A 76-year-old man comes to the office due to right ear pain. He first experienced mild pain several weeks ago and has also noticed that his pillow is wet in the morning with discharge from the ear. The patient saw another provider 2 weeks ago and was given oral ciprofloxacin but has not had any relief since. He has type 2 diabetes mellitus treated with metformin, sitagliptin, and glyburide. He admits to occasionally skipping his medications and does not regularly check his blood glucose at home. The patient has a 50-pack-year smoking history.
His temperature is 36.7 C (98 F), blood pressure is 134/78 mm Hg, and pulse is 90/min. On physical examination, ulceration with exudation is present in the right ear canal, and manipulation of the right pinna evokes mild pain.
Laboratory results are as follows:

CT scan of the base of the skull reveals areas of bony erosion involving the right auditory canal. Cultures of the ear exudate are obtained.
Which of the following is the best next step in management of this patient?

Question

A 76-year-old man comes to the office due to right ear pain.  He first experienced mild pain several weeks ago and has also noticed that his pillow is wet in the morning with discharge from the ear.  The patient saw another provider 2 weeks ago and was given oral ciprofloxacin but has not had any relief since.  He has type 2 diabetes mellitus treated with metformin, sitagliptin, and glyburide.  He admits to occasionally skipping his medications and does not regularly check his blood glucose at home.  The patient has a 50-pack-year smoking history.
His temperature is 36.7 C (98 F), blood pressure is 134/78 mm Hg, and pulse is 90/min.  On physical examination, ulceration with exudation is present in the right ear canal, and manipulation of the right pinna evokes mild pain.
Laboratory results are as follows:

CT scan of the base of the skull reveals areas of bony erosion involving the right auditory canal.  Cultures of the ear exudate are obtained.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient has pain and ulceration of the external ear with local erosion into the bone. Likely causes include invasive squamous cell cancer (SCCa) and malignant otitis externa (MOE). MOE is an invasive pseudomonal infection that is seen in older patients with uncontrolled diabetes. It is characterized by severe pain and purulent discharge and is unresponsive to topical antimicrobial therapy. MOE may progress to osteomyelitis of the skull and cause cranial nerve palsies. Most cases will respond to oral fluoroquinolone therapy, and intravenous third-generation cephalosporins (with or without an aminoglycoside) can be used in patients with suspected ciprofloxacin resistance or allergy. In contrast to MOE, which presents acutely with moderate to severe pain and a very high erythrocyte sedimentation rate (ESR), SCCa tends to have mild symptoms, a subacute presentation, and a normal to slightly elevated ESR. This patient did not respond to treatment for MOE, and a biopsy is indicated to exclude SCCa. (Choice A) Fungal MOE is an uncommon invasive infection of the ear. It manifests as severe MOE, often in patients who fail antipseudomonal therapy. It is usually seen in immunosuppressed patients, especially those with HIV. (Choice C) Intensive insulin therapy is indicated in type 2 diabetes with significant hyperglycemia that has failed oral medications. This patient has mild hyperglycemia due to medication noncompliance, and intensive insulin therapy is not needed at this time. (Choice D) Cultures for bacteria and fungi may be useful for directing therapy in patients with MOE. However, this patient has features suggesting SCCa, and biopsy need not be delayed for culture results. (Choice E) Technetium-99m bone scan is very sensitive in detecting bone involvement, but it is less sensitive in differentiating MOE from SCCa. Educational objective: Malignant otitis externa presents in older patients with diabetes with severe pain, ear discharge, erosion of the surrounding bones, and a very high erythrocyte sedimentation rate (ESR). Patients with squamous cell cancer of the external ear generally have milder symptoms, a subacute presentation, and a lower ESR. A tissue biopsy is often required to differentiate between these 2 conditions. __________ References: Analysis of 95 cases of squamous cell carcinoma of the external and middle ear. (http://www.ncbi.nlm.nih.gov/pubmed/16431060)

A 76-Year-Old Man Comes to the Office Due to Right