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Clinics of Otorhinolaryngology

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Clin of Otorhinolaryngology(2017)
1:1 003

Research Article

Malignant Otitis Externa in Developing Country

Adegbiji WA1, Aremu SK2*, Nwawolo CC3, Alabi SB4 and Lasisi AO5
1
ENT Department, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
2
ENT Department,Federal Teaching Hospital,Ido-Ekiti, Nigeria
3
ENT Department, Lagos University Teaching Hospital, Lagos, Nigeria
4
ENT Department, University of Ilorin Teaching Hospital, Ilorin, Nigeria
5
ENT Department, University College Hospital, Ibadan, Nigeria

Abstract
Objective: Malignant otitis externa is a potentially life threatening infection of external auditory canal
and skull base in an immunocompromised person. The outcome tends to be fatal due to the skull base
osteomyelitis, especially if diagnois is delayed or is poorly treated. This epidemiological study in developing
country is aimed at sensitizing for high level of suspicious early diagnosis and treatment.
Method: This is a prospective study of patients with diagnosis of malignant otitis externa managed in a
tertiary hospital between year 2012 - 2016. All consented patients with the disorder were enrolled into the
study. Data obtained were collated and analysed.
Result: Nine patients with malignant otitis externa were seen during the study period. Male to female ratio
was 1:1. The peak was between 61 and 70 years. The most frequent symptoms were otalgia 9 (100%)
and hearing loss 9 (100%) while cranial neuropathy was encountered in 6 (66.7%). The most implicated
microganisms was Pseudomonas aeruginosa 7(28%). All patients had combination of both medical and
surgical intervention. There was 1death (11.1%).
Conclusion: Malignant otitis external is a complication of diabetes with high morbidity, however prompt
diagnosis and treatment could mitigate the mortality.
Keywords: Malignant otitis externa; Diabetes; Immune compromised patient.

Introduction
Malignant otitis externa is a fatal, progressive and aggressive infection of the external auditory canal
extending to the temporal bone and base of skull in immunocompromised individuals, elderly diabetes
mellitus are often especially affected. There are microorganisms which could be responsible but
infection with Pseudomonas aureginosa is the most common [1].
In 90% of cases, the disease involves Pseudomonas aureginosa infection in the elderly diabetic.
Infrequently, it affects younger age groups who are immune compromised eg HIV, AIDS and
malnutrition. The most common offending organisms is 95% Pseudomonas aeruginosa. Other
infrequently incriminating bacterial are Staphylococcus aureus, Klebsiella spp and fungal eg Aspergillus
species [2,3]. The infections begin in the external auditory canal and spread along the vascular and
fascial planes, extending into the temporal bone through the external auditory canal osseocartilaginous
junction or fissures of Santorini [4]. The infection causes bony erosion to involve intracranial structures
which is the main cause of death. In addition to this, patients who are elderly and diabetics have
innate defects in chemotaxis and phagocytosis of polymorphonuclear lymphocytes, monocytes, and
macrophages which aid spread of the disease. The disease is staged based on extent of soft tissue
and bony involvement or development of neurologic complications [5,6]. In stage l, the disease is
limited to the external auditory canal, in stage ll there is extension to temporal bone with cranial

Received March 10, 2017; Accepted April 06, 2017; Published April 12, 2017
*Corresponding author: Aremu shuaib Kayode, ENT Department, Federal Teaching Hospital, Ido-Ekiti, Nigeria, Tel: +2348033583842;
E-mail: Shuaib.aremu@gmail.com
Citation: Adegbiji WA, Aremu SK, Nwawolo CC, Alabi SB, Lasisi AO (2017) Malignant Otitis Externa in Developing Country. Clin of
Otorhinolaryngology (2017) 1:1 003

Volume 1: Issue 1: 003 1

Volume 1: Issue 1: 003 2

nerve neuropathaties and, in stage lll, there is intracranial The data obtained were collated and entered into and
extension. Stage l has a good prognosis while stage lll is analysed using SPSS version 18.
fatal at presentation.
Results
The clinical features include: painful external ear canal
and the ipsilateral jaw, purulent otorrhea usually offensive, A total of 9 patients presented with diagnosis of malignant
hearing impairments, and occipital and temporal headache. otitis externa out of 10,014 patients seen during the study
There may be associated facial and pharyngeal symptoms in period. There were 5 male with 4 female with a Male to
advanced cases. Clinical examination revealed tender pinna, Female ratio of 1:1. The mean age of the study group was 64
edematous pinna including external auditory meatus and years. Table1. The peak age involvement was 61-70 years.
granulation polyps [7-9].
Diabetic mellitus was implicated in 8 (88.9%) while AIDS
Diagnosis is made by high index of suspicion, was found in 1 (11.1%)
microbiological culture of the organism and radiological
Microbiological study of ear discharge and tissue biopsy
investigations which include Computerised Tomography
from wound debridement culture and sensitivity revealed
Scan (CT scan) and Magnetic Resonance Imaging(MRI).
7(28%) Pseudomonas aureginosa. Staphylococcus aureus
CT Scan is the investigation of choice as it delineates
with Klebsiella sp were noted to account for 1(11.1%) each.
subtle changes in bone density and establishes the extent
of soft tissue swelling. Radioisotope scans are also useful This is shown in figure 1.
for monitoring treatment response, particularly Technetium In our study of malignant otitis externa, 77.8% present with
99. Serial monitoring of CRP and ESR can help to evaluate diseases of maximum duration of 8 week duration while
response to the administered antibiotics. it is more than 8 weeks in 22.2%. The findings on clinical
The management includes meticulous aural toilet, antibiotics history and examination were 100%of earache, and tender
such as Ciprofloxacin or antifungal agent and blood glucose ear while least finding was 3(33.3%) of fever. Right ear was
control in patients with diabetes [10-13]. Hyperbaric oxygen responsible for 66.7% while left ear was responsible for
can be considered for cases with intracranial complication. 33.3% cases of the malignant otitis externa. We recorded
Surgical management mostly limited to biopsy for microbial 100%cases of unilateral malignant otitis externa.As shown
and histological diagnosis. Histologically, granulation in figure 2. Malignant otitis externa affected 66.7% of right
tissue is characterized by non-specific inflammation with ear while 33.3% of left ear was noted but no bilateral ear
inflammatory cell infiltration and hyperplasia of squamous was recorded.
epithelium [14].
Associated complications of malignant otitis externa were
This prospective study is aimed at identify the possible 6 (66.7%) cranial nerve palsy as commonest, infratemporal
complications, clinical manifestations, diagnosis, and and neck space abscess in 1 (11.1%) each. No associated
management outcome of malignant otitis externa in our complication in 2 (22.2%) of the patients studied. There was
study population. no mortality in any patient studied. As it was revealed in
Materials and Methods table 2.

This is a prospective hospital based study. The patients with

Age group/years Frequency/n
a diagnosis of malignant otitis externa were seen over of 5
51-60 2
years, January 2012 to December 2016. 61-70 4
The study was carried out in ear, nose and throat clinic of 71-80 2
81-90 1
ENT Department of Ekiti state university teaching hospital
Total=9
located in south western part of Nigeria. This is one of the
centre for management of diabetic mellitus. Table 1: Age distribution of patients with malignant
otitis externa
Informed consent to be enrolled into this study was obtained
from the patient or guardian before their enrollment into the
Pseudomonas aeruginosa Staphylococcus aureus Klebsiella sp
study.
Interviewer assisted questionnaires were given to obtain 11.1%
(1)
information from the 9 patients or guardians. The data
obtained were on biodata, presenting complaints, detailed
11.1% (1)
ear, nose and throat history, past medical history, family and
social history.
General physical examination to determine patient health 77.8% (7)
status. Detail ear, nose and throat examination was performed
to determine the extent of the disease.
Management information data were obtained and
documented. These also includes detail data on requested Figure 1: Bacteriology of malignant otitis externa
investigations, medical and surgical treatment.

Citation: Adegbiji WA, Aremu SK, Nwawolo CC, Alabi SB, Lasisi AO (2017) Malignant Otitis Externa in Developing Country. Clin of
Otorhinolaryngology (2017) 1:1 003
Volume 1: Issue 1: 003 3

to these pathogenesis [22]. This work revealed absence of

Frequency % complication in 2 (22.2%) while facial nerve affectation
occurred in 6 (66.6%).
Earache
Headache Clinical presentation of malignant otitis externa are often
Otorrhea
present with an earache, ear discharge which does not respond
Hearing loss
Tinnitus to standard treatment regimes of ear toilet and antibiotic
Fever therapy [23-25]. This condition may also present with cranial
Tenderear
Granulation tissue
nerve palsies, trismus when the pathology extended beyond the
external auditory canal. All, 100% of our studied population
presented with otalgia and this is similar to other documented
findings in previous research [15].
Figure 2: Clinical features of patients with malignant
otitis externa In the early management of malignant otitis externa
debridement and biopsy of the external auditory meat us
with subsequent cultures and sensitivity were repeated
Complication Number Percentage(%) during the early phase of our management as in previous
Nil study. Treatment for the disorder also requires initial
2 22.2
Cranial nerve palsy
6 66.6 hospitalisation for aggressive targeted antimicrobial therapy
Neck space abscess and
1 11.1 based on microscopy, cultureand sensitivity results. Our
gangrene
1 11.1 treatment rgime includes combination of both surgical
Infratemporal abscess
1 11.1
Septicemia and medical therapy. The outcomes of treatment depend
on the disease stage at presentation. Only 1 (11.1%) of our
Table 2: Complication of malignant otitis externa patients presented with stage lll. Our mortality record was
1 (11.1%). Prompt diagnosis and antibiotic administration
All the patients had combination of both medical and has improved our mortality and morbidity results. It is still
surgical intervention. alarming that mortality remains around 33% and increases to
Discussion 80% with cranial nerve involvement in previous findings15.
However the predictor of complications includes skull base
This rare fatal malignant otitis externa was found to be more osteomyelitis, and multiple cranial nerves.
common in males than females in previous research work.
Same study revealed high mortality over a period 10 years Conclusion
of more than half of the studied patients [15]. Our study Malignant otitis externa remain uncommon pathology in
showed equal male to female proportion and mortality of otorhinollaryngological practice worldwide. Early diagnosis
less than 50% of the studied population. These findings may with prompt, timely and appropriate management will
be due to high rate of suspicious of malignant otitis externa produce good outcome. It is therefore advised that diabetes
among diabetes mellitus patients at the study centre. patient with earache should be promptly referred by their
Malignant otitis externa typically arises in patients who managing physician.
are immune suppressed. The most commonly affected
immunosuppressed patients is diabetes mellitus in elderly Conflict of Intrest
patients. While it occurred in younger age patients who are The authors declared that there are no conflicts of intrest.
AIDS, malnourished, or immune suppression from cancer
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Otorhinolaryngology (2017) 1:1 003
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Citation: Adegbiji WA, Aremu SK, Nwawolo CC, Alabi SB, Lasisi AO (2017) Malignant Otitis Externa in Developing Country. Clin of
Otorhinolaryngology (2017) 1:1 003