Malignant Otitis Externa: Diagnostic Dilemma in a Patient with Atypical Presentation
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CLINICAL REPORT
Malignant Otitis Externa: Diagnostic Dilemma in a Patient with Atypical Presentation Ashish Jain1
•
Vikas Sharma1 • S. S. Fatima1
Received: 26 July 2020 / Accepted: 17 August 2020 Ó Association of Otolaryngologists of India 2020
Abstract Malignant otitis externa (MOE) is a relatively rare complication of Otitis externa with a tendency to spread to other parts of temporal bone and skull base. Pseudomonas aeruginosa is the most common pathological agent. It generally occurs in the elderly with poorly controlled diabetes. In this report we present a case of MOE with atypical initial presentation causing immense conundrum in deciphering the diagnosis early. Keywords Malignant otitis externa Skull base osteomyelitis Diabetes mellitus Pseudomonas aeruginosa
Introduction Malignant otitis externa (MOE) is a rare but serious complication of Otitis externa. It originates in the external auditory canal (EAC) and spreads to petrous apex, skull base and the surrounding soft tissues resulting in a potentially life-threatening condition called Skull base osteomyelitis (SBO) [1]. Pseudomonas aeruginosa, a Gram-negative bacillus is attributed to be the leading cause of this infection [2]. MOE and SBO more frequently affects the elderly and diabetics. Other immunosuppressive conditions like HIV/ AIDS, steroid usage, chemotherapy, anemia, leukemia, lymphoma, neoplasia and renal transplantation also predispose to this condition [1]. & Ashish Jain [email protected] 1
Department of Otolaryngology, Military Hospital Kirkee, Range Hills, Pune, Maharashtra 411020, India
Patients with MOE generally present with severe unremitting otalgia and scanty purulent milky otorrhea, less frequently with hearing loss and rarely with cranial neuropathies, facial palsy being the most common [3]. In this report, we present a unique case of diagnostic dilemma where the history and otoendoscopic features suggested MOE but the radiological evaluation revealed concomitant extensive disease in middle ear and mastoid indicating Otitis media with complication.
Case Presentation 72-year-old lady with poorly controlled diabetes, presented with complaints of severe Otalgia and profuse mucopurulent Otorrhea from right ear for 04 days. She also developed sudden onset right sided facial weakness. Patient is a known diabetic and hypertensive for 25 years and had suffered a stroke with right hemiparesis 8 years back. There was no history of trauma, aural irrigation, otitis media, ear surgery, prolonged steroid use in past. Otoendoscopic examination (Fig. 1a) revealed an edematous deep EAC with dense granulations predominantly on the floor and purulent discharge. Tympanic membrane (TM) could not be visualized. She had LMN type Grade V (House-Brackmann) Facial nerve palsy on the right. Pus swab was taken from affected ear and revealed Pseudomonas aeruginosa, acid fast staining was negative and no fungal elements seen. High resolution computed tomography (HRCT) of temporal bone (0.6 mm) (Fig. 1b) showed hypodense opacification in midd
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