119 / 264
the gallium scan to return to normal, but because there can
be a lag period between resolution of disease and a nor-
mal scan result, we may be overtreating in these cases. A
drop in the ESR can be used as a monitor for response
to treatment, whereas a negative result in the gallium scan
is an indicator to stop treatment altogether.
All 3 patients we report here had already been treated
in the community. Patient 3 was particularly interesting, as
she was actually referred as a case of glomus jugular tu-
mor. She was found, instead, to have 2 organisms on tissue
culture, with
Aspergillus
being one of them. Her disease
even progressed to involve the contralateral temporal
bone through the clivus. All 3 patients had previously neg-
ative swab cultures. They all had findings confined to the
middle ear but were complaining of ear pain/trismus/
headache out of proportion to their clinical findings.
Various protocols of empiric treatment, which would
cover the most likely organisms in culture-negative MOE,
have been proposed. Djalilian et al. (15) recommended in-
travenous administration of ceftazidime or aztreonam for
penicillin-allergic patients along with high-dose oral cip-
rofloxacin and topical aminoglycoside steroid drops. None
of these empiric protocols include amphotericin. Owing
to its toxic nature, empiric amphotericin treatment for
culture-negative MOE is not justified. With the intro-
duction of voriconazole, which has few adverse effects,
one might consider adding it as an empiric treatment for
culture-negative MOE.
CONCLUSION
The otolaryngologist must have a high index of suspi-
cion for any patient with a background of immunosup-
pression (diabetes or otherwise) with ear pain out of
proportion to the clinical findings, which can sometimes
be subtle or confined to the middle ear. It is specific in
such cases that fungal MOE should be considered, with
tissues and/or middle ear aspirates sent for fungal culture
and appropriate treatment started. This can spare the patients
grief, frustration, and, sometimes, unnecessary surgery.
Voriconazole has been very effective in treating
Aspergillus
MOE on an outpatient basis. Like quinolones
in
Pseudomonas
infection, it dramatically changes the
treatment of
Aspergillus
MOE from inpatient to outpa-
tient with much fewer adverse effects and less toxicity.
Acknowledgments:
The authors thank Aiman Ali,
B.Sc.
Radiology Sciences, in his help with the computed tomographic
scans included in this article.
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