Practical and reliable monitoring therapy of necrotizing otitis externa

Abdul Aziz Ashoor

doi:10.4103/1319-8491.289578

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ORIGINAL ARTICLE

Year : 2004 | Volume : 6 | Issue : 1 | Page : 12-15

Practical and reliable monitoring therapy of necrotizing otitis externa

Abdul Aziz Ashoor
King Fahd Hospital of the University, Al Khobar, Saudi Arabia

Date of Web Publication

12-Jul-2020

Correspondence Address:
(FA-HNO) Abdul Aziz Ashoor
ENT Department King Fahd Hospital of the University P.O. Box 40181 Al-Khobar 31952
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289578

Abstract

Objective
This is a retrospective clinical study aiming to come up with an effective and practical monitoring system for the treatment of necrotizing external otitis.
Methodology : During the last 6 years ( 1997-2003), 9 patients with the diagnosis of necrotizing external otitis (NEO) were admitted to the ENT-ward at King Fahd Teaching Hospital for treatment. After admission, a detailed history was taken followed by a thorough ENT examination and relevant investigations such as; Diabetes Mellitus Profile (DM), Erythrocytes Sedimentation Rate (ESR), Ear Swab for eulture and sensitivity (C/S), Computed Tomography (CT) and scintigraphy using technicium 99 and/ or Gallium 67, After diagnosis were achieved, treatment of the infection and controlling of D.M. was started and after discharge a long term follow up was initiated. Their treatment were monitored using effective subjective and objective assessment measurements.
Results : All cases (apart from 3) responded very well to the antibiotic treatment. Before discharge (7-32 days) patients were put on oral treatment. Patients with cranial nerve involvement (3) showed good to poor improvement. One of them has expired due to carotid artery heamorrhage. Under treatment clinical symptoms such as ear pain, discharges and granulations disappeared. Also ear culture; DM and ESR went back to normal or were controlled. Radiological changes showed remarkable improvement.
Conclusion : Clinical and laboratory assessment measurements arc practical and reliable in monitoring patientfs therapy in particular the ESR. The radiological modalities are useful in detecting soft tissue and bony involvement but are not reliable enough in monitoring therapy.

Keywords: Otitis, otitis externa malignant, monitoring of necrotizing external otitis, otitis externa treatment, ear infection

How to cite this article:
Ashoor AA. Practical and reliable monitoring therapy of necrotizing otitis externa. Saudi J Otorhinolaryngol Head Neck Surg 2004;6:12-5

How to cite this URL:
Ashoor AA. Practical and reliable monitoring therapy of necrotizing otitis externa. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2004 [cited 2023 Mar 27];6:12-5. Available from: https://www.sjohns.org/text.asp?2004/6/1/12/289578

Introduction :

Necrotizing external otitis (NEO) is a virulent necrotizing infection of the external auditory canal (EAC) that affects skin, cartilage and in severe cases bone. Chandler,1968 ^[1], who used the term malignant external otitis described the disease as a severe, invasive external otitis, primarily affecting the elderly diabetic patients and caused by pseudomonas aeruginosa. Affected patients, present with progressive otalgia, purulent ear discharge and persistent granulation tissue in the inferior aspect of the EAC at the bony-cartilaginous junction ^[1],[2].

Diagnosis is based on these clinical findings. Radio-isotope scanning, CT scanning and MR1 have been claimed to be helpful not only in establishing the diagnosis, but also in defining disease extent and evaluating response to therapy. Treatment of NEO traditionally included anti-pseudomona! agents such as 3rd generation cephalosporins and aminoglycoside ear drop for long duration. Surgery has secondary place.

The aim of this study was to comc up with an effective monitoring system for the treatment of necrotizing external otitis.

Material and Methods :

Over the last 6 years (1997-2003) 9 patients with the preliminary diagnosis of necrotizing externa otitis (NEO) were admitted to our ENT ward at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, for investigation and treatment. After admission a detailed history have been taken from all patients in particular regarding earachc, ear discharge, hearing problem, duration of the disease, previous medication and diabetes mellitus. This was followed by thorough examination of ear, nose, throat, cranial nerves, blood pressure, vestibular system and hearing and then followed by relevant investigations for NEO such as: computed tomography (CT) of mastoid and temporal bone at the beginning and post treatment, fasting and random blood sugar, swab for culture and sensitivity (C/S), erythrocytes sedimentation rate (ESR); at beginning and weekly during treatment and during follow up, Scintigraphy (technicium 99 and Gallium 67) were done outside our hospital for patients with facial nerve palsy. Diabetic patients were seen by the physician and were put on sliding scale insulin treatment. Antibiotics were given intravenously (ciprofloxacin or ceftazidime). Aminoglycoside eardrops and antifungal (Floconazole) ear drops were given. Patients were discharged once their pain disappeared, diabetes was controlled, car swab wass negative, ESR returned back to normal, and CT and Scintigraphy findings were getting better. Before discharge, patients were shifted to oral antibiotic and hypoglycemic agents. Patients were followed up for 3-6 months. Diabetic patient were followed up also by the physician. Patients with Facial nerve palsy were seen and followed up. also, by the neurologist, ophthalmologist and physiotherapist.

Patients response to therapy was monitored using the above mentioned clinical, laboratory and imaging parameters.

Results:

During the last 6 years, 9 patient with NEO have been admitted to our hospital for treatment. All were males, with an age range of 51-72 year (mean 61.5y). Their main complaint and the reason for seeing the ENT- Specialist was the severe throbbing earache specially at night. It was associated with purulent ear discharge (8/9 cases), tinnitus ( 6/9), vertigo (1/9) and hearing loss (9/9). Their hospitals stay ranged from 7-32 days depending on their response to treatment.

On examination all patients external canals were occupied with granulation tissue (8/9), polyps, (1/9) and associated with edema, narrowing of canal and purulent discharge. At the end of the first week of treatment, 6 of the patients were relieved of their earache, and the remaining 3 could sleep comfortably with mild analgesics. On discharge most of granulations have disappeared and the ears became dry. Three patients presented with facial nerve palsy; one grade II and two grade V. Under treatment the grade II palsy showed good improvement. While the other two showed no improvement at all. One of them has expired due to massive haemorrhage from the internal carotid artery.

Ear cultures showed pseudomonas aeroginosa in six patient, streptococci & enterococci in one, commensal in one and Candida parasitosis in one patient. All nine patients responded very well to treatment and on discharge from hospital their cultures were negative.

At time of admission all patientis ESRs were elevated. It ranged from 21-120 mm/hr. (mean of 70mm hr). Under treatment ESR regressed gradually to reach a normal values at day of discharge in 6 patients and remained unchanged in three .

All patients CTs showed picture of ostietis of the temporal bone, and the mastoid bone with haziness of the boundaries and soft tissue shadow inside the mastoid air cells, the middle ear and EAC causing narrowing of it. There was soft tissue inflammation at the base of the skull specially the infratemporal region. Scintigraphy showed high tissue activity at the base of skull, temporal and mastoid bone.

By the end of treatment all non complicated patients CTs showed remarkable soft tissue resolution and bony mineralization.

Complicated cases (3) showed worsening of their findings reflected in poor clinical improvements. Their scintigraphies did not show any improvement. On admission all patients had uncontrolled D.M. with fasting blood sugar ranging between 154-548 (mg/dl). All of them had type II D.M. and have been put by the inernist on sliding scale insulin treatment. At day of discharge five patients showed normal blood sugar, while the remaining four remained uncontrolled (despite of all treatment trials). All patients were discharged on oral hypoglycemic drug.

During their stay in hospital all patients received i.v. antibiotic such as ciprofloxacin or ceftazidime alone or ciprofloxacin in combination with ceftazidime or mesopenem and antimycotic (floconazole) in one patient.

The effectiveness of treatment was monitored through improvement of earache, lowering of ESR, normalization of DM, disappearance of granulation tissue from EAC, negativity of cultures, clearance or improvement of CT and radioisotope scans. Patients were discharged on oral antibiotic for 2-4 weeks. Follow up was weekly or bi- weekly for 3-6 months, during which patients ESR, FBS, ear culture, CT and Scintigraphy were checked in addition to clinical examination.

Discussion:

In reviewing the literature about ecrotizing external otititis (NEO) the reader notices that there is no mention of a clear system devoted to proper monitoring of therapy of NEO. There is a scattered mentioning of different procedures which may be of help in assessing the treatment of the disease. In this study we were trying to put together a practical, reliable and scientific sound, assessment measures to help the treating physician to monitor the effectiveness of therapy on his patients. We could divide these evaluation measurements in three types; those based on clinical findings, those based on laboratory data and those based on imaging. Among the clinical indicators for a positive response to treatment are : the improvement of ear pain and improvement of external ear canal conditions. Among the laboratory indicators for a positive response to therapy arc: the control of blood sugar in DM, normalization of ESR and negativity of ear culture for bacteria and fungi. These three measurements are objective in nature as the CT and Radio Isotope scanning. The main complain of our patients was the severe throbbing pain keeping them awake at night and not responding to even the strongest analgesics. By the end of the first week of treatment the majority of patients were free of pain and the minority relieved from pain through simple analgesics. Myerhoff etal,1997^[3], and Wright,1997,^[4] found that the earliest sign of response to therapy is a decrease in pain. Even before there is a visible change in the ear canal, the nurse may report that the patient demands analgesics less often. The second but very important measurement for a positive response to therapy is the improvement of the condition of the external ear canal in the sense of less edema, less narrowing, and granulation tissues and less discharge ^[3],[4], All our patients without exception left the hospital with a normal and dry ear canal.

Another very reliable objective sign of recovery is a better diabetic control. Myerhoff et al, 1997,^[3] and John et al,1998,^[5] stated that the most important part of therapy is gaining control of the patientis diabetes and better diabetic control is an early sign of recovery. There is a strong correlation between the amount of improvement of the disease and the degree of control of patient’s diabetes ^[3].

All our patients (apart from the complicated three) left the hospital with well controlled diabetes and on oral hypoglycemics.

The second objective and important sign for the success of treatment is the negativity of bacterial culture of the car canal as stated by Wright,1997,^[4], Under the effect of therapy all our cases had negative cultures at time of discharge.

The third objective and the most reliable indicator for the success of therapy is the ESR as it has shown in our study.

Bath et al,1998,^[6] and Amoroso el al, 1996,^[7] found that serial measurements of the ESR correlate very well with their patientis condition. Following therapy their patients improved clinically with reduction in ESR. ESR provided a useful parameter to monitor patient’s progress during regular follow up in the outpatient department. A similar finding has been reported by others ^[8],[9]

The other 2 remaining objective assessment measurements used in monitoring therapy response in NEO are CT and radioisotope scanning. Radiological assessment in form of CT and radioisotope scanning has proven to show not only the extent of the disease and degree of bony destruction, but also to help in monitoring the response to treatment. Resset al,1997,^[10] and Amorosa et al,1996,^[7] demonstrated clearly the value of CT scanning in detailed assessment of NEO extension, in evaluating the response to treatment and in identification of recurrence. Mendelson et al,1983,^[11] and Gold et al,1984,^[12] showed how it is possible to detect the resolution of soft tissue inflammation by CT and this may be used in motoring therapy and screening for recurrence.

The majority of our cases (apart from the 3 complicated ones) showed on CT a remarkable soft tissue resolution under the effect of treatment.

Radio-Isotope scanning in form of Technetium 99 and Gallium 67 have been used for a long time for diagnostic purpose and to monitor response to therapy. It shows areas of high tissue activity and as such it may be used to monitor disease activity and therapy response. Technetium 99 is taken up preferentially by osteoblasts and as such shows areas of osteoblastic activity enabling detection of osteomylitis. As bone remodeling persists for some time, it cannot provide the necessary information required to know when it is safe to stop medication ^[6],[8].

On the other hand Gallium 67 is taken by granulocytes and as such localizes areas of intense inflammation. Hcncc both procedures could be used to monitor bony and soft tissue aclivity^[6],[8].

Al-Doussary et al,1998,^[13] stated that Gallium 67 scan is a sensitive way to diagnose and follow up the regression of the disease in response to medical treatment. Combacchio et al,1993,^[14] reported that Technicium 99 is a better inflammation index and as such can be used to monitor the response to therapy . Our three (3) complicated cases have been monitored by radioisotope scanning and it showed minor improvement in response to medication.

Conclusion :

Necrotizing External Otitis is a serious and fata! disease affecting mostly elderly diabetic patients. During the last decades a great advances have been made to reduce the mortality and morbidity rate. The importance of monitoring the activity of the disease to judge both the efficacy of treatment and when to stop, is imperative. The clinical and laboratory assessment measurement, are practical and reliable in particular the ESR. Radiological modalities are useful in detecting both the soft tissue and bony involvement and can therefore assess the extent of infection. Changes in the scan may, however take considerable time or indeed, never return to normal, which possibly limit their use in following the disease activity and their reliability in monitoring therapy.

References

1.	Chandler Jr. Malignant External Otitis. Laryngoscope 1968; 78: 1257-94.
2.	Buliatzhi A, Sadc J. Malignant External Otitis . J. Laryngol Otol 1987; 101: 205-10.
3.	Meyerhoff W., Caruso V.G. Trauma and infection of External Canal. In Giuckman J. MeycrhofT W. Paparella M. and Shumrick D. edt. Otolaryngology. 4th ed. Philadelphia- W.B. Saunders pp 2792-2793,1997.
4.	Wright D. Disease of the External Canal. In : Scotth Browns Otolaryngology 6th Edition London (Booth J. cd)Butterworth ; 3/6/16.1997.
5.	John A, Hawake M. Infection of the External Ear In: Otolaryngology Head and Neck Surgery 3rd Cumming C.W. Fredrickson J.M., Harker L.A. edt. 3rd edition London Mosby yearbook pp. 2792-2793.1998.
6.	Bath A P, Rowe JR. Innes A J. Clinical records malignant otitis externa with optic neuritis. JLaryngol Otol 1998; 112:274-277.
7.	Amorosa L., Modugno GC., Pirodda A. Malignant External Otitis Review and Personal experience. Acta Otolaryngol suppl. 1996; 521: 3-16.
8.	Weinroth SE, Schesscl D., Tuazon Cu. Malignant Otitis Externa in Aids patients: Case report and review of the literature. ENT 1994; 73 (10) 772-774.
9.	Rubin J. Curtin HD, Yu VL, Kamerer DB. Malignant External Otitis: Utility of CT in diagnosis and follow up. Radiology 1990; 174 (2): 391-4
10.	Ress B.D., Luntz M., Telischi F.F., BalkanzT.J. and Whiteman M L.H. Necrotizing External Otitis in patients with Aids.Laryngoscope 1997; 107: 465-470.
11.	Mendelson DS., Som P.M. Mendelson MH., Parisier SC. Malignant Otitis Externa: The role of computed tography and radionuclides in evaluation. Radiology 1983; 149: 745-749.
12.	Gold, Som PM., Lucente Fe, LawSon W., Mendelson M., Parisier Sc. Radiographic findings in progressive necrotizing malignant external otitis. Laryngoscope 1984; 94: 363-66.
13.	Al-Doussary S., Attalah M., A1 Rahab A., Ammar A., and Guafar M. Otitis Externa Malignant. A case report and review of literature. Otolaryngol Pol 1998; 52 (1): 19-22.
14.	Combacchio F., Di Eredita R. Biron E, Chierichetti F., Ferlin G. Marchioric. Follow up of necrotizing external otitis Acta Otorhinolaryngol Ital 1993; 13 (6): 517-24.