Acute Dx: What Cause of Sudden Illness?

THE CASE:

For the past 2 days, an elderly woman has had severe pain in anddischarge from the right ear. She has diabetes, which is well controlled with anoral hypoglycemic agent, and eczematous dermatitis.What do you suspect is the cause of the patient's otic symptoms?

• Otitis media
• Malignant otitis externa
• Foreign body
• Herpes zoster oticus

DISCUSSION:

The patient has

malignant otitis externa,

an infectionof the external ear and temporalbone. The scaling lesions are attributableto her eczema. Malignant otitisexterna, which was first described byToulmouche in 1838, is almost alwaysseen in immunocompromised persons;patients with diabetes are especiallyvulnerable.Patients with "simple" otitis externacomplain of otalgia and a purulentdischarge; in those with malignantotitis externa, the external ear istender and erythematous and the surroundingarea is swollen. Patientsmay be febrile or exhibit signs of systemictoxicity.

Pseudomonas aeruginosa

is theculprit organism in 95% of cases.Other possible causative organismsinclude

Aspergillus, Proteus

species,

Staphylococcus aureus,

and

Staphylococcusepidermitis.

Cranial nerve involvement maydevelop; cranial nerves VII (mostcommon), IX to XII, V, and VI aremost often affected. Intracranial complicationssuch as meningitis, brainabscess, and dural sinus thrombosismay occur; they are usually seen inpatients with severe disease.Suspect malignant otitis externawhen a patient has ear pain out ofproportion to the clinical findings inaddition to the signs listed above.Laboratory evaluation may demonstratea normal or mildly elevatedwhite blood cell count and an elevatederythrocyte sedimentation rate.Imaging studies for evidence of osteomyelitismay include CT or a technetium99m or gallium 67 scan.Patients are initially hospitalizedand referred to an ear, nose, andthroat or infectious disease specialist.Systemic antibiotics--such as ciprofloxacin,ceftazidime, ticarcillin/clavulanate,or gentamycin--are generallyprescribed by the specialist. Surgicalintervention may be required forcomplications.

Otitis media

is most commonlyseen in children, in whom it is frequentlyoverdiagnosed. Patients oftenpresent with earache, hearing loss,fever, and a history of recent upperrespiratory tract infection. Confirmatoryfindings include inflammation ofthe tympanic membrane, poor visualizationof the normal middle-ear landmarks,and a decrease in the normalmovement of the tympanic membranewith insufflation. The organismsmost commonly responsible forotitis media include

Pneumococcus

species,

Haemophilus influenzae,

and

Moraxella catarrhalis.

In most European countries,analgesics are the only treatment offeredunless the symptoms persist orcomplications develop. In the UnitedStates, most physicians prescribe antibioticsin addition to symptomatictreatment; however, the use of antibioticsin this setting is undergoingmajor reevaluation.

¹

A

foreign body

in the ear is a relativelycommon phenomenon, especiallyin children, but it is also seen inadults--particularly those who arementally impaired. A variety of materials--including beads, toys, batteries,and vegetative matter--may be inserted;occasionally, an insect may enter the ear. Patients may complainof discomfort, bleeding, or hearingloss. Physical examination usuallyconfirms or refutes their symptoms.Treatment consists of removal of theforeign body. Antibiotics may be requiredin the event of infection; symptomatictreatment may be offered fordiscomfort. Occasionally, referral toan ear, nose, and throat specialist iswarranted, especially if a foreign bodyhas been present for a prolonged periodand secondary inflammationfrom ear canal traumatization preventssimple removal.

Herpes zoster oticus

results fromreactivation of the varicella zostervirus. It is most often seen in elderlypatients, who usually complain of severeotalgia and a blister-like rash onthe ear. The rash is the same vesiculareruption seen with herpes zosterand may not be present on the initialvisit. The distribution involves only 1dermatome. Other complaints mayinclude ocular discomfort, hearingloss, vertigo, and painful lesions onother areas of the face. Physical examinationoften reveals a vesicular exanthemof the external auditory canaland sometimes paralysis of the facialnerve (Ramsay Hunt syndrome).Treatment measures includeacyclovir and adequate analgesia.Complications such as ocular involvementrequire an emergent ophthalmologicconsultation.

References:

REFERENCE:

1.

American Academy of Pediatrics Subcommitteeon Management of Acute Otitis Media. Diagnosisand management of acute otitis media.

Pediatrics.

2004;113:1451-1465.

FOR MORE INFORMATION:

• Mirza N. Otitis externa: management in the primarycare office. Postgrad Med. 1996;99:153-154,157-158.
• Pfaff JA, Moore JP. Eye, ear, nose and throat.Emerg Med Clin North Am. 1997;15:327-340
• Rubin J, Yu VL. Malignant external otitis: insightsinto pathogenesis, clinical manifestations, diagnosis,and therapy. Am J Med. 1988;85:391-398.