A 72-year-old woman comes to the emergency department due to right ear pain and drainage for the past 2 days. She saw her primary care physician approximately a week ago for decreased hearing in the right ear and underwent aural irrigation to remove impacted cerumen. The patient's medical history is notable for hypertension, diabetes mellitus, and rheumatoid arthritis. Current medications include hydrochlorothiazide, enalapril, metformin, and methotrexate. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 146/74 mm Hg, pulse is 100/min, and respirations are 16/min. There is marked tenderness with motion of the right earlobe. Purulent discharge and granulation tissue are noted on the floor of the right external auditory canal at the osseocartilaginous junction. The tympanic membrane appears intact.
Which of the following is the most likely cause of this patient's acute findings?

Question

A 72-year-old woman comes to the emergency department due to right ear pain and drainage for the past 2 days.  She saw her primary care physician approximately a week ago for decreased hearing in the right ear and underwent aural irrigation to remove impacted cerumen.  The patient's medical history is notable for hypertension, diabetes mellitus, and rheumatoid arthritis.  Current medications include hydrochlorothiazide, enalapril, metformin, and methotrexate.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 146/74 mm Hg, pulse is 100/min, and respirations are 16/min.  There is marked tenderness with motion of the right earlobe.  Purulent discharge and granulation tissue are noted on the floor of the right external auditory canal at the osseocartilaginous junction.  The tympanic membrane appears intact. 
Which of the following is the most likely cause of this patient's acute findings?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bea4_e272_8f63_9dec5ce23622_MD0005_00 This patient has an acutely inflamed ear canal with purulent drainage and granulation tissue formation. In an older patient with comorbid diabetes (or other immunosuppressing conditions) this is concerning for malignant otitis externa (MOE). MOE usually begins as a superficial external otitis but progresses rapidly to involve the adjacent bones at the base of the skull. A recent history of aural irrigation (ie, for cerumen disimpaction) is a common finding. Patients with MOE have marked pain with manipulation of the ear. Systemic signs (eg, fever) are common. Granulation tissue in the external canal at the bone-cartilage margin is pathognomonic for MOE but is not always present. There may be severe edema and occlusion of the canal, but the tympanic membrane is usually intact. Most (>95%) cases of MOE are due to Pseudomonas aeruginosa, although other bacteria and fungi (eg, Aspergillus) are occasionally seen. Untreated MOE can progress rapidly to involve the skull base, temporomandibular joint, and cranial nerves, leading to osteomyelitis and cranial nerve palsies. (Choice A) Actinomyces is an anaerobic bacterium of the oral cavity that can cause invasive disease of the mandible and surrounding tissues. Older patients with diabetes are at increased risk. However, actinomycosis causes a slow-growing, nontender mass, multiple sinus tracts, and a granular purulent discharge ("sulfur granules"). (Choices B and C) Acute otitis media presents with an inflamed, bulging tympanic membrane and middle ear effusion. Mastoiditis is a bacterial infection of the mastoid air cells and is a potential complication of untreated or recurrent otitis media, primarily in young children. This patient's infection appears to be external to the tympanic membrane. (Choice E) Ramsay Hunt syndrome (also known as herpes zoster oticus) is a manifestation of reactivated varicella zoster virus. It is characterized by ear pain, external auditory vesicles, and ipsilateral facial paralysis. Educational objective: Malignant otitis externa is an invasive infection of the external ear canal, usually caused by Pseudomonas aeruginosa. It is typically seen in elderly, diabetic patients and is characterized by severe pain and granulation tissue at the floor of the canal at the osseocartilaginous junction.

A 72-Year-Old Woman Comes to the Emergency Department Due to Right