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A. E. TARAZI ET AL.

looked normal. One year later, she remains pain free with normal result in the ear examination.

flat tympanogram. Erythrocyte sedimentation rate was 115 mm/h. Computed tomographic scan of the temporal bones showed soft tissue fullness of the left pharyngeal mucosal and retropharyngeal spaces and slight soft tissue infiltra- tion of the left parapharyngeal fat plane. There was total opacification of the left mastoid air cells, antrum, and the middle ear cavity. The middle ear ossicles were intact. Both external auditory canals, the right middle ear cav- ity and ossicles, and the right inner ear structures were within normal limits. Magnetic resonance imaging of the neck showed sig- nificant soft tissue edema and enhancement at the left in- fratemporal fossa, with contiguous involvement of the parapharyngeal, retropharyngeal, pharyngeal mucosal, and part of the masticator spaces. Midline extension in the form of clival osteomyelitis was also observed, as was ex- tension into the left temporal fossa as manifested by in- tracranial dural enhancement via foramen ovale. Bone and gallium scans showed focal increased activ- ity within the left mastoid bone as well as moderate to intense activity within the base of the left side of the cra- nium, mainly within the sphenoid bone. A left-sided myringotomy with tube was performed. The aspirate culture was negative for species, and the patient was treated empirically with intravenously admin- istered ceftazidime 2 g every 12 hours and orally admin- istered ciprofloxacin 750 mg for 2 weeks. Pain improved and ESR decreased to 75 mm/h. The patient was dis- charged on orally administered ciprofloxacin 750 mg twice a day. One month later, she started complaining of bi- lateral ear pain. The right tympanic membrane was dull with some air fluid level in the middle ear. On the left side, there was granulation tissue over the tympanic mem- brane and around the myringotomy tube. This tissue was sent for culture and grew P. aeruginosa and Aspergillus species. P. aeruginosa was sensitive to ciprofloxacin. However, the patient’s ESR rose to 88 mm/h, and she was readmitted 6 weeks later. A magnetic resonance image of the temporal bones showed a slightly less pronounced infiltrative process involving the left cranial base. Involve- ment of the clivus remained about the same. Increased soft tissue and bony inflammatory changes/enhancement were noted within the region of the right cranial base, parapha- ryngeal and carotid spaces, as well as partial involve- ment of the right parotid space. Increased inflammatory changes of the mastoid air cells of the right ear were also present. The patient began receiving intravenously administered ciprofloxacin 400 mg every 12 hours and orally admin- istered voriconazole 200 mg twice a day. Her condition started to improve, with resolving pain and resolution of the granulation tissue. Her ESR dropped to 65 mm/h. She was discharged 3 weeks later on orally administered cip- rofloxacin 750 mg twice a day and orally administered voriconazole 200 mg twice a day for another 3 months. Her blood glucose level was under control. Erythrocyte sedimentation rate decreased to 25 mm/h, and the tube on the left was removed, and both tympanic membranes

DISCUSSION

Partially treated MOE is particularly challenging be- cause of the culture-negative status. Unfortunately, this is the most common type of patient observed in a tertiary care setting. They are also a high-risk group in terms of complications (7). By the time of evaluation by the otolaryngologist, the patient has been frustrated by the lack of sleep and severe otalgia, trismus, and headaches. Because of the nonspe- cific clinical presentation, cases of MOE are frequently missed. Jacobsen and Antonelli (8) reviewed 51 patients with MOE, with diagnosis delayed for more than 2 months. Fifty-five percent of those patients were observed at the request of other otolaryngologists. In 68%, the referral was for other diagnoses, including chronic suppurative otitis media, cholesteatoma, or otalgia. The one common denom- inator was pain out of proportion to the clinical findings. A high index of suspicion is needed in any elderly patient who is diabetic with ear pain out of proportion to the ear findings. The absence of ear canal findings does not preclude the diagnosis of MOE. As a matter of fact, cases of Aspergillus MOE are more commonly confined to the middle ear rather than the outer ear. Taking tissues for culture and biopsies from the middle ear, and/or mid- dle ear effusion, is essential to identify the offending or- ganism and to rule out rare cases of malignancy in the middle ear and/or the mastoid. Common ear swabs may only reveal fungal contaminants of the outer ear canal. A highly elevated ESR is quite common and computed to- mographic scans or magnetic resonance images delineate the extent of disease, but positive results in bone and gallium scans establish the diagnosis. Voriconazole is recommended as first-line therapy for invasive aspergillosis (9). An important characteristic of voriconazole is its availability in tissues and bones (10). The activity of this agent has been documented in vitro against Aspergillus isolates from the middle ear (11). Al- though the most commonly used antifungal therapy for aspergillosis infection of the external auditory canal was amphotericin B, the first successful use of voriconazole has been reported in 2 patients with MOE (4). Voricona- zole has been used successfully as salvage and primary therapy, either alone or in combination with surgical de- bridement (8,12,13). Itraconazole also has been used sub- sequent to amphotericin B in therapy for aspergillous osteomyelitis (14). Voriconazole has the advantage of pre- dictable therapeutic levels after oral administration, in contrast to itraconazole, which yields a lower concentra- tion after oral administration. A positive culture justifies taking the patient on oral voriconazole for at least 2 months, until results from the patient’s examination are completely normal and ESR is back to normal. Some advocate waiting for the results of

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