Surgical Treatment of Malignant Otitis Externa MOE A New Hope Although Challenging

Objective: Malignant external otitis is an aggressive inflammatory condition of the external auditory canal. Most often affects elderly patients with diabetes mellitus. This is a serious disease which spreads in the skull base associated with cranial nerve complications and high morbidity-mortality rate. Malignant otitis externa requires urgent diagnosis and treatment. The primary and most effective treatment is to control the diabetes and to fight infection with the proper antibiotic in adequate dose and duration. If medical treatment fails aggressive surgical management is the only option to save life. We present a short experience in the management of this disease. The aim of this study was to present our experience with the surgical management of malignant otitis externa. Methods: 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, were investigated for all patients. Results: During the last 5 years (2014-2019), 5 patients with the diagnosis of malignant otitis externa were admitted to our hospital for investigation and treatment. All between 60 and 70 years of age, with severe persistent otalgia, purulent otorrhea, granulation tissue in the external auditory canal, and diffuse external otitis, and there were 2 patients with facial nerve palsy. Patients were confirmed to have diabetes. Ear swabs for culture and sensitivity usually revealed Pseudomonas aeruginosa. One patient by systemic antibiotic and two patients were treated by Local debridement and systemic antibiotics were sufficient to control the disease. Two patients were treated by aggressive surgical debridement (skull base debridement) with 360degree Facial nerve decompression. Patients were recovered from dreadful necrotizing infection but with facial paralysis. Conclusion: Malignant otitis externa is still a serious disease associated with cranial nerve complications and high morbiditymortality rate. The primary and most effective treatment is to control the diabetes and to fight infection with the proper antibiotic in adequate dose and duration, debridement of necrotic tissue, and sometimes aggressive surgical management. Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus.

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Malignant otitis externa — a serious complication of diabetes mellitus

Practical Diabetes International ◽

10.1002/pdi.1960050410 ◽

1988 ◽

Vol 5 (4) ◽

pp. 177-179 ◽

Cited By ~ 1

Author(s):

G A Vernham ◽

D Robinson ◽

A Resouly ◽

K M Shaw

Keyword(s):

Diabetes Mellitus ◽

Otitis Externa ◽

Malignant Otitis Externa

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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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Malignant otitis externa in a 21-year-old male patient with Prader–Willi syndrome

SAGE Open Medical Case Reports ◽

10.1177/2050313x19834827 ◽

2019 ◽

Vol 7 ◽

pp. 2050313X1983482

Author(s):

Marcos Frata Rihl ◽

Felipe Marchiori Bau ◽

Igor de Oliveira ◽

Manoela Astolfi Vivan ◽

Roseane Cardoso Marchiori

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Male Patient ◽

Otitis Externa ◽

Invasive Infection ◽

Prader Willi Syndrome ◽

Malignant Otitis Externa ◽

Life Threatening

Malignant otitis externa is an invasive infection of the external auditory canal and temporal bone with potentially life-threatening complications. Elderly patients with type 2 diabetes mellitus are the population most commonly affected by malignant otitis externa, but any type of immunosuppression predisposes to the disease. Prader–Willi syndrome is a genetic cause of obesity, often associated with insulin resistance and type 2 diabetes mellitus. This report describes a case of a 21-year-old male patient with Prader–Willi syndrome who had malignant otitis externa that progressed to sepsis during hospitalization. To the best of the authors’ knowledge, this is the first description of malignant otitis externa in a young patient with Prader–Willi syndrome.

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Malignant Otitis Externa (MOE) causing cerebral abscess and facial nerve palsy

Journal of Hospital Medicine ◽

10.1002/jhm.651 ◽

2010 ◽

Vol 5 (7) ◽

pp. E6-E8 ◽

Cited By ~ 2

Author(s):

John Roberts ◽

Línea Larson-Williams ◽

Farrah Ibrahim ◽

Ali Hassoun

Keyword(s):

Facial Nerve ◽

Otitis Externa ◽

Nerve Palsy ◽

Facial Nerve Palsy ◽

Cerebral Abscess ◽

Malignant Otitis Externa

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Surgical management of benign necrotizing otitis externa

The Journal of Laryngology & Otology ◽

10.1017/s0022215100126015 ◽

1994 ◽

Vol 108 (2) ◽

pp. 101-105 ◽

Cited By ~ 5

Author(s):

P. J. Wordmald

Keyword(s):

Differential Diagnosis ◽

Surgical Management ◽

Otitis Externa ◽

Rare Condition ◽

Vascular Supply ◽

External Ear ◽

Unknown Aetiology ◽

Necrotizing Otitis Externa ◽

Malignant Otitis Externa

AbstractBenign necrotizing otitis externa (BNOE) is a rare condition of unknown aetiology which is characterized by the formation of an avascular bony sequestrum of the tympanic plate. The vascular supply of the tympanic plate is easily compromized as demonstrated by the development of avascular necrosis in radionecrosis of the tympanic plate and malignant otitis externa. Recognition of BNOE as distinct from malignant otitis externa and carcinoma of the external ear is important as the treatment differs greatly. BNOE also forms an important part of the differential diagnosis of recalcitrant otitis externa.Management of BNOE has been unclear with long-term medical treatment being advocated. In this series of five patients, the surgical management of four patients with BNOE is described. Surgery was successful in all these patients and is advocated as an alternative to medical management.

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A study on correlation between clinical prognostic markers glycated hemoglobin, erythrocyte sedimentation rate and C-reactive protein levels and the stage of disease in malignant otitis externa

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20212899 ◽

2021 ◽

Vol 7 (8) ◽

pp. 1306

Author(s):

Subin Antony ◽

Anita Ross ◽

Deepthi Satish

Keyword(s):

Diabetes Mellitus ◽

Erythrocyte Sedimentation Rate ◽

Sedimentation Rate ◽

Etiologic Agent ◽

Clinical Staging ◽

C Reactive Protein ◽

Duration Of Diabetes ◽

Reactive Protein ◽

Erythrocyte Sedimentation ◽

Otoscopic Examination

Background: Objectives of the study were to establish a clinical correlation between the stages of MOE and biochemical markers namely glycated Hb (HbA1c), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels, to identify improvement in clinical symptomology in MOE following treatment and to correlate with the duration of diabetes mellitus with treatment outcome.Methods: Patients with diabetes mellitus, otalgia and ear discharge presenting to ENT OPD were subjected to detailed history and clinical examination. Otoscopic examination was done. Pus from the EAC was taken for culture and sensitivity. Baseline glycated Hb, ESR and CRP levels and HRCT temporal bone in axial and coronal planes was done. According to clinical findings and CT findings the patients were staged using chandlers staging. Patients were followed up after 1st and 2nd month and otoscopic examination with blood tests was repeated and staged accordinglyResults: Fall in the levels of glycated HbA1c serves as a good prognostic indicator of the disease. Duration of diabetes has no significant impact on the disease prognosis. Most common etiologic agent is Pseudomonas aeruginosa. In spite of improvement in clinical features and inflammatory parameters there was no improvement in clinical staging with treatment. There was a significant fall in ESR and CRP values after treatment for 2 months with antibiotics and analgesics.Conclusions: The study highlights the need to control infection with medical line of treatment which can be monitored by ESR, CRP and glycated HbA1c and that the role for surgical management is limited for stage 1, 2 and 3.

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Fungal Malignant Otitis Externa with Facial Nerve Palsy: Rare Case

Global Journal of Otolaryngology ◽

10.19080/gjo.2017.07.555725 ◽

2017 ◽

Vol 7 (5) ◽

Author(s):

Said Anajar

Keyword(s):

Facial Nerve ◽

Otitis Externa ◽

Rare Case ◽

Nerve Palsy ◽

Facial Nerve Palsy ◽

Malignant Otitis Externa

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Clinical Profile of Patients with Malignant Otitis Externa in a Tertiary Care Centre

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2020/617 ◽

2020 ◽

Vol 7 (50) ◽

pp. 3022-3026

Author(s):

Nandakumar Choorakkattukara Raman ◽

Thulaseedharan Sreedharan ◽

Ajayan Paithottiyil Varkey

Keyword(s):

Computed Tomography ◽

Pseudomonas Aeruginosa ◽

Complete Remission ◽

External Auditory Canal ◽

Facial Palsy ◽

Otitis Externa ◽

Clinical Profile ◽

Immunocompromised Patients ◽

Malignant Otitis Externa ◽

Culture And Sensitivity

BACKGROUND Malignant otitis externa (MOE) is a rare disorder occurring in elderly immunocompromised patients mainly in diabetics. Other immunocompromised conditions are myeloid malignancies, iatrogenic suppression secondary to treatment of malignancies, organ transplant patients, and HIV (Human Immunodeficiency Virus) patients. Most common causative organism is Pseudomonas aeruginosa. Staphylococcus aureus, Staphylococcus epidermidis also have been reported. Aspergillus species is the most common fungal pathogen causing this condition. METHODS This is a cross sectional study to find out the clinical profile of patients treated for MOE in the department of ENT of Government Medical College, Thrissur, Kerala. Sample size was 32. Patients were given a self-made questionnaire containing questions on age, gender, clinical history, and history of past illness. After getting the filled form, informed consent was taken. They then underwent general examination as well as ENT evaluation with emphasis on otological examination which included examination of ear and surrounding area. Swab from external auditory canal (EAC) was sent for culture and sensitivity. Granulations were taken from EAC to rule out malignancy. Antibiotics and antifungals depending on the pathogen were given for adequate duration. RESULTS Males were more commonly affected (78 %). Mean age of population is 60.97 ± 10.2 years. Diabetes mellitus was seen in 21 patients, of which 16 showed uncontrollable diabetes. Otalgia was present in all the patients. 14 patients showed ear discharge. Facial palsy was present in 8 patients only. Increased ESR was seen in all patients. Culture and sensitivity of all patients showed growth of Pseudomonas only. CT (Computed Tomography) revealed soft tissue in external auditory canal of all patients. At the end of the study, complete remission was seen in 18 patients. Follow up was done in 3 months and 6 months. Facial palsy was relieved in 50 % patients. CONCLUSIONS MOE predominantly affects elderly immunocompromised patients especially patients with uncontrollable diabetes. Most common organism isolated was Pseudomonas aeruginosa. Otalgia which felt more in night (nocturnal otalgia), otorrhoea, granulation in external auditory canal are the important parameters for the diagnosis of this condition. HRCT (High-Resolution Computed Tomography) temporal bone is used to see the extent of disease and also for diagnosis. ESR and CRP levels indicate the prognosis. Complete remission seen in most of the patients and facial palsy3 was relieved in 50 %. This study can be used to predict the disease progression, and to formulate a treatment plan so that morbidity and mortality associated with it can be avoided as much as possible. KEYWORDS Malignant Otitis Externa, Necrotising Otitis Externa, Pseudomonas aeruginosa, Nocturnal Otalgia, Immuno Compromised Condition

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