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Necrotizing (malignant) external otitis
Ophir Handzel1, Doron Halperin
1Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel. ohandzel@clalit.org.il
Abstract:
Necrotizing (malignant) external otitis, an infection involving the temporal and adjacent bones, is a relatively rare complication of external otitis. It occurs primarily in immunocompromised persons, especially older persons with diabetes mellitus, and is often initiated by self-inflicted or iatrogenic trauma to the external auditory canal. The most frequent pathogen is Pseudomonas aeruginosa. Patients with necrotizing external otitis complain of severe otalgia that worsens at night, and otorrhea. Clinical findings include granulation tissue in the external auditory canal, especially at the bone-cartilage junction. Facial and other cranial nerve palsies indicate a poor prognosis; intracranial complications are the most frequent cause of death. Diagnosis requires culture of ear secretions and pathologic examination of granulation tissue from the infection site. Imaging studies may include computed tomographic scanning, technetium Tc 99m medronate bone scanning, and gallium citrate Ga 67 scintigraphy. Treatment includes correction of immunosuppression (when possible), local treatment of the auditory canal, long-term systemic antibiotic therapy and, in selected patients, surgery. Family physicians and others who provide medical care for immunocompromised patients should be alert to the possibility of necrotizing external otitis in patients who complain of otalgia, particularly if they have diabetes mellitus and external otitis that has been refractory to standard therapy. Susceptible patients should be educated to avoid manipulation of the ear canal (i.e., they should not use cotton swabs to clean their ears) and to minimize exposure of the ear canal to water with a high chloride concentration. Appropriate patients should be referred to an otolaryngologist.
Insights
Necrotizing external otitis is a rare but serious infection, often seen in diabetics. Early detection and treatment are crucial to prevent severe complications and death.
Area of Science:
- Otolaryngology
- Infectious Diseases
- Immunocompromised Host
Background:
- Necrotizing external otitis (NEO) is a severe infection of the external auditory canal, temporal, and adjacent bones.
- It primarily affects immunocompromised individuals, particularly older adults with diabetes mellitus.
- Trauma to the ear canal, often self-inflicted or iatrogenic, frequently initiates the infection, with Pseudomonas aeruginosa being the most common pathogen.
Purpose of the Study:
- To describe the epidemiology, clinical presentation, diagnosis, and management of necrotizing external otitis.
- To highlight the importance of early recognition in immunocompromised patients, especially those with diabetes.
- To provide guidance for family physicians and other healthcare providers on managing this condition.
Main Methods:
- Review of clinical findings, including severe otalgia, otorrhea, and granulation tissue in the ear canal.
- Diagnostic methods involve culturing ear secretions and pathological examination of granulation tissue.
- Imaging studies such as CT scans and bone/gallium scintigraphy aid in diagnosis and staging.
Main Results:
- Facial and cranial nerve palsies are indicators of a poor prognosis.
- Intracranial complications represent the most frequent cause of mortality.
- Treatment involves addressing immunosuppression, local ear care, prolonged antibiotics, and potentially surgery.
Conclusions:
- Family physicians must maintain a high index of suspicion for NEO in immunocompromised patients with refractory otitis and otalgia, especially if diabetic.
- Patient education on avoiding ear canal manipulation and minimizing water exposure is vital.
- Prompt referral to an otolaryngologist is essential for appropriate management.