MALIGNANT OTITIS EXTERNA
WITH MASTOIDITIS AND
RETROAURICULA ABSCESS
Lusia, Dian Ayu Ruspita
Otorhinolaryngology Departement
Faculty of Medicine, Diponegoro University – Dr. Kariadi Hospital,
Semarang, Indonesia
BACKGROUND
BACKGROUND
CASE
An aggresive
infection of the
External Acousticus
Canal (EAC),
mastoid, skull base1
DISCUSSION
Malignant
Otitis Externa
CONCLUSION
Elderly
Immuno suppressed
90% Diabetes
Mellitus2
Pseudomonas aeruginosa1,3
1.
2.
3.
Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th ed. Philadelphia: Elseviers Saunders, 2015; 137: 2
115-22.
Hollis S, Evans K. Management of malignant (necrotising) otitis externa.The Journal of laryngology and otology. 2011;125:1212-7.
Lucente FE, Hanson M. Disease of the external ear. In : Snow JB, Wachym PA, eds. Ballanger`s Otorhinolaryngology Head and Neck Surgery. 17th ed. Connecticut: People`s Medical Pu
blishing House, 2009; 14: 191-200.
CASE
BACKGROUND
CASE
DISCUSSION
Male, 61 years old
 Persistent, severe Otalgia
right ear
 Otorrhea
 Cephalgia
 History of ear pricking
 Posterior of the right ear 
swollen, hyperemia, tender
 Diabetes Mellitus  never
take medicine and check up
CONCLUSION
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Physical Examination
General
Assessment
BP : 120 / 80
HR : 88 x / mnt
RR : 24 X / mnt
SpO2 : 99%
VAS scale : 5
Local
Assessment
Otoscopy of right ear
Yellowish otorrhea
Granulation tissue in
posteroinferior of EAC
No perforation of TM
Posterior of auricula : swollen,
tender, hyperemia
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Laboratory Finding
Parameter
Result
Parameter
Result
Haemoglobine
14,7 g/dL
Glucose
351 mg/µL
Hematocrite
41,8%
HbA1C
9,6%
Erytrocyte
4,97x10^6 /µL
Sodium
142 mmol/L
Leucocyte
4700 /µL
Potassium
5,2 mmol/L
Trombocyte
289.000 /µL
Chlorida
112 mmol/L
Ureum
21 mg/µL
PPT
13,5 s
Creatinine
0,9 mg/µL
PPTK
30,8 s
BACKGROUND
CASE
DISCUSSION
MS CT of Temporal Bone
• Granulation tissue in
the right EAC
• Bone erosion in
posterior wall of EAC
• Bone erosion of tip
temporal bone
CONCLUSION
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Timpanometry
R:L : type A
R : profound MHL
(PTA : 111,25 dB)
L : normal (PTA : 25 dB)
Audiometry
 Minimal Otorrhea in Right Ear
 Granulation tissue in the
posterior EAC
 No perforation of TM
Otoendoscopy
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Assessment
Malignant otitis externa with mastoiditis and
retroauricula abscess
Diabetic Mellitus type II
BACKGROUND
CASE
DISCUSSION
Treatment
Pre Surgical Treatment
1.Infection and Inflammation
• Ceftriaxone 1 gr/ 12 h iv
• Metil Prednisolone 62,5 mg
/ 12 h iv
• Ketorolac 30 mg / 8 h iv
2. DM
• Insuline (slidding scale,
glucose < 200 mg/dL)
CONCLUSION
Modified Mastoidectomy
1. Temporal Bone
Exploration
2. Eradicate the
Granulation tissue
3. Incision and Drainage
the Retroauricula
Absecess
Culture and Sensitivity
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Post Surgical Treatment
Culture :
Staphylococcus haemolyticus
Sensitivity Result :
Linezolid, Vancomycin,
Tetracycline, Tigecycline,
Nitrofurantoin, Rifampicin
1.Infection and Inflammation
• Vancomycin 1 g/ 12 h iv for 7
days
• Metil Prednisolone 62,5 mg /
24 h iv for 3 days
• Ketorolac 30 mg / 8 h iv
2. DM
• Lantus 20 units q.n sc
• Novorapid 8 units / 8 h sc
• Metformin 500 mg / 24 h po
BACKGROUND
CASE
DISCUSSION
Post Surgery
CONCLUSION
DISCUSSION
BACKGROUND
An aggresive
infection of the
External Acousticus
Canal (EAC),
mastoid, skull base1
CASE
DISCUSSION
Malignant
Otitis Externa
CONCLUSION
Elderly
Immuno suppressed
90% Diabetes
Mellitus2
Rarely
• Facial paralysis
• Other lower
Necrotiziing Otitis
cranial nerve
Externa / Skullbase
involvement 3
Osteomyelitis1
Pseudomonas aeruginosa1
1.
2.
3.
Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th ed. Philadelphia: Elseviers Saunders, 2015; 137: 2
115-22.
Hollis S, Evans K. Management of malignant (necrotising) otitis externa.The Journal of laryngology and otology. 2011;125:1212-7.
Lucente FE, Hanson M. Disease of the external ear. In : Snow JB, Wachym PA, eds. Ballanger`s Otorhinolaryngology Head and Neck Surgery. 17th ed. Connecticut: People`s Medical Pu
blishing House, 2009; 14: 191-200.
BACKGROUND
Malignant
Otitis Externa
• History
• Physical
Examination
• Supporting
finding
CASE
DISCUSSION
CONCLUSION
Symptoms
Sign
 Itch of the ears
 Persistent, deep
severe Otalgia
 Otorrhoea
 Diabetes
Mellitus
 Oedema and
erythema of EAC
 Otorrhea and
debris in the
meatus
 Granulation on
isthmus of EAC
 TM intact / no
perforation
BACKGROUND
CASE
DISCUSSION
Malignant
Otitis Externa
• History
• Physical
Examination
• Supporting
finding
Imaging Studies
• MS CT of Temporal
Bone
• MRI
• Technetium Bone
Scan
1. Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Sur
gery. 6th ed. Philadelphia: Elseviers Saunders, 2015; 137: 2115-22.
CONCLUSION
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Microbiology Culture
Malignant
Otitis Externa
• History
• Physical
Examination
• Supporting
finding
Pseudomonas aeruginosa1
Staphylococcus aureus,
S. Epidermidis,
Proteus mirabilis,
Klebsiella oxytoca,
fungus1
Staphylococcus haemolyticus
1. Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th
ed. Philadelphia: Elseviers Saunders, 2015; 137: 2115-22.
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Treatment
Treatment1,3
1. Medical Therapy
• Base on
microbiology findings
• Control of Diabetic
Mellitus
2. Surgical Theraphy
• Debridement
• Surgical Resection
1.
2.
 Vancomycin 1 g/ 12 h iv for 7 days
 Ciprofloxacin 500 mg / 12 h, po for 6
weeks
•
•
•
•
Insuline (slidding scale)
Lantus 20 units q.n sc
Novorapid 8 units / 8 h sc
Metformin 500 mg / 24 h po
 Debridement
 Modified Mastoidectomy
Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th ed. Philadelphia: Elseviers Saunders, 2015; 137: 2115
-22.
Lucente FE, Hanson M. Disease of the external ear. In : Snow JB, Wachym PA, eds. Ballanger`s Otorhinolaryngology Head and Neck Surgery. 17th ed. Connecticut: People`s Medical Publis
hing House, 2009; 14: 191-200.
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Complications
•Spread of infection
•Facial nerve paralysis
EAC
Santorini Fissure
Mastoid Cavity
Processus Mastoideus
Retroauricula Abscess
(subcutan)
Grandis JR, Bransetter BF, Yu V. The changing face of malignant (necrotising) external otitis : clinical, radiologycal, and anatomic correlations.
The Lancet Infectious Diseases. 2004
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Prognosis
Prognosis1
Prognosis
Dubia ad Bonam
Dubia
After the antibiotic era
Resistance of the
antibiotic
Gived antibiotic Vancomycin inj 1
gr / 12 hours for 7 days
Gived oral antibiotic for 6 weeks
Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th ed. Phila
delphia: Elseviers Saunders, 2015; 137: 2115-22.
BACKGROUND
CASE
DISCUSSION
CONCLUSION
Malignant Otitis Externa is an invasive infection that affected
elderly and diabetic patient
Staphylococcus haemolyticus was isolated from the right ear
The patognomonic sign and symptomes were otorrhea, deep
severe otalgia, granulation in the posteroinferior EAC
The treatment were based on culture finding and surgical
theraphy  had good outcome
Brant JA, Buckenstein MJ. Infectionof the external ear. In : Flint PW, et al, eds. Cummings Otolaryngology Head and Neck Surgery. 6th ed. Phila
delphia: Elseviers Saunders, 2015; 137: 2115-22.
Thank you
MALIGNANT OTITIS EXTERNA
WITH MASTOIDITIS AND
RETROAURICULA ABSCESS
Lusia, Dian Ayu Ruspita
Otorhinolaryngology Departement
Faculty of Medicine, Diponegoro University – Dr. Kariadi Hospital,
Semarang, Indonesia