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Diabetes mellitus and malignant external otitis: A case study
ORIGINAL ARTICLES
Diabetes Mellitus and Malignant External Otitis: A Case Study Silvana Manfrini Franc0 Gregorio Enrico Capoolicasa
ABSTRACT Malignant external otitis (MEO) is an infection of the external auditory meatus, that affects elderly diabetic patients. As this disease results in a high percentage of deaths, especially if the diagnosis is
delayed, we thought that it would be useful to cite a recent case study that was resolved in a positive way, in spite of the extent of the disease. (Journal of Diabetes and Its Complications 10;1:2-5, 1996.)
INTRODUCTION
peared 1 month earlier, with no fever. The physical examination showed a swelling of the right auricle and of the temporomandibular region; the right external auditory meatus showed an abundant purulent secretion and seemed occluded by a polypoid mass, smooth and easily bleeding. No further abnormalities were recorded. The remote pathological anamnesis stressed no important data, except the fact that the patient has been diabetic for 15 years, with a good glycometabolic balance, and was given glibenclamide and on a proper diet. The hematochemical tests showed high glycemic levels, combined high levels of HbAlc (9.5%), fructosamine (414 mmol/L), glycosuria and proteinuria. The ESR was high (51), as were the a-2-globulines. The conventional radiographs taken at the right temporomandibular joint and at the mastoid region did not show any significant alteration. The histological examination of the polypoid endoauricular mass testified a phlogistic granular tissue. The patient was treated with local medications and antibiotics (claritromycin 250 mg twice a day). Ten days later, the patient’s overall condition worsened: weight loss, very high glycemic levels, high ESR and persistence and abundant purulent secretion in the auditory meatus; the structure of the middle ear was no longer identifiable any more.
D
iabetes mellitus appears as a complex clinical syndrome with the hyperglycemia as the tip of the iceberg, under which one can find many complex alterations including glycolipidic and proteinic metabolism, the structure of the basal membranes, coagulation, and the peripheral blood lymphocyte subsets. We can probably relate this latest alteration to the fact that, in diabetic patients, it is possible to find uncommon mycotic and/or bacterial infectious diseases, which are not easily found in the nondiabetic population. We thought, therefore, that it would be useful to cite a case of malignant external otitis (MEO), which recently came under our observation and has been positively resolved, in spite of the seriousness and the extension of the disease. CASE REPORT The 71-year-old patient was first observed because of an otalgia and a hearing loss of the right ear that ap-
..-
--
Centro di Diabetologia e Malattie de1 Ricambio (S.M.), Senigallia; and, Clinica Medica 1 (F.C., E.C.) Universitl degli Studi di Perugia, Perugia, Italy Reprint requests to be sent to: Dr. Silvana Manfrini, Centro di Diabetologia e Malattie de1 Ricambio, Ospedale di Senigallia, 60019 Senigallia (AN) Italy. ]oumal of Diabetes and Its Complications 1996; 10:2-5 0 Elsevier Science Inc., 1996 655 Avenue of the Americas, New York, KY 10010
1056-8727:96!$15.00 SSDI 1056-8727(94)00043-P
] Diab Camp 1996; 10:2-5
DIABETES MELLITIJS AND MALIGNANT
The patient was then hospitalized in our Division, where he underwent therapy with insulin to control the glycemic levels. Radiographs of the petrosas and mastoids showed a veil in the right ethmoidal structure, a widening of the homolateral temporomandibular condyle and cysts due to a deposit. A computed tomography (CT) scan of the petromastoid region revealed some hyperdensity at the level of the muscular system of the infratemporal fossae, near the cranic base and the right mandibular condyle at the root of the masseter. The glenoid and the internal auditory duct seemed veiled, and the horizontal portion of the carotid canal seemed to be slightly decalcified (Figure 1). The above data could indicate a phlogosis of the concerned structures with an extension to the pararhinopharins deep muscular system, although we could not rule out other diagnoses (maybe expansive), stemming from the nasopharinx. The cultures performed on the samples taken from the auditory meatus revealed no presence of bacteria, aerobes, anaerobes, fungi, or parasites. Meanwhile, because of the paralysis of the recurrent nerve, a dysphonia appeared, and, 15 days later, because of the paralysis of the homolaterl cranial nerve, a diplopia also appeared. A new CT scan was performed, and it showed an exension of the phlogistic process, which by now covered the apex of the petrosa, of the right cochlar aqueduct, and of the rhinopharinx and infratemporal structures (Figures 2 and 3).
FIGURE 1 Computed tomography scan: opacity of the middle ear and ofthe mastoid cellular and of the right external auditory meatus.
EXTERNAL OTITIS
3
FIGURE 2 Computed tomography scan: erosion of the apex of the petrosas.
Magnetic imaging resonance (MRI) confirmed the presence of an infiltrating “pouring” lesion, probably of phlogistic nature, in the right superior parapharinx, reaching the paries posterior of the rhinopharynx, the base of the occipitis, and the apex of the right petrosas (Figure 4). A diagnosis of malignant external otitis was made and a specific antibiotic therapy was administered con-
FIGURE 3 Compufed tomography scan: right temporo-mandibular articulation: erosion of the glenoid cavity. Reappearance of the pneumatization of the external auditory meatus, of the mastoid, and of the middle ear.
4
MANFRINI
tl
AL
membrane was perfectly functional, whereas the audiometry showed a reducing mixed hypoacusia and absent stapedial reflexes. These examinations demonstrated that the patient recovered approximately 50% of the functionality of his right ear. DISCUSSION
FIGURE 4 Magnetic resonance imaging: “pouring” lesion in the right superior parapharynx extending to the cavernous cavity.
sisting of piperacillin 2 g three times a day and tobramycin 70 mg three times a day. Therapy lasted for a month, and the liver and kidney functionality were monitored. The complete remission of the paresis of the recurrent nerve and of diplopia was achieved, with the normalization of the ESR. Thus we went on treating our patient with cypropheoxacin (500 mg twice a day) for a further 2 months. We suspended the insulinic therapy and started the oral hypoglycemic therapy once again. A further MRI was performed 2 months after the beginning of the antibiotic therapy, and it showed a reduction of the extension of the right posterior-lateral paries of the rhinopharinx. Six months later the checkup showed a complete normalization of the medical report concerning the rhinopharinx (Figure 5). The otoscopy showed up a considerable cicatrix retraction and an opacity of the right tympanic membrane. The tympanometry showed that the reformed tympanic
FIGURE 5 Magrlefic resonance imaging: normalization of the medical report concerning the right rhinopharynx.
ME0 is the definition that best describes this infection of the external auditory meatus. This infectious disease is common in elderly diabetic patients and is determined by the Pseudomonas Aeruginosa. The infection can be transmitted either directly or by an invasion through the blood flow. It can cause an extended necrosis of the cartilage, soft bone, and tissue’*2 and it often involves the cranial nerves. Among the cranial nerves, the facial nerve is more often infected when it passes through the stylomastoid foramen (50% of cases), but other cranic nerves3,4 can be involved, often leading to a further worsening of the prognosis of this disease, which already has a high fatality rate (up to 50% according to certain authors).5 The starting point of this disease is often the joint between the bone tissue and the cartilage of the external auditory mcatus. It then extends itself to the middle ear, then to the temporal bone, and, later on, to the petrosas, also involving the cranial nerves. Moreover, through the accessory Santorini’s duct, the infection can reach the parotid, the temporomandibular articulation, and up to the muscle tissue and tendons of the neck. ME0 usually appears as a chronic infection of the ear, causing pain and purulent secretion of the ear. This infection is not responsive to any common topical phlogistic drugs, nor does it respond to any oral antibiotic therapy. It is often combined with ketoacidosis or uncontrollable diabetes. The objectivity can stress a progressive extension of the swelling and of the pain of the ear auricle, whereas the external auditory meatus presents a strong granulation and/or polypoid formation. Among the hematochemical tests, a leukocytosis is very uncommon, and the only marked anomaly is the increase of the EAR, which can be used to monitoring the disease. To diagnose the MEO, conventional radiology can delay the detection of soft tissue modifications and bone erosions, whereas scintiscan, even if highly sensitive, has scarce specificity.h CT scan is useful in defining the extent of the disease,7,8 whereas the MRI is more sensitive for a diagnosis.9 Aggressive surgery was once considered as a necessary step to treat this disease, however, the use of aminoglycosides and carbenicillin, combined with the local excision of the granulation tissue by a curettage of the cavity abcesses has proven to be as efficacious.” Among the newest therapeutics drugs, the fluoroquinolines seem to be the most useful for treatment.
1 Diub Comp 1996; 10:2-S
DIABETES
REFERENCES Chandler JR: Malignant external otitis and facial paralysis. Otolaryngol Clin North Am 7:375-383, 1974. Gold S, Som PM, Lucente FE, Lawson W, Mendelson M, Parisier SC: Radiographic findings in progressive necrotizing malignant external otitis. Luyngoscope 94: 363-366, 1984. Di Napoli RI’, Thomas JE: Neurological aspects of malignancy external otitis. Report of three cases. Mayo Clin Proc 46:339-344, 1971. Rubin J, TuVL: Malignant external patogenesis, clinical manifestations, apy. Am 1 Med 85:391-398, 1988.
otitis, Insightsents, diagnosis and ther-
MELLITUS
AND
MALIGNANT
EXTERNAL
OTITIS
5
5.
Casey JI: Host defense and infections in diabetes mellitus, in Ellemberg , Rifkins (ed), Diabetes MeIlitus. New York, Elsevier Science, 1990, pp. 621.
6.
Silva J, Harvey WC: Detection of infection with gallum 67 and scintigraphic imaging. ] infect Dis 130:125-131, 1974.
7
Chakeres DW, Kapila A, La Masters D: Soft tissue abnormalities of the external auditory canal: Subject review of CT findings. Radiology 156:105-109, 1985.
8,
Curtin HD, Wolfe I’, May M: Malignant external otitis, C.T. Evaluation. Radiology 145:383-388, 1987.
9.
Gherini SG, Brackman DE, Bradley WG: Magnetic resonance energy and computerized tomography in malignant external otitis. Layngoscope 96:542-548, 1986.
Diabetes Mellitus and Malignant External Otitis: A Case Study Silvana Manfrini Franc0 Gregorio Enrico Capoolicasa
ABSTRACT Malignant external otitis (MEO) is an infection of the external auditory meatus, that affects elderly diabetic patients. As this disease results in a high percentage of deaths, especially if the diagnosis is
delayed, we thought that it would be useful to cite a recent case study that was resolved in a positive way, in spite of the extent of the disease. (Journal of Diabetes and Its Complications 10;1:2-5, 1996.)
INTRODUCTION
peared 1 month earlier, with no fever. The physical examination showed a swelling of the right auricle and of the temporomandibular region; the right external auditory meatus showed an abundant purulent secretion and seemed occluded by a polypoid mass, smooth and easily bleeding. No further abnormalities were recorded. The remote pathological anamnesis stressed no important data, except the fact that the patient has been diabetic for 15 years, with a good glycometabolic balance, and was given glibenclamide and on a proper diet. The hematochemical tests showed high glycemic levels, combined high levels of HbAlc (9.5%), fructosamine (414 mmol/L), glycosuria and proteinuria. The ESR was high (51), as were the a-2-globulines. The conventional radiographs taken at the right temporomandibular joint and at the mastoid region did not show any significant alteration. The histological examination of the polypoid endoauricular mass testified a phlogistic granular tissue. The patient was treated with local medications and antibiotics (claritromycin 250 mg twice a day). Ten days later, the patient’s overall condition worsened: weight loss, very high glycemic levels, high ESR and persistence and abundant purulent secretion in the auditory meatus; the structure of the middle ear was no longer identifiable any more.
D
iabetes mellitus appears as a complex clinical syndrome with the hyperglycemia as the tip of the iceberg, under which one can find many complex alterations including glycolipidic and proteinic metabolism, the structure of the basal membranes, coagulation, and the peripheral blood lymphocyte subsets. We can probably relate this latest alteration to the fact that, in diabetic patients, it is possible to find uncommon mycotic and/or bacterial infectious diseases, which are not easily found in the nondiabetic population. We thought, therefore, that it would be useful to cite a case of malignant external otitis (MEO), which recently came under our observation and has been positively resolved, in spite of the seriousness and the extension of the disease. CASE REPORT The 71-year-old patient was first observed because of an otalgia and a hearing loss of the right ear that ap-
..-
--
Centro di Diabetologia e Malattie de1 Ricambio (S.M.), Senigallia; and, Clinica Medica 1 (F.C., E.C.) Universitl degli Studi di Perugia, Perugia, Italy Reprint requests to be sent to: Dr. Silvana Manfrini, Centro di Diabetologia e Malattie de1 Ricambio, Ospedale di Senigallia, 60019 Senigallia (AN) Italy. ]oumal of Diabetes and Its Complications 1996; 10:2-5 0 Elsevier Science Inc., 1996 655 Avenue of the Americas, New York, KY 10010
1056-8727:96!$15.00 SSDI 1056-8727(94)00043-P
] Diab Camp 1996; 10:2-5
DIABETES MELLITIJS AND MALIGNANT
The patient was then hospitalized in our Division, where he underwent therapy with insulin to control the glycemic levels. Radiographs of the petrosas and mastoids showed a veil in the right ethmoidal structure, a widening of the homolateral temporomandibular condyle and cysts due to a deposit. A computed tomography (CT) scan of the petromastoid region revealed some hyperdensity at the level of the muscular system of the infratemporal fossae, near the cranic base and the right mandibular condyle at the root of the masseter. The glenoid and the internal auditory duct seemed veiled, and the horizontal portion of the carotid canal seemed to be slightly decalcified (Figure 1). The above data could indicate a phlogosis of the concerned structures with an extension to the pararhinopharins deep muscular system, although we could not rule out other diagnoses (maybe expansive), stemming from the nasopharinx. The cultures performed on the samples taken from the auditory meatus revealed no presence of bacteria, aerobes, anaerobes, fungi, or parasites. Meanwhile, because of the paralysis of the recurrent nerve, a dysphonia appeared, and, 15 days later, because of the paralysis of the homolaterl cranial nerve, a diplopia also appeared. A new CT scan was performed, and it showed an exension of the phlogistic process, which by now covered the apex of the petrosa, of the right cochlar aqueduct, and of the rhinopharinx and infratemporal structures (Figures 2 and 3).
FIGURE 1 Computed tomography scan: opacity of the middle ear and ofthe mastoid cellular and of the right external auditory meatus.
EXTERNAL OTITIS
3
FIGURE 2 Computed tomography scan: erosion of the apex of the petrosas.
Magnetic imaging resonance (MRI) confirmed the presence of an infiltrating “pouring” lesion, probably of phlogistic nature, in the right superior parapharinx, reaching the paries posterior of the rhinopharynx, the base of the occipitis, and the apex of the right petrosas (Figure 4). A diagnosis of malignant external otitis was made and a specific antibiotic therapy was administered con-
FIGURE 3 Compufed tomography scan: right temporo-mandibular articulation: erosion of the glenoid cavity. Reappearance of the pneumatization of the external auditory meatus, of the mastoid, and of the middle ear.
4
MANFRINI
tl
AL
membrane was perfectly functional, whereas the audiometry showed a reducing mixed hypoacusia and absent stapedial reflexes. These examinations demonstrated that the patient recovered approximately 50% of the functionality of his right ear. DISCUSSION
FIGURE 4 Magnetic resonance imaging: “pouring” lesion in the right superior parapharynx extending to the cavernous cavity.
sisting of piperacillin 2 g three times a day and tobramycin 70 mg three times a day. Therapy lasted for a month, and the liver and kidney functionality were monitored. The complete remission of the paresis of the recurrent nerve and of diplopia was achieved, with the normalization of the ESR. Thus we went on treating our patient with cypropheoxacin (500 mg twice a day) for a further 2 months. We suspended the insulinic therapy and started the oral hypoglycemic therapy once again. A further MRI was performed 2 months after the beginning of the antibiotic therapy, and it showed a reduction of the extension of the right posterior-lateral paries of the rhinopharinx. Six months later the checkup showed a complete normalization of the medical report concerning the rhinopharinx (Figure 5). The otoscopy showed up a considerable cicatrix retraction and an opacity of the right tympanic membrane. The tympanometry showed that the reformed tympanic
FIGURE 5 Magrlefic resonance imaging: normalization of the medical report concerning the right rhinopharynx.
ME0 is the definition that best describes this infection of the external auditory meatus. This infectious disease is common in elderly diabetic patients and is determined by the Pseudomonas Aeruginosa. The infection can be transmitted either directly or by an invasion through the blood flow. It can cause an extended necrosis of the cartilage, soft bone, and tissue’*2 and it often involves the cranial nerves. Among the cranial nerves, the facial nerve is more often infected when it passes through the stylomastoid foramen (50% of cases), but other cranic nerves3,4 can be involved, often leading to a further worsening of the prognosis of this disease, which already has a high fatality rate (up to 50% according to certain authors).5 The starting point of this disease is often the joint between the bone tissue and the cartilage of the external auditory mcatus. It then extends itself to the middle ear, then to the temporal bone, and, later on, to the petrosas, also involving the cranial nerves. Moreover, through the accessory Santorini’s duct, the infection can reach the parotid, the temporomandibular articulation, and up to the muscle tissue and tendons of the neck. ME0 usually appears as a chronic infection of the ear, causing pain and purulent secretion of the ear. This infection is not responsive to any common topical phlogistic drugs, nor does it respond to any oral antibiotic therapy. It is often combined with ketoacidosis or uncontrollable diabetes. The objectivity can stress a progressive extension of the swelling and of the pain of the ear auricle, whereas the external auditory meatus presents a strong granulation and/or polypoid formation. Among the hematochemical tests, a leukocytosis is very uncommon, and the only marked anomaly is the increase of the EAR, which can be used to monitoring the disease. To diagnose the MEO, conventional radiology can delay the detection of soft tissue modifications and bone erosions, whereas scintiscan, even if highly sensitive, has scarce specificity.h CT scan is useful in defining the extent of the disease,7,8 whereas the MRI is more sensitive for a diagnosis.9 Aggressive surgery was once considered as a necessary step to treat this disease, however, the use of aminoglycosides and carbenicillin, combined with the local excision of the granulation tissue by a curettage of the cavity abcesses has proven to be as efficacious.” Among the newest therapeutics drugs, the fluoroquinolines seem to be the most useful for treatment.
1 Diub Comp 1996; 10:2-S
DIABETES
REFERENCES Chandler JR: Malignant external otitis and facial paralysis. Otolaryngol Clin North Am 7:375-383, 1974. Gold S, Som PM, Lucente FE, Lawson W, Mendelson M, Parisier SC: Radiographic findings in progressive necrotizing malignant external otitis. Luyngoscope 94: 363-366, 1984. Di Napoli RI’, Thomas JE: Neurological aspects of malignancy external otitis. Report of three cases. Mayo Clin Proc 46:339-344, 1971. Rubin J, TuVL: Malignant external patogenesis, clinical manifestations, apy. Am 1 Med 85:391-398, 1988.
otitis, Insightsents, diagnosis and ther-
MELLITUS
AND
MALIGNANT
EXTERNAL
OTITIS
5
5.
Casey JI: Host defense and infections in diabetes mellitus, in Ellemberg , Rifkins (ed), Diabetes MeIlitus. New York, Elsevier Science, 1990, pp. 621.
6.
Silva J, Harvey WC: Detection of infection with gallum 67 and scintigraphic imaging. ] infect Dis 130:125-131, 1974.
7
Chakeres DW, Kapila A, La Masters D: Soft tissue abnormalities of the external auditory canal: Subject review of CT findings. Radiology 156:105-109, 1985.
8,
Curtin HD, Wolfe I’, May M: Malignant external otitis, C.T. Evaluation. Radiology 145:383-388, 1987.
9.
Gherini SG, Brackman DE, Bradley WG: Magnetic resonance energy and computerized tomography in malignant external otitis. Layngoscope 96:542-548, 1986.