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

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