Necrotising otitis externa (NOE), also known as malignant otitis externa, is a rare but severe infection of the external auditory canal that can extend to the lateral skull base. It is most commonly caused by Pseudomonas aeruginosa and primarily affects elderly individuals or those with weakened immune systems, such as patients with diabetes or undergoing chemotherapy. If left untreated, the infection can spread to cranial nerves and even the central nervous system.
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While necrotising otitis externa is often referred to as "malignant otitis externa," it's important to differentiate between the severe form and what is sometimes termed "benign necrotising otitis externa" (BNOE). BNOE refers to cases where the infection is less invasive and primarily affects the superficial layers of the ear canal without deep tissue or bone involvement. It's typically associated with less severe symptoms and a better prognosis compared to the more aggressive malignant form. Treatment for BNOE often includes topical antibiotics and careful ear cleaning, but prompt evaluation by an ENT specialist is still essential to rule out progression to the more severe form.
The symptoms of necrotising otitis externa include:
These symptoms often persist despite initial treatments for ordinary otitis externa, making early diagnosis crucial to prevent further complications.
Necrotising otitis externa is typically triggered by prolonged bacterial infections of the outer ear canal, often linked to Pseudomonas aeruginosa. Risk factors include:
The infection begins in the ear canal and can progress to surrounding tissues and bones, causing significant damage if not treated promptly.
Diagnosing necrotising otitis externa requires a combination of clinical examination and imaging techniques. CT scans are often used to detect bone erosion, while MRI helps identify soft tissue abnormalities. Advanced imaging methods like PET/MRI can monitor inflammation and treatment response. Cultures of ear discharge are also essential to confirm the presence of Pseudomonas aeruginosa.
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Treatment for necrotising otitis externa involves:
Early referral to ENT specialists is recommended for patients with systemic symptoms or persistent infections.
In the UK, patients with suspected necrotising otitis externa should be promptly referred to an Ear, Nose, and Throat (ENT) specialist within the NHS (National Health Service). ENT specialists are equipped to conduct thorough examinations, obtain appropriate cultures, and initiate targeted antibiotic therapy. Given the potential for severe complications, it's crucial for patients to receive timely and expert care. The ENT team will also coordinate imaging studies and any necessary surgical interventions to manage the infection effectively.
With timely treatment, most cases of necrotising otitis externa show improvement within 6–8 weeks. However, delayed diagnosis can lead to serious complications such as cranial nerve damage or intracranial infections, which significantly increase morbidity and mortality rates
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Necrotising otitis externa is a rare but severe condition requiring prompt diagnosis and aggressive treatment. Awareness of its symptoms, risk factors, and treatment options is essential for improving outcomes in affected patients. If you suspect necrotising otitis externa, seek immediate medical attention from an ENT specialist in the UK.
Red flags indicating malignant otitis externa include:
1. Severe and persistent ear pain that worsens at night.
2. Foul-smelling discharge from the ear.
3. Lack of response to standard ear infection treatments.
4. Granulation tissue in the ear canal.
5. Facial nerve palsy or other cranial nerve involvement.
6. Presence of risk factors such as diabetes or immunosuppression.
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