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Malignant external otitis Necrotizing external otitis

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Presentation on theme: "Malignant external otitis Necrotizing external otitis"— Presentation transcript:

1 Malignant external otitis Necrotizing external otitis

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. 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

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

10 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

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 de’bridment ,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 , 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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