Question of the Week # 450 and #451

450) A 74 year old man with poorly controlled Diabetes Type II presents to your office with complaints of severe right ear pain since yesterday night. The Pain was particularly worse in the night and interfered with his sleep. He took some Advil but pain persisted. He also reports headache on right temporal aspect. On examination, his right external auditory canal is slightly red and swollen and extremely tender to touch. There is some white debris and granulation tissue at the junction of bone and the cartilage. Laboratory studies show normal WBC count with no left shift. Which of the following additional tests is useful in supporting the diagnosis? 

A) Comprehensive metabolic panel

B) Erythrocyte Sedimentation Rate

C) Anti-nuclear antibodies

D) Hemoglobin A1C.

E) Screening nares for MRSA ( Methicillin Resistant Staph. Aureus)

451) What is the most important next step in management?

A) Oral Cephalexin

B) Surgical resection

C) Intravenous Ciprofloxacin

D) Intravenous Ceftriaxone

E) Ciprofloxacin ear drops

10 Responses

  1. A, A

  2. B D -> then should make B -it’s a fungal infection maybe -> that’s why no shift to the left.

  3. I think this is a case of necrotizing otitis externa in a diabetic patient and would be treated with intravenous ciprofloxacin plus control of diabetes so I think the answer would be D and C

  4. Intravenous ceftriaxone

  5. Necrotizing otitis externa yes, but shouldn’t we Screen for MRSA too. So I answer E and C.

  6. B- ESR and C- Ciprofloxacin IV. ESR to support malignant otitis externa pathogen being pseudomomnas and ciprofloxacin IV covers the bug

  7. b,b

  8. B – C

    malignant external otitis ( elderly diabetic patient with nocturnal pain, unresponsive to advil, and granulation tissue at the bone-cartilage junction ….. )

    due to uptodate 21.2 :

    Laboratory parameters are generally normal in malignant external otitis, with the exception of an elevated erythrocyte sedimentation rate (ESR). Although nonspecific, a strikingly elevated ESR is the most characteristic laboratory abnormality and is a useful way of monitoring disease activity [ 3 ].

    Antipseudomonal antimicrobials are the mainstay of therapy for malignant external otitis. Prior to the development of systemic agents, the mortality from this disease approximated 50 percent with frequent recurrences [ 4 ]. Introduction of parenteral semisynthetic penicillins reduced the mortality to 20 percent [ 65 ]. Oral fluoroquinolones have generally replaced combination therapy with aminoglycosides or third-generation cephalosporins in the treatment of malignant external otitis.

    With the introduction of fluoroquinolones, the cure rate has increased to 90 percent, with few adverse effects reported.

    Ciprofloxacin (750 mg orally twice daily) remains the antibiotic of choice, although no comparative trials have been reported [ 66-72 ]. We usually initiate treatment with intravenous ciprofloxacin (400 mg every eight hours) until we obtain a subjective clinical response and/or a decrease in ESR. The remainder of the course of ciprofloxacin can be given orally

  9. malignant external otitis ( elderly diabetic patient with nocturnal pain, unresponsive to advil, and granulation tissue at the bone-cartilage junction ….. )

    due to uptodate 21.2 :

    Laboratory parameters are generally normal in malignant external otitis, with the exception of an elevated erythrocyte sedimentation rate (ESR). Although nonspecific, a strikingly elevated ESR is the most characteristic laboratory abnormality and is a useful way of monitoring disease activity [ 3 ].

    Antipseudomonal antimicrobials are the mainstay of therapy for malignant external otitis. Prior to the development of systemic agents, the mortality from this disease approximated 50 percent with frequent recurrences [ 4 ]. Introduction of parenteral semisynthetic penicillins reduced the mortality to 20 percent [ 65 ]. Oral fluoroquinolones have generally replaced combination therapy with aminoglycosides or third-generation cephalosporins in the treatment of malignant external otitis.

    With the introduction of fluoroquinolones, the cure rate has increased to 90 percent, with few adverse effects reported.

    Ciprofloxacin (750 mg orally twice daily) remains the antibiotic of choice, although no comparative trials have been reported [ 66-72 ]. We usually initiate treatment with intravenous ciprofloxacin (400 mg every eight hours) until we obtain a subjective clinical response and/or a decrease in ESR. The remainder of the course of ciprofloxacin can be given orally

  10. I think the answers are: B and C

    Diagnosis: Malignant otitis externa in an immunocompromised (diabetic) patient.

    Laboratory parameters are generally normal in malignant external otitis, with the exception of an elevated erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP). Although nonspecific, a strikingly elevated ESR or CRP is the most characteristic laboratory abnormality and is a useful way of monitoring disease activity.

    Antipseudomonal antimicrobials are the mainstay of therapy for malignant external otitis. For adults, ciprofloxacin (400 mg intravenously every 8 hours; 750 mg orally every 12 hours) remains the antibiotic of choice, although no comparative trials have been reported.

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