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 appropriate initial treatment for this patient's condition?

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 appropriate initial treatment for this patient's condition?

Quizplus · Accepted Answer

Explanation: Pseudomonas aeruginosa is responsible for almost all cases of malignant otitis externa (MOE), and systemic anti-pseudomonal therapy is required. Fluoroquinolones (eg, ciprofloxacin) are the preferred initial treatment, but anti-pseudomonal penicillins (eg, piperacillin), with or without aminoglycosides, and third-generation cephalosporins (eg, ceftazidime) are also effective and can be used for patients with contraindications to quinolones or suspected antimicrobial resistance. Treatment is usually initiated with intravenous medication. Inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) correlate with disease activity, and the patient can be converted to oral therapy when these tests normalize. 6-8 weeks of therapy is recommended. (Choice A) Topical acidifying agents (eg, acetic acid) can be used for mild, uncomplicated external otitis but are not adequate treatment for MOE. (Choice B) Hyperbaric oxygen can be considered as adjunctive treatment for MOE refractory to initial therapy. However, response rates are mixed, and antibiotics should be initiated first. (Choice D) Oral amoxicillin is not effective against P aeruginosa and should not be used. (Choice E) Topical antibiotics are not recommended for MOE as they are generally ineffective and can complicate microbiologic testing. Educational objective: Systemic anti-pseudomonal antibiotics should be used in the treatment of malignant external otitis. References: Malignant otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/18435997)

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