Necrotizing Otitis Externa: A Disease Barely Known to Neurosurgeons

Abstract

Necrotizing 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.

Resumo

Otite externa necrotizante (OEN), também conhecida como otite externa maligna (OEM), é uma doença infecciosa grave do conduto auditivo externo. Sem o tratamento adequado, pode progredir com acometimento da base do crânio. A bactéria Pseudomonas aeruginosa é o agente etiológico mais comum (∼ 90% dos casos), e afeta pacientes imunocomprometidos, principalmente diabéticos. Otalgia crônica severa, otorreia, e déficit em nervos cranianos são as apresentações clínicas mais comuns. Pacientes com OEN frequentemente são encaminhados ao neurocirurgião devido ao déficit neurológico e ao comprometimento da base do crânio. O diagnóstico é complexo e exige alto índice de suspeição. Diversos exames laboratoriais, de imagem e exclusão por histologia de neoplasia podem ser necessários. O tratamento precoce e agressivo reduz a morbimortalidade. Apresentamos quatro casos de OEN para ilustrar o espectro de apresentação clínica e exames complementares. De acordo com a literatura, é necessário mais empenho para o diagnóstico e o tratamento precoce, e o neurocirurgião tem importante papel nessas tarefas.

Keywords

otitis externa - malignant otitis - necrotizing otitis - diagnosis - cranial base osteomyelitis - treatment

Palavras-chave

otite externa - otite maligna - otite necrotizante - diagnóstico - osteomielite da base do crânio - tratamento

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