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Malignant external otitis Necrotizing external otitis Dr. WASEEM WATAD Dr. WASEEM WATAD.

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Presentation on theme: "Malignant external otitis Necrotizing external otitis Dr. WASEEM WATAD Dr. WASEEM WATAD."— Presentation transcript:

1 Malignant external otitis Necrotizing external otitis Dr. WASEEM WATAD Dr. WASEEM WATAD

2 Case 1. ( SH. Y ) n 80 years old n 3VD, PTCA, DM-type2, HTN, BPH n Ext. otitis with PO ABX and ear drops with improvement several months before admission n severe Rt. otalgia, facial pain Rt., and Rt. parotid mass at admission 19/09/04 n Rt ear discharge n Weight loss

3 Case 1. n CT scan (20/09/04): Rt parotid mass, infiltration of parapharyngeal fat, EAC, infratemporal fossa, Rt. lat. pterygoid and bony erosion and no lymphadenopathy n MRI (19/10/04) :process infiltrating the Rt. ear,temporal bone, TMJ, sphenoid sinus, infratemporal fossa and skull base n Biopsy of EAC polyp, parotid FNA (28/10/04) – mixed inflammation n Positive culture for p. aeruginosa

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

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

6 Case 2. n No improvement n Rt. Severe otalgia, ear discharge, persistent rt. ext. otitis, with granulation tissue n Elevated ESR, negative culture for p. aeruginosa n Start IV ceftazidime ( 5 weeks ) n Progression findings in serial CT/MRI

7 Case 2. n CT scan ( 14/11/04 ) - infiltration of the rt. parapharyngeal space, rt. Mastoid and middle ear, infiltrating of infratemporal fossa n MRI ( 24/21/04 ) – large mass in rt. parapharyngeal space with involvement of rt. TMJ and deep lobe of rt. Parotis n CT (01/05) infiltrating in rt. TMJ

8 Case 2. n De’bridment - (10/01/05),. (24/01/05), n Hx – inflammatory tissue n 2 weeks of AMIKACIN + MEROPENEM n Exacerbation of Rt. Otalgia, ear discharge and relapse of granulation tissue of EAC n Treatment failure ?? n 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 Temporal Maxilla Parietal Sphenoid Frontal Z Lat. Pterygoid Plate Pterygomaxillary Fissure Infratemporal Fossa

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

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

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

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

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

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

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

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

20 Therapeutic problems n Hyperbaric oxygen therapy –Daily, atm, 90 minutea, 30 courses –Indications : advanced stages, recurrent cases, refractory to ABX –Hypoxia impaired oxygen dependent bacterial killing by phagocytosis

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