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NECROTIZING OTITIS EXTERNA : Kevin Jonathan


406172069

DIAGNOSIS, TREATMENT, AND OUTCOME


OTITIS EXTERNA
DEFINISI
Otitis externa  Radang liang telinga akut maupun kronis yang disebabkan infeksi
bakteri, jamur, dan virus

Faktor yang mempermudah radang telinga luar :


• Perubahan pH liang telinga (dari normal atau asam menjadi basa)
• Udara yang hanhgat dan lembab  jamur mudah tumbuh
• Trauma ringan  mengorek telinga
KLASIFIKASI OTITIS EKSTERNA AKUT

Otitis eksterna
sirkumskripta (furunkel)

Otitis eksterna Difus


Sepertiga luar liang telinga
telinga mengandung
adneksa kulit (folikel rambut,
kelenjar sebasea, kelenjar
serumen)  infeksi pada
pilosebaseus  furunkel
Kuman penyebab utama :
Staphylococcus aureus atau
Staphylococcus albus

OTITIS EKSTERNA
SIRKUMSKRIPTA (FURUNKEL)
Tanda dan Gejala :
• Rasa nyeri yang hebat (tidak sesuai besar bisul)
• Terdapat gangguan pendengaran  bila furunkel
OTITIS besar dan menyumbat liang telinga

EKSTERNA
SIRKUMSKRIPTA Terapi : (Tergantung keadaan furunkel)

(FURUNKEL) • Abses  Aspirasi. Lokal diberikan antibiotik salep


(polymixin B atau bacitracin) atau anti septik (asam
asetat 2-5% dalam alkohol)
• Dinding furunkel tebal  Insisi + drain untuk
mengaliri nanah
Mengenai kulit liang telinga
duapertiga dalam. Kulit
liang telinga tampak
hiperemis dan edema
dengan batas tak tegas

Kuman penyebab utama


adalah Staphylococcus albus,
Escherichia coli, dsb.

OTITIS EKSTERNA DIFUS


Tanda dan gejala :
•Nyeri tekan tragus
•Liang telinga sempit
•Dapat ditemukan pembesaran KGB regional disertai
OTITIS nyeri tekan

EKSTERNA •Sekret berbau (tidak mengandung musin)

DIFUS Terapi :
•Membersihkan liang telinga
•Memasukkan tampon antibiotik
•Dapat diberikan antibiotik sistemik
Infeksi jamur  dipermudah
oleh kelembaban tinggi dan
udara yang hangat

Penyebab tersering adalah


Pityrosporum spp. ,
Aspergilus spp. , dapat juga
ditemukan Candida albicans
atau jamur yang lain.

OTOMIKOSIS
Tanda dan Gejala :
•Rasa gatal dan penuh ditelinga
•Dapat tidak ada keluhan

OTOTMIKOSIS Terapi :
Membersihkan liang telinga dengan 
•Larutan asam asetat 2% dalam alkohol
•Larutan lodium povidon 5%
•Dpaat diberikan obat anti-jamur salep (nistatin,
klotrimazol)
Disebut juga otitis eksterna
nekrotikans  Infeksi difus di
liang telinga luar dan struktur
lain disekitarnya. Biasa terjadi
pada orang tua dengan
penyakit diabetes melitus

Peradangan meluas secara


progresif ke lapisan subkutis,
tulang rawan dan ke tulang
disekitarnya  timbul kondritis,
osteitis, dan osteomielitis yang
menghancurkan tulang
temporal
OTITS EKSTERNA MALIGNA
Tanda dan Gejala
•Rasa gatal di liang telinga  dengan cepat diikuti
rasa nyeri
•Sekret yang banyak

OTITIS •Pembengkakan liang telinga


•Rasa nyeri semakin hebat
EKSTERNA •Liang telinga tertutup jaringan granulasi yang cepat
tumbuh
MALIGNA •Dapat mengenai saraf fasial  paralisis fasial

Kelainan patologik yang penting  Osteomielitis yang


progresif (Pseudomonas aeroginosa).
Terapi :
Pengobatan harus cepat  sesuai hasil kultur dan
OTITIS resistensi
Diberikan golongan fluoroquinolone (ciprofloxasin)
EKSTERNA dosis tinggi PO sambil menunggu kultur.

MALIGNA Pada keadaan berat  Antibiotik parenteral +


kombinasi dengan amioglikosida selama 6 – 8
minggu.
Seringkali diperluka debridement
NECROTIZING OTITIS EXTERNA:
DIAGNOSIS, TREATMENT, AND OUTCOME
IN A
CASE SERIES
NECROTIZING OTITIS EXTERNA
 severe infection that typically affects the elderly,
diabetic, and immunocompromised patients

Antoher term = skull-base osteomyelitis (describes the


pathophysiology and local spread of the disease process)

Main causative organism.  P. aeruginosa; Fungal


pathogens may cause NOE
CLINICAL PRESENTATION

Severe  Granulation tissue


Unremitting otalgia

Aural fullness

Otorrhea

Hearing loss.
METHODS

Study  approved by the Sheba Medical Center


ethics committee

The database  from tertiary university-affiliated


medical center between 2009 and 2015
•Severe, unremitting otalgia or sensation of aural
fullness with duration of over 2 weeks.
DIAGNOSIS •Physical findings consistent with external otitis.

CRITERIA •Signs and symptoms unresponsive to outpatient


treatment of over 1 week.
Because the variability of the disease presentation,
only patients with one or more of the following were
included In this study:
1. Evidence of external ear canal bone exposition or
destruction on physical examination.
2. Radiologic evidence of bone erosion.
RESULTS
BACKGORUND & CLINICAL CHARACTERISTICS
Total of 25 cases  7 women (28%) and 18 men (72%) [mean age of 73.8
(range, 27–93)]

Diabetes mellitus (DM)  present in 84% of the patients (21/25), 14 (66%)


insulin dependent. Mean hemoglobin A1c (HbA1C) level : 7.8 (range, 5.2–9.8).

approximately 95% of the patients presented to our hospital between the


months of April and October  the weather is usually warm and humid in israel.
LABORATORY TESTS

15 (60%) of the patients  anemic

The mean albumin level  3.8 g/dL.

inflammatory markers :
• 28% leukocytosis with Neutrophilia
• 88% elevated C-reactive protein (mean level of 49)
• 44% elevated ESR (mean level of 63 mm/h)
MICROBIOLOGY

Microbiologic cultures were taken


from all infected ears. Organisms 
identified in 80% (20/25).
P. aeruginosa was the main
causative organism and was present
in 10 cultures (50%). When
antimicrobial sensitivity was tested,
30% of the P. aeruginosa-positive
cultures were multidrug-resistant.
The second most common pathogen
was fungi – 35% (7/20).
Tissue specimens  sent for histologic evaluation in
68% (17/25) of the patients, obtained by external
canal biopsy alone or during surgical debridement.
Most common findings :
•pathologic changes compatible with acute and/or
chronic inflammation
HISTOLOGY •Granulation
•Ulceration
•Two patients showed histologic evidence of fungal
infection, one presenting with findings compatible with
an invasive infection.
IMAGING

21 patients  CT – Scan (imaging modality of choice). Remaining patients, CT was not


performed due to the impression of a limited disease with rapid clinical improvement. Result :
• 19 (90%) of 21 scans  bone erosion was seen : mostly of the external ear canal and mastoid.
• 7 (33%) of 21 scans  temporomandibular joint (TMJ) and/or infratemporal fossa involvement.
• 5 (24%) of 21 scans  base of skull involvement.
Magnetic resonance imaging (MRI)  performed in 7 patients, usually with CT scan showing
extensive disease involvement. The main purpose : determine soft tissue or intracranial
involvement.

Relevant findings (MRI) : involvement of the Eustachian tube, prevertebral fascia,


nasopharynx, and muscles of mastication (used for preoperative assessment)
TREATMENT
Primary treatment  oral fluoroquinolones +/− intravenous (IV) amoxicillin and
clavulanic acid.

Second line treatment  IV carbapenems, ceftazidime, or piperacillin/ tazobactam.


used in cases of severe disease (skull-base involvement) as the primary therapy or in
patients unresponsive to first line agents over 2 weeks. Most of the patients had
already received oral systemic and/or local antibiotics prehospitalization;

The duration of systemic antibiotic treatment is 4–6 weeks in cases with clinical
improvement.

Antifungal therapy was directed based on positive cultures for fungal organisms.
In 11 (44%) of 25 patients the systemic antibiotic
SYSTEMIC treatment was changed based on culture sensitivity.
Mean overall duration of systemic treatment was 5.4
ANTIBIOTICS weeks.
23 patients (92%)  treated w. local fluoroquinolones
(ciprofloxacin, ofloxacin) drops, 2 of them combined
with dexamethasone drops.

LOCAL 2 patients were treated locally with a combination of


dexamethasone, neomycin, and polymyxin B.
ANTIBIOTICS The mean overall duration of local treatment during
hospitalization was 4.1 weeks; some of these patients
continued local treatment after discharge.
patients with limited or no response to systemic and
local antibiotic treatment with a compatible surgical
risk underwent local surgical debridement of the
external ear canal and surrounding structures.
•12 patients (68%)  External canal debridement
SURGERY under local anesthesia
•5 patients (20%)  mastoidectomy under general
anesthesia: 3 simple, 1 modified radical, and 1
radical. No surgical complications were noted.
Two patients with a persistent disease were sent for
HYPERBARIC hyperbaric oxygenation treatment outside our
institution. One of these patients eventually improved
TREATMENT while the other was lost to follow-up.
Overall mean hospitalization duration  14.52 days
(range, 3–78 days).
Pain management  mean VNRS score of 5 (assessed twice
daily)
Majority of patients, auricular discharge and
edema/granulation tissue in the external ear canal
DAILY FOLLOW-UP continued throughout most of their hospitalization period.

DURING Three patients developed neurological deficits:


HOSPOTALIZATION •2 patients  initial presentation of facial palsy & other
cranial neuropathies (cranial nerves 9, 10, and 12)
•1 patient who developed facial palsy and loss of
consciousness.
20 (80%) patients improved clinically (signs and symptoms).
Of the 5 that did not improve :
•2 cases of disease-related death
•2 patients survived but showed residual neurological
deficits.
•1 patient died during hospitalization (unrelated reason)
OUTCOME The overall death and disease-related mortality rates were
12% and 8%. 6 patients (24%) required rehospitalization.
Patients with involvement of the TMJ, infratemporal fossa, or
base of skull on CT scan showed prolonged hospitalization
and adverse prognosis. Mean hospitalization duration =
29.4 days. Age did not correlate with adverse prognosis
(neurological deficits, rehospitalization, or death)