The surgical management of recalcitrant malignant external otitis

Abstract

Aggressive medical management and surgical debridement is curative in most cases of malignant external otitis. Recently, four patients with this condition were treated at the University of California, San Francisco, who did not respond to conventional therapy. In each case, appropriate intravenous antibiotics, diabetic management, and extensive excision of involved tissue failed to eradicate the infection. Progression of the disease was evidenced by any one of the following: 1. Persistence of granulation tissue in the external auditory canal, 2. Development of cranial neuropathies during treatment, 3. Other signs or symptoms of active infection for more than two weeks after institution of therapy. Any one of these criteria was considered an indication for more radical surgical intervention. In three patients, the operative procedure consisted of a subtotal temporal bone resection to gain access to the primary focus of infection and provide adequate drainage. The common finding in each case was an abscess cavity in the soft tissues at the base of the skull. A description of the clinical course and surgical management of malignant external otitis forms the basis of this communication.

Malignant Otitis Externa: A Retrospective Analysis and Treatment Outcomes

“…Other treatment strategies are close follow-up of blood glucose levels (12), repeated local debridement of necrotic tissue, and hyperbaric oxygen therapy (13). Surgery has a limited role in the treatment of MOE (14).…”

Benign necrotizing osteitis of the external auditory meatus

“…The management of malignant otitis externa is mainly medical with long term antibiotic therapy. Surgery has been advocated in recalcitrant malignant otitis externa which progresses while under appropriate therapy (Raines and Schindler, 1980) and in severe radionecrosis (Birzgalis, 1993). Literature on the treatment for benign necrotizing osteitis is sparse and surgical management has been advocated only if a long period of medical therapy fails (Wormald, 1994).…”

Surgical management of benign necrotizing otitis externa

“…Extensive surgery has been advocated by Raines and Schindler (1980) when malignant otitis externa progresses while under appropriate therapy and by Birzgalis et al (1993) for severe radionecrosis and thus the principle of debridement and removal of dead tissue to allow healing to occur is well established.…”

“…The blood supply of the tympanic plate is relatively poor with a susceptibility to radionecrosis (Birzgalis et al, 1993) and development of sequestra in malignant otitis externa (Nadol, 1980). The two factors that contribute to diabetics having a high predisposition to malignant otitis externa are microangiopathy and immune suppression (Raines and Schindler, 1980;Uri etal., 1984;Salit era/., 1985;Hammond, 1987). As the tympanic plate appears to have a relatively poor blood supply, the additional microangiopathy that may accompany diabetes appears to predispose it to avascular necrosis and the formation of bony sequestra.…”