Malignant otitis externa: Difference between revisions

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==Background==
==Background==
[[File:Gray907.png|thumb|Ear anatomy]]
*Life-threatening infection of external ear/canal, soft tissue, +/- spread to skull base
*Life-threatening infection of external ear/canal, soft tissue, +/- spread to skull base
*Diabetes and immunosuppression are main risk factors
*Diabetes and immunosuppression are main risk factors
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*Granulation tissue often seen in the ear canal floor
*Granulation tissue often seen in the ear canal floor
*Facial nerve often first CN involved<ref>Pfaff JA, Moore GP: Otolaryngology, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, Ch 72.</ref>
*Facial nerve often first CN involved<ref>Pfaff JA, Moore GP: Otolaryngology, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, Ch 72.</ref>
*CN IX, X, or XI involvement
*[[cranial nerve palsies|CN IX, X, or XI involvement]]
*Trismus
*Trismus


===Pediatrics===
===Pediatrics===
*More rapidly progressive than in adults
*More rapidly progressive than in adults
**[[Fever]], leukocytosis, bacteremia/[[sepsis]]
**[[Fever]], [[leukocytosis]], bacteremia/[[sepsis]]
*TM, middle ear, and facial nerve more likely to be affected
*TM, middle ear, and facial nerve more likely to be affected


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{{Ear DDX}}
{{Ear DDX}}


==Diagnosis==
==Evaluation==
[[File:PMC3292638 13244 2011 126 Fig5 HTML.png|thumb|Malignant external otitis. Axial CT scan in bone window demonstrates destruction of mastoid segment of petrous bone. There were also subtle cortical destructions visible in tympanic bone.]]
*Imaging<ref>Nussenbaum B et Al. Malignant Otitis Externa Workup. Medscape, Jul 14 2015. http://emedicine.medscape.com/article/845525-workup#c4</ref>
*Imaging<ref>Nussenbaum B et Al. Malignant Otitis Externa Workup. Medscape, Jul 14 2015. http://emedicine.medscape.com/article/845525-workup#c4</ref>
**Most authors support CT initially, but CT fails to dx early osteomyelitis since 30% bone destruction needed for detection
**Most authors support CT initially, but CT fails to diagnose early osteomyelitis since 30% bone destruction needed for detection
**MRI more sensitive for intracranial complications
**MRI more sensitive for intracranial complications
*Labs
*Labs
**WBC usually normal or slightly elevated
**WBC usually normal or slightly elevated
**Left shift uncommon
**Left shift uncommon
**Elevated ESR differentiates from MOE from acute external otitis or malignancy
**Elevated ESR and CRP
***Differentiates from MOE from acute external otitis or malignancy
***However, not required for diagnosis<ref>Hosmer, K: Ear Disorders, in Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM (eds): Emergency Medicine, A Comprehensive Study Guide, ed 8. New York, McGraw-Hill, 2016, Ch 242:p 1581-2.</ref>


==Treatment==
==Management==
===Adults===
===Adults===
*[[Antipseudomonal cephalosporin]] OR [[fluoroquinolone]]
*[[Antipseudomonal cephalosporin]] '''OR''' [[fluoroquinolone]]


===Peds===
===Peds===
*[[Imipenem]] OR ([[aminoglycoside]] + [[antipseudomonal penicillin]])
*[[Imipenem]] '''OR''' ([[aminoglycoside]] + [[antipseudomonal penicillin]])


==Disposition==
==Disposition==
*Contact ENT for disposition decision; early infection may be managed as outpt
*Contact ENT for disposition decision; early infection may be managed as outpatient


==Complications==
==Complications==
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*[[Otitis Media (Peds)]]
*[[Otitis Media (Peds)]]


==Source==
==References==
*Tintinalli
<references/>
 


[[Category:ENT]]
[[Category:ENT]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 05:54, 6 January 2022

Background

Ear anatomy
  • Life-threatening infection of external ear/canal, soft tissue, +/- spread to skull base
  • Diabetes and immunosuppression are main risk factors
  • Pseudomonas causes >90% of cases
  • Begins as simple otitis externa

Clinical Features

Adults

  • Otitis externa that has not resolved despite 2-3wks of topical antibiotics
  • Otalgia often out of proportion for routine otitis externa
  • Edema of external auditory canal
  • Granulation tissue often seen in the ear canal floor
  • Facial nerve often first CN involved[1]
  • CN IX, X, or XI involvement
  • Trismus

Pediatrics

  • More rapidly progressive than in adults
  • TM, middle ear, and facial nerve more likely to be affected

Differential Diagnosis

Ear Diagnoses

External

Internal

Inner/vestibular

Evaluation

Malignant external otitis. Axial CT scan in bone window demonstrates destruction of mastoid segment of petrous bone. There were also subtle cortical destructions visible in tympanic bone.
  • Imaging[2]
    • Most authors support CT initially, but CT fails to diagnose early osteomyelitis since 30% bone destruction needed for detection
    • MRI more sensitive for intracranial complications
  • Labs
    • WBC usually normal or slightly elevated
    • Left shift uncommon
    • Elevated ESR and CRP
      • Differentiates from MOE from acute external otitis or malignancy
      • However, not required for diagnosis[3]

Management

Adults

Peds

Disposition

  • Contact ENT for disposition decision; early infection may be managed as outpatient

Complications

See Also

References

  1. ↑ Pfaff JA, Moore GP: Otolaryngology, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, Ch 72.
  2. ↑ Nussenbaum B et Al. Malignant Otitis Externa Workup. Medscape, Jul 14 2015. http://emedicine.medscape.com/article/845525-workup#c4
  3. ↑ Hosmer, K: Ear Disorders, in Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM (eds): Emergency Medicine, A Comprehensive Study Guide, ed 8. New York, McGraw-Hill, 2016, Ch 242:p 1581-2.
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