Advertisement

Malignant Otitis Externa

  • Marlene L. Durand
Chapter

Abstract

Malignant otitis externa (MOE) is a rare, invasive infection of the temporal bone that arises in the external auditory canal. Most cases are due to Pseudomonas and occur in older diabetic patients. Untreated infection can extend to surrounding soft tissues and bones (temporomandibular joint, nasopharynx, petrous apex , skull base). The infection is subacute to chronic in presentation but potentially life-threatening. The correct diagnosis is often missed for weeks to months because the clinician is unfamiliar with the signs and symptoms of MOE. The high mortality rate seen in early series prompted the adjective “malignant,” but recent series have demonstrated that cure is possible in all cases if MOE is diagnosed early and treated appropriately. This chapter reviews the clinical features, diagnostic evaluation, and treatment of MOE.

Keywords

Malignant otitis externa Invasive otitis externa Necrotizing otitis externa Skull base osteomyelitis Petrous apex osteomyelitis 

References

  1. 1.
    Meltzer PE, Kelemen G. Pyocyaneous osteomyelitis of the temporal bone, mandible and zygoma. Laryngoscope. 1959;69:1300–16.CrossRefGoogle Scholar
  2. 2.
    Chandler JR. Malignant external otitis. Laryngoscope. 1968;78:1257–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Cohen D, Friedman P. The diagnostic criteria of malignant external otitis. J Laryngol Otol. 1987;101:216–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Sudhoff H, Rajagopal S, Mani N, et al. Usefulness of CT scans in malignant external otitis: effective tool for the diagnosis, but of limited value in predicting outcome. Eur Arch Otorhinolaryngol. 2008;265:53–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Stroman DW, Roland PS, Dohar J, Burt W. Microbiology of normal external auditory canal. Laryngoscope. 2001;111(11 Pt 1):2054–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Salit IE, Miller B, Wigmore M, Smith JA. Bacterial flora of the external canal in diabetics and non-diabetics. Laryngoscope. 1982;92(6 Pt 1):672–3.CrossRefPubMedGoogle Scholar
  7. 7.
    Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009;201:71–115.PubMedGoogle Scholar
  8. 8.
    Walker J, Moore G. Pseudomonas aeruginosa in hospital water systems: biofilms, guidelines, and practicalities. J Hosp Infect. 2015;89:324–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Grandis J, Stoehr G, Yu VL, et al. Aural irrigation with water: a potential pathogenic mechanism for inducing malignant external otitis? Arch Otol Rhinol Laryngol. 1990;99:117–9.CrossRefGoogle Scholar
  10. 10.
    Zikk D, Rapoport Y, Himelfarb MZ. Invasive external otitis after removal of impacted cerumen by irrigation (letter). N Engl J Med. 1991;325:969–70.PubMedGoogle Scholar
  11. 11.
    Ford GR, Courteney-Harris RG. Another hazard of ear syringing: malignant otitis externa. J Laryngol Otol. 1990;104:709–10.CrossRefPubMedGoogle Scholar
  12. 12.
    Rubin J, Yu VL. Malignant external otitis: insights into pathogenesis, clinical manifestations, diagnosis, and therapy. Am J Med. 1988;85:391–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Hamzany Y, Soudry E, Preis M, et al. Fungal malignant external otitis. J Infect. 2011;62(3):226–31.CrossRefPubMedGoogle Scholar
  14. 14.
    Al-Noury K, Lotfy A. Computed tomography and magnetic resonance imaging findings before and after treatment of patients with malignant external otitis. Eur Arch Otorhinolaryngol. 2011;268:1727–34.CrossRefPubMedGoogle Scholar
  15. 15.
    Chen YA, Chan KC, Chen CK, Wu CM. Differential diagnosis and treatment of necrotizing otitis externa: a report of 19 cases. Auris Naris Larynx. 2011;28:666–70.CrossRefGoogle Scholar
  16. 16.
    Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and implications for diagnosis and treatment. Otolaryngol Head Neck Surg. 2014;151:112–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Franco-Vidal V, Blanchet H, Bebear C, et al. Necrotizing external otitis: a report of 46 cases. Otol Neurotol. 2007;28:771–3.CrossRefPubMedGoogle Scholar
  18. 18.
    Hariga I, Mardassi A, Belhaj Younes F, et al. Necrotizing otitis externa: 19 cases’ report. Eur Arch Otorhinolaryngol. 2010;267:1193–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Chin R, Roche P, Sigston E, Valance N. Malignant otitis externa: an Australian case series. Surgery. 2012;10:273–7.Google Scholar
  20. 20.
    Meade TK, Anari S, El Badawey MR, Zammit-Maempel I. Malignant otitis externa: case series. J Laryngol Otol. 2010;124:846–51.CrossRefPubMedGoogle Scholar
  21. 21.
    Stevens SM, Lambert PR, Baker AB, Meyer TA. Malignant otitis externa: a novel stratification protocol for predicting treatment outcomes. Otol Neurotol. 2015;36:1492–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Pulcini C, Mahdyoun P, Cua E, et al. Antibiotic therapy in necrotizing external otitis: case series of 32 patients and review of the literature. Eur J Clin Microbiol Infect Dis. 2012;31:3287–94.CrossRefPubMedGoogle Scholar
  23. 23.
    Lambor DV, Das CP, Goel HC, et al. Necrotising otitis externa: clinical profile and management protocol. J Laryngol Otol. 2013;127:1071–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Bhat V, Aziz A, Kumar Bhandary S, et al. Malignant otitis externa – a retrospective study of 15 patients treated in a tertiary healthcare center. Int Adv Otol. 2015;11:72–6.CrossRefGoogle Scholar
  25. 25.
    Loh S, Loh WS. Malignant otitis externa: an Asian perspective on treatment outcomes and prognostic factors. Otolaryngol Head Neck Surg. 2013;148:991–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Karaman E, Yilmaz M, Ibrahimov M, et al. Malignant otitis externa. J Craniofac Surg. 2012;23:1748–51.CrossRefPubMedGoogle Scholar
  27. 27.
    Weinroth SE, Schessel D, Tuazon CU. Malignant otitis externa in AIDS patients: case report and review of the literature. Ear Nose Throat J. 1994;73:772–8.PubMedGoogle Scholar
  28. 28.
    Rubin J, Yu VL, Stool SE. Malignant external otitis in children. J Pediatr. 1988;113:965–70.CrossRefPubMedGoogle Scholar
  29. 29.
    Guerrero-Espejo A, Valenciano-Moreno I, Ramirez-Llorens R, Perez-Monteagudo P. Malignant otitis externa in Spain. Acta Otorrhinolaringol Esp. 2017;68:23–8.CrossRefGoogle Scholar
  30. 30.
    Sylvester MJ, Sanghvi S, Patel VM, et al. Malignant otitis externa hospitalizations: analysis of patient characteristics. Laryngoscope. 2017;127(10):2328–36.CrossRefPubMedGoogle Scholar
  31. 31.
    Chawdhary G, Liow N, Democratis J, Whiteside O. Necrotising (malignant) otitis externa in the UK: a growing problem. Review of five cases and analysis of national Hospital Episode Statistics trends. J Laryngol Otol. 2015;129:600–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Mardinger O, Rosen D, Minkow B, et al. Temporomandibular joint involvement in malignant external otitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:398–403.CrossRefPubMedGoogle Scholar
  33. 33.
    Mani N, Sudhoff H, Rajagopal S, et al. Cranial nerve involvement in malignant external otitis: implications for clinical outcome. Laryngoscope. 2007;117:907–10.CrossRefPubMedGoogle Scholar
  34. 34.
    Stern Shavit S, Soudry E, Hamzany Y, Nageris B. Malignant external otitis: factors predicting patient outcomes. Am J Otolaryngol. 2016;37:425–30.CrossRefPubMedGoogle Scholar
  35. 35.
    Omran AA, El Garem HF, Al Alem RK. Recurrent malignant otitis externa: management and outcome. Eur Arch Otorhinolaryngol. 2012;269:807–11.CrossRefPubMedGoogle Scholar
  36. 36.
    Walton J, Coulson C. Fungal malignant otitis externa with facial nerve palsy: tissue biopsy aids diagnosis. Case Rep Otolaryngol. 2014;2014:192318.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Mion M, Bovo R, Marchese-Ragona R, Martini A. Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital. 2015;35:307–13.PubMedPubMedCentralGoogle Scholar
  38. 38.
    McLaren O, Potter C. Scedosporium apiospermum: a rare cause of malignant otitis externa. BMJ Case Rep. 2016;2016:bcr2016217015.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Rubin J, Curtin HD, Yu VL, Kamerer DB. Malignant external otitis: utility of CT in diagnosis and follow up. Radiology. 1990;174:391–4.CrossRefPubMedGoogle Scholar
  40. 40.
    Mattucci KF, Setzen M, Galantich P. Necrotizing otitis externa occurring concurrently with epidermoid carcinoma. Laryngoscope. 1986;96:264-266.CrossRefGoogle Scholar
  41. 41.
    Grandis JR, Hirsch BE, Yu VL. Simultaneous presentation of malignant external otitis and temporal bone cancer. Arch Otolaryngol Head Neck Surg. 1993;119:687–9.CrossRefPubMedGoogle Scholar
  42. 42.
    al-Shihabi BA. Carcinoma of temporal bone presenting as malignant otitis externa. J Laryngol Otol. 1992;106(10):908.CrossRefPubMedGoogle Scholar
  43. 43.
    Foden N, Burgess C, Damato S, Ramsden J. Concurrent necrotising otitis externa and adenocarcinoma of the temporal bone: a diagnostic challenge. BMJ Case Rep. 2013;2013:bcr2013009155.  https://doi.org/10.1136/bcr-2013-009155.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Goh JPN, Karandikar A, Loke SC, Tan TY. Skull base osteomyelitis secondary to malignant otitis externa mimicking advanced nasopharyngeal cancer: MR imaging features at initial presentation. Am J Otolaryngol. 2017;38:466–71.CrossRefPubMedGoogle Scholar
  45. 45.
    Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med. 2002;347:408–15.CrossRefPubMedGoogle Scholar
  46. 46.
    Patterson TF, Thompson GR III, Denning DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1-e60.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Parize P, Chandesris MO, Lanternier F, et al. Antifungal therapy of Aspergillus invasive otitis externa: efficacy of voriconazole and review. Antimicrob Agents Chemother. 2009;53:1048–53.CrossRefPubMedGoogle Scholar
  48. 48.
    Maertens JA, Raad II, Marr KA, et al. Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomised-controlled, non-inferiority trial. Lancet. 2016;387(10020):760–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev. 2013:CD004617.Google Scholar
  50. 50.
    Rubin J, Stoehr G, Yu VL, et al. Efficacy of oral ciprofloxacin plus rifampin for treatment of malignant external otitis. Arch Otolaryngol Head Neck Surg. 1989;115:1063–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Lang R, Goshen S, Kitzes-Cohen R, et al. Successful treatment of malignant external otitis with oral ciprofloxacin: report of experience with 23 patients. J Infect Dis. 1990;161:5357–540.CrossRefGoogle Scholar
  52. 52.
    Doroghazi RM, Nadol JB, Hyslop NE, et al. Invasive external otitis. Report of 21 cases and review of the literature. Am J Med. 1981;71:603–14.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Infectious Diseases, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Infectious Disease Service, Massachusetts Eye and Ear InfirmaryHarvard Medical SchoolBostonUSA

Personalised recommendations