Malignant otitis externa

1. Malignant Otitis Externa
• Nishchal Gupta

2. Introduction
• Malignant otitis externa is an aggressive and
potentially life-threatening infection of the
softtissues of the external ear and surrounding
structures, quickly spreading to involve the
periosteum and bone of the skull base.
• Synonyms :
▫ Necrotizing Otitis Externa
▫ Skull Base osteomyelitis

3. • Malignant otitis externa is a misnomer as it is
not a neoplastic process.
• In 1968, Chandler described this otitis externa as
malignant because he observed an aggressive
clinical behavior, poor treatment outcome, and a
high mortality rate for the patients affected by
this disease.

4. Microbiology:
• Bacterial :
▫ Pseudomonas aeruginosa (95%)
▫ Staphylococcus aureus , S epidermidis
• Fungus
▫ Aspergillus Fumigatus, A. Flavus, A. Niger

5. Predisposing Factors
• Uncontrolled diabetes above 55 years of age.
• Immunocompromised - Acquired Immune
Deficiency Syndrome (AIDS) or malignancy and
are on immunosuppressive drugs like
azathioprine, methotrexate, cyclophosphamide
and cyclosporine.
• Malnutrition
• Anemia(Children)
• Organ Transplant Recipent

6. Pathogenesis

7. CLINICAL FEATURES
SYMPTOMS
• Pain-severe excruciating pain in external and
deep meatus (gets worse when moving head)
• Discharge:
Initial stage =Mucopurulent
Late stage=Purulent and blood stained
• Deafness-sensorineuronal hearing loss
• Facial nerve palsy-lower motor neuron
type(loss of taste sensation in anterior 2/3 of
the tongue on the affected side ,weakness in
facial muscle)

8. Ottorhea Facial Nerve Palsy

9. • Difficulty swallowing
• Persistent itching in the ear canal
• Swollen and red skin around the ear
• Fever and headache sometimes
• Neck stiffness

10. SIGNS
• Pinna will be doughy on palpation
• Tenderness on pulling the pinna
• Mastoid tenderness in late cases

11. OTOSCOPIC EXAMINATION
Hallmark =Granulation
tissue in deep meatus at
the bony cartilagenous
junction

12. • External Auditory Canal(EAC) is narrow and
discharge present
• Sagging of the posterior meatal wall
• Tympanic membrane is normal in early cases
• May show bulge,congestion and granulation if
middle ear is involved
• Signs of multiple cranial nerve palsies in late
cases

13. STAGING AND CLASSIFICATION
• Stage 1:Clinical evidence of malignant otitis
externa with infection of soft tissue beyond the
external auditory canal,but negative Tc-99 bone
scan
• Stage 2:soft tissue infection beyond EAC with
positive Tc-99 bone scan
• Stage 3:As above,but with cranial nerve paralysis
3a -single
3b-multiple
• Stage 4:Meningitis,empyema,sinus thrombosis or
brain abscess

14. Diagnosis of malignant Otitis Externa
• There is no single pathognomonic criterion that
defines malignant otitis externa
• History: Age, Diabetic, may also give history of
trauma to ear by irrigation or cleaning
• Complete head and neck examination: Signs of
otitis externa with or without cranial nerve palsy

15. Investigations
• Ear swab for Culture & Sensitivity
▫ Positive for Pseudomonas
• Blood examination: Complete blood count
• ESR, CRP are raised
• Fasting Blood Sugar & HbA1C for the status of
the blood glucose level.
• RFT & LFT are not for diagnosis but are
important because the patient has to be treated
with antibiotics for longer period.
• Tissue biopsy to rule out malignancy.

16. Radiological Invstigations
▫ CT Scan/MRI with galium contrast will show
evidence of temporal bone involvement and extent
of the ear.
▫ TC 99 isotope bone scan – demonstrate increased
uptake in the region of skull base in active case.

17. Management
• Medical management:
▫ Glucose control
▫ Aural toilet
▫ Systemic anti-Pseudomonas antibiotics (treatment
of choice )
▫ Hyperbaric Oxygen Therapy

18. Medical Management
• Fluoroquinolones are active against P.
aeruginosa.
• For at least 6 to 8 weeks- oral and
intravenous ciprofloxacin
• Ceftazidime provide an alternative to
ciprofloxacin with or without Aminoglycoside
• Amphotericin B is the most commonly used
antifungal agent for fungal

19. Hyperbaric Oxygen (HBO):
• HBO increases the partial pressure of oxygen,
improving hypoxia and allowing greater
oxidative killing of bacteria.
• Used only as an adjunct to antimicrobial therapy

20. Surgical Management
• Local debridement of necrotic tissues and bone.
• Wide surgical excision of infected tissue and
bone may be required sometime.

21. Cranial Nerve Complications
• Cranial nerves can be affected by inflammation
along the skull base or by a neurotoxin produced
by Pseudomonas species.
• The facial nerve (VII) is affected most commonly,
usually at the stylomastoid foramen.
• As the disease progresses, cranial nerves IX, X,
and XI can be affected at the jugular foramen,
followed by XII at the hypoglossal canal.
• Cranial nerves V and VI can be affected if the
disease extends to the petrous apex.

22. Intracranial Complications
• Meningitis, brain abscess, and dural sinus
thrombosis.
• Sigmoid Sinus Thrombosis- if cranial
neuropathies related to jugular foramen is
present.
• Cavernous Sinus Thrombosis- if Cranial nerve V
& VI are involved.

23. •THANK YOU!!