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Abstract
Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.
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Affiliation(s)
- Sriram Vaidyanathan
- Department of Radiology and Nuclear Medicine, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK.
| | - Ravi Kumar Lingam
- Department of Radiology, Northwick Park & Central Middlesex Hospitals, London North West University Healthcare NHS Trust, Imperial College London, Watford Road, London HA1 3UJ, UK
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Lamry NA, Misron K, Tengku Kamalden TMI, Aziz A, Salim R. Synchronous Occurrence of Bilateral Malignant Otitis Externa: Report of a Rare Case. Korean J Fam Med 2020; 42:483-486. [PMID: 32456405 PMCID: PMC8648487 DOI: 10.4082/kjfm.20.0071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022] Open
Abstract
Malignant otitis externa (MOE) is a rare and potentially life-threatening disease of the ear and temporal bone. Bilateral simultaneous MOE is extremely rare. Due to bilaterally symmetrical facial nerve palsy, it can easily be missed at the initial presentation, causing delay in management. Here, we report a case of bilateral MOE managed aggressively with regular ear toileting, ear packing with a ribbon gauze soaked with topical antimicrobials, and long-term intravenous and oral antibiotics. The patient showed good improvement in pain control, facial nerve status, and ear findings.
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Affiliation(s)
- Nur Adillah Lamry
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kota Bharu, Malaysia
| | - Khairunnisak Misron
- Department of Otorhinolaryngology Head and Neck Surgery, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | | | - Azliana Aziz
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kota Bharu, Malaysia
| | - Rosdan Salim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kota Bharu, Malaysia
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van Kroonenburgh AMJL, van der Meer WL, Bothof RJP, van Tilburg M, van Tongeren J, Postma AA. Advanced Imaging Techniques in Skull Base Osteomyelitis Due to Malignant Otitis Externa. CURRENT RADIOLOGY REPORTS 2018; 6:3. [PMID: 29416952 PMCID: PMC5778178 DOI: 10.1007/s40134-018-0263-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW To give an up-to-date overview of the strengths and weaknesses of current imaging modalities in diagnosis and follow-up of skull base osteomyelitis (SBO). RECENT FINDINGS CT and MRI are both used for anatomical imaging, and nuclear techniques aid in functional process imaging. Hybrid techniques PET-CT and PET-MRI are the newest modalities which combine imaging strengths. SUMMARY No single modality is able to address the scope of SBO. A combination of functional and anatomical imaging is needed, in the case of newly suspected SBO we suggest the use of PET-MRI (T1, T2, T1-FS-GADO, DWI) and separate HRCT for diagnosis and follow-up.
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Affiliation(s)
- A. M. J. L. van Kroonenburgh
- Department of Radiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - W. L. van der Meer
- Department of Radiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - R. J. P. Bothof
- Department of Anesthesiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - M. van Tilburg
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - J. van Tongeren
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - A. A. Postma
- Department of Radiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
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Hariga I, Mardassi A, Belhaj Younes F, Ben Amor M, Zribi S, Ben Gamra O, Mbarek C, El Khedim A. Necrotizing otitis externa: 19 cases' report. Eur Arch Otorhinolaryngol 2010; 267:1193-8. [PMID: 20058154 DOI: 10.1007/s00405-009-1194-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Accepted: 12/23/2009] [Indexed: 10/20/2022]
Abstract
Necrotizing otitis externa is an uncommon but severe infectious disease of the external auditory canal. Patients at risk are those immunodepressed or having diabetes. The causal germ is often Pseudomonas aeruginosa. Over a period of 10 years (1997-2006), we treated 19 patients: 94.7% had diabetes (insulin dependent in 6 cases). The causal germ was P. aeruginosa in 59% of cases. The pretherapeutic work-up included a computed tomography and a scintigraphy practiced in order to confirm diagnosis and assess the extension. Medical treatment was based on a parenteral antibiotic therapy using a third-generation cephalosporin and a fluoroquinolones. Local treatment of the auditory canal including cleaning and application of antimicrobial agents was performed in all the cases. Surgical debridement of soft tissue and infected bone was performed in one patient who did not respond to medical management. Repeated scintigraphies with gallium were used to follow the course under treatment in only three cases. We had a 89.4% cure rate with only three cases of recurrence. We reviewed the data in the literature on necrotizing otitis externa and present the important diagnostic, imaging, and therapeutic aspects of the disease.
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Affiliation(s)
- Ines Hariga
- ENT Department, Habib Thameur Hospital, Tunis, Tunisia
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Rubin Grandis J, Branstetter BF, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. THE LANCET. INFECTIOUS DISEASES 2004; 4:34-9. [PMID: 14720566 DOI: 10.1016/s1473-3099(03)00858-2] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Sun SS, Tsai SC, Shiau YC, Kao CH. Simultaneous Tc-99m MDP and Ga-67 citrate uptake of benign lymphoid hyperplasia in the mastoid region. Clin Nucl Med 2001; 26:797. [PMID: 11507308 DOI: 10.1097/00003072-200109000-00019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- S S Sun
- Department of Nuclear Medicine, China Medical College Hospital, No. 2 Yuh-Der Road, Taichung 404, Taiwan
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Abstract
Lesions in the skull base may present difficulties in diagnosis primarily because the access needs to be invasive and one has to rely on imaging that may still be misleading. The case presented here illustrates this example in that the patient had abnormalities on computed tomography (CT) and magnetic resonance image (MRI) scans quite convincing of malignancy but which with time proved, essentially through clinical judgment, to be skull base osteomyelitis secondary to malignant external otitis (OME).
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Affiliation(s)
- N Subburaman
- Department of Otolaryngology, Pilgrim Hospital, Boston, UK
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Affiliation(s)
- B E Hirsch
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Montefiore University Hospital, PA
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Menachof MR, Jackler RK. Otogenic skull base osteomyelitis caused by invasive fungal infection. Otolaryngol Head Neck Surg 1990; 102:285-9. [PMID: 2108420 DOI: 10.1177/019459989010200315] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- M R Menachof
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco 94117
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Morrison GA, Bailey CM. Relapsing malignant otitis externa successfully treated with ciprofloxacin. J Laryngol Otol 1988; 102:872-6. [PMID: 3199005 DOI: 10.1017/s002221510010670x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Two cases are presented, both patients with advanced relapsing malignant otitis externa. The antibiotic ciprofloxacin has strong anti-pseudomonal activity. It was given orally for six months to both patients, following administration of the traditional parenteral antibiotic courses, and in each case the disease has been extinguished. We therefore recommend that the management of patients shown to have malignant otitis externa should include strict diabetic control, regular local aural toilet, gentamicin ear drops and a six week course of parenteral antipseudomonal antibiotic agents (usually gentamicin and azlocillin) together with metronidazole to cover any anaerobic element in the infection. This regimen should be followed by a six month course of oral ciprofloxacin (750 mg b.d.). Indium scans should be used to monitor recovery. We believe that this regimen can significantly reduce the morbidity and mortality of patients suffering from malignant otitis externa with cranial nerve involvement.
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Affiliation(s)
- G A Morrison
- Royal National Throat, Nose and Ear Hospital, London
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Abstract
Malignant external otitis is an infection of the external ear canal, mastoid, and base of the skull caused by Pseudomonas aeruginosa. The condition occurs primarily in elderly patients with diabetes mellitus. Current theories on pathogenesis and anatomic correlations are reviewed. Severe, unrelenting otalgia and persistent otorrhea are the symptomatic hallmarks of the disease, whereas an elevated erythrocyte sedimentation rate is the only distinctive laboratory abnormality. Iatrogenic causes such as administration of broad-spectrum antibiotics and aural irrigation may play a predisposing role in high-risk populations. The disease can result in cranial polyneuropathies (with facial nerve [VII] paralysis being the most common) and death. The mainstay of treatment is administration of antipseudomonal antibiotics for four to eight weeks. Recurrence is common, and mortality remains at about 20 percent despite antibiotic therapy. Given the increasing longevity of diabetic patients, the frequency of this disease is increasing. Internists, family practitioners, and ambulatory care physicians must now be cognizant of the presenting symptoms, while infectious disease specialists and otolaryngologists need to be appraised of strides in diagnosis and therapy. The role of surgery should be minimized. Use of new diagnostic radiologic modalities and new antipseudomonal antibiotics discussed in this review should lead to improved outcome.
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Affiliation(s)
- J Rubin
- Department of Otolaryngology, University of Pittsburgh, Pennsylvania
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Sabater F, Mensa J, Doménech J, Loncá M, Carulla M. Necrotizing external otitis treated with ciprofloxacin. A case report. J Laryngol Otol 1988; 102:606-7. [PMID: 3411213 DOI: 10.1017/s0022215100105857] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Necrotizing (malignant) external otitis is a severe infection caused by Pseudomonas aeruginosa which occurs mainly in elderly diabetics or in immuno-depressed patients (Chandler, 1968). The management of this condition requires the association between an aminoglycoside antibiotic and an antipseudomonal beta-lactamic, given parenterally during a 4 to 6 week period. Sometimes it is necessary to continue the therapy for months until there is no evidence of residual disease (Strauss et al., 1982). Ciprofloxacin is a quinolone with antipseudomonal activity which can be taken orally, and it is a useful alternative to the current treatment. The authors report a case of necrotizing external otitis which was successfully treated with ciprofloxacin.
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Affiliation(s)
- F Sabater
- Dept. of Otolaryngology, Hospital Clínic of Barcelona
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