|Year : 2011 | Volume
| Issue : 3 | Page : 127-129
Malignant otitis externa: An unusual presentation
Rejee Ebenezer, Feroze Khan, Sasikumaran Nair, M Sajilal
Department of ENT, Dr. SMCSI Medical College Hospital, Karakonam, Trivandrum, Kerala, India
|Date of Web Publication||26-Dec-2011|
Department of ENT, Dr. SMCSI Medical College, Karakonam, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
Destruction of condyle of mandible is an extremely rare complication of malignant otitis externa. Here we describe such a rare instance in a patient with malignant otitis externa. It is very important to diagnose this category of patients and treat them accordingly. The available data indicate the need for external drainage. We report a case with malignant otitis externa with temporomandibular involvement treated successfully with radical mastoidectomy and drainage of the joint through the external auditory canal and an external incision was avoided.
Keywords: Malignant otitis externa, Temporomandibular joint, Radical mastoidectomy
|How to cite this article:|
Ebenezer R, Khan F, Nair S, Sajilal M. Malignant otitis externa: An unusual presentation. Indian J Otol 2011;17:127-9
| Introduction|| |
Destruction of condyle of mandible is an extremely rare complication of malignant otitis externa. Usually this condition requires external drainage. The alternative may be a radical mastoidectomy and drainage of the joint through the external auditory canal thereby avoiding an external incision.
| Case Report|| |
A 60-year-old male patient, presented to us with complaints of discharge fromthe left ear of 7 months duration which was foul smelling and occasionally blood stained. He also had associated dull aching pain in left ear with swelling in the left preauricular region of 3 months duration. He was a known diabetic, hypertensive with ischemic heart disease and was on treatment for the past 6 years. On examination of the left ear there was edema of external auditory canal with purulent discharge and granulations on the floor and anterior wall with diffuse swelling over the preauricular region extending up to the zygomatic arch. There was tenderness over the left temporomandibular joint with no restriction of joint movements. There was no mastoid tenderness, neck rigidity or signs of raised intracranial tension. Cranial nerves examination revealed House Brackmans grade 2 paresis of left facial nerve. Hematological investigations revealed raised ESR and high blood sugars. Pus culture grew Pseudomonas aeuroginosa, sensitive to gentamycin, ceftazidime, ciprofloxacin, and piperacillin. X-ray mastoid showed destruction of the mandibular condyle on the left [Figure 1]. Computed tomography of the temporal bone [Figure 2] showed left mastoiditis with destruction of the mandibular condyle with infra temporal cellulitis and no intracranial extension. Pure tone audiogram showed a severe mixed hearing loss in the right ear and profound hearing loss in the left ear.
|Figure 1: X ray mastoid left side showing destruction of mandibular condyle|
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|Figure 2: Computed tomography of the temporal bone showing left mastoiditis with destruction of the mandibular condyle with infra temporal cellulites|
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Patient was treated with intravenous ciprofloxacin for 10 days and blood sugar was controlled with insulin. In view of no clinical improvement he was taken up for surgery. Intraoperatively there was edema of the external auditory canal; a granulation polyp arising from the anterior canal wall with a dehiscence in the anterior canal wall communicating with the temporomandibular joint. The tympanic membrane was retracted and the mastoid antrum was filled with granulations and pus. The long process of incus was necrosed and stapes suprastructure was absent. Oval window was dehiscent. Patient underwent radicalmastoidectomy with drainage of temporomandibular joint through anterior canal wall. Patient was followed up at regular intervals and the mastoid cavity healed well with improvement of facial paresis and preauricular swelling. Computed tomography was repeated after one year which showed sclerotic changes in the left temporomandibular joint with no evidence of inflammation in the mastoid [Figure 3].
|Figure 3: Computed tomography repeated after one year showing sclerotic changes in the left temporomandibular joint with no evidence of inflammation|
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| Discussion|| |
Malignant otitis externa is a severe penetrating infection which spreads outside the confines of the external auditory canal to involve temporal bone, mastoid air cells and periaural soft tissues. It is a rare but important condition having a mortality rate of between 23%-75%.  Clinical diagnosis in the early stage is difficult because the symptoms are similar to acute otitis externa. Diabetes mellitus is an important predisposing factor in up to 94% of patients.  Cohen D et al, divided the diagnostic criteria of malignant otitis externa into two categories: obligatory and occasional.  The obligatory criteria are: pain, edema, exudates, granulations, micro abscess (when operated), positive bone scan or failure of local treatment often more than 1 week and possibly pseudomonas in culture. The occasional criteria include diabetes, cranial nerve involvement, positive radiograph, debilitating condition and old age. All of the obligatory criteria must be present in order to establish the diagnosis. The presence of occasional criteria alone does not establish it. The importance of Tc99 scan in detecting osteomyelitis is stressed. When bone scan is not available, a trial of 1-3 weeks of local treatment is suggested. Failure to respond to such treatment may assist in making the diagnosis of malignant otitis externa. Our patient fulfilled both the criteria to make the diagnosis of malignant otitis externa. Involvement of temporomandibular joint is very rare in malignant otitis externa. According to Smith et al., anatomically the anterior bony canal wall is related to the joint; the joint capsule is attached to the squamotympanic suture.  Congenital dehiscence of the cartilaginous canal, the inconstant fissures of Santorini, or a dehiscent squamotympanic suture may account for spread of infection to the joint. Mardinger et al. has shown an incidence of TMJ involvement in 14% of cases.  Temporomandibular joint involvement in malignant otitis externa is associated with a resistant disease process and hence prolonged administration of antibiotics is the treatment of choice. Surgical debridement of joint is necessary in case of abscess formation or osteomyelitic destruction of the condyle of mandible. According to Raines et al. 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 like a subtotal temporal bone resection to gain access to the primary focus of infection and provide adequate drainage. Midwinter et al. described two cases of osteomyelitis of the temporomandibular joint in patients with malignant otitis externa which was treated by external drainage.  Our patient was treated with radical mastoidectomy and drainage of the joint through the external auditory canal and an external incision was avoided.
| Acknowledgement|| |
The author would like to acknowledge Dr. SMCSI Medical College, Karakonam, Trivandrum, Kerala, India.
| References|| |
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|3.||Smith PG, Lucente FE. Topic. In: Cummings CW, editor. Text book of Otolaryngology Head and Neck Surgery. 3 th ed. Toronto: Elsevier Mosby; 1986. p. 2899. |
|4.||Mardinger O, Rosen D, Minkow Z, Ophir D, Hirshberg A. Temporomandibular joint involvement in malignant external otitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:398-403. |
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[Figure 1], [Figure 2], [Figure 3]