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NECROTIZING OTITIS EXTERNA

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1.NECROTIZING OTITIS EXTERNA ( Short note 2003)

A.k.a: Malignant Otitis Externa

 

DEFINITION:

Rare complication of Otitis Externa

Severe infection of temporal and adjacent bone

May lead to osteomyelitis of temporal bone and skull base

Commonly caused by Pseudomonas aeruginosa

Typically seen in immunocompromised and DM patients

 

COHEN DIAGNOSTIC CRITERIA:

 

MAJOR:

 

 MINOR:

 
A-    MicroAbscess A – Age (elderly)
B-   Bone scan positive B – Bacterial culture (pseudomonas – 98%)
C-   Cruciating pain C – Cranial nerve palsy
D-   Discharge D – DM/ debilitating illness
E-   Edema E – ESR raised
G-  Granulation tissue  
F-   Failed medical therapy  

 

 

DIAGNOSIS:

Lab: ESR, swab c&s, HPE of granulation tissue, TWC, Glucose, Creatinine level

Imaging:

CT scan – to exclude temporal bone SCC. Findings: soft tissue enhancement in EAC +/- abscess

Technetium 99 – for diagnosis (absorbed by osteoclast and osteoblast)

Galium 67 – for prognosis (absorbed by macrophages)

 

TREATMENT:

Medical – IV abx (anti-pseudomonal): Ciprofloxacin 1/12, sugar control, pain control, ear toileting

Surgical – mastoidectomy + debridement of granulation tissue

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Neck mass – long case / short case

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History:

  1. Site
  2. Duration
  3. Onset
  4. Progress
  5. Pain
  6. Secondary changes – ulceration/ discharge
  7. Aggravating factor
  8. Relieving factor
  9. Assoc symtoms: Dyspnea/ Dysphagia/ Trismus / Change of voice
  10. Fever
  11. URTI hx
  12. LOA / LOW
  13. H/o Trauma
  14. Any other swelling elsewhere
  15. Similar hx in the past

Examination:

Inspection:

  1. Number
  2. Site
  3. Size
  4. Shape
  5. Surface
  6. Edge
  7. Skin changes – colour / ulcer / punctum/ discharge/ necrotic patch
  8. Scar – transcervical / schobinger/ modified blair
  9. Trachea deviation
  10. Pulsatile
  11. Movement on deglutition
  12. Movement on protrusion of tongue

Palpation:

  1. Local rise of temperature
  2. Tenderness
  3. Confirm inspector findings – number / site/ size/ shape/ surface
  4. Consistency
  5. Mobility
  6. Fixity to overlying skin
  7. Pulsation – expansile/ transmitted
Special tests on swelling:
– Transillumination test
Percussion
– Retrosternal extension
Auscultation
– Bruit: vascular
Examination of regional lymph nodes
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Relative Prevalence of Neck Mass Etiologies

Type Common Uncommon Rare
Acute
Cytomegalovirus infection

Epstein-Barr virus infection

Staphylococcal or streptococcal infection

Toxoplasmosis

Viral upper respiratory infection
Acute sialadenitis

Arteriovenous fistula

Bartonella henselae infection

Hematoma

Human immunodeficiency virus infection

Mycobacterium tuberculosis infection

Parotid lymphadenopathy

Pseudoaneurysm

—
Subacute
Squamous cell carcinoma of the upper aerodigestive tract
Amyloidosis

Lymphoma

Metastatic cancer

Parotid tumor

Sarcoidosis

Sjögren syndrome
Castleman disease

Kikuchi disease

Kimura disease

Rosai-Dorfman disease
Chronic

Thyroid pathology
Branchial cleft cyst

Carotid body tumor

Glomus jugulare tumor

Glomus vagale tumor

Laryngocele

Lipoma

Thyroglossal duct cyst
Liposarcoma

Parathyroid carcinoma

Reference:

1. Soo-Geun Wang. Differential Diagnosis and Treatment of Neck Masses. J Korean .Med Assoc. 2007 Jul;50(7):613-625.

2. James Haynes et all.  Evaluation of Neck Masses in AdultsAm Fam Physician. 2015 May 15;91(10):698-706.

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Keratosis obturans vs external ear canal cholesteatoma 

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