 2011 was performed. Patients were identified by their admission diagnostic code, and computerised records examined. Twenty patients were identified. A facial palsy was present in 12 patients (60 per cent). Blood cultures were uniformly negative, and culture of ear canal granulations was non-diagnostic in 71 per cent of cases. Pseudomonas aeruginosa was isolated in only 10 (50 per cent) cases; one strain was resistant to ciprofloxacin but all were sensitive to ceftazidime. Two cases of fungal skull base osteomyelitis were identified. The mortality rate was 15 per cent. The patients' treatment algorithm is presented. Our treatment algorithm reflects the need for multidisciplinary input, early microbial culture of specimens, appropriate imaging, and prolonged and systemic antimicrobial treatment. Resolution of infection must be confirmed by close follow up and imaging.

Necrotizing Otitis Externa

Objective: Evaluate the cases of necrotizing otitis externa (NOE) with regard to gender, mean age, comorbidities, clinical presentation, involvement of cranial nerve and its resolution, isolated germs at culture of swabs or biopsies of EAM, and findings at image evaluation. Method: The patient presented severe otalgia, auricular plenitude and right peripherical facial palsy. He submitted to a swab test and also to a biopsy of the external auditory meatus. Other examinations were requested: a complete blood count, C-reactive protein, a mastoid computer tomography, and mastoid scintigraphy. Results: Ten patients were evaluated, 4 of them were women and 6 men. All of them had type II diabetes. The most common initial finding was external meatus polyps (90% of the cases), followed by cranial nerve palsy (50% of the cases). There was complete remission of that palsy in 51% of the cases, incomplete remission in 16%, and no remission in 33% after treatment. In most of the cases, Pseudomonas aeruginosa was found (60%). Mastoid and external auditory meatus alterations were the most common disturbance in computed tomography. Conclusion: This case reports a patient with a cellular immunosuppression disease which appeared to have an NOE complicated by cranial nerve paralysis based on his clinical picture and complementary evaluation except for the scintigraphy study. The histopathological analysis revealed a neoplastic etiology for the ear involvement.

Pathology Quiz Case 1

A 61-YEAR-OLD MAN PRESENTED WITH SEvere otalgia and otorrhea. He had a 35year history of right-sided intermittent otorrhea, aural fullness, and tinnitus and a 3-month history of decreased balance. Topical and systemic antibiotic therapy was initiated, but his symptoms persisted, and new symptoms of severe facial pain and fever developed. He had no history of immunocompromise. Physical examination revealed an edematous, mildly erythematous right external auditory canal, with purulent discharge obscuring the tympanic membrane. There was no pain with movement of the pinna. Temperature, light touch, and sharp and dull stimuli were reduced in the right trigeminal distribution. Audiometric testing showed a down-sloping, moderate to profound mixed hearing loss in the patient’s right ear. Computed tomography of the temporal bone with intravenous contrast showed opacification of the right middle ear, sclerotic mastoid with erosion of the carotid canal adjacent to the eustachian tube, and a peripherally enhancing low-density petrous apex collection (Figure1). Gadolinium-enhanced magnetic resonance imaging also demonstrated a low-signal focus in the right petrous apex, with enhancement and thickening of the cisternal portion of the right trigeminal nerve and meninges of the posterior clivus and sphenoid wing (Figure 2). Hematoxylin-eosinstainingofbiopsyspecimensofgranulomatous tissue from the protympanum and petrous apex demonstratedacuteandchronicallyinflamedciliatedcolumnarepitheliumandgranulation tissue(Figure3).GrocottGomori methenamine-silver nitrate staining (Figure 4) showedaggregatesofgram-positive filamentousbacteria in entangledmasses focallybreakingup intococcoidandbacillary forms.Cultures identifiedProteusmirabilis,Enterococcus avium, and multiple strains of Corynebacterium species with sensitivity to ciprofloxacin. What is your diagnosis?

Internal-Carotid-Artery Dissection and Cranial-Nerve Palsies

A 45-year-old woman presented to the emergency department 3 days after the acute onset of severe dysphagia, breathy dysphonia, and earache and pulsatile tinnitus in the left ear. Her medical history was unremarkable. Physical examination revealed leftward deviation of the protruded tongue that was consistent with a lesion in cranial nerve XII, hypernasal speech and rightward deviation of the soft palate on phonation that was consistent with lesions in cranial nerves IX and X, and a paralyzed left vocal cord detected on laryngoscopic examination that was consistent with a lesion in cranial nerve X (see video). Axial magnetic resonance images . . .