Dear Friends,
Let us play a small quiz.It goes like this ...I will tell you the h/o the patient and show you his findings...then we answer a few questions..Let us start in right earnest...
Patient GP,69 years of age came with h/o severe earache and discharge Lt. Ear.Examination revealed granulations in the floor of the EAC and also a CP.Biopsy of the granulations showed chronic granulation tissue.Patient is a known diabetic....initially uncontrolled now better with proper medications.After reviewing the photo and VDO of the same let us answer a few questions.
LEVEL 1 -
1) What is the probable diagnosis?
2) What is the causative oeganism?
LEVEL 2 -
1) What is the line of Treatment?
2) What are the complications one needs to look
out for?
HINTS...
1) The name for this condition was first coined
by Chandler in 1968.
2) It is one of the 2 Famous MISNOMERS in
ENT.
BEST OF LUCK.......
The probable diagnosis is malignant otitis externa.. the points in favor of this are 1.earache 2.granulations in floor of EAC.3.diabetic pt.4.age and sex factor.i.e.>60 ,male.
ReplyDeleteThe cause is pseudomonas.
Treatment for pseudomonas is tobramycin,gentamycin(parenteral)and other penicillins,cephalosporins,fluoroqinolones.
The complications are involvement of facial nerve.Also osteomyelitis of temporal bone,other cranial nerves involved via skull base,CNS infection.
Surgically removal ,debridement of all necrotic tissue.
It is a misnomer because it is no more malignant as antibiotics are effective against pseudomonas infection.
Out of 2 misnomer you were talking about other will be cholesteatoma. .
ReplyDeleteI agree with swati's answer.....its Malignant otitis externa.
ReplyDeleteBut will the perforation and discharge be due to otitis media or extension of otitis externa??
n does debridement include the tympanic membrane as wel if granulations appear on it??
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteAntibiotics that have activity against P. aeruginosa include:
ReplyDelete* aminoglycosides (gentamicin, amikacin, tobramycin);
* quinolones (ciprofloxacin, levofloxacin, and moxifloxacin)
* cephalosporins (ceftazidime, cefepime, cefoperazone, cefpirome, but not cefuroxime, ceftriaxone, cefotaxime)
* antipseudomonal penicillins: ureidopenicillins and carboxypenicillins (piperacillin, ticarcillin: P. aeruginosa is intrinsically resistant to all other penicillins)
* carbapenems (meropenem, imipenem, doripenem, but not ertapenem)
* polymyxins (polymyxin B and colistin)
* monobactams (aztreonam)
These antibiotics must all be given by injection, with the exception of fluoroquinolones and of aerosolized tobramycin. For this reason, in some hospitals, fluoroquinolone use is severely restricted in order to avoid the development of resistant strains of P. aeruginosa. In the rare occasions where infection is superficial and limited (for example, ear infections or nail infections), topical gentamicin or colistin may be used.
There has been some research success with treating mice with phage therapy, raising the survival rate from 6% to 22-87%.
Phage therapy against ear infections caused by Pseudomonas aeruginosa was reported in the journal Clinical Otolaryngology in August 2009.
ReplyDeletei completely agree with swatis answer.just thought id add a little info on this ''malignant organism'' which causes this unique disease. with the chances of SO MANY LIFE threatening complications and increasing drug resistance..one may wonder..is it really a misnomer :) ?
Diabetes control is also an essential part of treatment and is a MUST!!!!!!!!. When MOE goes unrecognized and untreated, the infection continues to smolder and over weeks or months can spread deeper into the head and involve the bones of the skull base, constituting skull base osteomyelitis (SBO). The infecting organism is ALMOST always pseudomonas aeruginosa, but it can instead be fungal (aspergillus or mucor). MOE and SBO are not amenable to surgery, but exploratory surgery may facilitate culture of unusual organism(s) that are not responding to empirically used anti-pseudomonal antibiotics.
ReplyDeleteAs the skull base is progressively involved, the adjacent exiting cranial nerves and their branches, especially the facial nerve and the vagus nerve, may be affected, resulting in facial paralysis and hoarseness, respectively. If both of the recurrent laryngeal nerves are paralyzed, shortness of breath may develop and necessitate tracheotomy. Profound deafness can occur, usually later in the disease course due to relative resistance of the inner ear structures. Gallium scans are sometimes used to document the extent of the infection but are not essential to disease management. Skull base osteomyelitis is a chronic disease that can require months of IV antibiotic treatment, tends to recur, and has a significant mortality rate.
ReplyDeleteDear Rakesh,Signseeker and Swati,
ReplyDeleteThank you very much for a very prompt and involved response.Well,you have got it right.It is Malignant Otitis Externa.
It is a misnomer b'cause it is not a neoplastic lesion at all as the name suggests.Probably it reflects the very fact that this condition ,if not treated aggressively, is attendant with a high rate of mortality.But that too has become less with better antibiotics and more comprehensive evaluation and treatment.The mortality rate has gone down from 20% to 01%.
It is also called as NECROTIZING OTITIS MEDIA due to Osteomyelitis of the Temporal Bone.Mortality is due to INTRACRANIAL INFECTION/S or ASPIRATION.
Diagnosis besides a proper history and examination is complimented by RADIONUCLEOTIDE SCANNING (SCINTIGRAPHY).Technecium -99 bone scan shows increased uptake in involved areas s/o bone metabolism ...very sensitive.But the pitfall is that the uptake remains high even after the active process goes into remission.Here Gallium - 67 is more effective.It is a better indicator of the activity of the disease.It's uptake is determined by the activity of the disease.So in essence,it reflects the response to the treatment.It monitors the effectiveness of the treatment.ESR still remains a very good indicator of the activity of the disease.
Various sources talk about different groups of Antibiotics.Parenteral Antibiotics in the form of Second and third generation Cephalosporins for 6 to 12 weeks are suppose dto be very effective.Oral Quinolones like Ciprofloxacillin for 6 to 8 weeks have shown promising results.May be complimented by Aminoglycosides.
Local treatment in the form of Antibiotic Ear Drops also are recommended.
A regular follow up with evaluation of CNS is very important.
Various Cranial Nerve Palsies develop with advancement of the disease...this is to do with spread of disease along the skull base....strats with 7th Nerve and then involves 9th,10th and 12th nerve.
Surgery in the form of Debridement was recommended earlier assuming that it removed the dead necrosed tissue.But the results can be disappointing to sy the least...it is believed facilitate the spread of the disease.So it is rserved from only extreme cases where conservative treatment is showing no tangible results.