Malignant otitis externa is sometimes frustrating to treat as the response is not dramatic as in many of the inflammatory conditions. In the presence of granulations in the external auditory canal, in addition to the medical line of treatment, when should one think of surgical intervention, and what should be the limit of surgical intervention?
The cornerstone of management is medical namely antibiotics, strict control of diabetes and hyperbaric oxygen. We would only undertake surgical intervention if there is sequestrum of bone which needs debridement.
Thank you Md Saleem.. At times, we tempt to take biopsy, since many patients are past middle age/elderly.. what is your opinion? how long we should wait for the response to medical treatment, for biopsy?
I had only a few cases of malignant otitis externa and none surgical intervention, but debridement would be necessary in absence of response to medical treatment, or clinical worse with risk to life, without considering space of time.
This depends on the condition of the patient. Surgical intervention with synchronous IV culture directed antibiotic is indicated when there is complication even if it is occurred in the beginning of the disease. Non complicated cases can be treated by culture directed IV antibiotic and watchable follow up by repeated investigation.
Most patients have a clear suggestive history. However cultures are sometimes misleading and biopsies are routinely performed. Antibiotics, local clearance and hyperbaric oxygen with strict diabetic control are our routine. However with the occasional involvement of the middle ear and mastoid and severe pain, surgery is sometimes indicated and here a subtotal petrosectomy with obliteration may be necessary. I think that the strict dogma of non-surgical intervention should be revised in some patient in whom the clinical progress is unsatisfactory and the mastoid is constantly infected with severe pain.
Extensive surgical intervention is discouraged in the management of malignant otitis media. Surgery is reserved for local debridement of tissues, bony sequestration removal and drainage of abscesses because removal of affected temporal bone is insufficient due to the mode of spread of this aggressive disease i.e via the vessels and along fascial planes.
Thank you Badr Mostafa and Adeyi Adoga for you responses..
I believe presence of extensive granulations may prevent the antibiotics from reaching the site of infection. Also, they may allow further growth of organism, worsening the situation. Regular assessment of the disease, to look for the response of therapy should guide the treating surgeon to intervene..
Our routine is similar to the above. But, in the recent years we found that fungal etiology plays an important role. We have lots of these patients referred to us. After local treatment of external auditory canal and IV antibiotics, if we encounter not a good response we will start systemic anti-fungal drugs before surgery. This algorithm was very successful and in the past 4 years i do not remember any surgical intervention by the indication of poor medical response, and we have one of these patients every week or two.
Two points on the discussion:
1. I would like to emphasize Ali Kouhi's point! We all read and think about Pseudomonas when talking about Malignant Otitis, but Fungi also exist! Cultures are not always positive, given the history of antibiotic use prior to culture. In my practice, I prefer to administer both intravenous quinolones and AntiFungal medications at the same time, in cooperation with the Infectious disease specialists.
2. I believe that one should consider surgery when surgery can be radical. and remove ALL infected tissue. In that concept, I would only consider surgery when the Nuclear scan shows a very localized focus of disease AND at the same time medical treatment has failed. If Nuclear scan shows extensive disease with skull base osteomyelitis, a radical surgical treatment is not possible in any way and would most probably deteriorate the patient's status.
Our first approach is IV Abx against Pseuomonas bacteria, if this approach failed we will start a systemic antifungal course. This is all that these kind of patients need. In our institution experience there is no indication for surgical intervention for cranial nerve palsies, but bone sequestration is a valid option for performing surgical intervention. But the prevalence of bone sequestration in MEO is very low. Anyway, surgical manipulation in a patient with poor circulation may cause further damages and compromise her/his prognosis.
- Badges
- Science topic
- Similar topics
- Medicine
- Epidemiology