Malignant external otitis Necrotizing external otitis

1
Malignant external otitis Necrotizing external
otitis

• Dr. WASEEM WATAD

2
Case 1. ( SH. Y )

• 80 years old
• 3VD , PTCA , DM-type2 , HTN , BPH
• Ext. otitis with PO ABX and ear drops with
  improvement several months before admission
• severe Rt. otalgia , facial pain Rt. , and Rt.
  parotid mass at admission 19/09/04
• Rt ear discharge
• Weight loss

3
Case 1.

• CT scan (20/09/04) Rt parotid mass ,
  infiltration of parapharyngeal fat , EAC ,
  infratemporal fossa , Rt. lat. pterygoid and
  masseter .no bony erosion and no lymphadenopathy
• MRI (19/10/04) process infiltrating the Rt.
  ear,temporal bone , TMJ, sphenoid sinus ,
  infratemporal fossa and skull base
• Biopsy of EAC polyp, parotid FNA (28/10/04)
  mixed inflammation
• Positive culture for p. aeruginosa

4
Case 1.

• IV ABX treatment ( cephalosporine and quinolones
  ) with ear drops and toilette
• Improvement in pain , ear discharge
• There was no CN involvement

5
Case 2. ( Va. D )

• 68 years old
• DM-type 2 , HTN
• Hyperlipidemia , s/p CVA
• Rt. Nasopharyngeal mass biopsy no malignancy
  (11/04)
• Bil. Ext. otitis 09/04 ( several weeks before
  admittion ) prolong ABX treatment (
  semi-synthetic penicillin , quinolone) and ear
  drops

6
Case 2.

• No improvement
• Rt. Severe otalgia , ear discharge , persistent
  rt. ext. otitis , with granulation tissue
• Elevated ESR , negative culture for p. aeruginosa
• Start IV ceftazidime ( 5 weeks )
• Progression findings in serial CT/MRI

7
Case 2.

• CT scan ( 14/11/04 ) - infiltration of the rt.
  parapharyngeal space , rt. Mastoid and middle
  ear, infiltrating of infratemporal fossa
• MRI ( 24/21/04 ) large mass in rt.
  parapharyngeal space with involvement of rt. TMJ
  and deep lobe of rt. Parotis
• CT (01/05) infiltrating in rt. TMJ

8
Case 2.

• Debridment - (10/01/05) ,. (24/01/05),
• Hx inflammatory tissue
• 2 weeks of AMIKACIN MEROPENEM
• Exacerbation of Rt. Otalgia , ear discharge and
  relapse of granulation tissue of EAC
• Treatment failure ??
• Further therapy
• Broad spectrum of ABX combination of
  cephalosporines and quinolone
• Surgical treatment mastoidectomy /-
  tympanoplasty , ablation of granulating and
  necrotizing tissue, bone and cartilage
  sequestrations
• HBO

9
(No Transcript)
10
MEO - criteria

• Sade (1989)
• Severe EXT. otitis unresponsive to at least 10
  days of conservative treatment
• Increasing agonizing pain exacerbated at night
• Granulation tissue in the base of EAC
• Repeated isolation of pseudomonas
• Levenson (1991)
• Refractory otitis ext.
• Severe otalgia , worse at night
• Purulent exudate , granulation tissue
• Recovery of P. aeruginosa
• DM , immune state compromise
• Positive Tc-99 bone scan of temporal bone

11
etiopathogenesis
12
MEO - staging

• Corey (1985)
• I - Infection of bone and soft tissue without
  cranial nerves lesions or intracranial lesions
• II - cranial nerve paralysis
• a- VII paralysis only
• b- Multiple cranial nerves paralysis
• III meningitis , epidural empyema , subdural
  empyema or brain abscess

13
NEO - diagnosis

• Clinical findings
• Laboratory tests
• Culture
• Ga-67, Tc-99 scans
• HR-CT with contrast
• Biopsy of granulation tissue

14
mortality

• 46 (1968)
• 10 recent articles
• High mortality in facial n. paralysis

15
Management cont.

• HR-CT contrast evaluation
• Ga-67 (every 4 weeks) follow up with treatment
• Management underlying process ( DM /
  immunosuppressive)
• Surgical debridment ,drinage intracranial ext.
  , brain abscess
• 6 weeks of ABX , repeat cultures , oral ABX after
  2 weeks of cessation of symptoms

16
Management cont.

• Deep biopsy of granulation tissue underlying
  carcinoma

17
Therapeutic problems

• Main problem is
• Choice of the ABX
• Duration of treatment

18
Therapeutic problems

• Duration of treatment
• Standard indication ( 6-8 weeks )
• Identifying objective parameter of definitive
  recovery
• Healing of skin EAC
• ESR
• Ga-67

19
Therapeutic problems

• Surgical treatment
• Complementary role
• Mastoidectomy /- tympanoplasty
• Recommendation biopsy , cleansing , ablation of
  necrotizing and granulation tissue and the bone ,
  cartilage sequestrations

20
Therapeutic problems

• Hyperbaric oxygen therapy
• Daily , 2.4-3 atm, 90 minutea , 30 courses
• Indications advanced stages , recurrent cases,
  refractory to ABX
• Hypoxia impaired oxygen dependent bacterial
  killing by phagocytosis