Presentation
2 months of right ear drainage and pain, persistent despite a course of amoxicillin-clavulanate and ear drops containing ciprofloxacin and dexamethasone. Unable to use hearing aid.
Patient Data
Right ear canal soft tissue thickening with erosions of the bony external auditory canal and lateral mastoid cortex. Right middle ear and mastoid opacification. Normal left temporal bone.
Case Discussion
The ear canal soft tissue thickening with lateral temporal bone erosions most likely represented necrotizing/malignant otitis externa. The presence of middle ear and mastoid fluid suggested otitis media but this diagnosis is of secondary importance. An alternative diagnosis to consider would be ear canal carcinoma, particularly if there was no improvement with appropriate antibiotics.
In this case, a biopsy was obtained, which showed dense acute and chronic inflammation and no tumor. Cultures returned only skin flora but the clinical diagnosis remained infection. A prolonged course of oral levofloxacin was instituted, which covers Pseudomonas aeruginosa, the most common pathogen in these cases. A follow-up MRI while on treatment showed residual soft tissue inflammation but no spread to central skull base osteomyelitis. The patient's pain and ear drainage improved and it was not necessary to convert to intravenous antibiotics. Off antibiotics for one month, symptoms did not recur.
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