Necrotizing Otitis Externa due to Aspergillus Flavus Requiring Surgical Treatment
2Radiology Department, Nicosia General Hospital
3Medical School, European University
Background: Necrotizing otitis externa (NEO) of fungal etiology is characterized by difficulties in diagnosis and treatment. Beside the therapeutic benefit, surgical intervention is often required for diagnostic purposes as well in such cases.
Objective: To report a rare case of NEO caused by Aspergillus Flavus which required surgical intervention.
Methods: Αn 80 years old man was admitted to our hospital with a severe persisting infection at the left temporal bone area without any improvement signs after administration of metronidazole/ceftazidime for seven days in another institution.
Results: Clinical examination revealed extreme oedema of the EAC skin with secretion and preauricular swelling. Temporal bone CT scan showed slight cortical bone erosion at the posterior EAC wall, whereas bone scan with Technetium 99m confirmed the diagnosis of NEO. Microbiological and histological examination was negative. A combination therapy was initiated with daily debridement, topical dressing and tazobactam-piperacillin / ciprofloxacin and meropenem consecutively in total for 10 weeks. Strict control of diabetes mellitus was achieved with insulin therapy. A new CT scan indicated persistence of temporal bone inflammation with extension to the temporomandibular joint and to the temporalis muscle. Surgical debridement of the temporal bone and the joint was decided. In the removed inflammatory material Aspergillus Flavus was isolated. Intravenous voriconazole was commenced for two weeks, which was followed by a 12 weeks of oral voriconazole. The clinical response was rapid and favourable. The patient is still without recurrence signs 11 months after the completion of the treatment.
Conclusion: Clinical suspicion of fungal NEO should be considered in cases with no response in empirical anti-microbial medication. Surgical treatment may play a key role in diagnosis and therapy when conservative medication fails and when the initial microbiological examination is negative.
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