Malignant Otitis Externa Clinical Presentation

  • Author: Brian Nussenbaum, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jul 27, 2011
 

History

  • Diabetes (90%) or immunosuppression (illness or treatment related)
  • Severe, unrelenting, deep-seated otalgia
  • Temporal headaches
  • Purulent otorrhea
  • Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
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Physical

  • Inflammatory changes are observed in the external auditory canal and the periauricular soft tissue.
  • The pain is out of proportion to the physical examination findings.
    • Marked tenderness is present in the soft tissue between the mandible ramus and mastoid tip.
    • Granulation tissue is present at the floor of the osseocartilaginous junction. This finding is virtually pathognomonic of malignant external otitis (MEO). Otoscopic examination may also reveal exposed bone.
  • The cranial nerves (V-XII) should be examined.
  • Mental status examination should be performed. Deterioration of the mental status may indicate intracranial complication.
  • The tympanic membrane is usually intact.
  • Fever is uncommon.
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Causes

  • Diabetes (90% of patients)
    • Diabetes is the most significant risk factor for developing malignant external otitis (MEO).
    • Small-vessel vasculopathy and immune dysfunction associated with diabetes are primarily responsible for this predisposition.
    • The cerumen of patients with diabetes has a higher pH and reduced concentration of lysozyme, which may impair local antibacterial activity.
    • No difference in predisposition is found between diabetes types I and II.
    • The predisposition is not necessarily related to the severity of glucose intolerance or periods of hyperglycemia.
  • Immunodeficiencies, such as lymphoproliferative disorders or medication-related immunosuppression
  • AIDS
    • Malignant external otitis (MEO) associated with AIDS may have a different pathophysiology than classic malignant external otitis (MEO).
    • Patients present with similar symptoms but are generally younger and do not have diabetes.
    • Granulation tissue may be absent in the external auditory canal.
    • Pseudomonas is not necessarily the dominant causative organism.
    • Patients with AIDS generally have a poorer outcome than patients with diabetes.
  • Aural irrigation: As many as 50% of cases of malignant external otitis (MEO) have been reported to be preceded by traumatic aural irrigation in patients with diabetes.
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Contributor Information and Disclosures
Author

Brian Nussenbaum, MD, FACS  Associate Professor, Vice Chair for Clinical Affairs, Co-director of Fellowship in Microvascular Head/Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine

Brian Nussenbaum, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Peter S Roland, MD  Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Alcon Labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear Corp Honoraria Board membership; Med El Corp travel grants Consulting

Specialty Editor Board

Jack A Shohet, MD  President, Shohet Ear Associates Medical Group, Inc; Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, School of Medicine

Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, American Tinnitus Association, and California Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gerard J Gianoli, MD  Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Vesticon, Inc. None Board membership

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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