From the Guidelines
Malignant otitis externa with facial nerve palsy requires immediate, aggressive treatment with intravenous antibiotics and surgical debridement to prevent morbidity, mortality, and improve quality of life. The recommended approach is:
- Start IV antipseudomonal antibiotics immediately:
- Ciprofloxacin 400mg IV every 8 hours, or
- Ceftazidime 2g IV every 8 hours, as suggested by 1
- Add oral ciprofloxacin 750mg twice daily for 6-8 weeks after discharge
- Perform urgent surgical debridement of necrotic tissue, as recommended by 1
- Monitor facial nerve function closely and consider facial nerve decompression if no improvement within 2-3 weeks, as discussed in 1 and 1
- Control blood glucose levels if the patient is diabetic, as emphasized by 1
- Provide supportive care for facial paralysis (eye lubrication, facial exercises), as suggested by 1 and 1
- Follow up with serial CT or MRI scans to assess disease progression, as recommended by 1
This aggressive approach is necessary because malignant otitis externa is a severe, potentially life-threatening infection that can spread to the skull base and cranial nerves, as highlighted by 1. Pseudomonas aeruginosa is the most common causative organism, hence the use of antipseudomonal antibiotics. Surgical debridement is crucial to remove infected tissue and improve antibiotic penetration. Facial nerve involvement indicates advanced disease and requires close monitoring and possible surgical intervention to prevent permanent paralysis, as discussed in 1 and 1.
The diagnosis of malignant otitis externa can be confirmed with a raised erythrocyte sedimentation rate plus an abnormal computed tomography or magnetic resonance imaging scan, as suggested by 1. It is essential to differentiate malignant otitis externa from other conditions, such as Bell's palsy, and to provide prompt treatment to prevent complications and improve outcomes, as emphasized by 1 and 1.
In terms of quality of life, patients with malignant otitis externa and facial nerve palsy may experience significant functional and psychological impairment, as discussed in 1 and 1. Therefore, it is crucial to provide supportive care and consider referral to specialists, such as facial plastic and reconstructive surgeons, ophthalmologists, and counselors, to address the emotional and physical consequences of persistent facial paresis/paralysis.
From the Research
Diagnosis of Malignant Otitis Externa with Facial Nerve Palsy
- The diagnosis of malignant otitis externa is based on a high index of suspicion and confirmed by histopathologic changes and radionuclide studies, such as Gallium 67 citrate scan 2
- Computed tomography (CT) scans can confirm temporal bone involvement extending outside the external auditory canal 3
- Laboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), can help identify patients with facial nerve palsy who are at higher risk of complications 4
- Ear swabs for culture and sensitivity can reveal the presence of Pseudomonas aeruginosa, the most common causative organism 5, 2
Treatment of Malignant Otitis Externa with Facial Nerve Palsy
- The most effective treatment is to control diabetes and fight infection with proper antibiotics, debridement of necrotic tissue, and sometimes aggressive surgical management 5, 2
- Local debridement and local and systemic antibiotic treatment can be sufficient to control the disease 5
- Facial nerve decompression may be necessary in cases of facial paralysis 5
- Hyperbaric oxygen therapy may be performed in cases of facial nerve palsy 5
- Anti-Pseudomonas antibiotics, such as ciprofloxacin, are the treatment of choice, but should be guided by culture and sensitivity results 2
- Long-term, high-dose antibiotic treatment may be necessary to ensure complete resolution of the infection 3
Prognosis and Outcome
- Cranial nerve involvement, including facial nerve palsy, can affect the clinical outcome in terms of morbidity and mortality 3
- Patients with facial nerve palsy are at higher risk of complications and may require more aggressive treatment 4
- Early diagnosis and treatment can improve outcomes and reduce the risk of complications 5, 2, 6