Abstract

The diagnostic criteria of malignant external otitis (MEO) have

been reviewed. They were divided into two categories: obligatory
and occasional. The obligatory criteria are: pain, edema, exudate,
granulations, microabscess (when operated), positive bone scan
or failure of local treatment often more than 1 week, and possibly
pseudomonas in culture. The occasional criteria are diabetes,
cranial nerve involvement, positive radiograph, debilitating
condition and old age. All of the obligatory criteria must be present
in order to establish the diagnosis. The presence of occasional
criteria alone does not establish it. The importance of Tc99 scan in
detecting osteomyelitis is stressed. When bone scan is not
available, a trial of 1-3 weeks of local treatment is suggested.
Failure to respond to such treatment may assist in making the
diagnosis of MEO

Necrotizing External Otitis (Malignant Otitis Externa)

Necrotizing External Otitis (NEO) is a potentially lethal infection of the

EAC and adjacent structures typically seen in elderly diabetic or
immunocompromised patients. Pseudomonas aeruginosa is the bacteria
most commonly responsible for this infection, which begins as an acute
otitis externa and frequently progresses to a skull base osteomyelitis with
resultant cranial neuropathies. Meltzer and Kelemen first described the
disease process in 1959, but the name is credited to Chandler with his
precise description of the clinical entity in 1968. The diagnosis of NEO is
based on clinical and laboratory evidence along with the suspicions of the
treating physician.

The typical patient is an elderly diabetic with poor metabolic control and
evidence of otitis externa not responding to the usual local therapy. The
typical complaints are deep-seated aural pain, discharge, and fullness. A
history of diabetes or an immunocompromised state (neoplasm,
immunosuppressive therapy, HIV, etc.) should be elicited. Examination of
the involved ear canal reveals inflammation and granulation tissue at the
bony cartilaginous junction. Purulent secretions are common, and
excessive inflammation may occlude the canal and obscure the TM.
Disease beyond the EAC may extend anteriorly into the parotid through
the fissures of Santorini or inferiorly into the soft tissue below the
tympanic ring. Cranial nerve involvement may appear as early as one
week after the onset of symptoms, with the facial nerve most commonly
involved, followed by X and XI. Various imaging techniques have been
employed to help is the diagnosis of NEO, including plain films,
computerized tomography (CT), technetium-99(Tc99) bone scan, gallium
scan, and magnetic resonance imaging. Computerized tomography
scanning is particularly useful

for following soft tissue extension of infection and subtle bony changes,
and is the radiological test of choice today. Tc99 scanning and gallium
scans are reliable in identifying osteomyelitis of the temporal bone and
skull base. The gallium scan reverts to normal with successful treatment,
and is therefore useful for evaluating effectiveness of therapy.

Cohen and Friedman established diagnostic criteria to distinguish NEO

from AEO, based on obligatory and occasional signs. The signs were
determined from a review of the current literature and were divided into
major signs (appeared in 100% of cases) and minor signs (appeared only
in some of cases). Major signs included: pain, exudates, edema,
granulations, microabscess, positive Tc99 scan, and failure of local
treatment after more than 1 week. Minor signs included: Pseudomonas,
positive radiograph, diabetes, cranial nerve involvement, debilitating
condition, and old age. It was noted, however, that Pseudomonas was
found in 98% of cases reported, but did not technically meet the
requirement for being a major sign of NEO.

Treatment with parenteral anti-Psuedomonal antibiotics should be

continued for a minimum of 4 weeks. Local canal debridement is an
essential part of therapy and should be started immediately and continued
until granulation tissue resolves and healing ensues. Pain control is
usually necessary and, underlying disease states must be controlled. The
use of topical antimicrobial agents is controversial, because they are
insufficient for invasive infection and tend to hinder culture isolation of
the offending pathogen. Hyperbaric oxygen has been used with varying
success in some reports. Resolution of otalgia, decreased drainage and a
falling ESR indicate a response to therapy. The duration of antimicrobial
therapy depends on serial gallium scans performed at 4-week intervals.
Surgical debridement of tissue and infected bone is usually reserved for
those patients not responding to medical management. There is no
universal agreement on the need for prophylactic or therapeutic facial
nerve decompression.

Mortality remains significant with the death rate essentially unchanged n

20 years despite the introduction of newer antibiotics. Increased mortality
is associated with mental status deterioration and cranial nerve
involvement, with the highest mortality seen in cranial polyneuropathies.
Recurrence is not uncommon with rates ranging from 9% to 27%.
Infection can recur as long as four to 12 months after cessation of
antibiotic therapy, so periodic follow-up and re-evaluation of ESR is
essential to proper management of this disease.

Translate :
Necrotizing Eksternal Otitis (ganas Otitis Externa)
Necrotizing Eksternal Otitis (NEO) adalah infeksi yang
berpotensi mematikan dari EAC dan struktur yang
berdekatan biasanya terlihat pada pasien diabetes atau
immunocompromised tua. Pseudomonas aeruginosa
adalah bakteri yang paling umum bertanggung jawab
untuk infeksi ini, yang dimulai sebagai otitis eksterna akut
dan sering berkembang ke osteomyelitis dasar tengkorak
dengan neuropati kranial yang dihasilkan. Meltzer dan
Kelemen pertama kali dijelaskan proses penyakit pada
tahun 1959, tapi nama dikreditkan ke Chandler dengan
deskripsi yang tepat tentang entitas klinis pada tahun
1968. Diagnosis NEO didasarkan pada bukti klinis dan
laboratorium bersama dengan kecurigaan dari dokter
yang merawat.
Pasien yang khas adalah diabetes usia lanjut dengan
kontrol metabolik yang buruk dan bukti otitis externa tidak
menanggapi terapi lokal biasa. Keluhan khas mendalam
nyeri aural, debit, dan kepenuhan. Sebuah riwayat
diabetes atau negara immunocompromised (neoplasma,
terapi imunosupresif, HIV, dll) harus ditimbulkan.
Pemeriksaan saluran telinga yang terlibat mengungkapkan
peradangan dan jaringan granulasi di persimpangan
rawan tulang. sekresi purulen yang umum, dan
peradangan yang berlebihan dapat menutup jalan kanal
dan mengaburkan TM. Penyakit luar EAC dapat
memperpanjang anterior ke parotis melalui celah dari
Santorini atau inferior ke dalam jaringan lunak di bawah
cincin timpani. keterlibatan saraf kranial mungkin muncul
sedini satu minggu setelah timbulnya gejala, dengan saraf
wajah paling sering terlibat, diikuti oleh X dan XI. Berbagai
teknik pencitraan telah digunakan untuk membantu
adalah diagnosis NEO, termasuk film polos, computerized
tomography (CT), technetium-99 (Tc99) bone scan, gallium
scan, dan MRI. Computerized tomography scanning sangat
berguna
untuk mengikuti perpanjangan jaringan lunak infeksi dan
perubahan tulang halus, dan tes radiologi pilihan hari ini.
Tc99 scanning dan scan gallium handal dalam
mengidentifikasi osteomielitis temporal dasar tulang dan
tengkorak. Galium Scan beralih ke normal dengan
pengobatan yang berhasil, dan karena itu berguna untuk
mengevaluasi efektivitas terapi.
Cohen dan Friedman didirikan kriteria diagnostik untuk
membedakan NEO dari AEO, berdasarkan tanda-tanda
wajib dan sesekali. Tanda-tanda ditentukan dari tinjauan
literatur saat ini dan dibagi menjadi tanda-tanda utama
(muncul di 100% dari kasus) dan tanda-tanda kecil (hanya
muncul dalam beberapa kasus). tanda-tanda utama
termasuk: nyeri, eksudat, edema, granulasi, microabscess,
positif memindai Tc99, dan kegagalan pengobatan lokal
setelah lebih dari 1 minggu. tanda-tanda kecil termasuk:
Pseudomonas, radiografi positif, diabetes, keterlibatan
saraf kranial, kondisi yang melemahkan, dan usia tua.
Telah dicatat, bagaimanapun, bahwa Pseudomonas
ditemukan pada 98% dari kasus yang dilaporkan, tetapi
tidak secara teknis memenuhi persyaratan untuk menjadi
tanda utama NEO.
Pengobatan dengan antibiotik anti-Psuedomonal
parenteral harus dilanjutkan selama minimal 4 minggu.
debridement kanal lokal merupakan bagian penting dari
terapi dan harus segera dimulai dan berlanjut sampai
resolves jaringan granulasi dan penyembuhan terjadi
kemudian. kontrol nyeri biasanya diperlukan dan, negara
penyakit yang mendasari harus dikendalikan. Penggunaan
agen antimikroba topikal kontroversial, karena mereka
tidak cukup untuk infeksi invasif dan cenderung
menghambat isolasi budaya patogen menyinggung.
oksigen hiperbarik telah digunakan dengan berbagai
keberhasilan di beberapa laporan. Resolusi otalgia,
penurunan drainase dan ESR jatuh menunjukkan respon
terhadap terapi. Durasi terapi antimikroba tergantung
pada scan gallium seri dilakukan pada interval 4 minggu.
debridement jaringan dan tulang yang terinfeksi biasanya
disediakan untuk pasien tidak menanggapi manajemen
medis. Tidak ada kesepakatan universal tentang perlunya
dekompresi saraf wajah profilaksis atau terapi.
Kematian tetap signifikan dengan tingkat kematian pada
dasarnya tidak berubah n 20 tahun meskipun pengenalan
antibiotik baru. Peningkatan mortalitas terkait dengan
mental yang kerusakan status dan keterlibatan saraf
kranial, dengan angka kematian tertinggi terlihat pada
polineuropati kranial. Kekambuhan tidak jarang dengan
tarif mulai dari 9% menjadi 27%. Infeksi dapat kambuh
selama empat sampai 12 bulan setelah penghentian
terapi antibiotik, sehingga periodik tindak lanjut dan
evaluasi ulang ESR adalah penting untuk manajemen yang
tepat dari penyakit ini.