From the Guidelines
Malignant otitis externa in a patient with diabetes mellitus (DM) should be managed with aggressive treatment, including systemic antifungal therapy and local measures.
Key Considerations
- Patients with DM are susceptible to recurrent bacterial otitis media, otitis externa, and Aspergillus otomycosis due to impaired mucosal or cutaneous immunity 1.
- Aspergillus otomycosis may involve the middle ear if the tympanic membrane has been perforated, and can lead to chronic fungal mastoiditis if left untreated 1.
- Topical therapy using irrigations with acetic acid or boric acid may be beneficial, as well as topical antifungal creams and ointments 1.
- Orally administered antifungals such as itraconazole, voriconazole, or posaconazole may be effective, but there are no published studies to support their use 1.
Treatment Approach
- In immunocompromised patients, such as those with DM, systemic antifungal therapy appears necessary 1.
- Local measures, including cerumen removal, may be used in addition to systemic therapy 1.
- A variety of topical therapeutic options have been used, including cresylate, alcohol, nystatin, amphotericin B 3% topical solution, and others 1.
From the Research
Management of Malignant Otitis Externa in Patients with Diabetes Mellitus
- The management of malignant otitis externa (MOE) in patients with diabetes mellitus (DM) typically involves long-term broad-spectrum antibiotics 2.
- Controlling diabetes and fighting infection with proper antibiotics, debridement of necrotic tissue, and sometimes aggressive surgical management are crucial in managing MOE 3.
- Local debridement and local and systemic antibiotic treatment are often sufficient to control the disease, while facial nerve decompression may be necessary in cases of facial paralysis 3.
- Hyperbaric oxygen therapy may also be performed in cases of facial nerve palsy 3, 4.
- Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus, and improvement of computed tomography and radioisotope scanning 3.
Factors Affecting Patient Outcomes
- The presence of diabetes mellitus, facial nerve palsy, positive CT scan, and age above 70 are factors that correlate with and predict disease-specific mortality in patients with MOE 5.
- Patients with two or more of these features are at higher risk of poor outcomes and require prolonged, vigorous treatment 5.
- The severity of diabetes, rate of insulin dependence, and incidence of immunosuppression are not predictive of undergoing surgery in patients with MOE 2.
Treatment Approaches
- Intravenous aminoglycoside and penicillin derivatives, limited surgery, and hyperbaric oxygenation may be used in the treatment of MOE 4.
- Appropriate antibiotics should be given according to the results of bacterial culture and sensitivity tests, and 99Technetium scans and 67gallium scans may be performed to evaluate the extent of involvement and monitor the effects of treatment 6.