Malignant Otitis Externa

Malignant Otitis Externa

Q. 1

Malignant otitis externa is caused by _____________________

 A

Staphylococcus aureus

 B

Pseudomonas aeruginosa 

 C

Candida albicans

 D

Candida albicans

Q. 1

Malignant otitis externa is caused by _____________________

 A

Staphylococcus aureus

 B

Pseudomonas aeruginosa 

 C

Candida albicans

 D

Candida albicans

Ans. B

Explanation:

 

MALIGNANT (NECROTISING) OTITIS EXTERNA:

  • It is an inflammatory condition caused by pseudomonas infection usually in the elderly diabetics, or in those on immunosuppressive drugs.
  • Its early manifestations resemble diffuse otitis externa but there is excruciating pain and appearance of granulations in the meatus. Facial paralysis is common. Infection may spread to the skull base and jugular foramen causing multiple cranial nerve palsies. Anteriorly, infection spreads to temporomandibular fossa, posteriorly to the mastoid and medially into the middle ear and petrous bone.
  • CT scan is useful, to know the extent of disease.
  • Treatment consists of high doses of i.v. antibiotics directed against pseudomonas (tobramycin, ticarcillin or third generation cephalosporins). Antibiotics are given for 6-8 weeks or longer. Diabetes should be controlled. Surgical debridement of devitalised tissue and bone should be done judiciously.

Q. 2

Malignant otitis externa results from infection by which of the following organisms

 A Klebsiella
 B Enterococcus
 C Pseudomonas aeroginosa
 D Strep tococcal pneumonia
Q. 2

Malignant otitis externa results from infection by which of the following organisms

 A Klebsiella
 B Enterococcus
 C Pseudomonas aeroginosa
 D Strep tococcal pneumonia
Ans. C

Explanation:

Pseudomonas aeroginosa


Q. 3

Which of the following is true regarding malignant otitis externa?

 A

Caused by pseudomonas

 B

Seen in elderly diabetics

 C

Granulation tissue may be present in the external auditory canal

 D

All the above

Q. 3

Which of the following is true regarding malignant otitis externa?

 A

Caused by pseudomonas

 B

Seen in elderly diabetics

 C

Granulation tissue may be present in the external auditory canal

 D

All the above

Ans. D

Explanation:

Q. 4

Which of the organism causes malignant otitis externa?

 A

Staphylococcus aureus

 B

Pseudomonas aeruginosa

 C

Candida albicans

 D

E. coli

Q. 4

Which of the organism causes malignant otitis externa?

 A

Staphylococcus aureus

 B

Pseudomonas aeruginosa

 C

Candida albicans

 D

E. coli

Ans. B

Explanation:

Malignant (necrotizing) otitis externa is a particularly aggressive life-threatening form of infection caused by Pseudomonas aeruginosa infection. It usually in the elderly diabetics, or in those on immunosuppressive drugs. Its early manifestations resemble diffuse otitis externa but there is excruciating pain and appearance of granulations in the meatus. Facial paralysis is common.


Q. 5

Which of the following is NOT a typical feature of malignant otitis externa?

 A

Caused by Pseudomonas aeruginosa

 B

Patients are usually old

 C

Mitotic figures are high

 D

Patient is immunocompromised

Q. 5

Which of the following is NOT a typical feature of malignant otitis externa?

 A

Caused by Pseudomonas aeruginosa

 B

Patients are usually old

 C

Mitotic figures are high

 D

Patient is immunocompromised

Ans. C

Explanation:

High mitotic figures are suggestive of a malignant pathology. Malignant otitis externa is an infective condition, not a malignant one.


Q. 6

External otitis is also known as:

 A

Glue ear

 B

Malignant otitis externa

 C

Telephonists ear

 D

ASOM

Q. 6

External otitis is also known as:

 A

Glue ear

 B

Malignant otitis externa

 C

Telephonists ear

 D

ASOM

Ans. C

Explanation:

Humidity and hot climate are one of the predisposing factors for otitis externa. Hence – otitis externa is also k/a Singapore ear (where climate is hot & humid) or Telephonist ear as talking on phone causes humidity around ear) or Swimmers ear.

 


Pseudomonas aeruginosa is a normal inhibitant of external ear. Its numbers are kept in balance by the normal acidity of EAC. Prolonged swimming or abusive use of cotton typed ear buds can alter the pH, producing a more basic environment in which pseudomonas grows rapidly.



Q. 7

Malignant otitis externa is caused by: 

 A

S. aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Q. 7

Malignant otitis externa is caused by: 

 A

S. aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Ans. C

Explanation:

Ans. is c is P. aeruginosa


Q. 8

True statement about malignant otitis externa is:

 A

Not painful

 B

Common in diabetics and old age

 C

Caused by streptococcus

 D

All of the above

Q. 8

True statement about malignant otitis externa is:

 A

Not painful

 B

Common in diabetics and old age

 C

Caused by streptococcus

 D

All of the above

Ans. B

Explanation:

Q. 9

Malignant otitis externa is:

 A

Malignancy of external ear

 B

Caused by hemophilus influenzae

 C

Blackish mass of aspergillus

 D

Pseudomonas infection in diabetic patient

Q. 9

Malignant otitis externa is:

 A

Malignancy of external ear

 B

Caused by hemophilus influenzae

 C

Blackish mass of aspergillus

 D

Pseudomonas infection in diabetic patient

Ans. D

Explanation:

Q. 10

Malignant otitis externa is characterized:

 A

Caused by pseudomonas aeruginosa

 B

Malignancy of external auditory canal

 C

Granulation tissue is seen in the floor of external auditory canal

 D

a and c

Q. 10

Malignant otitis externa is characterized:

 A

Caused by pseudomonas aeruginosa

 B

Malignancy of external auditory canal

 C

Granulation tissue is seen in the floor of external auditory canal

 D

a and c

Ans. D

Explanation:

Q. 11

An elderly diabetic presents with painful ear discharge and edema of the external auditory canal with facial palsy, not responding to antibiotics. An increased uptake on technetium bone scan is noted. The most probable diagnosis is

 A

Malignant otitis externa

 B

Malignancy of the middle ear

 C

Infective disease of the middle ear

 D

Malignancy of nasopharynx with Eustachian tube ob­struction

Q. 11

An elderly diabetic presents with painful ear discharge and edema of the external auditory canal with facial palsy, not responding to antibiotics. An increased uptake on technetium bone scan is noted. The most probable diagnosis is

 A

Malignant otitis externa

 B

Malignancy of the middle ear

 C

Infective disease of the middle ear

 D

Malignancy of nasopharynx with Eustachian tube ob­struction

Ans. A

Explanation:

Q. 12

Facial nerve palsy is seen in:

 A

Seborrheic otitis externa 

 B

Otomycosis

 C

Malignant otitis externa 

 D

Eczematous otitis externa

Q. 12

Facial nerve palsy is seen in:

 A

Seborrheic otitis externa 

 B

Otomycosis

 C

Malignant otitis externa 

 D

Eczematous otitis externa

Ans. C

Explanation:

Q. 13

A female diabetic having severe ear pain and granulation tissue in external ear with Facial palsy is due to:

 A

Malignant otitis externa 

 B

Herpes zoster otitis

 C

Otomycosis

 D

None

Q. 13

A female diabetic having severe ear pain and granulation tissue in external ear with Facial palsy is due to:

 A

Malignant otitis externa 

 B

Herpes zoster otitis

 C

Otomycosis

 D

None

Ans. A

Explanation:

 

 Malignant otitis externa – can cause destruction of tissues of canal, pre and post auricular region by various enzymes like leci­thinase and hemolysis.

Infection can spread to skull base and jugular foramen causing multiple cranial nerve palsies in which most common is facial nerve palsy.



Q. 14

Diffuse otitis externa is also known as:

 A

Glue ear

 B

Malignant otitis externa

 C

Telephonist’s ear

 D

ASOM

Q. 14

Diffuse otitis externa is also known as:

 A

Glue ear

 B

Malignant otitis externa

 C

Telephonist’s ear

 D

ASOM

Ans. C

Explanation:

Q. 15

Regarding necrotizing otitis externa all are true except:

 A

Caused by pseudomonas

 B

Surgery never done

 C

Facial nerve involved

 D

Common in diabetics

Q. 15

Regarding necrotizing otitis externa all are true except:

 A

Caused by pseudomonas

 B

Surgery never done

 C

Facial nerve involved

 D

Common in diabetics

Ans. B

Explanation:

Q. 16

Facial nerve palsy is seen in this condition:

 A

Seborrheic otitis externa 

 B

Otomycosis

 C

Malignant otitis externa 

 D

Cerebellar abscess

Q. 16

Facial nerve palsy is seen in this condition:

 A

Seborrheic otitis externa 

 B

Otomycosis

 C

Malignant otitis externa 

 D

Cerebellar abscess

Ans. C

Explanation:

Q. 17

A 75-year old diabetic patient presents with severe ear pain and granulation tissue at external auditory canal with facial nerve involvement. The most likely diagnosis is:

 A

Malignant otitis externa

 B

Nasopharyngeal carcinoma

 C

Acute suppurative otitis media

 D

Chronic suppurative otitis media

Q. 17

A 75-year old diabetic patient presents with severe ear pain and granulation tissue at external auditory canal with facial nerve involvement. The most likely diagnosis is:

 A

Malignant otitis externa

 B

Nasopharyngeal carcinoma

 C

Acute suppurative otitis media

 D

Chronic suppurative otitis media

Ans. A

Explanation:

Q. 18

 Causative organism for malignant otitis externa is

 A

Hemophilus

 B

Staphylococcus

 C

Streptococcus

 D

Pseudomonas

Q. 18

 Causative organism for malignant otitis externa is

 A

Hemophilus

 B

Staphylococcus

 C

Streptococcus

 D

Pseudomonas

Ans. D

Explanation:

 

Malignant/necrotizing otitis externa is a disorder involving inflammation and damage of the bones and cartilage at the base of the skull.

Malignant otitis externa is caused by the spread of an outer ear infection (otitis externa, also called swimmer’s ear). It is an uncommon complication of both acute swimmer’s ear and chronic swimmer’s ear.

Risks for this condition include:

  • Chemotherapy
  • Diabetes
  • Weakened immune system

External otitis is often caused by difficult-to-treat bacteria such as pseudomonas. The infection spreads from the floor of the ear canal to the nearby tissues and into the bones at the base of the skull.

The infection and inflammation may damage or destroy the bones. The infection may spread more and affect the cranial nerves, brain, or other parts of the body.


Q. 19

Malignant otitis externa is caused by:   

 A

S.aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Q. 19

Malignant otitis externa is caused by:   

 A

S.aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Ans. C

Explanation:

 

Malignant (necrotising) otitis externa is an inflammatory condition caused by pseudomonas infection

Necrotizing external otitis (malignant otitis externa)

  • It is an uncommon form of external otitis occurs mainly in elderly diabetics.
  • It can develop due to a severely compromised immune system.
  • Beginning as infection of the external ear canal, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal.

The hallmark of malignant otitis externa (MOE) is unrelenting pain that interferes with sleep and persists even after swelling of the external ear canal may have resolved with topical antibiotic treatment.

Natural history

  • MOE follows a much more chronic and indolent course than ordinary acute otitis externa.
  • There may be granulation involving the floor of the external ear canal, most often at the bony-cartilaginous junction.
  • Paradoxically, the physical findings of MOE, at least in its early stages, are often much less dramatic than those of ordinary acute otitis externa.
  • In later stages there can be soft tissue swelling around the ear, even in the absence of significant canal swelling. While fever and leukocytosis might be expected in response to bacterial infection invading the skull region, MOE does not cause fever or elevation of white blood count.

Treatment of MOE

  • Unlike ordinary otitis externa, MOE requires oral or intravenous antibiotics for cure.
  • Diabetes control is also an essential part of treatment.
  • When MOE goes unrecognized and untreated, the infection continues to smolder and over weeks or months can spread deeper into the head and involve the bones of the skull base, constituting skull base osteomyelitis (SBO). The infecting organism is almost always pseudomonas aeruginosa, but it can instead be fungal (aspergillus or mucor).
  • MOE and SBO are not amenable to surgery, but exploratory surgery may facilitate culture of unusual organism(s) that are not responding to empirically used anti-pseudomonal antibiotics.
  • The usual surgical finding is diffuse cellulitis without localized abscess formation. SBO can extend into the petrous apex of the temporal bone or more inferiorly into the opposite side of the skull base.

Complications

  • As the skull base is progressively involved, the adjacent exiting cranial nerves and their branches, especially the
    facial nerve and the vagus nerve, may be affected, resulting in facial paralysis and hoarseness, respectively.
  • If both of the recurrent laryngeal nerves are paralyzed, shortness of breath may develop and necessitate tracheotomy.
  • Profound deafness can occur, usually later in the disease course due to relative resistance of the inner ear structures

Q. 20

Sago grain appearance is seen in ‑

 A

Healed myringitis bullosa

 B

Otomycosis

 C

Malignant otitis externa

 D

Keratosis obturans

Q. 20

Sago grain appearance is seen in ‑

 A

Healed myringitis bullosa

 B

Otomycosis

 C

Malignant otitis externa

 D

Keratosis obturans

Ans. A

Explanation:

Ans. is ‘a’ i.e., Healed myringitis bullosa

Otitis externa haemorrhagica

  • This condition is also known as Bullous myringitis or myringitis bullosa.
  • This condition is extremely painful and has sudden onset.
  • It is thought to be due to mycoplasma pneumoniae or viral infection, usually influenza’.
  • There may be a mild conductive deafness and a mildly discharging car.
  • The appearance of haemorrhagic bullae on the tympanic membrane and in the deep meatus is characteristic. The bullae are filled with serosanguinous fluid and blood.
  • On healing, bullae look like Sago-grain.
  • Therefore “Sago-grain” appearance of tympanic membrane is seen in healed myringitis bullosa.

Q. 21

Malignant otitis externa is caused by ‑

 A

S. aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Q. 21

Malignant otitis externa is caused by ‑

 A

S. aureus

 B

S. albus

 C

P. aeruginosa

 D

E. coli

Ans. C

Explanation:

Ans. is ‘c’ i.e., P. aeruginosa

Malignant otitis externa

Malignant otitis externa, also called necrotizing external otitis, is a misnomer as it is not a neoplastic condition, rather it is an infectious condition. Malignant otitis externa is a disorder involving inflammation and damage of the bones and cartilage at the base of skull in temporal bone as a result of spread of infection from outer ear. Malignant otitis externa is often caused by difficult to treat bacteria such as pseudomonas aeruginosa. Only rare cases of malignant otitis externa due to S.aureus, Proteus mirabilis and Aspergillus fumigatus have been reported. The infection spreads from the floor of the ear canal to the nearby tissues and into the bones at the base of the skull. The infection and inflammation may damage or destroy the bones. The infection may spread more and affect the cranial nerves, brain, or other parts of the body.

Predisposing factors for malignant otitis externa

Elderly diabetics (most common predisposing factor)

Individuals with altered immune function (immunodeficiency)

Chemotherapy

Clinical features of malignant otitis externa

Severe pain :- inside the ear and may get worse when moving head.

Granulation tissue in the external auditory canal, at the junction of bony and cartilagenous part.

Drainage from the ear – yellow, yellow – green, foul smelling, persistent.

Fever

Itching of ear or ear canal

Troubled swallowing & weakness of face.

Complications

Cranial nerve palsies :- most commonly facial nerve is involved. Other cranial nerves can also be involved (glossopharyngeal, vagus, spinal accessory, hypoglossal, abducens, trigeminal).

Jugular venous thrombosis

Cavernous sinus thrombosis

Meningitis

Treatment of malignant otitis externa

In all cases, the external ear canal is cleansed and a biopsy specimen of the granulation tissue sent for culture. IV antibiotics is directed against the offending organism. For Pseudomonas aeruginosa, the most common pathogen, the regimen involves an antipseudomonal penicillin or cephalosporin (3′d generation piperacillin or ceftazidime) with an aminoglycoside. A fluoroquinolone antibiotic can be used in place of the aminoglycoside. Ear drops containing antipseudomonal antibiotic e.g. ciproflaxacin plus a glucocorticoid is also used. Early cases can be managed with oral and otic fluoroquinolones only. Extensive surgical debridement once an important part of the treatment is now rarely needed.


Q. 22

Fowl smelling ear discharge with presence of pale granulation tissue in ear in an adolescent boy is suggestive of ‑

 A

Cholesteatoma

 B

Exostosis

 C

Otomycosis

 D

Malignant otitis externa

Q. 22

Fowl smelling ear discharge with presence of pale granulation tissue in ear in an adolescent boy is suggestive of ‑

 A

Cholesteatoma

 B

Exostosis

 C

Otomycosis

 D

Malignant otitis externa

Ans. A

Explanation:

Ans. is ‘a’ i.e., Cholesteatoma

Fowl smelling ear discharge with presence of granulation tissue in earin adolescent boy is suggestive chronic suppurativeotits media of the unsafe type (atticoantral disease). Such patients have underlying cholesteatomaalongwith evidence of bone destruction.

Clinical features of cholesteatoma/atticoantral CSOM

  • Otorrhoea :- Scanty, foul smelling discharge due to bone destruction.
  • Hearing loss :- Initially conductive due to destruction of ossicles. Later sensorineural element may be added, which results in mixed hearing loss.
  • Bleeding :- May occur from granulation or the polyp when cleaning the ear.
  • Tympanic membrane show posterior marginal or attic perforation. Also granulation tissue and polyps may be present in ear.

Q. 23

Malignant otitis externa is most commonly caused by –

 A

P. aeruginosa

 B

S. aureus

 C

St. penumoniae

 D

S. epidermidis

Q. 23

Malignant otitis externa is most commonly caused by –

 A

P. aeruginosa

 B

S. aureus

 C

St. penumoniae

 D

S. epidermidis

Ans. A

Explanation:

Ans. is ‘a’ i.e., P. aeruginosa


Q. 24

In malignant otitis externa which nerve commonly affected ‑

 A

Abducent

 B

Facial

 C

Auditory

 D

Vagus

Q. 24

In malignant otitis externa which nerve commonly affected ‑

 A

Abducent

 B

Facial

 C

Auditory

 D

Vagus

Ans. B

Explanation:

 

Most commonly facial nerve is involved. Other cranial nerves can also be involved (glossopharyngeal, vagus, spinal accessory, hypoglossal, abducens, trigeminal).



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