Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Malignant Otitis Externa Clinical Presentation

  • Author: Brian Nussenbaum, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 16, 2016
 

History

See the list below:

  • 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
Next

Physical

See the list below:

  • 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.
Previous
Next

Causes

See the list below:

  • 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.
Previous
 
 
Contributor Information and Disclosures
Author

Brian Nussenbaum, MD, FACS Christy J and Richard S Hawes III Professor, Vice Chair for Clinical Affairs, Division Chief, Head and Neck Surgery, Patient Safety Officer, 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, 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, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for 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 Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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, California Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Envoy Medical .

References
  1. Chandler JR. Malignant external otitis. Laryngoscope. 1968 Aug. 78(8):1257-94. [Medline].

  2. Karaman E, Yilmaz M, Ibrahimov M, Haciyev Y, Enver O. Malignant otitis externa. J Craniofac Surg. 2012 Nov. 23(6):1748-51. [Medline].

  3. Chandler JR. Malignant external otitis: further considerations. Ann Otol Rhinol Laryngol. 1977 Jul-Aug. 86(4 Pt 1):417-28. [Medline].

  4. Franco-Vidal V, Blanchet H, Bebear C, Dutronc H, Darrouzet V. Necrotizing external otitis: a report of 46 cases. Otol Neurotol. 2007 Sep. 28(6):771-3. [Medline].

  5. Soudry E, Joshua BZ, Sulkes J, Nageris BI. Characteristics and prognosis of malignant external otitis with facial paralysis. Arch Otolaryngol Head Neck Surg. 2007 Oct. 133(10):1002-4. [Medline].

  6. Mani N, Sudhoff H, Rajagopal S, Moffat D, Axon PR. Cranial nerve involvement in malignant external otitis: implications for clinical outcome. Laryngoscope. 2007 May. 117(5):907-10. [Medline].

  7. Nawas MT, Daruwalla VJ, Spirer D, Micco AG, Nemeth AJ. Complicated necrotizing otitis externa. Am J Otolaryngol. 2013 Nov-Dec. 34(6):706-9. [Medline].

  8. Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and implications for diagnosis and treatment. Otolaryngol Head Neck Surg. 2014 Mar 26. [Medline].

  9. Gruber M, Roitman A, Doweck I, et al. Clinical utility of a polymerase chain reaction assay in culture-negative necrotizing otitis externa. Otol Neurotol. 2015 Apr. 36 (4):733-6. [Medline].

  10. Peleg U, Perez R, Raveh D, Berelowitz D, Cohen D. Stratification for malignant external otitis. Otolaryngol Head Neck Surg. 2007 Aug. 137(2):301-5. [Medline].

  11. Lee JE, Song JJ, Oh SH, Chang SO, Kim CH, Lee JH. Prognostic Value of Extension Patterns on Follow-up Magnetic Resonance Imaging in Patients With Necrotizing Otitis Externa. Arch Otolaryngol Head Neck Surg. 2011 Jul. 137(7):688-93. [Medline].

  12. Levenson MJ, Parisier SC, Dolitsky J, Bindra G. Ciprofloxacin: drug of choice in the treatment of malignant external otitis (MEO). Laryngoscope. 1991 Aug. 101(8):821-4. [Medline].

  13. Benecke JE Jr. Management of osteomyelitis of the skull base. Laryngoscope. 1989 Dec. 99(12):1220-3. [Medline].

  14. Davis JC, Gates GA, Lerner C, Davis MG Jr, Mader JT, Dinesman A. Adjuvant hyperbaric oxygen in malignant external otitis. Arch Otolaryngol Head Neck Surg. 1992 Jan. 118(1):89-93. [Medline].

  15. Ling SS, Sader C. Fungal malignant otitis externa treated with hyperbaric oxygen. Int J Infect Dis. 2008 Sep. 12(5):550-2. [Medline].

  16. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev. 2013 May 31. 5:CD004617. [Medline].

  17. Berenholz L, Katzenell U, Harell M. Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa. Laryngoscope. 2002 Sep. 112(9):1619-22. [Medline].

  18. Stevens SM, Lambert PR, Baker AB, Meyer TA. Malignant Otitis Externa: A Novel Stratification Protocol for Predicting Treatment Outcomes. Otol Neurotol. 2015 Sep. 36 (9):1492-8. [Medline].

  19. Mion M, Bovo R, Marchese-Ragona R, Martini A. Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital. 2015 Oct. 35 (5):307-13. [Medline]. [Full Text].

  20. Foden N, Burgess C, Damato S, et al. Concurrent necrotising otitis externa and adenocarcinoma of the temporal bone: a diagnostic challenge. BMJ Case Rep. 2013 Nov 6. 2013:[Medline].

  21. Chin RY, Nguyen TB. Synchronous malignant otitis externa and squamous cell carcinoma of the external auditory canal. Case Rep Otolaryngol. 2013. 2013:837169. [Medline]. [Full Text].

  22. Bae WK, Lee KS, Park JW, et al. A case of malignant otitis externa caused by Candida glabrata in a patient receiving haemodialysis. Scand J Infect Dis. 2007. 39(4):370-2. [Medline].

  23. Okpala NC, Siraj QH, Nilssen E, Pringle M. Radiological and radionuclide investigation of malignant otitis externa. J Laryngol Otol. 2005 Jan. 119(1):71-5. [Medline].

  24. Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis. 2004 Jan. 4(1):34-9. [Medline].

  25. Sudhoff H, Linthicum FH Jr. Malignant external otitis: temporal bone histopathology case of the month. Otol Neurotol. 2003 Mar. 24(2):346-7. [Medline].

Previous
Next
 
Anatomy of the ear.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.