Malignant external otitis: further considerations

Predictive role of facial nerve palsy improvement in malignant external otitis

PURPOSE

To evaluate the effects of different factors on facial nerve palsy improvement in patients with malignant external otitis (MEO) and the predictive role of improvement on MEO.

METHODS

Data were collected from all MEO patients with facial paralysis who were hospitalized between 2012 and 2017 at a tertiary referral center. We contacted patients at least 6 months after their admission to evaluate their facial nerve function and survival rate.

RESULTS

In a study of 19 samples with a mean age of 69.1 years, 9 patients (47.7%) had some or complete improvement, while 10 (52.6%) had no or very minimal improvement. In this study, there was no statistically significant difference between patients with and without facial nerve palsy improvement in terms of age, sex, usage of antifungal treatment alongside antibiotics, duration of hospital stays, HbA1c level, presentation of hearing loss and vertigo, the severity of facial palsy, comorbidity score, mean of fasting blood sugar, leukocytosis, first ESR and ESR drop, CRP and physiotherapy. We found a positive correlation between improving facial palsy and patients' survival rates.

CONCLUSION

Considering the possible influence of facial paralysis improvement prognosis on MEO patients' survival, it could affect our approach to the disease.

Rare Diseases of the Middle Ear and Lateral Skull Base

Otalgia, otorrhea and hearing loss are the most common ear-related symptoms that lead to the consultation of an otolaryngologist. Furthermore, balance disorders and affections of the cranial nerve function may play a role in the consultation. In large academic centres, but also in primary care, the identification of rare diseases of the middle ear and the lateral skull base is essential, as these diseases often require interdisciplinary approaches to establish the correct diagnosis and to initiate safe and adequate treatments. This review provides an overview of rare bone, neoplastic, haematological, autoimmunological and infectious disorders as well as malformations that may manifest in the middle ear and the lateral skull base. Knowledge of rare disorders is an essential factor ensuring the quality of patient care, in particular surgical procedures. Notably, in untypical, complicated, and prolonged disease courses, rare differential diagnoses need to be considered.

Facial nerve paralysis in malignant otitis externa: comparison of the clinical and paraclinical findings

BACKGROUND

Malignant otitis externa is an uncommon but critical challenging disease with some degree of cranial nerve involvement.

AIM/OBJECTIVE

to examine the factors leading to facial paralysis in these patients and clarify indications for aggressive treatment in the group most at risk.

MATERIAL AND METHODS

In a case-control study, demographic, clinical, laboratory, audiometric, imaging, and treatment characteristics of 139 patients in groups with and without facial paralysis were analysed.

RESULTS

45 patients (32.4%) had facial paralysis. Compared to patients without facial nerve involvement, patients with facial palsy had a higher rate of inflammatory markers (mean erythrocyte sedimentation rate on admission [67.71 vs 51.16 mm/h], and the average of total ESR [64.27 vs 54.46 mm/h], as well as the mean C-reactive protein [38.96 vs 27.53 mg/L]). Also, the involvement of the facial canal (p < .01) and nasopharyngeal space (p < .05) were related to the incidence of facial paralysis.

CONCLUSION

Nasopharyngeal extension of the inflammation and facial nerve canal erosion might be useful as predictors of facial nerve dysfunction. The elevated erythrocyte sedimentation rate is correlated with the increased risk of facial paralysis, and aggressive medical management is more crucial.

SIGNIFICANCE

Improvement in predicting the outcome of patients with malignant otitis externa.

Malignant (necrotizing) externa otitis: the experience of a single hyperbaric centre

INTRODUCTION

Malignant otitis externa (MOE) is a potentially life-threatening infection of the soft tissues of the external ear, quickly spreading to involve the periosteum and bone of the skull base. Treatment includes antibiotics and eventually surgery. Hyperbaric oxygen treatment (HBOT) has been proposed as an adjunctive therapy. However, in the tenth consensus conference, this disease was considered as a non-indication for HBOT. The aim of this study was to evaluate the effectiveness of HBOT in MOE treatment.

METHODS

Retrospective and observational study was conducted of patients with MOE treated in our centre. Staging of the disease was made according to the clinicopathological classification system.

RESULTS

From March 1998 to November 2016, 16 patients were referred. 6% patients were on stage 1 of the disease at the time they were referred, 20% in stage 2, 7% in stage 3a, 13% in stage 3b and 53% in stage 4. Seven (43.75%) patients had VII nerve palsy and three (18.75%) patients had multiple nerve palsy. Average length of symptoms of disease was 5 months (maximum 11 months). Average number of sessions was 33 and the length of hospitalization prior to HBOT (median 90 days) was significantly longer than the time between beginning HBOT and cure (p = 0.028, Wilcoxon signed rank test). There were no fatalities due to MOE and all patients were considered free of disease after HBOT.

CONCLUSION

HBOT was well tolerated and revealed to be a helpful adjuvant treatment in MOE. According to our data, HBOT should be considered for patients who failed conventional treatments and in severe cases.

[Atypical skull base osteomyelitis suspected of spreading inflammation from the ear canal with unilateral multiple cranial neuropathy and cerebral infarctions]

A 76-year-old man, who had undergone surgery for esophageal cancer in 2010, presented to our hospital in April 2017 complaining of prolonged slight fever, loss of appetite, and dysphagia. Initial evaluation revealed a paralyzed left vocal cord, slight muscle weakness of the extremities, left facial paralysis, hoarseness, left sternocleidomastoid and trapezius muscle weakness, tongue deviation to the left, and left hypacusia-suggesting a diagnosis of Garcin's syndrome. Laboratory tests revealed increased white blood cells and C-reactive protein. Cerebrospinal fluid (CSF) analysis showed mild pleocytosis (predominantly polymorphonuclear cells), elevated protein, and low CSF/plasma glucose ratio. CT showed mild clival erosion, with no evidence of carcinoma recurrence. Brain contrast-enhanced MRI showed abnormal clival marrow, enhanced soft tissue and dura matter from the clivus to the atlantoaxial joint, enhanced soft tissue around the left ear canal, multiple cerebral infarctions in the left watershed zones, and left internal carotid stenosis. There was excessive ear wax and inflammation of the left external acoustic meatus but no otorrhea or otalgia. On the basis of his overall presentation, he was diagnosed with atypical skull base osteomyelitis due to external otitis. He was treated with antibiotic treatment that included ceftazidime for the Pseudomonas aeruginosa detected on bacterial cultures. He did not respond to treatment and died approximately 4 months later. Skull base osteomyelitis is thus an important differential diagnosis candidate after finding unilateral, multiple cranial neuropathy, underscoring the importance of prompt treatment when suspected.

Skull base osteomyelitis: current microbiology and management

INTRODUCTION

Skull base osteomyelitis typically presents in an immunocompromised patient with severe otalgia and otorrhoea. Pseudomonas aeruginosa is the commonest pathogenic micro-organism, and reports of resistance to fluoroquinolones are now emerging, complicating management. We reviewed our experience of this condition, and of the local pathogenic organisms.

METHODS

A retrospective review from 2004 to 2011 was performed. Patients were identified by their admission diagnostic code, and computerised records examined.

RESULTS

Twenty patients were identified. A facial palsy was present in 12 patients (60 per cent). Blood cultures were uniformly negative, and culture of ear canal granulations was non-diagnostic in 71 per cent of cases. Pseudomonas aeruginosa was isolated in only 10 (50 per cent) cases; one strain was resistant to ciprofloxacin but all were sensitive to ceftazidime. Two cases of fungal skull base osteomyelitis were identified. The mortality rate was 15 per cent. The patients' treatment algorithm is presented.

CONCLUSION

Our treatment algorithm reflects the need for multidisciplinary input, early microbial culture of specimens, appropriate imaging, and prolonged and systemic antimicrobial treatment. Resolution of infection must be confirmed by close follow up and imaging.

Skull base osteomyelitis secondary to malignant otitis externa

PURPOSE OF REVIEW

Skull base osteomyelitis secondary to malignant otitis externa was first described in 1959. Since then, advances have been made in the diagnosis, treatment, and clinical outcomes of this condition.

RECENT FINDINGS

This review discusses the pathophysiology and microbiology of malignant otitis externa. The review highlights the sometimes subtle presenting symptoms and recent advances in imaging and their practical application to diagnosing and monitoring the disease. Therapy for malignant otitis externa has changed since this entity was first described; this article reviews the medical, surgical, and adjuvant therapies and the relevant controversies.

SUMMARY

The review discusses the history, pathogenesis, diagnosis, and treatment of skull base osteomyelitis in the context of malignant otitis externa with particular emphasis on HIV, children, and other immunodeficient states.

Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa

OBJECTIVE

To determine whether there has been an increase in ciprofloxacin-resistant pseudomonas malignant otitis externa, and if this has increased the morbidity of the disease.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

Twenty-eight patients over 13 years.

RESULTS

The records of a total of 28 patients who were admitted between 1988 and 2001 with the diagnosis of malignant otitis externa were reviewed. Seven patients had ciprofloxacin-resistant pseudomonas on their hospital culture and sensitivity test. Five of the 7 resistant cases appeared in the last 3 years, as opposed to 2 of the 7 who appeared in the 10 years before that period. In our series, there is a significant trend developing over time of pseudomonas resistant to treatment with ciprofloxacin. No increased morbidity or mortality was found in the ciprofloxacin-resistant pseudomonas group compared with the remaining patients who were sensitive to ciprofloxacin.

CONCLUSIONS

In our series, resistance to ciprofloxacin in patients with malignant otitis externa is increasing over time. This may have an impact on the relatively successful outpatient treatment of these patients in the past decade. A return to inpatient or outpatient intravenous treatment with third-generation cephalosporins/antipseudomonal penicillins and more frequent debridement will be required in these patients.

Malignant otitis external-our experience

Malignant external otitis is an extremly morbid ostomnyelits of external auditary canal, mastoid and skitil base caused by pseudomonas arergenosa. We report our experience with six cases, which we came across in ten years.Patitents' profile our management and results are presented. A need for increasing awareness tif the condition and the probability uj early diagnosis with a high index of suspicion in the early stages is discussed. Attempt also is done to review a few recent articles with special emphasis on imaging techniques and radioistope scans.

Malignant external otitis in an immunodeficient infant. a case report & review of literature

Malignant External Otitis (MEO) usually occurring in middle aged or elderly diabetics is uncommonly seen in children and rarely in infants. Various studies done so far have proved that immunological disturbance is present in case of MEO, Eliashiv et al (1978) and Yust et al (1980) have proved that cell mediated immunity is depressed in cases of MEO occurring in diabetics. MEO occurring in a four month old grosslly immunadeficient infant is indeed a very rare presentation. Occurrence of MEO in immttuo-suppressed children, & in cases of AIDS, and conclusions of various immunological studies along with this presentaion emphasize the need of regular immuological work up in all cases of MEO.

Sinusitis with contiguous abscess involvement of the clivus and petrous apices. Case report

A wide spectrum of diseases may involve the clivus, such as primary neoplasms, metastatic disease, and inflammatory, vascular, hematopoietic, and infectious processes. Of these, osteomyelitis of the skull base and/or clival-petrous abscess are unusual, but may occur as a result of contiguous spread from the paranasal sinuses, namely, the posterior ethmoid and sphenoid, as was demonstrated by this patient. In this case report we discuss the pertinent anatomy, imaging studies, pathogenesis, and medical and surgical management of this case.

Infections and diabetes: mechanisms and prospects for prevention

Infections remain a serious hazard for the diabetic patient. Good metabolic control is a major factor in limiting the development and spread of infections and, most importantly, the development of diabetic complications which predispose to infections. In some patients recurrent infections can pose a problem, particularly if there is evidence of secondary immunodeficiency. In these patients adjuvant therapies, including Biological Responses Modifiers (BRMS) should be considered. Several factors could predispose diabetic patients to infections. These factors include: genetic susceptibility to infection; altered cellular and humoral immune defense mechanisms; local factors including poor blood supply and nerve damage, and alterations in metabolism associated with diabetes. In the context of a diabetic patient all or some of these factors may operate. The purpose of this review is to assess the relative contribution of these potential mechanisms in leading to infection in patients with diabetes.

Characteristics of cerumen in diabetic patients: a key to understanding malignant external otitis?

Malignant externa otitis is a potentially fatal disease in diabetic and other immunocompromised patients. Cerumen contains defense properties that protect the patient against infection. We tested the hypothesis that patients with diabetes mellitus have abnormalities in their cerumen that affect the environment of their external auditory canals and may predispose them to malignant externa otitis.

Carcinoma of temporal bone presenting as malignant otitis externa

A 69-year-old man presented with a three-month history of otalgia and tenderness of the right ear and a one-week history of a painful right parotid swelling. Examination revealed granulation tissue in the right ear canal with normal looking tympanic membranes and a parotid abscess. Repeated biopsies from the ear canal and parotid showed non-specific inflammation. Repeated cultures from both areas grew Ps. aeruginosa. The patient's condition improved following three weeks of intensive treatment for malignant otitis externa only to relapse five weeks after the end of treatment. He received a second course, only to improve temporarily. He developed a right facial nerve palsy five weeks after he was first seen, followed four months later by palsies of all cranial nerves except the olfactory, before dying, seven months after his first appointment. The radiological, histological and post-mortem findings are discussed.

Bell's palsy. A diagnosis of exclusion

In cases of acute unilateral facial weakness, a careful and systematic evaluation is necessary to identify the cause. Idiopathic facial paralysis (Bell's palsy) is a diagnosis of exclusion. It is also the most common cause of unilateral facial weakness seen by primary care physicians. The most important aspect of initial treatment is eye protection. Administration of systemic oral corticosteroids may lessen severity and duration of symptoms.

Branchial cleft cyst manifesting as hypoglossal nerve palsy

Hypoglossal nerve palsy occurred in 2 patients with infected second branchial arch cleft cyst. This very unusual complication of the congenital anomaly has been related to the mechanical compression of the mass. Histologic features of the perineural coat were also suggestive for this etio-pathogenesis.

Osteomyelitis of the skull base, etiology unknown

OSB can occur in the absence of an obvious contiguous source of infection. When a patient has persistent unilateral headache, elevated ESR, and radiographic evidence of a lytic skull-base lesion, the clinician should consider OSB as a potential diagnosis. A baseline gallium scan should be obtained before biopsy, since surgery or trauma can also produce positive results on radionuclide scans. Technetium-phosphate bone scans should also be performed before any surgical manipulation. However, positive results from a gallium or technetium scan in this setting are not conclusive evidence of infection. At biopsy, the otolaryngologist-head and neck surgeon should consider sending a specimen to the microbiology department for culture in addition to the specimen sent for routine pathologic study; this procedure could minimize delay in diagnosis. Establishing the diagnosis in these patients without obvious contiguous infection can be difficult, demanding perseverance and an appropriate index of suspicion. Once the diagnosis is confirmed, intravenous antibiotic therapy should begin immediately. The duration of therapy must be individualized; patients may require from 4 weeks to several months of treatment. Response to therapy is indicated by resolution of symptoms, normalization of ESR, and reversal of abnormalities on radionuclide scans. Serial gallium scans are particularly useful in following response to treatment.

Malignant external otitis in an infant

Ten cases of malignant external otitis in children have been reported hitherto. These are reviewe, and an eleventh case, a three-month-old infant associated with genetic granulocytopenia, is presented. On the grounds of the reported paediatric cases, the erudition in childhood is compared with the more common form in the adult, and is found to be much less linked with diabetes mellitus and to have a far better prognosis, with practically no mortality.

Ciprofloxacin treatment of malignant external otitis

The Ear, Nose, and Throat department of the Meir Hospital treated 91 patients with malignant external otitis during the past 16 years. The last 23 patients with malignant external otitis were treated with ciprofloxacin 750 mg twice daily, combined with local excision of the aural lesion. The records of 61 of our previous 68 patients who underwent surgery and were hospitalized and treated with an intravenous extended-spectrum penicillin and gentamicin for six to eight weeks, were analyzed. Twenty-one of 23 patients treated with ciprofloxacin were cured; therapy failed in two patients. Treatment averaged 16.8 days of hospitalization, and bacteriologic eradication was achieved after an average of 7.04 days, as compared with 49 and 15.3 days, respectively, in the group of patients with the intravenous treatment. The mean peak concentrations of ciprofloxacin in serum varied between 2.5 and 3.7 micrograms/ml, and the drug concentrations in different ear tissues were 0.2 to 13 micrograms/g. The treatment with ciprofloxacin was well tolerated with no significant side effects, whereas serious side effects were noted in 45.9 percent of the previous intravenously treated group. The concentrations of the drug in serum and ear tissues were higher than the average minimal inhibitory concentration for Pseudomonas aeruginosa. Use of ciprofloxacin treatment, combined with local excision of the aural lesion, will bring about healing of malignant external otitis in the majority of cases. Ciprofloxacin can be given on an ambulatory basis after a relatively short period of hospitalization.

Use of ceftazidime for malignant external otitis

During the past 2 years we have used ceftazidime (Fortaz), a third-generation cephalosporin, in the treatment of eight patients with progressive necrotizing "malignant" external otitis. Ceftazidime is very active against Pseudomonas species and provides penetration into the CSF. Our results suggest that this medication has several advantages over the previously recommended combinations of aminoglycosides and semisynthetic penicillins, including improved cure rate, lower toxicity, and simpler administration schedules. We review our experience with ceftazidime in the treatment of eight patients.

Histopathology of the soft parts in 50 patients with malignant external otitis

Reports concerning the lesions of the skin coverage of the external ear canal in malignant external otitis (M.E.O.) are very few. To evaluate this problem, we studied the skin lesions of 45 skin biopsies from 40 M.E.O. patients, 23 from regions covering the osseous part of the ear structure, seven from the cartilaginous part of the external canal and 15 from both parts. The epidermis was normal in nine, thickened in 16, with acanthotic thickening and pseudoepitheliomatous hyperplasia in 20. In the dermis the amount of collagen was normal, but it was infiltrated by the inflammatory process. Acute inflammation was observed in 16 biopsies, subacute in 23, chronic in six. A mixture of acute and chronic changes was present in 18 biopsies. No major abnormalities of the vasculature could be detected. The distinguishing pathological feature of M.E.O. concerns the typical topographic distribution of the inflammation in the osseous part of the external ear canal.

Malignant external otitis in children

Malignant external otitis in the pediatric population is primarily a disease of children with chronic illness or immunosuppression. The presence of severe, unrelenting otalgia, otorrhea with isolation of Pseudomonas aeruginosa, a markedly elevated erythrocyte sedimentation rate, and evidence of bone destruction on computed tomography scan should alert the clinician to the diagnosis. Unlike adults, children have a higher incidence of seventh nerve paralysis earlier in the course of the infection. They also manifest more frequent involvement of the middle ear with tympanic membrane destruction. The short interval between the onset of symptoms and facial nerve dysfunction highlights the necessity of prompt diagnosis and institution of anti-Pseudomonas therapy. Our review suggests that this destructive bacterial infection is an emerging clinical entity in children; 73% of the cases have been reported since 1980. Pediatricians should therefore be familiar with the clinical presentation of this treatable infection. Substantial morbidity could be alleviated by prompt diagnosis and early antibiotic treatment.

Malignant external otitis: treatment with fluoroquinolones

Malignant external otitis (MEO) is still a potentially lethal disease. Early treatment based on a correct diagnosis is the most important single factor in achieving a cure for the disease. The preferred treatment is long-term systemic antibiotics followed by surgical intervention. Hyperbaric oxygen therapy may be supplemented in refractory cases. A new fluoroquinolone, Ciprofloxacin, has been successfully used in four cases of MEO which did not respond to the accepted treatment. Ciprofloxacin is active against a broad spectrum of bacteria, including Pseudomonas aeruginosa, and several clinical studies have demonstrated its efficacy in the treatment of urinary tract and soft tissue infections, osteomyelitis, pneumonia, and gastroenteritis. This report is the first of which we are aware to document the use of Ciprofloxacin in the treatment of MEO.

Acute pseudomonas mastoiditis in children

Five children with acute pseudomonas mastoiditis were treated and followed up in our medical center during a period of three years. The main clinical features of the disease include predilection for young male infants, a high rate of local aggressiveness, prolonged hospitalization for repeated surgical procedures, and the need for several courses of intravenous specific antimicrobial therapy. Although correctly diagnosed and promptly treated, these patients may be destined to chronic ear disorders.

Malignant external otitis versus acute external otitis

Malignant External Otitis (MEO) and Acute External Otitis (AEO) are clinically very similar in their beginnings. It is important to differentiate between them very early. Bone scanning is the best diagnostic tool. Eight cases of AEO and MEO are herewith presented.

Malignant external otitis

During the years 1972-1985, 50 patients with malignant external otitis (MEO) were seen in our department. All our patients complained of severe earache; they presented initially with an apparently simple external otitis, but failed to improve when the usual measures were adopted. They all presented with granulation tissue in the external ear canal, and five of our patients had multiple cranial nerve involvement. MEO is in effect a severe external otitis which, if untreated, proceeds towards an osteomyelitis of the skull base. MEO is more prevalent in the summer, when external otitis is rampant. In some years, a relatively large number of these patients appear; in others there are none. The reason for this is unknown. In Israel, the disease is more prevalent in Jews than in Arabs. Diabetes was present in 68 per cent of our patients-severe diabetes in 42 per cent, mild diabetes in 26 per cent but 32 per cent of our patients were diabetes-free. The only otological past history in our patients was of a recent traumatic insult to the external ear canal; this was the case in about 8 per cent of them. Today, the treatment of choice of this important disease is local debridement supplemented by appropriate antibiotic treatment for 6-8 weeks. This should include some semi-synthetic penicillin to which pseudomonas aeruginosa is sensitive, combined with an appropriate aminoglycoside. During the earlier years of our encounter with MEO, two of our 10 patients died of it; later on, when we learned better how to treat it, the mortality rate decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnostic criteria of malignant external otitis

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.

Malignant external otitis in a young diabetic patient

A case of malignant external otitis in a young diabetic is reported. This entity should be suspected in diabetics of all ages and in all immune-deficient patients presenting with aural discharge, associated with a dehiscence of the meatal wall, meatal granulations or post-aural abcess. Gentamicin/Carbenicillin combination obviated the need for major surgery.

Abnormalities in and around the ear: congenital, traumatic, inflammatory, and neoplastic

Lesions on or about the auricle may be of congenital, traumatic, inflammatory, or neoplastic origin. For congenital lesions, appropriate treatment and correction of hearing loss are important concerns. The most common traumatic lesions, subperichondral hematomas and keloids, require accurate diagnosis and appropriate treatment to prevent development of further problems. Inflammatory lesions are usually easy to diagnose from the patient's complaints of recent onset of pain, erythema, and edema. Neoplasms, especially squamous cell carcinoma, should be considered in differential diagnosis of a sore that does not heal. When treatment of a periauricular abnormality involves surgery, biopsy, or incision and drainage, care should be taken not to jeopardize the facial nerve.

Infection and diabetes: the case for glucose control

This review summarizes data concerning the host resistance to infection in diabetes and the influence of an acute infection upon the endocrinologic-metabolite status of the diabetic patient. While it is well known that acute infections lead to difficulty in controlling blood sugar levels and the infection is the most frequently documented cause of ketoacidosis, controversy persists as to whether or not patients with diabetes mellitus are more susceptible to infection than age- and sex-matched nondiabetic control subjects. Our data obtained from the charts of 241 diabetic patients who were being followed as outpatients show a striking direct correlation between the overall prevalence of infection (p less than 0.001) and the mean plasma glucose levels (representing three or more fasting glucose determinations taken at times when no evidence of infection existed). There is a significant diminution in intracellular bactericidal activity of leukocytes with Staphylococcus aureus and Escherichia coli in subjects with poorly controlled diabetes in comparison with the control group. Serum opsonic activity for both Staph. Aureus and E. coli were significantly lower than in the control subjects. Taken together, the results from published reports as well as our data suggest to us that good control of blood sugar in diabetic patients is a desirable goal in the prevention of certain infections (Candida vaginitis, for example) and to ensure maintenance of normal host defense mechanisms that determine resistance and response to infection.

Advanced necrotizing external otitis treated by suboccipital craniectomy

Necrotizing external otitis is a destructive infection caused by Pseudomonas aeruginosa. It may spread to surrounding soft tissue, cartilage and bone from the skin of the external canal and cause cranial nerve palsy. Most of the disease occurs in elderly diabetics and is accompanied by high mortality in an extended case in spite of intensive antibiotic therapy. A case of advanced necrotizing external otitis with palsies of VI to XII cranial nerves was presented. The patient, 69-year-old male, took a favorable course after complete debridement by suboccipital craniectomy followed by intensive antibiotic therapy. This procedure was performed by co-operation with a neurosurgeon. Characteristics of the pathology, criteria for the diagnosis and method of treatment are discussed; the authors stress the importance of early diagnosis and necessity of complete meticulous debridement on the extended case with multiple nerve palsies.