eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > External Ear Diseases

External Ear, Malignant External Otitis: Treatment & Medication

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
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
Contributor Information and Disclosures

Updated: May 19, 2009

Treatment

Medical Care

Treatment includes meticulous glucose control, aural toilet, systemic and ototopic antimicrobial therapy, and hyperbaric oxygen therapy.10

  • Systemic antibiotic choice: Until the development of third-generation antipseudomonal cephalosporins, long-term intravenous antibiotics using an antipseudomonal penicillin and aminoglycoside were the mainstay of medical treatment.
    • Several authors have demonstrated the effectiveness of intravenous ceftazidime monotherapy in the treatment of malignant external otitis (MEO).
    • Fluoroquinolones that attain high soft tissue and bone levels with oral doses were then developed. Subsequently, several authors have demonstrated the efficacy of oral ciprofloxacin monotherapy.
    • Although no established treatment guidelines are available, case series and anecdotal experience suggest that initial outpatient therapy with oral ciprofloxacin is efficacious for patients without a fluoroquinolone allergy, cranial neuropathy, or intracranial complication and who do not require hospital admission for diabetes or pain management.
    • The widespread use of fluoroquinolones for upper respiratory infections and simpler ear infections is beginning to confound the typical clinical spectrum of malignant external otitis (MEO). Ciprofloxacin-resistant P aeruginosa has been increasingly isolated in patients with malignant external otitis (MEO), accounting for as many as 33% of isolates in patients who failed outpatient management in a study by Berenholz et al.11 Most notably in this patient population, 63% of isolates from 1998-2001 were resistant to ciprofloxacin, whereas only 15% of isolates were found to be resistant in the 10 years before this 3-year period. No increased morbidity or mortality was found in patients with ciprofloxacin-resistant Pseudomonas. Patients with resistant P aeruginosa require parenteral antibiotics with antipseudomonal beta-lactam antibiotics with or without an aminoglycoside.
  • Duration of therapy
    • Symptoms and examination findings improve with appropriate therapy, but these changes do not correlate with the length of needed therapy. Despite symptom relief, prolonged antimicrobial treatment as indicated for osteomyelitis is still indicated.
    • Imaging studies are helpful in determining the adequate length of treatment for each patient.
    • Treatment response should be evaluated with a gallium citrate Ga 67 scan every 4-6 weeks during treatment. Benecke recommended ending treatment 1 week after the gallium citrate Ga 67 scan findings return to normal and confirming this with a repeat scan 1 month after the treatment is stopped. Using this protocol for 13 patients, the average duration of treatment was 8.8 weeks with a range of 4-17 weeks.
  • Hyperbaric oxygen therapy
    • This should be used only as an adjunct to antimicrobial therapy; it should not be used alone.
    • Hyperbaric oxygen therapy may be helpful for patients with complications, experiencing a poor response to therapy, or with recurrent cases.

Surgical Care

  • Chandler advocated surgery in his original report when appropriate antimicrobials were not available; he had very poor results, with a 50% mortality rate.
  • Surgical removal of the lesion requires resection of large portions of the temporal bone.
  • Because of the histopathology of malignant external otitis (MEO), removal of contiguous areas of bone may not be sufficient because of the spread of infection through vascular and fascial planes.
  • Surgery is now reserved for local debridement, removal of bony sequestrum, or abscess drainage.
  • Facial nerve decompression is not indicated for patients with facial paralysis.

Consultations

  • Consultation with internal medicine specialists is required for the management of diabetes and other comorbidities.
  • Infectious-disease consultants may help with the choice of antibiotics in complicated cases.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Antibiotics

The choice of antimicrobial therapy and whether treatment can be delivered PO versus IV, as monotherapy, or on an outpatient basis need to be carefully individualized to each patient. Refer to Medical Care for further discussion of these issues.


Ciprofloxacin (Cipro)

A DNA gyrase inhibitor that prevents DNA replication.

Adult

1500-2250 mg/d PO/IV divided bid/tid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in epilepsy or other conditions that have a low seizure threshold; in prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; dehydration or urine alkalinization should be avoided


Ceftazidime (Fortaz, Tazicef, Tazidime)

Third-generation cephalosporin that inhibits bacterial cell wall synthesis by adhering to penicillin-binding proteins. Can be either bactericidal or bacteriostatic depending on the organism, tissue penetration, and drug dosage.

Adult

1-2 g IV q8h

Pediatric

Not established

Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels; concomitant use with aminoglycosides can provide synergistic activity against P aeruginosa

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment


Ticarcillin/clavulanate (Timentin)

Extended-spectrum penicillin/beta-lactamase inhibitor. Ticarcillin binds to penicillin-binding proteins, thus inhibiting bacterial cell wall synthesis. Clavulanate binds irreversibly to beta-lactamases, thus preventing inactivation of ticarcillin.

Adult

3.1 g IV q6h

Pediatric

Not established

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; use cautiously in patients with sodium restrictions


Gentamicin (Garamycin, Jenamicin)

Binds to 30S ribosomal subunit, thus inhibiting bacterial protein synthesis. Aminoglycosides have bactericidal activity against P aeruginosa. Bacterial strains resistant to one aminoglycoside still may be sensitive to other antibiotics within this category.

Adult

3-5 mg/kg/d IV in equally divided doses q8h or 5-7 mg/kg/d IV administered qd; dose is adjusted based on serum drug levels

Pediatric

Not established

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, and prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly); concomitant use with penicillin can provide synergistic activity against P aeruginosa

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; dehydration can increase risk of ototoxicity and nephrotoxicity; can aggravate muscle weakness in patients with myasthenia gravis or parkinsonism

More on External Ear, Malignant External Otitis

Overview: External Ear, Malignant External Otitis
Differential Diagnoses & Workup: External Ear, Malignant External Otitis
Treatment & Medication: External Ear, Malignant External Otitis
Follow-up: External Ear, Malignant External Otitis
Multimedia: External Ear, Malignant External Otitis
References
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References

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Further Reading

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Keywords

malignant external otitis of the external ear, external ear, malignant external otitis, MEO, invasive external otitis, necrotizing external otitis, progressive external otitis, skull base osteomyelitis, ear infection, pseudomonal osteomyelitis of the temporal bone, Pseudomonas aeruginosa, P aeruginosa, diabetes, malignant external otitis

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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

Medical Editor

Jack A Shohet, MD, Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California Irvine; Otolaryngologist, Shohet Ear Associates Medical Group, Inc
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: Envoy Medical Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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 unstricted gift unknown

 
 
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