An elderly diabetic with excruciating pain in ear, appearance of granulation in meatus, skull base infection with facial paralysis should be treated with
All clinical features are suggestive of malignant otitis externa, an inflammatory condition of the external ear. Malignant otitis externa (also k/a Necrotizing external otitis) Malignant otitis externa is an inflammatory condition of the external ear usually spreading deep to cause osteomyelitis of temporal bone and base of skull. 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 [May also be seen in pts. who received radiotherapy to skull base I The most frequent pathogen is Pseudomonas aeruginosa. Others may be S. aureus, Staphylococcus epidermidis, Aspergillus, Actinomyces, and some gram-negative bacterial. One of the hallmarkof malignant otitis externs is granulation tissue in the external auditory canal, especially at the hone-cailage junction. As the infection spreads to the temporal bone, it may extend into the cranium and result in cranial nerve palsies (commonly the facial nerve) Cranial nerve involvement indicates poor prognosis. Death is usually due to intracranial complications such as sigmoid sinus thrombosis. It has high moality rate due to which the name 'malignant' is used for this disease. Treatment Includes correction of immunosuppression (when possible), local treatment of the auditory canal, long-term systemic antibiotic therapy, and in selected patients, surgery. - In all cases, the external ear canal is cleansed and a biopsy specimen of the granulation tissue sent for culture. - IV antibiotics is directed against the offending organism. - For Pseudomonas aeruginosa, the most common pathogen, the regimen involves an antipseudomonal penicillin or cephalosporin (3rd generation-piperacillin or ceftazidime) with an aminoglycoside. A fluoroquinolone antibiotic can be used in place of the aminoglycoside. Ear drops containing antipseudomonal antibiotic e.g. ciproflaxacin plus a glucocoticoid is also used. - Early cases can be managed with oral and otic fluoroquinolones only. - Extensive surgical debridement once an impoant pa of the treatment is now rarely needed.
Penicillin
Ciprofloxacin
2nd generation ciphalosporin
Erythromycin