Malignant Otitis Externa: A Risky Business
30 September 2019 (online)
Introduction Malignant otitis externa or necrotizing otitis externa or skull base osteomyelitis is an invasive infection in the external auditory canal and skull base where the patient presents with excessive purulent ear discharge associated with severe ear pain with or without cranial nerve involvement. The most common cranial nerve to be involved is the facial nerve.
Case Presentation A 70-year-old diabetic man came with complaints of severe left ear pain and left ear discharge for 2 months and headache and facial deviation for 1 week. On examination, he had tenderness over the tragus and pain on pulling the auricle. External auditory canal was edematous and granulation present. Deviation of angle of mouth toward right was noted. Minimal palsy of left side of soft palate was noticed. Computed tomography showed irregular lytic destruction in the left middle ear. We managed the patient with diabetic control, and broad-spectrum antibiotics through oral, intravenous, and topical routes. Patient was symptomatically feeling better.
Discussion Toulmouche in 1838, was the first to report a case of malignant external otitis. In 1968, Chandler described an aggressive clinical behavior, poor treatment outcome, and a high-mortality rate for the patients affected by this disease. MOE is an aggressive infection in the external auditory canal. It is more common in elderly males with uncontrolled diabetics. Imaging, like computed tomography, magnetic resonance, technetium bone scanning, and radioisotope scanning, helps in confirming diagnosis and extend of spread. Treatment is aggressive medical therapy with pseudomonal coverage. Early infections may be treated with an oral fluoroquinolone (ciprofloxacin), except for resistant organisms. More advanced cases may require parenteral antibiotics with diabetes control and regular follow-up. Hyperbaric oxygen therapy has been used as an adjunct to medical therapy. Surgical debridement of nonviable sequestra of bone is also done.
Conclusion The symptoms and line of management vary with stage at which we diagnose. The earlier it is diagnosed the better the prognosis. As it is a bone eating disease of skull base, it has all the dangers involved and thus requires an aggressive and quick treatment.