Necrotizing otitis externa due to Aspergillus in an immunocompetent patient

An 85-year-old, nondiabetic man is described with necrotizing (malignant) otitis externa. The patient developed facial nerve paralysis in the presence of a progressive cellulitis and chondritis of the external auditory meatus. Destruction of the bony meatus and mastoid and obliteration of normal soft-tissue planes at the skull base were documented by computed tomographic scans. Aspergillus fumigatus was isolated from the external meatus and deep tissue specimens. Fungal invasion of bone and soft tissue was confirmed histopathologically. Pseudomonas aeruginosa was never isolated. This case is unusual from both the standpoint of etiology and host susceptibility in that the patient had no apparent underlying disease. Amphotericin B and rifampin therapy following radical mastoidectomy halted the progression of disease. Finally, this case illustrates the pitfalls of empiric antibacterial therapy for necrotizing otitis externa without cultural confirmation of the etiologic agent.

Conchomeatoplasty for chronic otitis externa

Chronic moisture is a major cause of chronic otitis externa (COE). Moisture combined with inadequate lubrication of the stratum corneum and retention of keratin debris promote bacterial and fungal growth. In most cases of COE, creating a well-aerated, dry, self-cleaning external auditory canal prevents further infection. This can usually be accomplished by medical treatment that includes suction and swabbing. Antibiotic-steroid ear drops control infection and inflammation. Alcohol flush and warm-air ventilation dry the canal, and a hydrophobic cream lubricates and seals the stratum corneum from moisture, fungus, and bacteria. An anatomic variation, a narrow external auditory meatus leading to poor ventilation, is frequently associated with COE, which does not respond to conventional therapy. A previously unreported simple lateral conchomeatoplasty is presented. No other described meatoplasty corrects both the conchal cartilage projection and inadequate meatal skin circumference which, together, cause the small meatus. The lateral conchomeatoplasty has been used by this author for over 20 years on 35 ears. All patients showed improvement; most had complete control.

The draining ear. Otitis media and externa

Otorrhea, or discharge from the ear, may be associated with otitis media or otitis externa. Each episode of otorrhea requires examination of the external ear canal and middle ear to determine the origin and extent of disease, a complete understanding of the pathogenesis, and a therapeutic approach that considers the microbiology and the extent of tissue invasion. This review focuses on infections of the middle ear and external ear commonly associated with otorrhea. The pathogenesis, clinical manifestations, methods of diagnosis, and medical and surgical therapies are presented.

[Human lagochilascariasis in Venezuela: description of a fatal case]

Lagochilascaris minor Leiper, 1909, puede producir lesiones graves, con invasión de músculo, hueso, ojo, oido medio, pulmones o cerebro. En este trabajo se comunica uri caso de lagochilascariasis en unajóvem de 17anos venezolana, que desarrolló signos de hipertensión endocraneana. Se revisan las publicaciones sobre lagochilascariasis y los aspectos clínicos-patológicos de la invasión dei sistema nervioso central por estos vermes.

Pseudomonas infections associated with hot tubs and other environments

Infections due to Pseudomonas aeruginosa are not confined to the hospital intensive care unit. This paper examines the association of P. aeruginosa and several community-acquired infections. Hot tub folliculitis is a recently described disorder occurring in outbreaks among persons who unknowingly immerse themselves in contaminated whirlpools, spas, or swimming pools. The green nail syndrome and other dermatoses are also reviewed. Infective endocarditis, invasive external otitis, and puncture would osteomyelitis are serious infections that carry high risks for the patient and challenge the physician's most potent therapies.

Sulfamylon allergy simulating chondritis

A case of atopic reaction to Sulfamylon is described that occurred in a patient receiving this medication as a topical treatment for burned ears. The presenting signs were similar to those of a persistent chondritis, with which it was initially confused. All signs and symptoms cleared rapidly after the Sulfamylon was discontinued. Physicians should be aware of this entity so as to avoid inappropriate surgical debridement of ears with this relatively minor problem.

Otitis externa associated with aquatic activities (swimmer's ear)

Infections of the ear canal may vary in terms of severity. Their frequency and morbidity qualify them as significant aquatic problems. The aquatic environment adds the conditional variable of moisture to the ear canal. Usually bacteria are introduced with the moisture and in the warm environment of the canal multiply, generate debris, invade the canal lining, and generate the symptoms of otitis externa. Fortunately, the incidence of this condition can be minimized by eliminating moisture in the canal. In situations where excessive moisture is likely to be introduced such as in swimmers, scuba divers, and deep sea divers the prophylactic measures of desiccation and acidification of the canal should be used. They are very effective. In the saturation diver, ear canal infections are not likely to resolve without interruption of diving activities. Individuals who have recurring ear canal infections require evaluation by an ear specialist to identify possible remedial problems that can trigger infection. Correction of anatomical problems or underlying dermatoses can prevent recurrences of OE.

Necrotizing external otitis in children: report of two cases and review of the literature

Necrotizing external otitis is described almost exclusively in elderly diabetics. A review of the literature revealed 12 children, ages 2 months to 21 years, who have been described with this problem. Two additional patients are reported here. In children the male:female ratio is 1:1, whereas in adults a 2:1 male preponderance is seen. Diabetes mellitus, present in 94.7% of adults, is seen in only 21% of children. Facial nerve paralysis occurs in 35% of the children as compared to 52% of the adults. Facial paralysis was permanent in 100% of the children, but only 36.3% of the surviving adults had permanent facial paralysis. Surgical intervention had no significant effect on either group. Other pediatric complications include external auditory canal stenosis (29%), auricular cartilage deformity (11%), and sensorineural hearing loss (18%). A 40% to 50% mortality rate is seen in adults whereas no deaths have been reported in children. The clinical presentation of necrotizing external otitis in children shares some features with the disease as described in adults. However, notable differences do exist and form the basis of this report. The proposed pathophysiology of necrotizing external otitis in adults and its significance for disease in children are also discussed.

[A severe form of external otitis: necrosing diabetic otitis]

Otitis externa are of usual observation in inter-tropical regions. Pseudomonas aeruginosa is responsible generally. But, when immunodeficiency is associated or on diabetic diathesis, such an otitis externa can be extremely dangerous: extensive osteitis of the base of the skull, paralysis of the last pairs of cervical nerves rapidly creeping, built a clinical identity called malignant external otitis, leading to death in 50% of the cases.

Marine-acquired infections. Hazards of the ocean environment

Numerous pathogenic bacteria are found in seawater. They can cause several environmental infections, such as conjunctivitis, otitis externa, wound infections, pneumonia, and gastrointestinal illness. The incidence of some of these infections could be lowered if people took care to avoid eating undercooked seafood, swimming in brackish water, or sustaining lacerations in a marine environment. However, such infections will probably increase in frequency as more people visit ocean resorts. Prompt elimination of the infective agent, adequate wound care, and avoidance of reexposure can minimize the severity of the condition.

Malignant external otitis with optic neuritis

Malignant external otitis (MEO) is a progressive necrotizing infection which spreads to the skull base. The causative organism is usually Pseudomonas aeruginosa and 90% of the patients are diabetic. The infection gains access to the skull base at the temporal bone. Cranial nerve involvement is common. We present a case of malignant external otitis causing blindness due to optic neuritis. Progressive vascular involvement along the skull base is the pathogenic mechanism that best explains spread from the temporal bone to the orbital apex.

Vanishing earrings

Four children who presented with impacted earrings are described. We suggest that the insertion of earrings in children under 10 years has hazards and recommend the use of sterling silver or 9 ct gold if the procedure is to be done in young children.

Malignant external otitis in a diabetic adolescent

Malignant external otitis (MEO) is an unusual medical problem. The case reported is that of a diabetic adolescent who presented with severe ear pain unresponsive to oral antibiotics and analgesics. The diagnosis of MEO was made, and he was successfully treated with a combination of intravenous anti-Pseudomonas agents. A review of the pediatric cases, guidelines for diagnosis, length of treatment, and prognosis are presented.

[Malignant external otitis caused by Pseudomonas aeruginosa. Report of 3 cases]

The cases of three patients aged over sixty, diabetic for a long time and having clinical, otological, neurological and microbiological findings of malignant external otitis by Pseudomonas aeruginosa are registered. The first patient, a 62 years old woman, had important neurological alterations, such as proven P. aeruginosa meningitis and involvement of the 6th, 7th, 8th, 9th and 10th left cranial nerves. Although mortality and morbidity rates of cases with these characteristics are reported to be high, this patient survived. The second was a 64 years old male with the classical complaints of this condition consisting of persistent and intensive ear pain, serous purulent discharge and an emerging tumourous lesion in the left external ear canal. Good results were obtained with the surgical treatment administered along with an antimicrobial plan which remained incomplete because the patient has requested his discharge from the hospital. In less than one month, he was again hospitalized already presenting neurological manifestations (paralysis of the 6th cranial nerve) following a fatal course in a few days. The third was also a male patient, 70 years old, whose initial complaints occurred after a month a butterfly penetrated his right ear during his sleep. In spite of the presence of neurological troubles (facial paralysis and stupor) he survived with a prolonged antibiotic therapy. After a literature revision on this pathology, considerations are made concerning its pathogeny, clinical findings, diagnosis, therapy and prognosis.