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Malignant otitis externa.

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An 84-year-old woman was referred by an outside otolaryngologist for evaluation of a persistent left ear canal polyp. The referring otolaryngologist had excised the polyp on several occasions with recurrences each time. The patient initially presented with a 10week history of severe left otalgia described as sharp and shooting, which was more noticeable at night. She complained of a small amount of yellowish to bloody drainage from the left ear and worsening left-sided hearing loss for the preceding year. She denied tinnitus, vertigo, and imbalance. She had no history of otitis media, otologic trauma, or a family history of ear disease. She did not have any cranial nerve deficits. Her medical history was significant for insulin-dependent diabetes requiring insulin twice per day.

Examination of the left ear revealed a large, epithelialized granulation tissue polyp on the posteroinferior aspect of the cartilaginous external auditory canal (EAC) with some keratin trapping medial to it (figure 1). The tympanic membrane was thickened and somewhat hemorrhagic in appearance but was otherwise intact. There was no evidence of cholesteatoma. The Weber test was nonlocalizing, and the Rinne test was positive on the right and equivocal on the left. Audiometry showed progressively down-sloping, moderately severe to profound, mixed hearing loss with only 8% speech discrimination in the left ear.

Computed tomography (CT) showed partial opacification of the left mastoid air cells and middle ear cavity and thickening of the left tympanic membrane and skin of the left EAC. Gallium and technetium nuclear scans were urgently ordered, which revealed focal uptake in the left inferior temporal bone.

Based on the severe otalgia, recurring granulation tissue, history of insulin-dependent diabetes, and nuclear imaging findings, the patient was diagnosed with ma lignant otitis externa (MOE). She was prescribed ciprofloxacin 750 mg by mouth twice per day with the intention of initiating intravenous antibiotics. By the time of her delayed follow-up 5.5 weeks later, she had already experienced dramatic improvement of her pain.

Microscopic examination of the left ear at the follow-up visit revealed a dramatic reduction in the granulation tissue at the bony-cartilaginous junction (figure 2). Therefore, it was decided to continue oral antibiotic treatment for a total of 6 weeks. Two months after the patient completed her course of antibiotics, otoscopy showed complete resolution of the polyp (figure 3). She was seen again 2 months later; she reported no pain at that time, and her left EAC remained clear.

MOE is a severe, progressive bacterial infection of the EAC that leads to osteomyelitis of the skull base, usually caused by Pseudomonas aeruginosa. MOE typically affects elderly diabetics but can also be seen in severely immunocompromised individuals. It commonly presents with severe otalgia and purulent otorrhea. In addition to osteomyelitis of the temporal bone, cranial nerve palsies and septic thromboembolism can result. (1) The diagnosis of MOE is made using patient history, the presence of granulation tissue in the EAC, an elevated erythrocyte sedimentation rate, and increased uptake in the temporal bone on nuclear imaging. (2)

The treatment of uncomplicated MOE is medical, consisting of systemic antibiotics. The advent of antipseudomonal antibiotics has significantly reduced the mortality of this disease since its first description in 1968.3 Intravenous aminoglycosides and semisynthetic penicillins were the original mainstays of treatment. Although effective, they required prolonged hospitalization and caused increased morbidity from side effects, including nephrotoxicity and ototoxicity. Since its development, oral ciprofloxacin has largely replaced intravenous therapy for management of uncomplicated MOE.

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Ciprofloxacin can achieve high concentrations in bone and soft tissues and is efficacious for initial outpatient therapy in patients without intracranial spread or cranial nerve disease. (4) Oral ciprofloxacin has been shown to be effective as (1) monotherapy, (2) in conjunction with rifampin, or (3) as adjunctive therapy following a full course of aminoglycoside and semisynthetic penicillin therapy. (4)

Drug resistance of Pseudomonas to ciprofloxacin is an emerging problem. Approximately one-third of isolates have been reported to be resistant to this drug. (5) Resistance is facilitated by the widespread use of ciprofloxacin for upper respiratory infections and other otologic infections. (5) Some have suggested that development of ciprofloxacin resistance by Pseudomonas can be prevented by reserving the use of quinolones for resistant or invasive infections. (2,5)

References

(1.) Omran AA, El Garem HF, Al Alem RK. Recurrent malignant otitis externa: Management and outcome. Eur Arch Otorhinolaryngol 2012;269(3):807-11.

(2.) Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face of malignant (necrotising) external otitis: Clinical, radiological, and anatomic correlations. Lancet Infect Dis 2004;4(l):34-9.

(3.) Chandler JR. Malignant external otitis. Laryngoscope 1968;78(8):1257-94.

(4.) Levenson MJ, Parisier SC, Dolitsky J, Bindra G. Ciprofloxacin: Drug of choice in the treatment of malignant external otitis (MEO). Laryngoscope 1991;101(8):821-4.

(5.) Berenholz L, Katzenell U, Flarell M. Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa. Laryngoscope 2002;112(9):1619-22.

From the Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.
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Title Annotation:OTOSCOPIC CLINIC
Author:Fang, Christina H.; Sun, James; Jyung, Robert W.
Publication:Ear, Nose and Throat Journal
Article Type:Brief article
Geographic Code:9INDI
Date:Apr 1, 2015
Words:833
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