Nasal Endoscopy and FESS: maneuver, indications, aims, complications

Here is how to manage/ treat a case of malignant O.E.

 Immediate management

• Hospitalization is a must.
• Consultation of infectious diseases specialists.
• Culture and sensitivity should be made before starting antibiotic therapy in order  to guide antimicrobial selection.

Bacterial malignant otitis externa:

• Start treatment with Antipseudomonal antibiotics (systemic) as detailed below.
• Recently, Combined theraby (aminoglycosides or third-generation cephalosporins) has been replaced by "Fluoroquinolones".
• Treatment course goes as follows:

- Start with Ciprofloxacin 400mg IV/8 hours, As soon as treatment response is seen, transition to oral 750mg po twice daily should be done.

- Only Ciprofloxacin has aclinical effect, not other fluoroquinolones.

- Poor vascularization of EAC may require higher doses.

- Culture and sensitivity is essential to guide treatment because there is increasing pseudomonal resistance to fluoroquinolones.

List of antibiotics that can be used as anti-pseudomonas with doses:

• Ciprofloxacin: 400mg/ 8hours, IV (as described above).
• Piperacillin-tazobactam (usually combined with an aminoglycoside): 4-6 gm/4-6 hours, IV.
• Ticarcillin-clavulanate (usually combined with an aminoglycoside)  : Dose 3g/4 hours, IV.
• Cefepime: 2g/12 hours, IV.
• Tobramycin (combined with an antipseudomonal pencillin): 1-1.66mg/kg/8 hours, IV.
• Gentamicin: the same dose as Tobramycin.
• Ceftazidime: the same dose as Cefepime.

Treatment of Fungal malignant otitis externa

- This kind should be suspected if there is negative cultue and failure of patient's response to antibiotics.

- Drugs of choice are liposomal amphocterin followed by oral itraconazole for up to 12 weeks.

Surgical management (E.N.T):

• Debridement of the EAC.
• Biopsy is mandatory to rule out malignancy.
• Surgical removal of infected bone, just in case of failure of antimicrobial therapy.

Therapies under experiments:

Hyperbaric oxygen (till now, no proved efficacy) can be used in resistant cases as an adjuvant measure.

Monitoring management of malignant otitis externa (Prognosis)

A. Examination:

1. Examination of the external auditory canal, and assessing soft tissue erythema.
2. Cranial nerves examination.
3. Lymph node examination: Pre- and post-auricular in addition to cervical.
4. Hearing tests should also be done prior to therapy.

B. Monitoring laboratory tests:

• E.S.R: done every week to assess response to treatment course.
• CBC, C7, LFTS: Done during IV antimicrobial therapy to monitor drug side effects.

Long-term treatment

- Prolonged treatment of 6-8 weeks is usually required depending on clinical symptoms (night pain), physical findings.

- Formal auditological hearing test after completion of treatment.

Common hazards of management

• Fungal infection should be considered if the patient doesn't respond to antibiotics or negative C&S.
• Culture of discharge should be done before starting anti-microbial course.

References