Malignant Otitis Externa 

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

Background

Toulmouche was probably the first physician to report a case of malignant external otitis (MEO), in 1838. In 1959, Meltzer reported a case of pseudomonal osteomyelitis of the temporal bone. In 1968, Chandler discussed the clinical characteristics of malignant external otitis (MEO) and defined it as a distinct clinical disease.[1] He described this external otitis as malignant because he observed an aggressive clinical behavior, poor treatment outcome, and a high mortality rate for the patients affected by this disease.

The subsequent development of effective antibiotics for treating pseudomonal infections has improved the treatment outcomes for patients with malignant external otitis (MEO). Thus, some physicians have suggested that the term malignant should be abandoned in order to provide a more accurate description of the disease process.

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Pathophysiology

Malignant external otitis (MEO) is an infection that affects the external auditory canal and temporal bone. The causative organism is usually Pseudomonas aeruginosa, and the disease commonly manifests in elderly patients with diabetes. The infection begins as an external otitis that progresses into an osteomyelitis of the temporal bone. Spread of the disease outside the external auditory canal occurs through the fissures of Santorini and the osseocartilaginous junction.

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Epidemiology

Frequency

United States

Malignant external otitis (MEO) is more common in humid and warm climates than in other climates.

Mortality/Morbidity

  • Cranial neuropathy
    • Cranial nerves can be affected by inflammation along the skull base or by a neurotoxin produced by Pseudomonas species. The facial nerve (VII) is affected most commonly, usually at the stylomastoid foramen. As the disease progresses, cranial nerves IX, X, and XI can be affected at the jugular foramen, followed by XII at the hypoglossal canal. Cranial nerves V and VI can be affected if the disease extends to the petrous apex.
    • In 1977, Chandler reported a 32% incidence of facial nerve paralysis.[2] The incidence of facial nerve paralysis appears to have decreased with the development of more effective medical therapy as shown by Franco-Vidal et al who reported a 20% incidence of facial nerve paralysis in 46 treated patients.[3] The other cranial nerves are affected less frequently than the seventh cranial nerve. The development of cranial neuropathy generally was thought to reflect advanced-stage disease associated with a worse prognosis. More recently, Corey et al, Soudry et al, and Mani et al suggested that the presence of facial nerve paralysis does not worsen the prognosis.[4, 5] Recovery of facial nerve function is poor and unpredictable, and should not be used as an indicator of successful treatment. Other cranial nerves that are affected have a higher rate of recovery.
  • Intracranial complications: These complications rarely occur in the absence of cranial nerve palsies. Meningitis, brain abscess, and dural sinus thrombosis may ensue. Cranial neuropathies related to the jugular foramen should raise concern for sigmoid sinus thrombosis. Cavernous sinus thrombosis should be considered if cranial nerves V or VI are affected. Intracranial complications reflect severe disease and are commonly fatal.
  • Comorbid conditions: Patients with malignant external otitis (MEO) almost always have diabetes, often with other multiple medical problems. During the course of therapy, Chandler found some deaths related to pneumonia, uremia, myocardial infarction, strokes, and liver failure. Franco-Vidal showed that patients with systemic immunodeficiencies had a worse prognosis.[3]

Sex

Malignant external otitis (MEO) is more common in males than in females.

Age

Malignant external otitis (MEO) has been reported in all age groups but is most common in patients who are elderly (age, >60 y).

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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

References

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

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

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

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

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

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

  7. 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. Jul 2011;137(7):688-93. [Medline].

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

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

  10. 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. Jan 1992;118(1):89-93. [Medline].

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

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

  13. Rubin J, Yu VL, Stool SE. Malignant external otitis in children. J Pediatr. Dec 1988;113(6):965-70. [Medline].

  14. Amorosa L, Modugno GC, Pirodda A. Malignant external otitis: review and personal experience. Acta Otolaryngol Suppl. 1996;521:3-16. [Medline].

  15. 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].

  16. Chandler JR. Malignant external otitis and osteomyelitis of the base of the skull. Am J Otol. Mar 1989;10(2):108-10. [Medline].

  17. Chandler JR. Pathogenesis and treatment of facial paralysis due to malignant external otitis. Ann Otol Rhinol Laryngol. Oct 1972;81(5):648-58. [Medline].

  18. Corey JP, Levandowski RA, Panwalker AP. Prognostic implications of therapy for necrotizing external otitis. Am J Otol. Jul 1985;6(4):353-8. [Medline].

  19. Driscoll PV, Ramachandrula A, Drezner DA, Hicks TA, Schaffer SR. Characteristics of cerumen in diabetic patients: a key to understanding malignant external otitis?. Otolaryngol Head Neck Surg. Oct 1993;109(4):676-9. [Medline].

  20. Epstein JS, Ganz WI, Lizak M, Grobman L, Goodwin WJ, Dewanjee MK. Indium 111-labeled leukocyte scintigraphy in evaluating head and neck infections. Ann Otol Rhinol Laryngol. Dec 1992;101(12):961-8. [Medline].

  21. Gehanno P. Ciprofloxacin in the treatment of malignant external otitis. Chemotherapy. 1994;40 Suppl 1:35-40. [Medline].

  22. Gherini SG, Brackmann DE, Bradley WG. Magnetic resonance imaging and computerized tomography in malignant external otitis. Laryngoscope. May 1986;96(5):542-8. [Medline].

  23. Gold S, Som PM, Lucente FE, Lawson W, Mendelson M, Parisier SC. Radiographic findings in progressive necrotizing "malignant" external otitis. Laryngoscope. Mar 1984;94(3):363-6. [Medline].

  24. Grandis JR, Curtin HD, Yu VL. Necrotizing (malignant) external otitis: prospective comparison of CT and MR imaging in diagnosis and follow-up. Radiology. Aug 1995;196(2):499-504. [Medline].

  25. Johnson MP, Ramphal R. Malignant external otitis: report on therapy with ceftazidime and review of therapy and prognosis. Rev Infect Dis. Mar-Apr 1990;12(2):173-80. [Medline].

  26. Kimmelman CP, Lucente FE. Use of ceftazidime for malignant external otitis. Ann Otol Rhinol Laryngol. Sep 1989;98(9):721-5. [Medline].

  27. Lang R, Goshen S, Kitzes-Cohen R, Sadé J. Successful treatment of malignant external otitis with oral ciprofloxacin: report of experience with 23 patients. J Infect Dis. Mar 1990;161(3):537-40. [Medline].

  28. Mendelson DS, Som PM, Mendelson MH, Parisier SC. Malignant external otitis: the role of computed tomography and radionuclides in evaluation. Radiology. Dec 1983;149(3):745-9. [Medline].

  29. Meyers BR, Mendelson MH, Parisier SC, Hirschman SZ. Malignant external otitis. Comparison of monotherapy vs combination therapy. Arch Otolaryngol Head Neck Surg. Sep 1987;113(9):974-8. [Medline].

  30. Nadol JB Jr. Histopathology of Pseudomonas osteomyelitis of the temporal bone starting as malignant external otitis. Am J Otolaryngol. Nov 1980;1(5):359-71. [Medline].

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

  32. Redleaf MI, Angeli SI, McCabe BF. Indium 111-labeled white blood cell scintigraphy as an unreliable indicator of malignant external otitis resolution. Ann Otol Rhinol Laryngol. Jun 1994;103(6):444-8. [Medline].

  33. Ress BD, Luntz M, Telischi FF, Balkany TJ, Whiteman ML. Necrotizing external otitis in patients with AIDS. Laryngoscope. Apr 1997;107(4):456-60. [Medline].

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

  35. Rubin J, Yu VL. Malignant external otitis: insights into pathogenesis, clinical manifestations, diagnosis, and therapy. Am J Med. Sep 1988;85(3):391-8. [Medline].

  36. Seabold JE, Simonson TM, Weber PC, et al. Cranial osteomyelitis: diagnosis and follow-up with In-111 white blood cell and Tc-99m methylene diphosphonate bone SPECT, CT, and MR imaging. Radiology. Sep 1995;196(3):779-88. [Medline].

  37. Slattery WH 3rd, Brackmann DE. Skull base osteomyelitis. Malignant external otitis. Otolaryngol Clin North Am. Oct 1996;29(5):795-806. [Medline].

  38. Stokkel MP, Boot CN, van Eck-Smit BL. SPECT gallium scintigraphy in malignant external otitis: initial staging and follow-up. Case reports. Laryngoscope. Mar 1996;106(3 Pt 1):338-40. [Medline].

  39. Stokkel MP, Takes RP, van Eck-Smit BL, Baatenburg de Jong RJ. The value of quantitative gallium-67 single-photon emission tomography in the clinical management of malignant external otitis. Eur J Nucl Med. Nov 1997;24(11):1429-32. [Medline].

  40. Strauss M, Aber RC, Conner GH, Baum S. Malignant external otitis: long-term (months) antimicrobial therapy. Laryngoscope. Apr 1982;92(4):397-406. [Medline].

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

  42. Uri N, Gips S, Front A, Meyer SW, Hardoff R. Quantitative bone and 67Ga scintigraphy in the differentiation of necrotizing external otitis from severe external otitis. Arch Otolaryngol Head Neck Surg. Jun 1991;117(6):623-6. [Medline].

 
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