Malignant Otitis Externa Treatment & Management

Updated: Feb 11, 2022
  • Author: Brian Nussenbaum, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Medical Care

Treatment includes meticulous glucose control, aural toilet, systemic and ototopic antimicrobial therapy, and hyperbaric oxygen therapy. [4, 5]

Systemic antibiotic choice

Until the development of third-generation antipseudomonal cephalosporins, long-term intravenous antibiotics using an antipseudomonal penicillin and aminoglycoside were the mainstay of medical treatment.

Several authors have demonstrated the effectiveness of intravenous ceftazidime monotherapy in the treatment of malignant external otitis (MEO).

Fluoroquinolones that attain high soft tissue and bone levels with oral doses were then developed. Subsequently, several authors have demonstrated the efficacy of oral ciprofloxacin monotherapy.

Although no established treatment guidelines are available, case series and anecdotal experience suggest that initial outpatient therapy with oral ciprofloxacin is efficacious for patients without a fluoroquinolone allergy, cranial neuropathy, or intracranial complication and who do not require hospital admission for diabetes or pain management.

The widespread use of fluoroquinolones for upper respiratory infections and simpler ear infections is beginning to confound the typical clinical spectrum of malignant external otitis (MEO). Ciprofloxacin-resistant P aeruginosa has been increasingly isolated in patients with malignant external otitis (MEO), accounting for as many as 33% of isolates in patients who failed outpatient management in a study by Berenholz et al. [21] Most notably in this patient population, 63% of isolates from 1998-2001 were resistant to ciprofloxacin, whereas only 15% of isolates were found to be resistant in the 10 years before this 3-year period. No increased morbidity or mortality was found in patients with ciprofloxacin-resistant Pseudomonas. Patients with resistant P aeruginosa require parenteral antibiotics with antipseudomonal beta-lactam antibiotics with or without an aminoglycoside.

A retrospective study by Carlton et al indicated that as rising antimicrobial resistance complicates treatment for malignant external otitis (MEO), multidrug and long-term parenteral antibiotic therapy with extended inhospital treatment are needed in select cases. [22]

Duration of therapy

Symptoms and examination findings improve with appropriate therapy, but these changes do not correlate with the length of needed therapy. Despite symptom relief, prolonged antimicrobial treatment as indicated for osteomyelitis is still indicated.

Imaging studies are helpful in determining the adequate length of treatment for each patient.

Treatment response should be evaluated with a gallium citrate Ga 67 scan every 4-6 weeks during treatment. Benecke recommended ending treatment 1 week after the gallium citrate Ga 67 scan findings return to normal and confirming this with a repeat scan 1 month after the treatment is stopped. Using this protocol for 13 patients, the average duration of treatment was 8.8 weeks with a range of 4-17 weeks.

Hyperbaric oxygen therapy

This should be used only as an adjunct to antimicrobial therapy; it should not be used alone. Hyperbaric oxygen therapy may be helpful for patients with complications, experiencing a poor response to therapy, or with recurrent cases.


Surgical Care

See the list below:

  • Chandler advocated surgery in his original report when appropriate antimicrobials were not available; he had very poor results, with a 50% mortality rate.

  • Surgical removal of the lesion requires resection of large portions of the temporal bone.

  • Because of the histopathology of malignant external otitis (MEO), removal of contiguous areas of bone may not be sufficient because of the spread of infection through vascular and fascial planes.

  • Surgery is now reserved for local debridement, removal of bony sequestrum, and abscess drainage.

  • Facial nerve decompression is not indicated for patients with facial paralysis.



See the list below:

  • Consultation with internal medicine specialists is required for the management of diabetes and other comorbidities.

  • Infectious-disease consultants may help with the choice of antibiotics in complicated cases.