Recurrent malignant otitis externa with multiple cranial nerve involvement: A case report

Introduction. Necrotizing otitis externa is a rare but conditionally fatal infection of external auditory canal with extension to deep soft tissue and bones, resulting in necrosis and osteomyelitis of the temporal bone and scull base. This condition is also known as malignant otitis due to an aggressive behavior and poor treatment response. Early diagnosis of malignant otitis is a difficult challenge. We present an illustrative case of necrotizing otitis externa and suggest some strategies to avoid diagnostic and treatment pitfalls. Case Outline. A 70-year-old patient presented with signs of malignant otitis externa, complicated by peripheral facial palsy. Adequate diagnostic and treatment procedures were performed with clinical signs of resolution. The recurrence of malignant infection had presented three months after previous infection with multiple cranial nerve neuropathies and signs of jugular vein and lateral sinus thrombosis. An aggressive antibiotic treatment and surgery were carried out, followed by substantial recovery of the patient and complete restoration of cranial nerves? functions. Conclusion. Necrotizing otitis externa is a serious condition with uncertain prognosis. The suspicion of malignant external otitis should be raised in cases of resistance to topical treatment, especially in patient with predisposing factors. Evidence-based guideline for necrotizing otitis externa still doesn?t exist and treatment protocol should be adjusted to individual presentation of each patient.

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Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges in Atypical Presentation

Otolaryngology ◽

10.1016/j.otohns.2005.03.024 ◽

2005 ◽

Vol 133 (1) ◽

pp. 121-125 ◽

Cited By ~ 53

Author(s):

Amar Singh ◽

Mazin Al Khabori

Keyword(s):

Skull Base ◽

Cranial Nerve ◽

Otitis Externa ◽

Cranial Nerves ◽

Contralateral Side ◽

Lateral Sinus ◽

Skull Base Osteomyelitis ◽

Atypical Symptoms ◽

Malignant Otitis Externa ◽

Atypical Manifestations

OBJECTIVE: We sought to document the diagnostic and management difficulties in masked skull base osteomyelitis secondary to malignant otitis externa, with emphasis on establishing diagnostic criteria in recurrence. STUDY DESIGN: Retrospective analysis of 3 cases of inadequately treated malignant otitis externa in elderly diabetic individuals leading to recurrence and atypical manifestations of skull base osteomyelitis on contralateral side with or without multiple cranial nerve involvement. RESULTS: Two of the 3 cases died of the disease despite aggressive treatment. One case was treated successfully with combination of antipsuedamonal microbial drugs for 8 to 12 weeks and hyperbaric oxygen therapy. Major complications such as thrombosis of lateral sinus and internal jugular vein, meningitis, ophthalmoplegia, blindness, cervical spine erosion and paralysis of all cranial nerves with exception of Ist cranial nerve were observed. CONCLUSION: There is high morbitity and mortality associated with skull base osteomyelitis. In partially treated cases of malignant otitis externa, atypical symptoms and findings of unilateral severe otalgia, unremitting headache, and presence of high ESR, unilateral OME, constitute diagnostic clues of skull base osteomyelitis. Such cases require further investigation with CT, MRI, Technetium 99 and gallium 67 scintigraphy and aggressive management.

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Comprehensive management of malignant otitis externa with tuberculosis and cranial nerve paresis in geriatrics

Oto Rhino Laryngologica Indonesiana ◽

10.32637/orli.v50i1.355 ◽

2020 ◽

Vol 50 (1) ◽

pp. 77

Author(s):

Ratna Dwi Restuti

Keyword(s):

Diabetes Mellitus ◽

Temporal Bone ◽

Cranial Nerve ◽

Cranial Nerve Palsy ◽

Otitis Externa ◽

Nerve Palsy ◽

Geriatric Patients ◽

Cranial Nerve Palsies ◽

Malignant Otitis Externa ◽

Multiple Cranial Nerve

Background: Malignant otitis externa is an inflammatory condition of the external ear which has the propensity to spread to the skull base. It can be a difficult entity to treat as clinical presentation varies and response to treatment differs between patients. Purpose: Evaluating the management of malignant otitis externa with complications in geriatric patients who had multiple comorbidities. Case: A 71 years old female with a diagnosis of left malignant otitis externa with complications of multiple cranial nerve palsies (N.VII, IX, X) and comorbidity in the form of diabetes mellitus and chronic kidney disease. The patient underwent subtotal temporal bone resection and petrosectomy. Clinical Question: “Could surgical management of malignant otitis externa with cranial nerve palsies complication in geriatric patients with multiple comorbidities achieve better result than conservative treatment?” Review Method: Literature search using keywords ’malignant otitis externa’ OR ’temporal bone osteomyelitis’ AND ’geriatric’ OR ’elderly’ AND ’multiple cranial nerve palsy’ AND ’diabetes mellitus’ AND ’tuberculosis’ AND ’surgery’ OR ’surgical’ was conducted through Cochrane, Pubmed, and Google Scholar. Result: The search obtained 11 articles published in the last 10 years. Selection based on inclusion and exclusion criteria, 2 studies were found relevant with the topic. Conclusion: Management of malignant otitis externa with complications in geriatric patients with multiple comorbidities requires a multidisciplinary approach to determine the need for surgery intervention.Keywords: malignant otitis externa, cranial nerve palsy, subtotal temporal bone resection, geriatric, diabetes mellitus ABSTRAK Latar belakang: Otitis eksterna maligna adalah suatu kondisi peradangan pada telinga luar yang memiliki kecenderungan untuk meluas hingga ke dasar tengkorak. Penyakit ini menjadi sulit ditangani karena manifestasi klinis yang bervariasi dan respons terhadap pengobatan yang berbeda antara pasien. Tujuan: Mengevaluasi tatalaksana otitis eksterna maligna dengan komplikasi pada pasien geriatri yang memiliki komorbiditas multipel. Kasus: Pasien perempuan 71 tahun dengan diagnosis otitis eksterna maligna telinga kiri dengan komplikasi paresis saraf kranial multipel (n.VII, IX, X) dan penyakit penyerta berupa diabetes melitus dan gagal ginjal kronik. Pasien menjalani operasi reseksi tulang temporal subtotal dan petrosektomi. Pertanyaan klinis: “Apakah tatalaksana pembedahan memberikan hasil yang lebih baik dibandingkan terapi konservatif pada pasien geriatri dengan otitis eksterna maligna disertai paresis saraf kranialis dengan komorbiditas multipel.” Telaah Literatur: Dilakukan menggunakan kata kunci ’malignant otitis externa’ ATAU ’temporal bone osteomyelitis’ DAN ’geriatric’ ATAU ’elderly’ DAN ’multiple cranial nerve palsy’ DAN ’diabetes melitus’ DAN ’tuberculosis’ DAN ’surgery’ ATAU ’surgical’ pada beberapa sumber data seperti Cochrane, Pubmed, dan Google Scholar. Hasil: Didapatkan 11 artikel publikasi 10 tahun terakhir. Berdasarkan kriteria inklusi dan eksklusi diperoleh 2 artikel yang relevan dengan topik. Kesimpulan: Tatalaksana otitis eksterna maligna dengan komplikasi pada pasien geriatri dengan komorbiditas multipel, membutuhkan pendekatan multidisiplin terutama untuk menentukan perlunya dilakukan tindakan pembedahan.

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A case of malignant otitis externa following mastoidectomy

The Journal of Laryngology & Otology ◽

10.1017/s0022215100157986 ◽

1999 ◽

Vol 113 (12) ◽

pp. 1095-1097 ◽

Cited By ~ 9

Author(s):

S. K. Patel ◽

D. W. McPartlin ◽

J. M. Philpott ◽

S. Abramovich

Keyword(s):

Granulation Tissue ◽

Cranial Nerve ◽

Otitis Externa ◽

Cranial Nerves ◽

Complete Recovery ◽

Jugular Bulb ◽

Intravenous Antibiotics ◽

Cranial Nerve Palsies ◽

Malignant Otitis Externa ◽

Nerve Paresis

AbstractWe present a case of a 63-year-old diabetic male who developed malignant otitis externa following mastoidectomy. Extensive skull base osteomyelitis caused thrombosis of the jugular bulb and subsequent paralysis of cranial nerves VII, IX, X and XII. Hewas treated aggressively with intravenous antibiotics and debridement of granulation tissue in the mastoid bowl with full recovery of the cranial nerve palsies associated with recanalization of the jugular bulb. We believe this is the first reported case of malignant otitis externa to occur following mastoidectomy with complete recovery of the cranial nerve paresis.

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Unusual presentation of idiopathic intracranial hypertension

BMJ Case Reports ◽

10.1136/bcr-2020-234741 ◽

2020 ◽

Vol 13 (5) ◽

pp. e234741

Author(s):

Ayman Alboudi ◽

Emily C Johnson

Keyword(s):

Intracranial Hypertension ◽

Lumbar Puncture ◽

Cranial Nerve ◽

Idiopathic Intracranial Hypertension ◽

Cranial Nerves ◽

Imaging Studies ◽

Sixth Cranial Nerve ◽

Orbital Pain ◽

Atypical Presentations ◽

Multiple Cranial Nerve

Idiopathic intracranial hypertension typically presents with holocephalic headache associated with nausea, vomiting and bilateral papilledema. Involvement of the sixth cranial nerve is relatively common. The involvement of other cranial nerves, however, is rare in this disorder. We describe a patient with idiopathic intracranial hypertension who presented with episodic unilateral retro-orbital pain and multiple cranial nerve abnormalities without papilledema. Imaging studies excluded alternate diagnoses, and the immediate resolution of symptoms after lumbar puncture confirmed that these symptoms were due to intracranial hypertension. Atypical presentations of such a disabling yet treatable disorder is very important to recognise and address.

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Tumors Presenting as Multiple Cranial Nerve Palsies

Case Reports in Neurology ◽

10.1159/000456538 ◽

2017 ◽

Vol 9 (1) ◽

pp. 54-61 ◽

Cited By ~ 4

Author(s):

Kishore Kumar ◽

Rafeeq Ahmed ◽

Bharat Bajantri ◽

Amandeep Singh ◽

Hafsa Abbas ◽

...

Keyword(s):

Cranial Nerve ◽

Nerve Palsy ◽

Systemic Disease ◽

Cranial Nerves ◽

B Cell Lymphoma ◽

Abducens Nerve ◽

Cranial Nerve Involvement ◽

Nerve Involvement ◽

Cranial Nerve Palsies ◽

Multiple Cranial Nerve

Cranial nerve palsy could be one of the presenting features of underlying benign or malignant tumors of the head and neck. The tumor can involve the cranial nerves by local compression, direct infiltration or by paraneoplastic process. Cranial nerve involvement depends on the anatomical course of the cranial nerve and the site of the tumor. Patients may present with single or multiple cranial nerve palsies. Multiple cranial nerve involvement could be sequential or discrete, unilateral or bilateral, painless or painful. The presentation could be acute, subacute or recurrent. Anatomic localization is the first step in the evaluation of these patients. The lesion could be in the brain stem, meninges, base of skull, extracranial or systemic disease itself. We present 3 cases of underlying neoplasms presenting as cranial nerve palsies: a case of glomus tumor presenting as cochlear, glossopharyngeal, vagus and hypoglossal nerve palsies, clivus tumor presenting as abducens nerve palsy, and diffuse large B-cell lymphoma presenting as oculomotor, trochlear, trigeminal and abducens nerve palsies due to paraneoplastic involvement. History and physical examination, imaging, autoantibodies and biopsy if feasible are useful for the diagnosis. Management outcomes depend on the treatment of the underlying tumor.

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Focal Peripheral Neuropathy Associated with Lymphoma in Dogs

Acta Scientiae Veterinariae ◽

10.22456/1679-9216.107461 ◽

2021 ◽

Vol 49 ◽

Author(s):

Paloma Helena Sanches Da Silva ◽

Gleidice Eunice Lavalle ◽

Bernardo De Caro Martins ◽

Bruna Voltolin De Sena ◽

Ana Luísa Fajardo Ferreira ◽

...

Keyword(s):

Computed Tomography ◽

Peripheral Neuropathy ◽

Trigeminal Nerve ◽

Cranial Nerve ◽

Nerve Palsy ◽

Cranial Nerves ◽

Clinical Signs ◽

Canine Lymphoma ◽

Neurological Signs ◽

Chemotherapy Protocol

Background: Peripheral neuropathies result in sensory, motor or autonomic dysfunctions due to impairment of peripheral spinal or cranial nerves. Neoplasms such as lymphoma are cited as one of the many aetiological causes and it may affect the nerve directly, by compression, or indirectly, or paraneoplastic, by remote action of the neoplasm located in an extra-neural site. This study aimed to report two cases of cranial nerve neuropathy (trigeminal and facial) associated with canine lymphoma, contributing to a better understanding of its paraneoplastic effects on the nervous system, as well as the diagnosis and treatment of these conditions.Cases: Two cases of canine lymphoma associated with possible signs of paraneoplastic peripheral neuropathy were attended at the Veterinary Hospital from the Universidade Federal de Minas Gerais (HV UFMG). Case 1. A spayed mixed breed bitch, with lethargy and unilateral exophthalmos. Brain computed tomography revealed a retrobulbar mass and cytology was diagnostic for extranodal lymphoma. Subsequent to computed tomography, the dog was presented with hypotrophy of the facial musculature and difficulty in grasping food, consistent with trigeminal nerve palsy, which resolved after institution of the 19-week chemotherapy protocol from the University of Wisconsin. Nevertheless, disease reccurred and a rescue protocol was initiated. Case 2. A female Dalmatian, spayed, was diagnosed with multicentric lymphoma, after cytology of the left mandibular lymph node. Chemotherapy was initiated with the same protocol of the previous case. However, the disease progressed and it was observed facial asymmetry with ptosis of the left eyelid, pina and lips, in addition to difficulty in grasping food, suggesting facial and trigeminal cranial nerve palsy. Clinical signs resolved after institution of a rescue chemotherapy protocol. However, in both cases, disease progression and poor clinical condition resulted in decision of euthanasia and necropsy was not authorized.Discussion: Canine lymphoma is often associated with paraneoplastic syndromes, with neuropathy being one of its possible clinical manifestations. In spite of that its pathogenesis remains unclear, with little information in the veterinary literature. Diagnosis is challenging and must be initially based on recognition of neurological clinical signs and lesion localization, as in the reported cases with lesions located on the fifth and seventh cranial nerves. In the patient from the first case, the absence of clinical signs and laboratory abnormalities suggestive of endocrinopathies, associated with neurological signs restricted to the trigeminal nerve, bilaterally, before starting chemotherapy and without the identification of brain lesions in computed tomography, suggested paraneoplastic involvement as the cause of neuropathy. In the second case described, the absence of clinical signs and laboratory abnormalitiess suggestive of endocrinopathies or nutritional deficiencies, associated with neurological signs restricted to the facial and trigeminal cranial nerves, suggested direct or indirect tumour involvement. Both cases showed improvement of neurological clinical signs after chemotherapy which favored the therapeutic diagnosis. Nevertheless, failure to authorize necropsy of patients made it impossible to confirm that peripheral neuropathy is secondary to the remote effect of lymphoma.

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MULTIPLE CRANIAL NERVE PALSIES ASSOCIATED WITH THYROID AUTOIMMUNITY: HASHIMOTO'S THYROIDITIS- A CASE REPORT

10.36106/ijar/1802014 ◽

2021 ◽

pp. 51-52

Author(s):

Neeraja Ponnala ◽

Stephen Abraham Suresh Kumar ◽

J.Senthil Nathan

Keyword(s):

Hashimoto’S Thyroiditis ◽

Cranial Nerve ◽

Thyroid Autoimmunity ◽

Cranial Nerves ◽

Hashimoto's Thyroiditis ◽

Thyroid Peroxidase ◽

Cranial Nerve Involvement ◽

Cognitive Changes ◽

Cranial Nerve Palsies ◽

Multiple Cranial Nerve

Hashimotos's encephalopathy is an uncommon neurologic syndrome associated with Hashimoto's thyroiditis. Sometimes it may manifest years before onset of thyroid disease. The patients are usually euthyroid or midly hypothyroid. Antibodies against thyroid peroxidase are useful diagnostic marker of Hashimoto's thyroiditis. High levels of this antibody are associated with high 1 prevalence of hashimoto's encephalopathy . Clinical features are variable includes behavioral and cognitive changes, myoclonus, seizures, hemiparesis, involuntary movements, cerebellar signs, psychosis and coma, with relapsing and progressive course. Diagnosis is often overlooked but it is important as it is treatable cause of encephalopathy. Multiple cranial nerves involvement in Hashimoto's thyroiditis was reported in a very few patients, a rare association. Here we present a case of multiple cranial nerve involvement in a case of hashimoto's thyroiditis.

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Relapsing malignant otitis externa successfully treated with ciprofloxacin

The Journal of Laryngology & Otology ◽

10.1017/s002221510010670x ◽

1988 ◽

Vol 102 (10) ◽

pp. 872-876 ◽

Cited By ~ 15

Author(s):

G. A. J. Morrison ◽

C. M. Bailey

Keyword(s):

Cranial Nerve ◽

Otitis Externa ◽

Diabetic Control ◽

Cranial Nerve Involvement ◽

Parenteral Antibiotic ◽

Malignant Otitis Externa ◽

Oral Ciprofloxacin ◽

Antibiotic Agents ◽

Ear Drops ◽

Antibiotic Courses

AbstractTwo cases are presented, both patients with advanced maligant otitis externa.The antibiotic ciprofloxacin has strong anti-pseudomonal activity. It was given orally for six months to both patients, following administration of the traditional parenteral antibiotic courses, and in each case the disease has been extinguished. We therefore recommend that the management of patients shown to have malignant otitis externa should include strict diabetic control, regular local aural toilet, gentamicin ear drops and a six week course of parenteral antipseudomonal antibiotic agents (usually gentamicin and azlocillin) together with metronidazole to cover any anaerobic element in the infection. This regimen should be followed by a six month course of oral ciprofloxacin (750 mg b. d.). Indium scans should be used to monitor recovery. We believe that this regimen can significantly reduce the morbidity and mortality of patients suffering from malignant otitis externa with cranial nerve involvement.

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Malignant otitis externa: case series

The Journal of Laryngology & Otology ◽

10.1017/s0022215110000691 ◽

2010 ◽

Vol 124 (8) ◽

pp. 846-851 ◽

Cited By ~ 32

Author(s):

T Ali ◽

K Meade ◽

S Anari ◽

M R ElBadawey ◽

I Zammit-Maempel

Keyword(s):

Pseudomonas Aeruginosa ◽

Cranial Nerve ◽

Cranial Nerve Palsy ◽

Otitis Externa ◽

Nerve Palsy ◽

Case Series ◽

Case Review ◽

Retrospective Case ◽

North East ◽

Malignant Otitis Externa

AbstractBackground:In the light of current concerns regarding ciprofloxacin resistance and the changing face of malignant otitis externa, we reviewed cases of malignant otitis externa treated in our centre, in order both to evaluate the current epidemiology of the condition and to assess the status of drug resistance in our patient population.Method:Retrospective case review of all malignant otitis externa cases managed in a tertiary referral centre in the north-east of England between 2000 and 2009.Results:Forty-one patients were identified, but the required data were available for only 37 cases. Patients' ages ranged from 51 to 101 years (median, 81 years). Diabetes was present in 51 per cent of patients (19/37), facial nerve palsy in 40 per cent (15/37) and multiple cranial nerve palsy in 24 per cent (9/37). Pseudomonas aeruginosa was the most commonly isolated organism (54 per cent), sensitive to ciprofloxacin in all cases.Conclusions:The incidence of cranial nerve palsy in our study was higher than in previous reports. The incidence of diabetes and Pseudomonas aeruginosa in our cohort was much lower than previously reported. The Pseudomonas aeruginosa strains isolated were all sensitive to ciprofloxacin, despite recent reports on emerging resistance.

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A Case of Transient, Isolated Cranial Nerve VI Palsy due to Skull Base Osteomyelitis

Case Reports in Infectious Diseases ◽

10.1155/2014/369867 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 3

Author(s):

Brijesh Patel ◽

Anas Souqiyyeh ◽

Ammar Ali

Keyword(s):

Skull Base ◽

Cranial Nerve ◽

Facial Pain ◽

Otitis Externa ◽

Skull Bone ◽

Topical Antibiotics ◽

Skull Base Osteomyelitis ◽

Cranial Nerve Palsies ◽

Malignant Otitis Externa ◽

The Common

Otitis externa affects both children and adults. It is often treated with topical antibiotics, with good clinical outcomes. When a patient fails to respond to the treatment, otitis externa can progress to malignant otitis externa. The common symptoms of skull bone osteomyelitis include ear ache, facial pain, and cranial nerve palsies. However, an isolated cranial nerve is rare. Herein, we report a case of 54-year-old female who presented with left cranial nerve VI palsy due to skull base osteomyelitis which responded to antibiotic therapy.

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