Endgames Case Report

Ear pain and facial palsy

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6000 (Published 07 September 2012) Cite this as: BMJ 2012;345:e6000
  1. Aisha Egala, GP specialty registrar year 1 ,
  2. Philip J Clamp, ear, nose, and throat registrar,
  3. Daniel Hajioff, ear, nose, and throat consultant
  1. 1Southmead Hospital, Department of ENT Surgery, Bristol BS10 5NB, UK
  1. Correspondence to: A Egala aisha.egala{at}gmail.com

An 84 year old woman presented to our ear, nose, and throat emergency clinic with a seven week history of right sided earache and hearing loss. She had received treatment in the community, including aural microsuction, oral penicillin, and metronidazole. Despite this treatment her symptoms were worsening and the pain was now severe. During the previous day she had developed a right sided facial weakness. Her medical history included well controlled hypertension, glaucoma, and hypercholesterolaemia.

On clinical examination, she had a partial right facial nerve palsy with incomplete eye closure; her forehead muscles were also affected. Neurological examination was otherwise normal. She was afebrile and systemically well. The right ear canal was inflamed with granulation tissue and debris along its floor. After microsuction of debris, the tympanic membrane appeared normal.

Blood tests showed a raised C reactive protein and a white blood cell count at the upper end of the normal range.

Computed tomography of the temporal bones showed opacification of the right mastoid air cells but no bony erosion or evidence of intracranial infection.

Questions

  • 1 What is the likely diagnosis?

  • 2 What system is usually used to grade facial nerve palsy?

  • 3 How should this patient be managed?

Answers

1 What is the diagnosis?

Short answer

Necrotising (malignant) otitis externa.

Long answer

Necrotising otitis externa is erosive infection of the external ear canal and temporal bone, as shown in this patient by opacification of the right mastoid air cells (figure). It is also referred to as malignant otitis externa because of its aggressive and potentially fatal course, although this term is misleading because the condition is not cancerous.1 Deaths are caused by osteomyelitis and periostitis of the external auditory meatus, which can spread along the …

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