From the Guidelines
For treating malignant (necrotizing) otitis externa in a diabetic patient, the primary approach should be aggressive medical management combined with careful monitoring and potential surgical intervention if necessary, prioritizing morbidity, mortality, and quality of life as the outcome.
Initial Treatment
- Administer intravenous antipseudomonal antibiotics, such as ciprofloxacin 400 mg every 12 hours or ceftazidime 2 g every 8 hours, for at least 6-8 weeks, as Pseudomonas aeruginosa is isolated from exudate in the ear canal in more than 90% of cases 1.
- Ensure strict glycemic control to optimize healing and immune function, as diabetes is a significant risk factor for malignant otitis externa 1.
- Perform careful debridement of necrotic tissue in the external auditory canal, which is a crucial step in managing the infection 1.
- Provide topical antibiotic drops, such as ciprofloxacin or ofloxacin, to be instilled in the ear canal 3-4 times daily, to complement the systemic antibiotic therapy 1.
Ongoing Management
- Monitor treatment response with regular otoscopic examinations and imaging studies (CT or MRI) every 4-6 weeks, to assess the effectiveness of the treatment and detect any potential complications early 1.
- Continue antibiotic therapy until clinical improvement is evident and inflammatory markers (ESR, CRP) normalize, to ensure complete resolution of the infection 1.
- Consider hyperbaric oxygen therapy as an adjunctive treatment to improve tissue oxygenation and healing, which may be beneficial in promoting recovery 1.
Special Considerations
- Avoid ear canal irrigation, especially with tap water, as it may predispose to necrotizing otitis externa, particularly in diabetic patients 1.
- Consider reacidifying the ear canal with vinegar or acetic acid drops after treatment, to help restore the natural pH balance and prevent further infections 1.
- Be cautious when using solutions containing alcohol, as they may not be suitable for all patients, and consider alternative treatments if necessary 1.
By following this approach, healthcare providers can effectively manage malignant otitis externa in diabetic patients, minimizing the risk of complications and improving patient outcomes.
From the Research
Treatment Overview
The treatment for malignant (necrotizing) otitis externa in a patient with diabetes mellitus involves:
- Controlling the diabetes mellitus 2, 3
- Fighting the infection with proper antibiotics 2, 4, 3, 5, 6
- Debridement of necrotic tissue 2
- Sometimes, aggressive surgical management is necessary 2
Antibiotic Treatment
- The most common causative organism is Pseudomonas aeruginosa 2, 4, 3, 5, 6
- Antibiotics such as ciprofloxacin 4, 5 and ofloxacin 6 have been used to treat malignant otitis externa
- However, resistance to ciprofloxacin is developing, and bacterial isolates must be tested for sensitivity to antibiotics 5
Monitoring and Follow-up
- Monitoring of therapy response is done through:
- Serial magnetic resonance imaging or computed tomography may be more useful than isotope bone scan for diagnosis and assessing response to treatment 5