Malignant external otitis Necrotizing external otitis Dr. WASEEM WATAD

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

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

Case 1. IV ABX treatment ( cephalosporine and quinolones ) with ear drops and toilette Improvement in pain , ear discharge There was no CN involvement

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

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

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

Case 2. De’bridment - (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

Infratemporal Fossa Parietal Frontal Temporal Sphenoid Z Maxilla Lat. Pterygoid Plate Pterygomaxillary Fissure Infratemporal Fossa

MEO - criteria Sade’ (1989) : Levenson (1991) : 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

etiopathogenesis

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

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

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

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

Management – cont. Deep biopsy of granulation tissue – underlying carcinoma

Therapeutic problems Main problem is : Choice of the ABX Duration of treatment

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

Therapeutic problems Surgical treatment : Complementary role Mastoidectomy +/- tympanoplasty Recommendation – biopsy , cleansing , ablation of necrotizing and granulation tissue and the bone , cartilage sequestrations

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