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Maligns ārējās auss iekaisums
- 1. A L E K S A N D R A Š I L O V A , M F V I 4 . G R U P A M E N T O R E : D R . G U N T A S U M E R A G A Maligns ārējās auss iekaisums
- 2. Definīcija Ārējās auss iekaisuma nekrotizējoša forma, kas skar ārējo auss eju, galvaskausa pamatni un deniņu kaulu, kur tipiskais ierosinātājs ir Pseudomonas aeruginosa
- 3. Riska faktori Ārējās auss iekaisums Cukura diabēts Imūnkompromitēti pacienti Vecums
- 4. Etioloģija Pseudomonas aeruginosa (>90%) Reti: Staphylococcus aureus Proteus mirabilis Klebsiella oxytoca Pseudomonas cepacia Staphylococcus epidermis Sēnītes http://fineartamerica.com/featured/3-pseudomonas-aeruginosa-bacteria-sem-steve-gschmeissner.html http://www.sci-news.com/medicine/science-antibiotics-methicillin-resistant-staphylococcus-aureus-01548.html
- 5. Patoģenēze Pseudomonas invadē a/v ↓ Vaskulīts un tromboze ↓ Koagulācijas nekroze Santorini sprauga os temporale un processus mastoideus Foramen stylomastoideus → n.facialis Foramen jugularis → IX, X, XI nervi
- 6. Klīnika Ārējās auss iekaisuma simptomi: Otalģija Otoreja Dzirdes zudums Ekstra-aurikulāras izpausmes: Kakla limfadenopātija Trismus Galvassāpes
- 7. Komplikācijas Kraniālo nervu parēze: N. facialis – visbiežāk VIII, IX, X, XI nervi Venozā sinusa tromboze Meningīts
- 8. Diagnostika Laboratoriskie testi EGĀ ↑ CRO ↑ Leu N/↑ Glikoze Kreatinīns Ārējās auss apskate http://www.aafp.org/afp/2006/1101/p1510.html
- 9. Diagnostika Otoskopija Čūlas ārējās auss ejā Granulācijas audi kaula un skrimšļa savienojuma vietā http://gpent.blogspot.com/2013/02/definition-oe-is-inflammatory-typically_11.html http://eac.hawkelibrary.com/new/main.php?g2_itemId=353&g2_imageViewsIndex=1
- 10. Diagnostika Sekrēta uzsējums ar a/b jūtības testu 90% P. aeruginosa Granulācijas audu histoloģija http://otopathologynetwork.org/tbimages/chapter5/image436/
- 11. Diagnostika CT Izvertē temporālo kaulu
- 12. Diagnostika Kaulu scintigrāfija (technetium-99m-MDP) http://www.indianjotol.org/article.asp?issn=0971-7749;year=2011;volume=17;issue=4;spage=165;epage=166;aulast=Al-otaibi
- 13. Diagnostika Gallium 67 scintigrāfija
- 14. Ārstēšana Glikēmijas kontrole Lokāla terapija Nekrotisko audu un sekvestra debridement Lokāli antimikrobiālie līdzekļi
- 15. Ārstēšana Antibakteriāla terapija Antibiotiķis Deva Ciprofloksacīns 750 mg p/o ik pēc 12 st 400 mg i/v ik pēc 12 st Tikarcilīns/ klavulanskābe 3 g i/v ik pēc 4 st Piperacilīns/ tazobaktāms 4-6 g i/v ik pēc 4-6 st Ceftazidīms 2 g i/v ik pēc 8 st Cefepīms 2 g i/v ik pēc 12 st Tobramicīns 1-1,66 mg/kg i/v vai i/m ik pēc 8 st Gentamicīns 1-1,66 mg/kg i/v vai i/m ik pēc 8 st
- 16. Klīniskais gadījums Vīrietis, 70 gadi Sūdzības: Izteikta otalģija Otoreja Sējas asimetrija Anamnēze: CD
- 17. Klīniskais gadījums Kādi riska faktori ir pacientam? Vecums CD Kāda tipa sejas parēze ir pacientam? Perifēra parēze
- 19. Izmeklējumi Laboratoriskie testi: EGĀ 140 CRO 110 mg/L Otomikroskopija Audu tūska, nav iespejāma bungplēvītes vizuālizācija Granulācijas audi Sekrēts Uzsējums Candida Audiometrija Lb. – jaukta tipa dzirdes zudums Kr. – sensoneironāls dzirdes zudums
- 20. Izmeklējumi Kāda metode? Ko Jūs redzat?
- 21. Terapija Antibakteriālie preparāti: 3.p. cefalosporīns Klindamicīns Operatīva ārstēšana Kortikāla mastoidektomija Hipertrofēto un granulācijas audu ekscīzija
- 22. Pēc trīs mēnešiem Drudzis Nespēks Sejas asimetrija Rīšanas un runas traucējumi Garšas traucējumi Kādus nervus skara iekaisums? VII, IX, un X kraniālie nervi
- 23. Pēc trīs mēnešiem Otalģija Otoreja Uzsējums - ciprofloksacīn-resistenta Pseudomonas aeruginosa
- 24. Kāda metode? Ko Jūs redziet?
- 25. Terapija Antimikrobiāla terapija: Vankomicīns Cefdazidīms Metronidazols Pretsēnīšu preparāti Operatīva ārstēšana
- 26. Informācijas avoti Probst R. Grevers G. Iro H. Basic Otorhinolaryngology A Step-By-Step Learning Guide. Georg Thieme Verlag, 2006 Handzel O, Halperin D., Necrotizing (Malignant) External Otitis, Am Fam Physician. 2003 Jul 15;68(2):309- 312. Sang Kuk Lee, Se A Lee, Sang Woo Seon, Jae Hyun Jung, Jong Dae Lee, Jae Young Choi, Bo Gyung Kim, Analysis of Prognostic Factors in Malignant External Otitis Clinical and Experimental Otorhinolaryngology 2016; ceo.2016.00612 D Djerić, M Folić, M Janićijević, S Blažić, D Popadić, Recurrent malignant otitis externa with multiple cranial nerve involvement: A case report, Srp Arh Celok Lek. 2016 May-Jun;144(5-6):315-319
Editor's Notes
- They are elderly, diabetics with or without malignancy, with or without history of radiation, ķīmijterapija
- In diabetes mellitus, poor vascular supply resulting from microvascular disease is aggravated by pseudomonal vasculitis, which further restricts tissue perfusion. Diabetes mellitus is also associated with impaired polymorphonuclear cell function and a higher pH of cerumen in the aural canal.
- Dzirdes zudums – sakarā ar tūsku un pastiprinātu sekrēciju, kas aizsprosto dzirdes kanālu. Konduktīva tipa deep otalgia persisting for longer than 1 month Drudzis nav raksturīgs Involvement of structures beyond the soft tissues of the auditory canal occurs only in necrotizing external otitis. palsies generally are caused by the secretion of neurotoxins or the compressive effect of the destructive process through the relevant foramina
- Attēls - Malignant external otitis with pus draining from the necrotic ear canal and underlying osteomyelitic bone. The adjacent auricle demonstrates the swelling and loss of cartilaginous architecture characteristic of chondritis.
- Otoskopija – bungplēvīte neskarta
- CT scanning is used to determine the location and extent of diseased tissue (Figure 1). The temporal bone is the first bone to be affected, with imminent involvement of the petrous apex and mastoid. Extratemporal bone extension has become rare since the introduction of powerful antibiotics. In evaluating the CT scan, it is important to remember that at least one third of bone mineral must be lost before radiologic changes become apparent; conversely, bone remineralization continues long after the infection is cured. Thus, as related to the infectious process, pathology is late to appear on the CT scan and late to disappear. These factors limit the usefulness of CT scanning as a follow-up tool.
- Both osteoclasts and osteoblasts absorb 99mTc. Hence, bone scanning can locate a pathologic process in bone but is not informative about the nature of the process (infectious or other). Because the 99mTc scan remains positive as long as bone repair continues, this imaging modality is not helpful in follow-up Attēls - Tech bone scan showed increased uptake in left temporal region
- Since 67Ga is absorbed by macrophages and cells of the reticuloendothelial system, scanning with this radioisotope is a sensitive measure of ongoing infectious process (Figure 2).If 67Ga scintigraphy is available, it should be used for initial diagnosis and as a follow-up tool
- CD – vairākus gadus, labi kontrolēta glikēmija, regulāri novērojās pie endokrinologa
- CT scan: Inflammatory changes involving osseous portion of external auditory canal and mastoid process
- Histological analysis of meatal skin, middle ear mucosa and bony septa revealed signs of chronic inflammation and bone necrosis and calcification. The patient was discharged from the hospital after six weeks of systemic antibiotic therapy with clinical signs of recovery. During a two-month follow-up, otomicroscopy finding was normal and general condition significantly improved.
- CT scan and MR imaging showed devastating osteomyelitis of the petrous pyramid of the temporal bone, otomastoiditis and signs of jugular vein and lateral sinus thrombosis MR imaging: purulent collection involving skull base (A – coronal view; B – axial view)
- Intensive antibiotic therapy with vancomycin, ceftazidime, and metronidazole combined with antimycotics gave positive results on the condition of the patient, decreasing the levels of inflammatory parameters after seven weeks of treatment. Histological analysis and findings during revision surgery of the middle ear and mastoid cavity showed no signs of active inflammation. The patient presented substantial postoperative recovery that was verified on CT scan. During a six-month follow-up the patient’s hearing improved and cranial nerves functions were completely restored.