GRAND ROUND PRESENTATION

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ENT CONNECT MEETING11TH JUNE 2009

• MR OM CHAWLA FRCS
• CONSULTANT ENT SURGEON
• HONORARY SENIOR LECTURER UCL AND ROYAL FREE

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ENT CATSoverview
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Advantages

• Shorter waiting time
• 18 weeks
• Environment

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Disadvantages

• Investigations done off-site
• Training issues for junior doctors

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ENT CATS Patient Questionnaire

• 2008/2009

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Results

• 26 patients responded
• Overall very positive response

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Results
Question Yes No 1 2 3 4 5 Comments
Did you receive an appointment that was convenient to you? 26              
If not were you able to have an alternative 1              
How friendly and helpful were the staff? (1-5)         1 5 19  
Was the location of the service convenient 26              
If no why?               If you have a car.
Did you receive directions to the clinic? 15 3            
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Consultation Assessment
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General Comments

• I was very pleased with how quickly the
  appointment came through
• The staff and service were first class
• The treatment I received was excellent
• I feel it is a great service. As a disabled
  person it was much easier to come to the surgery
  rather than hospital
• I arrived a few minutes early and was seen
  almost immediately. The whole service was
  excellent

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CASE PRESENTATION
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BACKGROUND

• JE 66 yr old male
• Lt ear ache 15 week duration
• Became severe since 4 weeks
• Discharge blood stained purulent
• Deafness

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PAST MEDICAL HISTORY

• Insulin dependent diabetes mellitus15 yrs
• Diabetic neuropathy 5yrs
• Hypertension
• Transient ischemic attacks
• Prostatic hyperplasia

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LOCAL EXAMINATION

• Large polyp in left deep meatus
• No mastoid tenderness
• Conductive hearing loss Lt ear

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INVESTIGATIONS

• Pus swab Pseudomonas aeruginosa
• Audiogram Lt side 40-70 dB mixed hearing loss
• Radio-isotope scan Intensely increased tracer
  uptake within the left temporal bone confirming
  malignant otitis externa. Also, less intense
  increased tracer uptake further medially likely
  to represent petrous apex

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MANAGEMENT

• Medical
• Ciprofloxacin iv 400 mg BD x 4 days
• Followed by oral 500mg BD
• Analgesics Paracetamol, Diclofenac, Codeine
  phosphate
• Surgical
• Left Aural polypectomy biopsy (27/11/2007)

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BIOPSY REPORT

• Multiple fragments of inflammed granulation
  tissue with few multinucleated giant cells,
  keratin debris, marked chronic inflammatory cells
  with occassional spicules of bone

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• After 9 days of in-patient stay patient
  discharged on oral ciprofloxacin Gentisone HC
  ear drops analgesics

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FOLLOW UP

• At 2 week follow-up (11/12/2007)
• No pain but occassional tenderness in upper part
  of pinna
• No ear discharge
• At 6 week follow-up
• No pain / no tenderness / no ear discharge
• No granulations on TM
• Continued Oral Ciprofloxacin 250mg BD
• At 10 week follow-up
• Lt TM mildly inflammed but asymptomatic
• Continued Ciprofloxacin 250mg BD

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MALIGNANT OTITIS EXTERNA

• Meltzer (1959)
• Chandler (1968)
• Potentially fatal disease of external auditory
  canal
• Elderly, diabetic (86-90) and immuno-compromised
  patients
• Invasion through the fissure of Santorini
• Spreads rapidly invading surrounding soft tissue,
  cartilage and bones

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MALIGNANT OTITIS EXTERNA

• Causative organisms
• Pseudomonas aeruginosa (99)
• Others Aspergillus niger, Staphylococcus
  aureus, Proteus and Klebsiella

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MALIGNANT OTITIS EXTERNA

• PATHOPHYSIOLOGY
• Syringing for impacted wax
• Self-inflicted

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MALIGNANT OTITIS EXTERNA

• CT MRI
• MRI superior to CT in estimating anatomic extent
  of disease but cannot be used for monitoring
  therapy

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MALIGNANT OTITIS EXTERNA

• CLINICAL FINDINGS
• Granulation tissue in the external auditory canal
  bony-cartilaginous junction
• Facial and other cranial nerve palsies
• Intracranial complications

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MALIGNANT OTITIS EXTERNA

• INVESTIGATIONS
• Culture
• Imaging CT MRI
• Technetium Tc99m Medronate bone scanning
• Gallium citrate GA67 scintigraphy

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MALIGNANT OTITIS EXTERNA

• TREATMENT
• Local
• Long term systemic antibiotic therapy
• Correction of immunosuppression (when possible)
• Surgery
• Simple curretage
• Mastoidectomy
• Removal of diseased bone with reconstruction
• Facial nerve decompression

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• THANK YOU!!!!

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MALIGNANT OTITIS EXTERNA

• ANY QUESTIONS??