A 70-year-old man comes to the emergency department due to severe left ear pain. The pain has progressively worsened over the past 2 weeks. It is especially severe at night and is exacerbated by chewing, so the patient has difficulty sleeping and eating. He has been unable to wear his hearing aid on the left side, so he is unsure whether his hearing has worsened. Medical history is significant for hypertension, coronary artery disease, and type 2 diabetes mellitus complicated by peripheral neuropathy. Temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, and pulse is 98/min. On examination, the left external auditory canal is mildly edematous with purulent discharge and granulation tissue on the canal floor. The tympanic membrane is clear. Aside from hearing loss, cranial nerve examination is normal. Complete blood count is normal, and the erythrocyte sedimentation rate is 89 mm/hr. Which of the following is the best initial treatment for this patient?

Question

A 70-year-old man comes to the emergency department due to severe left ear pain.  The pain has progressively worsened over the past 2 weeks.  It is especially severe at night and is exacerbated by chewing, so the patient has difficulty sleeping and eating.  He has been unable to wear his hearing aid on the left side, so he is unsure whether his hearing has worsened.  Medical history is significant for hypertension, coronary artery disease, and type 2 diabetes mellitus complicated by peripheral neuropathy.  Temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, and pulse is 98/min.  On examination, the left external auditory canal is mildly edematous with purulent discharge and granulation tissue on the canal floor.  The tympanic membrane is clear.  Aside from hearing loss, cranial nerve examination is normal.  Complete blood count is normal, and the erythrocyte sedimentation rate is 89 mm/hr.  Which of the following is the best initial treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d398_6700_bc81_45f0735e16c2_MD0003_00 This patient with severe ear pain likely has necrotizing (malignant) otitis externa (NOE), a life-threatening infection of the external auditory canal extending to the skull base (osteomyelitis). Most patients are elderly and have diabetes mellitus. The most common manifestation is severe, unrelenting ear pain, especially at night; pain exacerbated by chewing may indicate spread of infection to the temporomandibular joint (TMJ). Other findings may include otorrhea and lower cranial nerve deficits (eg, facial [CN VII]). Otoscopy characteristically shows granulation tissue at the bony cartilaginous junction and an edematous external auditory canal, often with purulent drainage. As in other cases of osteomyelitis, an elevated erythrocyte sedimentation rate is often seen, although leukocyte count may be normal. Pseudomonas aeruginosa is the most common cause of NOE. Prior to the advent of antipseudomonal antibiotics (eg, fluoroquinolones), mortality was >50%. Intravenous ciprofloxacin is the drug of choice, even with the increased risk of tendon rupture in elderly patients. Surgical debridement (of necrotic bone) is reserved for patients not responding to medical therapy. Surgical excision, common before the advent of antipseudomonal antibiotics, is no longer used (Choice C). (Choice A) Although ampicillin/sulbactam is a broad-spectrum penicillin-beta lactamase inhibitor combination, it does not cover Pseudomonas. (Choices D and E) A topical combination of neomycin, polymyxin B, and corticosteroids can be used to treat some cases of OE (eg, those with intact tympanic membranes). OE may cause severe ear pain, but the extended time course, ear pain exacerbated by chewing (suggesting infection spread to the TMJ), presence of granulation tissue, and elevated erythrocyte sedimentation rate in this patient all raise concern for NOE. Educational objective: Necrotizing (malignant) otitis externa is a severe infection of the external auditory canal that extends to the skull base and is usually caused by Pseudomonas aeruginosa. It is seen most frequently in elderly patients with diabetes mellitus. Intravenous ciprofloxacin is the first-line therapy. References: Initial management of necrotizing external otitis: errors to avoid. (http://www.ncbi.nlm.nih.gov/pubmed/23276814) Malignant otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/18435997) Malignant otitis externa: a review. (http://www.ncbi.nlm.nih.gov/pubmed/12737420) Aural irrigation with water: a potential pathogenic mechanism for inducing malignant external otitis? (http://www.ncbi.nlm.nih.gov/pubmed/2301865)

A 70-Year-Old Man Comes to the Emergency Department Due to Severe