Malignant otitis media

1. Malignant Otitis Externa Presented by Kiran Patil

2. Introduction: Chandler published the first series of patients with progressive osteomyelitis of the temporal bone and termed the condition malignant otitis externa .

3. Definition Invasive infection in external auditory canal and skull base.

4. Antomy of external auditory canal

5. Causes and pathophysiology

6. Risk Factor Age Diabetes mellitus Any condition causing immunosuppression , Especially elderly patients

7. Microbiology The causative agent - Pseudomonas aeruginosa ( a gram-negative – aerobe) Other bacteria, including Staphylococcus aureus , S epidermidis , Proteus mirabilis , Klebsiella , fungal organism is Aspergillus fumigatus

8. Process of disease

9. Infection from the EAC spreads Through the fissures of Santorini , small perforations in the cartilaginous portion of the EAC Infection spreads medially to the tympanomastoid suture, and along venous canals and fascial planes The compact bone of the skull base becomes replaced with granulation tissue, Bone destruction Progressive spread of infection to skull base foramina causes cranial neuropathies(more Fascial ) Spread of infection to the sigmoid sinus can lead to septicthrombosis of the sigmoid sinus and internal jugular vein; meningitis and cerebral abscess may also complicate MOE

10. Clinical presentation Otalgia –throbbing pain Nocturnal pain and aggravated by chewing Otorrhea – pus discharge - yellow, yellow-green, foul smelling, persistent Hearing loss Fever Trouble swallowing Weakness in the face Voice loss

11. Physical examination Otoscope - purulent otorrhea with a swollen, tender external auditory canal are hallmarks. Granulation tissue or exposed bone is frequently seen on the floor of the canal at the bony–cartilaginous junction.

12. Diagnosis History and physical examination Laboratory- ESR level, culture swab Radiology and imaging studies CT scan- sensitive in diagnosing abscess formation and involvement of the mastoid, temporomandibular joint, infratemporal fossa , nasopharynx , petrous apex, and carotid canal MRI- MRI better shows changes in soft tissue, particularly dural enhancementand involvement of medullary bone spaces biopsy – to rule malignance Nuclear imaging- Technetium Tc 99m, scintigraphy (bone scan) , Gallium Ga 67 citrate

13. Management

14. Medical Management Long-term antibiotic- for at least 6 to 8 weeks- oral and intravensous ciprofloxacin (750 mg twice daily) has been proposed as the preferred initial antibiotic regimen Fluoroquinolones are active against P aeruginosa , , Cephalosporins - ceftazidime , provide an alternative to ciprofloxacin in the treatment of MOE Aminoglycoside Amphotericin B is the most commonly used antifungal agent for fungal

15. Hyperbaric oxygen (HBO)- HBO increases the partial pressure of oxygen, improving hypoxia and allowing greater oxidative killing of bacteria. HBO requires daily treatments for several weeks and side effects include oxygen toxicity, barotrauma , and tympanic membrane perforation

16. Surgical Management: Surgical excision play no role in the treatment. Debridement and or biopsy only indicated in rule the cancer.

17. Complication Damage to the cranial nerves, skull, or brain Return of infection, even after treatment Spread of infection to the brain or other parts of the body

18. Prevention To prevent an external ear infection: Dry the ear thoroughly after it gets wet. Avoid swimming in polluted water. Protect the ear canal with cotton or lamb's wool while applying hair spray or hair dye (if you are prone to getting external ear infections). After swimming, place 1 or 2 drops of a mixture of 50% alcohol and 50% vinegar in each ear to help dry the ear and prevent infection.

19. Nursing Management Pain assessment and Management Fever management Obtaining the Laboratory Samples especially cultures in aseptic ways. Medication Administration Infection Prevention Diet and Nutrition Health education Geriatric Care

20. Nursing Problem Altered comfort related ear Pain. Altered Body Temperature related to Infection Altered hearing perception related to ear discharge Knowledge deficit related to disease process, nutrition, and management.

21. Conclusion