MALIGNANT OTITIS EXTERNA

Dr Manohar Suryawanshi
ENT Resident, INHS Asvini
• Anatomy
• Introduction
• Microbiology
• Pathogenesis
• Diagnosis
• Investigations
• Treatment
Introduction
 Definition
• Aggressive and potentially life-threatening infection
of the soft tissues of the external ear and
surrounding structures, quickly spreading to involve
the periostium and bone of the skull base.
 Microbiology:

• Pseudomonas aeruginosa (95%)

• Fungus (A. Fumigatus, A. Flavus, A. Niger)

• Fungal MOE: HIV more commonly than in those who
have diabetes
• From middle ear or mastoid in contrast to
pseudomonal
• Pseudomonas infections CD4 levels < 100 cells/mm
• AspergillusCD4 counts <50 cells/mm
 Predisposing factors

• Diabetes mellitus

• Immuno-compromised status
 Pathophysiology:

• Cellulitis-> Chondritis-> Periostitis->

Osteitis ->Osteomyelitis
• Facial nerve (stylomastoid foramen) 60%
• IX, X and XI
• V and VI (petrous apex)
• Clivus and contralateral temporal bone can be
involved
• Infection can spread anteriorly into the sphenoid and
to the carotid
• Thrombosis of sigmoid sinus, IJV -> meningitis ->
cerebral abscess
• Haversian system of compact bone

• Pneumatoized portion of the temporal bone involved

late

• Otic capsule is usually spared

 Clinical features:

• Long-standing otalgia (worst at night) and otorrhea

• Cranial nerve palsy

• Headaches, fever

• Neck stiffness

• Altered levels of consciousness

Hallmark finding: granulation tissue on floor of the ear
canal at the bony-cartilaginous junction
 Clinical and microscopic differences between bacterial and fungal
malignant otitis externa
Pathogen Age Diabetes Immunosuppres Granulation Middle Histology
sion tissue ear/mastoid
involvement

Bacterial Older Common Common + - Gram -ve

rod

Fungal Younger Less More common - + Septate

common hyphae,
calcium
oxalate
crystals
 Diagnosis:

• Clinical

• Biopsy

• Pseudomonas aeruginosa on culture

• Supported by a positive bone scan and/or

the presence of microabscesses at surgery

• ESR, CRP
 Investigations:
• CT scan
• MRI
• Technetium-99m bone scan:
Osteoblastic activity
Highly sensitive for bony infection
• SPECT:
Good anatomic localization
 Gallium scan:

• Increased uptake during infection

• Monitoring and duration of antimicrobial

therapy
technetium Tc 99m MDP bone scan
Clinicopathological classification
1 Clinical evidence of malignant otitis externa with
infection of soft tissues beyond the external auditory
canal, but negative Tc-99 bone scan

2 Soft tissue infection beyond external auditory canal with

positive Tc-99 bone scan

3 As above, but with cranial nerve paralysis

3a- Single
3b -Multiple

4 Meningitis, empyema, sinus thrombosis or brain abscess

Treatment:

Medical

• Early infections- oral fluoroquinolone

• Advanced stages- parenteral antibiotics

may be indicated
• Monotherapy with Ceftazidime

• Tobramycin can be used with minimal toxicity if peak

level doses are closely monitored

• Implantable gentamicin

• HBOT
 Surgery:

• Debridement of nonviable sequestra of bone,

necrosed and Granulation tissues

• Wide resection:

Bony skull base

Stylomastoid foramen

Jugular bulb
• Introduction of viable, vascularized tissue into the
bed
 References
• Scott brown 7th edition
• Ballinger 16th edition
• Cummings 5th edition
• OCNA 2012
• Indian journal of nuclear medicine
THANK YOU