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Malignant otitis externa

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Malignant otitis externa is otitis externa which has spread to cause osteomyelitis of the skull base

  • all tissues (soft tissue, cartilage, and bone) area affected as osteomyelitis spreads along the skull base

It is due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue in the external canal

  • P aeruginosa is isolated from exudate in the ear canal in more than 90% of cases (1)

  • a facial nerve palsy occurs in 50% of patients with this condition, and nerves IX to XII may also be involved
    • initial clinical features are those of the initiating acute otitis externa, but untreated disease develops into a skull base osteomyelitis that can invade soft tissue, the middle ear, inner ear, or brain
    • facial nerve paralysis may be an early sign, with the glossopharyngeal and spinal accessory nerves less frequently involved (1)

  • affects immunocompromised patients, especially elderly diabetics
    • lavage of the ear canal for cerumen impaction in elderly or diabetic patients has been implicated as a contributing factor in malignant otitis externa (1)

  • may be life threatening

  • clinical diagnosis of necrotizing otitis externa can be confirmed with a raised CRP plus an abnormal computed tomography or magnetic resonance imaging
    scan

  • treatment includes surgical debridement and systemic antibiotics adequate to cover pseudomonal and staphylococcal infection, including methicillin-
    resistant S aureus

  • biopsy may be necessary to detect neoplasia if the diagnosis of malignant otitis externa is uncertain or response to therapy is incomplete (1)

  • if you suspect malignant otitis externa arrange an urgent (same day) ear, nose, and throat (ENT) review. A computed tomography imaging
    scan is typically required to confirm the diagnosis (2)

References.

  • Rosenfeld RM, Schwartz SR, Cannon CR, etal. Clinical practice guideline: acute otitis externa.Otolaryngol Head Neck Surg2014;150(Suppl):S1-24.doi: 10.1177/0194599813517083 pmid: 24491310
  • Barry V et al. 10-Minute Consultation - Otitis externa. BMJ2021;372:n714http://dx.doi.org/10.1136/bmj.n714

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