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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.
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: AspergillusVMalignant otitis externaV
Voriconazole.
Otol Neurotol 33: 769Y773, 2012.
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
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
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:
The authors disclose no conflicts of interest.
Otology & Neurotology
33:769Y773 2012, Otology & Neurotology, Inc.
Reprinted by permission of Otol Neurotol. 2012; 33(5):769-773.
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