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Complicated Necrotizing Otitis Externa Progressing to Coalescent Mastoiditis and Temporal Lobe Abscess

Axial magnetic resonance image in the T2 phase, showing an abscess that has extended into the right temporal lobe.

A 77-year-old man with a history of hypertension, chronic kidney disease, and poorly controlled type 2 diabetes mellitus presented to our intensive care unit from an outside hospital with complicated necrotizing otitis externa. One month prior, the patient developed purulent drainage from the right external auditory canal with associated hearing loss. One week prior, he was prescribed ciprofloxacin/dexamethasone otic suspension and oral ciprofloxacin tablets for his symptoms. Despite this regimen, he experienced progressive purulent otorrhea, along with subjective fevers, chills, headaches, and altered mental status. Upon presentation to the outside hospital, he was noted to have a leukocytosis of 18,000/mm3, with computed tomography of the facial bones demonstrating extensive opacification of the right external auditory canal, middle ear cavity, and mastoid air cells, along with adjacent soft tissue swelling and subcutaneous emphysema with the formation of a 5.6 cm × 4.1-cm abscess along the right cervical spine.

Upon arrival to our facility, his examination was notable for malodorous, purulent otorrhea from the right external auditory canal. Otoscopic examination of the right tympanic membrane was obscured by canal inflammation, and mild tenderness was elicited upon palpation of right posterior neck musculature. He was administered intravenous (IV) vancomycin, cefepime, and metronidazole. After prompt evaluation by the neurosurgery and otolaryngology services, magnetic resonance imaging of the brain and cervical spine was obtained, revealing bony erosion of the walls of the right external auditory canal and right lateral mastoid. Additionally, there was evidence of intracranial extension, with a 4.0 cm × 1.7-cm abscess located along the right temporal lobe (Figure).

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-Talha Demirci, MD, Sharon O’Brien, MDb

This article originally appeared in the February issue of The American Journal of Medicine.

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