114 / 264
assessment of disease involvement by CT and MRI remains
valuable. Although the extent of anatomical involvement
does not reliably predict outcome, those with clival involve-
ment indicating central skull base osteomyelitis were noted
to do much poorer with conventional treatment, and this
should be explored in future studies. The choice of antibio-
tic therapy is difficult in culture-negative cases in view of
increasing reports of antibiotic resistance in
P aeruginosa
,
but our outcomes with empirical combination therapy using
intravenous ceftazidime and oral fluoroquinolone suggests
that this regime remains effective.
Author Contributions
Shaun Loh
, data collection, entry, analysis and writing of manu-
script;
Woei Shyang Loh
, study idea, advice on analysis, review
of manuscript.
Disclosures
Competing interests:
None.
Sponsorships:
None.
Funding source:
None.
References
1. Chandler JR. Malignant external otitis.
Laryngoscope
. 1968;
78:1257-1294.
2. Carfrae MJ, Kesser BW. Malignant otitis externa.
Otolaryngol
Clin North Am
. 2008;41:537-549.
3. Rubin Grandis J, Branstetter BF, Yu VL. The changing face of
malignant external otitis: clinical, radiological, and anatomic
correlations.
Lancet Infect Dis
. 2004;4:34-39.
4. Soudry E, Hamzany Y, Preis M, Joshua B, Hadar T, Nageris
BI. Malignant external otitis: analysis of severe cases.
Otolaryngol Head Neck Surg
. 2011;144:758-762.
5. Franco-Vidal V, Blanchet H, Bebear C, Dutrone H, Darrouzet
V. Necrotizing external otitis: a report of 46 cases.
Otol
Neurotol
. 2007;28:771-773.
6. Rubin J, Yu VL. Malignant external otitis: insights into patho-
genesis, clinical manisfestations, diagnosis and therapy.
Am J
Med
. 1988;85:391-398.
7. Hariga I, Mardassi A, Younes FB, et al. Necrotizing otitis
externa: 19 cases’ report.
Eur Arch Otorhinolaryngol
. 2010;
267:1193-1198.
8. Geerlings SE, Hoepelman AI. Immune dysfunction in patients
with diabetes mellitus (DM).
FEMS Immunol Med Microbiol
.
1999;26:259-265.
9. Chen CN, Chen YS, Yeh TH, Hsu CJ, Tseng FY. Outcomes of
malignant external otitis: survival vs mortality.
Acta
Otolaryngol
. 2010;130:89-94.
10. Jacobsen LM, Antonelli PJ. Errors in the diagnosis and man-
agement of necrotizing otitis externa.
Otolaryngol Head Neck
Surg
. 2010;143:506-509.
11. Amorosa L, Modugno GC, Pirodda A. Malignant external otitis:
review and personal experience.
Acta Otolaryngol Suppl
. 1996;
521:3-16.
12. Mani N, Sudhoff H, Rajagopal S, Moffat D, Axon PR. Cranial
nerve involvement in malignant external otitis: implications
for clinical outcome.
Laryngoscope
.
2007;117:907-910
.
13. Peleg U, Perez R, Raveh D, Berelowitz D, Cohen D.
Stratification for malignant external otitis.
Otolaryngol Head
Neck Surg
.
2007;137:301-305
.
14. Sudhoff H, Rajagopal S, Mani N, Moumoulidis I, Aron PR,
Moffat D. Usefulness of CT scans in malignant external otitis:
effective tool for the diagnosis, but of limited value in predict-
ing outcome.
Eur Arch Otorhinolaryngol
. 2008;265:53-56.
15. Sreepada GS, Kwartler JA. Skull base osteomyelitis secondary
to malignant otitis externa.
Curr Opin Otolaryngol Head Neck
Surg
. 2003;11:316-323.
16. Livermore DM. Multiple mechanisms of antimicrobial resis-
tance in
Pseudomonas aeruginosa
: our worst nightmare?
Clin
Infect Dis
. 2002;34(5):634-640.
17. GIamarellou H, Kanellakopoulou L. Current therapies for
Pseudomonas aeruginosa
.
Crit Care Clin
. 2008;24(2):261-278.
18. Berenholz L, Katzenell U, Harell M. Evolving resistant
Pseudomonas
to ciprofloxacin in malignant otitis externa.
Laryngoscope
. 2002;112:1619-1622.
19. Jones ME, Karlowsky JA, Draghi DC, Thornsberry C, Sahm
DF, Nathwani D. Antibiotic susceptibility of bacteria most
commonly isolated from bone related infections: the role of
cephalosporins in antimicrobial therapy.
Int J Antimicrob
Agents
. 2004;23:240-246.
20. Jang CH, Park SY. Emergence of ciprofloxacin-resistant
Pseudomonas
in chronic suppurative otitis media.
Clin Otolaryngol
.
2004;29:321-323.
21. Levenson MJ, Parisier SC, Dolitsky J, Bindra G.
Ciprofloxacin: drug of choice in the treatment of malignant
external otitis (MEO).
Laryngoscope
. 1991;101:821-824.
22. Kimmelman CP, Lucente FE. Use of ceftazidime for malignant
external otitis.
Ann Otol Rhinol Laryngol
. 1989;98:721-725.
23. Rubin J, Stoehr G, Yu VL, Muder RR, Matador A, Kamerer
DB. Efficacy of oral ciprofloxacin plus rifampin for treatment
of malignant external otitis.
Arch Otolaryngol Head Neck
Surg
. 1989;115(9):1063-1069.
24. Korvick JA, Peacock JE, Muder RR, Wheeler RR, Yu VL.
Addition of rifampin to combination antibiotic therapy for
Pseudomonas aeruginosa
bacteremia: prospective trial using
the Zelen protocol.
Antimicrob Agents Chemother
. 1992;36(3):
620-625.
Otolaryngology–Head and Neck Surgery 148(6)
93