Malignant external otitis Malignant external otitis Necrotizing external otitisNecrotizing external otitis

Dr. WASEEM WATADDr. WASEEM WATAD

Case 1. Case 1. ( SH. Y )( SH. Y )

80 years old80 years old 3VD , PTCA , DM-type2 , HTN , BPH3VD , PTCA , DM-type2 , HTN , BPH Ext. otitis with PO ABX and ear drops Ext. otitis with PO ABX and ear drops

with improvement several months with improvement several months before admissionbefore admission

severe Rt. otalgia , facial pain Rt. , and severe Rt. otalgia , facial pain Rt. , and Rt. parotid mass at admission 19/09/04Rt. parotid mass at admission 19/09/04

Rt ear discharge Rt ear discharge Weight loss Weight loss

Case 1.Case 1. CT scan (20/09/04): Rt parotid mass , CT scan (20/09/04): Rt parotid mass ,

infiltration of parapharyngeal fat , EAC , infiltration of parapharyngeal fat , EAC , infratemporal fossa , Rt. lat. pterygoid and infratemporal fossa , Rt. lat. pterygoid and masseter .no bony erosion and no masseter .no bony erosion and no lymphadenopathylymphadenopathy

MRI (19/10/04) :process infiltrating the Rt. MRI (19/10/04) :process infiltrating the Rt. ear,temporal bone , TMJ, sphenoid sinus , ear,temporal bone , TMJ, sphenoid sinus , infratemporal fossa and infratemporal fossa and skull baseskull base

Biopsy of EAC polyp, parotid FNA (28/10/04) Biopsy of EAC polyp, parotid FNA (28/10/04) – mixed inflammation– mixed inflammation

Positive culture for p. aeruginosaPositive culture for p. aeruginosa

Case 1.Case 1.

IV ABX treatment ( cephalosporine IV ABX treatment ( cephalosporine and quinolones ) with ear drops and quinolones ) with ear drops and toiletteand toilette

Improvement in pain , ear Improvement in pain , ear dischargedischarge

There was no CN involvementThere was no CN involvement

Case 2. ( Case 2. ( Va. DVa. D ) )

68 years old68 years old DM-type 2 , HTN DM-type 2 , HTN Hyperlipidemia , s/p CVA Hyperlipidemia , s/p CVA Rt. Nasopharyngeal mass – biopsy no Rt. Nasopharyngeal mass – biopsy no

malignancy (11/04)malignancy (11/04) Bil. Ext. otitis 09/04 ( several weeks Bil. Ext. otitis 09/04 ( several weeks

before admittion ) prolong ABX before admittion ) prolong ABX treatment ( semi-synthetic penicillin , treatment ( semi-synthetic penicillin , quinolone) and ear drops quinolone) and ear drops

Case 2.Case 2.

No improvement No improvement Rt. Severe otalgia , ear discharge , Rt. Severe otalgia , ear discharge ,

persistent rt. ext. otitis , with persistent rt. ext. otitis , with granulation tissuegranulation tissue

Elevated ESR , negative culture for p. Elevated ESR , negative culture for p. aeruginosaaeruginosa

Start IV ceftazidime ( 5 weeks )Start IV ceftazidime ( 5 weeks ) Progression findings in serial CT/MRIProgression findings in serial CT/MRI

Case 2.Case 2.

CT scan ( 14/11/04 ) - infiltration of the CT scan ( 14/11/04 ) - infiltration of the rt. parapharyngeal space , rt. Mastoid rt. parapharyngeal space , rt. Mastoid and middle ear, infiltrating of and middle ear, infiltrating of infratemporal fossainfratemporal fossa

MRI ( 24/21/04 ) – large mass in rt. MRI ( 24/21/04 ) – large mass in rt. parapharyngeal space with involvement parapharyngeal space with involvement of rt. TMJ and deep lobe of rt. Parotisof rt. TMJ and deep lobe of rt. Parotis

CT (01/05) infiltrating in rt. TMJCT (01/05) infiltrating in rt. TMJ

Case 2.Case 2. De’bridment De’bridment -- (10/01/05) , (10/01/05) ,.. (24/01/05), (24/01/05), Hx – inflammatory tissueHx – inflammatory tissue 2 weeks of AMIKACIN + MEROPENEM2 weeks of AMIKACIN + MEROPENEM Exacerbation of Rt. Otalgia , ear discharge and Exacerbation of Rt. Otalgia , ear discharge and

relapse of granulation tissue of EACrelapse of granulation tissue of EAC Treatment failure ??Treatment failure ?? Further therapy :Further therapy :

– Broad spectrum of ABX – combination of Broad spectrum of ABX – combination of cephalosporines and quinolonecephalosporines and quinolone

– Surgical treatment – mastoidectomy +/- Surgical treatment – mastoidectomy +/- tympanoplasty , ablation of granulating and tympanoplasty , ablation of granulating and necrotizing tissue, bone and cartilage necrotizing tissue, bone and cartilage sequestrationssequestrations

– HBOHBO

Temporal

Maxilla

Parietal

Sphenoid

Frontal

Z

Lat. Pterygoid Plate

Pterygomaxillary Fissure

Infratemporal Fossa

MEO - criteriaMEO - criteria Sade’ (1989) :Sade’ (1989) :

– Severe EXT. otitis unresponsive to at least 10 days of Severe EXT. otitis unresponsive to at least 10 days of conservative treatmentconservative treatment

– Increasing agonizing pain exacerbated at nightIncreasing agonizing pain exacerbated at night– Granulation tissue in the base of EACGranulation tissue in the base of EAC– Repeated isolation of pseudomonasRepeated isolation of pseudomonas

Levenson (1991) :Levenson (1991) :– Refractory otitis ext.Refractory otitis ext.– Severe otalgia , worse at nightSevere otalgia , worse at night– Purulent exudate , granulation tissuePurulent exudate , granulation tissue– Recovery of P. aeruginosaRecovery of P. aeruginosa– DM , immune state compromiseDM , immune state compromise– Positive Tc-99 bone scan of temporal bone Positive Tc-99 bone scan of temporal bone

etiopathogenesisetiopathogenesis

MEO - stagingMEO - staging

Corey (1985) :Corey (1985) :– I - Infection of bone and soft tissue I - Infection of bone and soft tissue

without cranial nerves lesions or without cranial nerves lesions or intracranial lesionsintracranial lesions

– IIII - cranial nerve paralysis - cranial nerve paralysis a- VII paralysis onlya- VII paralysis only b- Multiple cranial nerves paralysisb- Multiple cranial nerves paralysis

– III – meningitis , epidural empyema , III – meningitis , epidural empyema , subdural empyema or brain abscesssubdural empyema or brain abscess

NEO - diagnosisNEO - diagnosis

Clinical findingsClinical findings Laboratory testsLaboratory tests CultureCulture Ga-67, Tc-99 scansGa-67, Tc-99 scans HR-CT with contrastHR-CT with contrast Biopsy of granulation tissueBiopsy of granulation tissue

mortalitymortality

46% (1968)46% (1968) 10% recent articles10% recent articles High mortality in facial n. paralysisHigh mortality in facial n. paralysis

Management – cont.Management – cont.

HR-CT contrast evaluationHR-CT contrast evaluation Ga-67 (every 4 weeks) follow up with Ga-67 (every 4 weeks) follow up with

treatmenttreatment Management underlying process ( DM / Management underlying process ( DM /

immunosuppressive)immunosuppressive) Surgical de’bridment ,drinage – Surgical de’bridment ,drinage –

intracranial ext. , brain abscessintracranial ext. , brain abscess 6 weeks of ABX , repeat cultures , oral 6 weeks of ABX , repeat cultures , oral

ABX after 2 weeks of cessation of ABX after 2 weeks of cessation of symptomssymptoms

Management – cont.Management – cont.

Deep biopsy of granulation tissue – Deep biopsy of granulation tissue – underlying carcinomaunderlying carcinoma

Therapeutic problemsTherapeutic problems

Main problem is :Main problem is :– Choice of the ABX Choice of the ABX – Duration of treatmentDuration of treatment

Therapeutic problemsTherapeutic problems

Duration of treatmentDuration of treatment– Standard indication ( 6-8 weeks )Standard indication ( 6-8 weeks )– Identifying objective parameter of Identifying objective parameter of

definitive recovery definitive recovery Healing of skin EACHealing of skin EAC ESRESR Ga-67Ga-67

Therapeutic problemsTherapeutic problems

Surgical treatment :Surgical treatment :– Complementary roleComplementary role– Mastoidectomy +/- tympanoplastyMastoidectomy +/- tympanoplasty– Recommendation – biopsy , Recommendation – biopsy ,

cleansing , ablation of necrotizing and cleansing , ablation of necrotizing and granulation tissue and the bone , granulation tissue and the bone , cartilage sequestrationscartilage sequestrations

Therapeutic problemsTherapeutic problems

Hyperbaric oxygen therapyHyperbaric oxygen therapy– Daily , 2.4-3 atm, 90 minutea , 30 Daily , 2.4-3 atm, 90 minutea , 30

coursescourses– Indications : advanced stages , Indications : advanced stages ,

recurrent cases, refractory to ABXrecurrent cases, refractory to ABX– Hypoxia impaired oxygen dependent Hypoxia impaired oxygen dependent

bacterial killing by phagocytosisbacterial killing by phagocytosis