HSC Section 8_April 2017

Reprinted by permission of Otol Neurotol. 2012; 33(5):769-773.

Otology & Neurotology 33: 769 Y 773 2012, Otology & Neurotology, Inc.

Fungal Malignant Otitis Externa: Pitfalls, Diagnosis, and Treatment

Antoine E. Tarazi, Jaffar A. Al-Tawfiq, and Rifat F. Abdi

Saudi Aramco Medical Services, Dhahran, Kingdom of Saudi Arabia

Hypothesis: Oral voriconazole is a viable alternative modality treatment to traditionally used intravenous vancomycin in the treatment of malignant otitis externa (MOE). Background: The incidence of MOE is on the rise, more so in Saudi Arabia where diabetes mellitus is endemic. Although Pseudomonas aeruginosa is the most common offending or- ganism, we are observing an increasing number of fungal MOE, in particular, Aspergillus species. The clinical findings in these patients can be quite different from those of the classic gram- negative bacteria. The incidence of diagnosed malignant otitis externa (MOE) seems to be on the rise since the first case de- scribed by Chandler in 1968, as the index of suspicion for this disease has increased among generalist physicians (1). Of all cases, 90% are attributed to Pseudomonas aeruginosa . Other reported offending organisms include Staphylococcus aureus , Staphylococcus epidermidis , Proteus mirabilis , Klebsiella oxytoca , and fungi species. The most common fungal organism is Aspergillus fumigatus (2). The first case of Aspergillus MOE was described in 1985 in a 68-year-old man with relapsing acute myelogenous leukemia (3). A recent review of the infectious disease literature found that 24 additional cases had since been reported (4). The traditional treatment of Aspergillus MOE has been intravenous administration of amphotorecin for 4 to 6 weeks. Voriconazole was approved by the U.S. Food and Drug Administration in 2002 for primary treatment of acute, invasive aspergillosis and is an excellent alter- native for the treatment of Aspergillus MOE because amphotericin has known adverse effects and toxicity in already-vulnerable patients (5). Diabetes mellitus (DM) is endemic in the authors’ coun- try, Saudi Arabia, with a reported incidence of 23.7% (6). Because of this high incidence and the hot and humid Address correspondence and reprint requests to Antoine E. Tarazi, M.D., FACS, c/o Saudi Aramco, PO Box 12937, Dhahran 31311, Kingdom of Saudi Arabia; E-mail: antoine.tarazi.1@aramco.com The authors disclose no conflicts of interest.

Methods: Chart review of patients with a diagnosis of MOE who underwent oral voriconazole treatment. Results: Three cases of Aspergillus MOE are reported in detail, pointing the pitfalls in clinical findings, diagnosis, and man- agement of this entity. Conclusion: Oral voriconazole proved to be an excellent al- ternative modality treatment in this population of patients with MOE. Key Words: Aspergillus V Malignant otitis externa V Voriconazole. Otol Neurotol 33: 769 Y 773, 2012. weather, we see a significant number of patients with MOE. Most of them have already been treated by a gen- eral practitioner with multiple short courses of oral and local antibiotics. In our clinical setting, we are rarely faced with the typical case of MOE, presenting with granulation tissue at the osseocartilagenous junction and multisen- sitive pseudomonas as the offending organism. The chal- lenges that present to us are the partially treated cases with culture-negative ear culture. Here we describe 3 cases of Aspergillus MOE treated effectively with oral voriconazole after failing previous treatment. Although voriconazole has been available for this purpose for nearly a decade, to our knowledge, there are no publications in the otologic literature advocating voriconazole as an alternative treatment for fungal MOE. Otologists in tertiary referral practices continue to eval- uate many cases treated first in general practice or even by other otolaryngologists, whose diagnosis may be made more difficult because of the previous treatment. The pre- sentation and clinical findings in these cases do not always conform to the classic presentation of bacterial MOE.

PATIENT REPORTS

Patient 1 This patient was a 77-year-old man with a history of poorly controlled Type 2 DM. He presented with a 2-month history of right ear pain and discharge. The pain was severe enough to interrupt his sleep. The patient had

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