A guide to managing disorders of the ear pinna and canal.

This review will help you troubleshoot everything from infections and foreign bodies to trauma and neoplasm.

Necrotizing Otitis Externa: A Disease Barely Known to Neurosurgeons

Necrotizing otitis externa (NOE), also known as malignant otitis externa (MOE), is a severe and rare infectious disease of the external auditory canal (EAC). Without treatment, it may progress to skull base involvement. The bacteria Pseudomonas aeruginosa is the most common causative agent (90% of the cases), and affects immunocompromised subjects, particularly diabetic patients. Severe chronic otalgia, otorrhea, and cranial nerve palsy are the most common clinical presentations. Patients with NOE are frequently referred to neurosurgery because of the neurological impairment and skull base compromise. The definitive diagnosis is frequently elusive, requiring a high index of suspicion. Several laboratorial tests, imaging modalities, and the histologic exclusion of malignancy may be required. An early diagnosis and aggressive treatment reduce morbidity and mortality. We present four NOE cases to illustrate the spectrum of clinical presentation and complementary exams. According to the literature, more effort for early diagnosis and treatment is required, and neurosurgeons play an important role in this task.

Perichondritis of the auricle: bacterial findings and clinical evaluation of different antibiotic regimens.

PURPOSE: Pseudomonas aeruginosa is commonly found in suppurative perichondritis, but the significant pathogens in non-abscess perichondritis are unclarified. We aimed to explore the bacterial findings and evaluate the effectiveness of different antibiotic regimes in the treatment of patients with perichondritis. METHODS: All patients treated for perichondritis at the two Ear-Nose-Throat Departments in Central Denmark Region (covering 20% of the Danish population) from January 1990 to October 2018 were included. RESULTS: In total, 112 patients with (n = 12) or without (n = 100) abscess were included in the study. Potential pathogens were found in 40 of 55 cultures. P. aeruginosa was recovered in 58% of abscess cases, while Staphylococcus aureus was predominant in non-abscess infections (49%). Eighty-two percent of S. aureus recovered were isolated as heavy or moderate growth. In non-abscess cases, no significant differences in clinical progress (p = 0.65), alteration in antibiotic therapy (p = 0.31), duration of hospitalization (p = 0.65), or frequency of relapse of infection (p = 1.00) or sequelae (p = 0.38) were found between patients treated with antibiotics covering S. aureus vs. P. aeruginosa. CONCLUSIONS: Our findings suggest that intravenous antibiotic therapy covering S. aureus is sufficient and appropriate empirical treatment in the majority of patients with non-abscess perichondritis. Antibiotic coverage should be expanded to include P. aeruginosa if the clinical response is disappointing or cultures grow P. aeruginosa. The risks and downsides to this approach seems limited as only a minority of patients suffered (minor) cosmetic sequelae and relapse of infection in our cohort of non-abscess perichondritis patients initially treated with antibiotics not covering P. aeruginosa.

Effective Inexpensive Management of Necrotizing Otitis Externa Is Possible in Resource-Poor Settings.

INTRODUCTION: Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well. MATERIALS AND METHODS: Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention. RESULTS: Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression. CONCLUSION: Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.

Fungal Malignant Otitis Externa Involves a Cascade of Complications Culminating in Pseudoaneurysm of Internal Maxillary Artery: A Case Report.

BACKGROUND Pseudomonal infection is the most common cause of malignant otitis externa (MOE), which typically affects elderly diabetic patients. Fungi are a rare cause of MOE. MOE can be life-threatening if not recognized and treated promptly. It can result in a wide spectrum of complications, including skull-base osteomyelitis, cranial nerve palsy, cerebral venous thrombosis, and brain abscess. Pseudoaneurysm formation of the intracranial vessels is a life-threatening complication of MOE that is seldom reported in the literature. CASE REPORT We report the case of a 66-year-old diabetic man with MOE who was initially treated with antipseudomonal antibiotics after negative initial culture results. His MOE resulted in a cascade of complications, including facial nerve palsy, skull base osteomyelitis, and sigmoid sinus thrombosis, and culminated in left maxillary artery pseudoaneurysm formation resulting in massive epistaxis and hemodynamic instability. Endovascular embolization resulted in a successful obliteration of the pseudoaneurysm. A subsequent functional endoscopic sinus surgical (FESS) tissue biopsy confirmed Candida glabrata as the etiological agent. The patient was successfully treated with antibiotics and antifungal and anticoagulation therapy, and was discharged home in good condition. CONCLUSIONS A high index of suspicion for the diagnosis of fungal MOE, particularly in intractable cases of MOE with negative initial cultures, should be maintained. Pseudoaneurysm formation is a life-threatening complication of MOE that is seldom reported in the literature and should be suspected in any patient with MOE who presents with epistaxis or intracranial bleeding.

Diagnosis and treatment of necrotising otitis externa and diabetic foot osteomyelitis - similarities and differences.

OBJECTIVE: Necrotising otitis externa is a severe inflammatory process affecting soft tissue and bone, mostly in diabetic patients. Diabetic patients are also at risk of diabetic foot osteomyelitis, another inflammatory condition involving soft tissue and bone. This review aimed to describe the similarities and differences of these entities in an attempt to further advance the management of necrotising otitis externa. METHOD: A PubMed search was conducted using the key words 'otitis externa', 'necrotising otitis externa', 'malignant otitis externa', 'osteomyelitis' and 'diabetic foot'.Results and conclusionThe similarities regarding patient population and pathophysiology between necrotising otitis externa and diabetic foot osteomyelitis raise basic questions concerning the effects of long-standing diabetes on the external ear. The concordance between local swabs and bone cultures in diabetic foot osteomyelitis is less than 50 per cent. If this holds true also to necrotising otitis externa, the role of deep tissue cultures should be strongly considered. Similar to diabetic foot osteomyelitis, magnetic resonance imaging should be considered in selected necrotising otitis externa subgroups.

External auditory canal cholesteatoma and benign necrotising otitis externa: clinical study of 95 cases in the Capital Region of Denmark.

OBJECTIVE: To identify epidemiological and pathophysiological factors, and treatment strategies, in external auditory canal cholesteatoma and benign necrotising otitis externa. METHODS: A retrospective case study was conducted of patients suffering from external auditory canal cholesteatoma and benign necrotising otitis externa admitted to tertiary hospitals, in the Capital Region of Denmark, over a five-year period. RESULTS: Eighty-three patients (95 ears) with external auditory canal cholesteatoma or benign necrotising otitis externa were identified. A minimum incidence rate of 0.97 per 100 000 inhabitants per year was demonstrated. Sixty-eight per cent of cases had a history of smoking. Most lesions (74 per cent) were localised in the floor of the ear canal. Treatment time was 3.2 months for patients who had surgery and 6.0 months for those who received conservative treatment. CONCLUSION: It is suggested that external auditory canal cholesteatoma and benign necrotising otitis externa are in fact the same disease, and therefore the diagnosis of external auditory canal cholesteatoma should be changed to benign necrotising otitis externa. Microangiopathy has a leading role in the aetiology. Surgery should be conducted in most cases.

A Case of Cutaneous Leishmaniasis guyanensis Mimicking Otitis Externa.

Cutaneous leishmaniasis typically presents as a painless papule progressing to an ulcer or plaque. In this case study of the ear, the disease manifested as a small painful bump progressing into redness and swelling about the ear with purulent drainage. After multiple oral/intravenous antipseudomonal, antistaphylococcal, and antifungal treatments, there was no improvement. The skin progressed to an erythematous plaque and hemorrhagic ulcer; punch biopsy and speciation revealed Leishmaniasis guyanensis. The patient was switched to a seven-dose course of intravenous L-amphotericin B (visceral leishmaniasis protocol). Within 21 days, pain and edema resolved and the ulcers healed. Three-month follow-up demonstrated no recurrence. Further studies are needed to evaluate the use of L-amphotericin B in Leishmaniasis guyanensis.

Is laterality of malignant otitis externa related to handedness?

Malignant otitis externa (MOE) usually affect patients with systemic diseases, especially diabetes mellitus. MOE is a mainly unilateral disease. Given that around 90% of human adults are right-handed we hypothesized that hand preference might be one of the factors involved in the development of MOE. All 38 of the patients whom we treated for MOE between August 2009 and November 2012 (28 males and 10 females, age range 43-91 years) had poorly controlled diabetes mellitus, and all of them reported itching in the involved ear. The difference in the laterality of MOE among our right- and left-handed subjects was significant: right hand dominance was associated mostly with right-sided MOE (24/34) and left hand dominance was associated with occurrence of MOE only in the left ears (4/4, p=0.006). These findings point to an unexpectedly strong relationship between the patient's handedness and laterality of his/her MOE, leading us to hypothesize that the development of MOE might be attributable to self-inflicted local trauma to the ear canal on the same side as the dominant hand.

Relative humidity of the external auditory canal in normal and abnormal ears, and its pathogenic effect.

OBJECTIVE: To find the relative humidity of the normal external ear canal and to demonstrate that the relative humidity of the external auditory canal was higher in abnormal ears, i.e. ears commonly associated with chronic discharge. SETTING: Secondary health care within the ENT departments of Addenbrooke's and Hinchingbrooke hospitals. DESIGN: A clinical observational study. PARTICIPANTS: Volunteers seen in ENT outpatients. Inclusion criteria for the normal ear group, was a normal ear with no history of infection or previous ear disease. Inclusion criteria for abnormal ear group commonly associated with chronic discharge. Exclusion criteria were the presence of pus or infection within the ear canal. METHOD: The relative humidity of the external ear canal was measured in normal and abnormal ears. Abnormal ears were grouped as those commonly associated with chronic discharge, mastoid cavities, tympanic perforations, recurrent otitis externa and hearing-aided ears. RESULTS: The range of relative humidity of normal ears is 40-70%. The humidity in abnormal ears was found to be significantly higher than the humidity in normal ears (P < 0.0001). CONCLUSION: The raised relative humidity in the external canal may explain the predisposition of certain abnormal ears to chronic discharge and infection. If the humidity of the canal could be brought down to a normal level, this could offer a new therapeutic treatment.

The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations.

Malignant (necrotising) external otitis is an invasive infection of the external auditory canal. Although elderly patients with diabetes remain the population most commonly affected, immunosuppressed individuals (eg, from HIV infection, chemotherapy, etc) are also susceptible to malignant external otitis. Pseudomonas aeruginosa is isolated from the aural drainage in more than 90% of cases. The pathophysiology is incompletely understood although aural water exposure (eg, irrigation for cerumen impaction) has been reported as a potential iatrogenic factor. The typical patient presents with exquisitely painful otorrhoea. If untreated, cranial neuropathies (most commonly of the facial nerve) can develop due to subtemporal extension of the infection. The diagnosis of malignant external otitis is based on a combination of clinical findings, an increased erythrocyte sedimentation rate, and radiographic evidence of soft tissue with or without bone erosion in the external canal and infratemporal fossa. Treatment consists of prolonged administration (6-8 weeks) of an antipseudomonal agent (typically an orally administered quinolone). With the introduction and widespread use of both oral and topical quinolones, there are reports of less severe presentation of malignant external otitis and even the emergence of ciprofloxacin resistance. Reservation of systemic quinolones for the treatment of invasive ear infections is recommended.

Malignant otitis externa: a review.

Malignant otitis externa is a rare but potentially fatal disease of the external auditory canal seen mostly among elderly, diabetic or immunocompramised patients. The causative organism is mainly Pseudomonas aeruginosa. The disease spreads rapidly, invading surrounding soft tissues, cartilage and bones causing their necrosis and even spreading to the cranial nerves. The disease can be fatal if treatment is not aggressive and timely, especially if it spreads outside the auditory canal with involvement of the cranial nerves. Treatment is mainly medical with antipseudomonal drugs like the third generation cephalosporin and the fluoroquinolones and local debridement. With aggressive treatment the mortality rate from this disease, which used to be 50% in the past has now been reduced to 10-20%. The pathophysiology of the disease, clinical presentation, diagnosis, treatment and the outcome has been discussed and reviewed.

Passive drainage versus primary closure after total ear canal ablation-lateral bulla osteotomy in dogs: 59 dogs (1985-1995).

OBJECTIVE: Compare passive wound drainage to primary closure of total ear canal ablation-lateral bulla osteotomy (TECA-LBO) in dogs. STUDY DESIGN: Retrospective analysis of medical records. SAMPLE POPULATION: Fifty-nine dogs with end-stage otitis externa or neoplasia of the external and middle ear. METHODS: Medical records of dogs with TECA-LBO were reviewed. Dogs were divided into postoperative drain and primary closure groups. Statistical analyses were performed to identify differences in data for signalment, preoperative treatment, duration of hospitalization, immediate complications, and long-term complications between groups. RESULTS: No significant differences were detected in signalment, diagnosis, and duration of medical management between groups (P > .05). Duration of hospitalization was greater for dogs in the drain group (P < .05). Immediate postoperative complications occurred in 26 of 59 dogs and included ipsilateral facial palsy, incision swelling, vestibular signs, premature drain removal, and one dog died of aspiration pneumonia. Long-term (> 6 months) complications were identified in 12 of 50 dogs and included dermatitis of the medial aspect of the pinna, chronic fistula formation, and permanent facial paralysis. No association between immediate or long term complications and method of closure was identified. CONCLUSIONS: Primary closure is an acceptable alternative in dogs undergoing TECA-LBO when surgical wound dead space can be managed with meticulous hemostasis, complete debridement of devitalized tissue, and accurate apposition of tissue planes.

Otitis externa: management of the recalcitrant case.

Most cases of otitis externa respond to routine treatment, however, there is a subset of patients who frequently develop otitis externa that is usually severe and recalcitrant to routine therapy. These patients include the immunocompromised, those with AIDS, transplant recipients, severe diabetics, patients treated with high dose steroids or chemotherapeutic agents, and those who are malnourished or are chronically ill. Local factors that lead to worsening of otitis externa include dermatitides and prior local irradiation. Patients who find topical therapy painful may be noncompliant with medications, and they too, may develop recalcitrant otitis externa. For successful treatment, a broad understanding of external auditory canal anatomy, the microbiology and pathophysiology of otitis externa, and available treatment options, including topical and systemic medications, must be attained. These topics are reviewed.

Otorragia persistente en pacientes con carcinoma prostático diseminado / Persistent external auditory meatus hemorrhage in a patient with disseminated prostatic carcinoma

Otorragia en paciente masculino de 77 años en mal estado general, visto en la consulta de O.R.L. por 12 horas de sangrado por conducto auditivo derecho. Se hizo taponamiento compresivo con gasa con adrenalina y cuidados médicos generales, a peras de lo cual siguió sangrando dos días mas. Estudios radiológicos, audiológicos y con microscopio descartaron tumor y hemotímpano; el cuadro semejaba la otitis externa hemorrágica descrita por Mawson. Exámenes de laboratorio manifestaron hipoplasia medular y la consulta urológica reveló adenocarcinoma prostático con metástasis diseminadas no accesibles a tratamiento. El estado general del paciente continuó deteriorándose y falleció poco después. No se efectuó autopsia y no fue posible determinar anatómicamente la causa del sangrado; se concluyó que fue una otitis externa hemorrógica en pacientes imunodeprimido y con hipoplasia medular por adenocarcinoma prostático con metástasis generalizadas

[Malignant otitis externa with disfunction of the temporomandibular articulation]. / Otitis externa maligna con disfunción de la articulación temporomandibular.

Here we present a case of a female patient 70 years old stricken with diabetes mellitud 40 years of evolution with manifestations of malignant external otitis accompanied by disfunction of the temporomandibular articulation. Here we will show the clinical characteristics and the diagnosis in our patient likewise its treatment. We will expound the most important aspects of the entity at this present time.