Reminder of important clinical lesson
CASE REPORT
Concurrent necrotising otitis externa and adenocarcinoma of the temporal bone: a diagnostic challenge Neil Foden,1 Christopher Burgess,1 Stephen Damato,2 James Ramsden1 1
Department of ENT, John Radcliffe Hospital, Oxford, UK Department of Pathology, John Radcliffe Hospital, Oxford, UK
2
Correspondence to Neil Foden, [email protected]
SUMMARY We present a case of an 81-year-old man who was diagnosed with a necrotising (malignant) otitis externa (NOE). Initial biopsies from the external auditory canal showed scanty squamous epithelium but no evidence of malignancy. Despite an initial improvement on intravenous antibiotics and subsequent discharge from hospital, the patient returned with worsening otalgia. Following readmission to the hospital, intravenous antibiotics were restarted. Despite this, the patient developed a lower motor neurone palsy of cranial nerve VII on the ipsilateral side of the pain. He was taken to the theatre for an exploration of the left mastoid with further biopsies. Adenocarcinoma was diagnosed histologically and the patient was started on palliative radiotherapy. This case adds to the known literature on metastatic disease in the temporal bone and highlights the need to exclude malignancy in cases of NOE.
BACKGROUND Malignant (necrotising) otitis externa was first described by Chandler in 1968.1 When otitis externa progresses to an osteomyelitis of the bony ear canal or skull base, it is termed ‘malignant/ necrotising otitis externa.’2 The latter description is preferred to avoid confusion with neoplasia. It is an infective not a neoplastic condition but can be fatal if advanced or inadequately treated. Necrotising otitis externa (NOE) is classically seen in the elderly, patients with diabetes mellitus and those who are immunocompromised.3 Malignancy arising in the temporal bone is rare. Squamous cell carcinoma (SCC) is most commonly seen.4 Adenocarcinoma is rarely seen and when it does, it is usually metastatic5 (usually from primaries in the lungs, breast, liver, kidneys, stomach or prostate) although it has been reported as being primary.6 Adenocarcinoma in the temporal bone with an unknown primary is exceptionally rare. We present a challenging case of concurrent NOE and undiagnosed adenocarcinoma of the temporal bone. It is essential to consider malignancy in all cases of NOE and the identification of infection does not necessarily preclude malignancy. To cite: Foden N, Burgess C, Damato S, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2013-009155
was being treated conservatively. There was no history of immunosuppression or diabetes mellitus. Despite regular aural microsuctioning and topical antibiotics in the clinic over a 2-week period, the condition progressed and otalgia disturbed his sleep. NOE was suspected. Swabs were taken for culture and sensitivity. A Pope wick was inserted into the external auditory canal (EAC), topical antibiotics (Sofradex: dexamethasone 0.05%, framecytin 0.5% and gramicidin 0.005%) were instilled and he was started on intravenous piperacillin/tazobactam. Blood results included a white cell count of 4.22, erythrocyte sedimentation rate 2.0 and a C reactive protein of 4.0. A CT temporal bone was arranged that showed extensive necrotising external otitis and mastoiditis (figure 1). The patient was taken to the theatre for an examination under anaesthetic and biopsy of the EAC. The histology was reported as scanty squamous epithelium, although the sample was superficial. The patient improved clinically with no further otalgia and normal inflammatory markers and was discharged on oral antibiotics. Two weeks after discharge, the patient was re-admitted with increasing otalgia. A further CT showed appearances in keeping with external otitis and mastoiditis with extensive cortical bony erosion of the EAC and mastoid. Intravenous antibiotics were restarted.
CASE PRESENTATION An 81-year-old man was seen in the ENT (ear, nose and throat) emergency clinic and diagnosed with otitis externa in the left ear. He had a history of chronic infection in a total hip replacement that
Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
Figure 1 Axial CT temporal bone showing necrotising external otitis and mastoiditis on the left. 1
Reminder of important clinical lesson Despite treatment, he developed a seventh (VII) cranial nerve palsy on the ipsilateral side. It was decided to proceed with a surgical exploration of the left mastoid, modified radical mastoidectomy and muscle obliteration of the cavity. Surgical findings included a dehiscent middle fossa plate and tegmen tympani with an intact but oedematous dura. The posterior canal wall of the EAC was dehiscent with erosion of the floor of the canal. Tissue samples were sent for microbiology and histology. The culture was positive for a growth of coagulase negative Staphylococcus.
INVESTIGATIONS Thyroid function tests, colorectal tumour markers and prostate specific antigen (PSA) were negative.
Pathological findings Biopsies were taken from the left EAC and deeper samples from the mastoid. Histology from the former revealed a poorly differentiated adenocarcinoma with widespread lymphovascular invasion and focal perineural invasion. The section from the mastoid biopsy section showed amorphous necrotic material with very occasional small clusters of malignant cells at the periphery (figure 2). Immunohistochemistry showed that the tumour cells were diffusely and strongly positive for cytokeratin 7 (CK7). CK20, thyroid transcription factor 1 (TTF1), PSA and CDX2 were negative.
Further imaging MRI of the head and neck with gadolinium contrast showed appearances suggestive of a mix of neoplastic infiltration at the petrous bone particularly at the anterior petrous ridge and a secondary otitis externa (figure 3). Delineation between the two areas was poor. Lymphadenopathy was noted in the parotid along with levels IIa, IIb and V. The level IIb node was more suspicious for neoplastic lymphadenopathy owing to its intermediate diffusion characteristics. A fluorodeoxyglucose-positron emission tomography of the whole body was subsequently performed. This revealed appearances of the temporal bone resection site in keeping with residual tumour and postsurgical inflammation with involved local lymph nodes and bone metastases in C7, T5 and the right
Figure 2 The tumour cells are principally arranged in solid nests with only focal lumen formation. There is marked nuclear pleomorphism and brisk mitotic activity. 2
Figure 3
MRI of the head revealing the tumour.
second rib. No alternative primary tumour site was demonstrated (figure 4).
DIFFERENTIAL DIAGNOSIS ▸ ▸ ▸ ▸ ▸
NOE SCC of the temporal bone Metastatic carcinoma of the temporal bone Fibrous dysplasia Paget’s disease
OUTCOME AND FOLLOW-UP The patient was discussed at a multidisciplinary team meeting. Surgery was not considered to be an option in light of the presence of metastatic disease. The patient subsequently underwent palliative radiotherapy of the affected area for pain relief.
DISCUSSION Diagnosing NOE is based on a thorough history and examination. A history of immunosuppression should alert clinicians. Suspicion should be raised by otalgia out of proportion to uncomplicated otitis externa, otorrhoea and findings of granulomatous tissue in the EAC. Uncomplicated otitis externa tends to respond to aural cleaning and topical antibiotics.7 Cultures must be sent for microbiology, tissue for histology and radiology (usually CT temporal bones) to assess for osteomyelitis or bony erosion. The most common causative organism is Pseudomonas aeruginosa.8 Negative cultures have been found in cases of NOE9 and the absence of a positive culture should not delay antimicrobial treatment. The differential diagnosis includes neoplasm, Paget’s disease, clival lesions and fibrous dysplasia. Biopsies are essential as there is much in common between osteomyelitis (NOE) and neoplasia on radiographic imaging, thus distinguishing the two can be difficult.10 Although neoplasms of the temporal bone are rare, they carry significant morbidity and mortality. Surgical resection can be difficult owing to complex regional anatomy and can often result in damage to the facial nerve and hearing loss.11 Metastatic adenocarcinoma of the temporal bone from a primary in the lung presenting with cranial nerve palsy has been described.12 Although less likely, primary adenocarcinoma of the temporal bone is thought to arise from the ceruminous glands,4 or mucosa of the middle ear, Eustachian tube, mastoid cells or mucous glands of the tympanum.13 They can be slow growing, often without causing metastases, but intracranial extension is possible.14 As Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
Reminder of important clinical lesson Contributors NF was involved in the conception of the idea to write the case report and writing the report. CB was involved in the writing of the report and obtaining radiography images. SD was involved in the histopathology interpretation. JR was involved in the editing of the case report. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
4 5
6
Figure 4 Positron emission tomography CT demonstrating uptake in the left temporal bone and cervical lymph nodes.
7 8
most adenocarcinomas found in the temporal bone are metastatic, it is imperative to try to exclude a primary elsewhere. Diagnostic pitfalls exist. The incidence of neoplasia in the middle ear/temporal bone is so low that many clinicians may not be alerted to the possibility of such a diagnosis; the symptoms are often non-specific (although bloody otorrhoea may be a useful indicator) and biopsies may not always prove adequate.15 This case was made much more challenging by virtue of the concurrent presence of two diagnoses at the same time. Neoplasia is considered a differential diagnosis for patients suspected of having NOE.16 Despite a thorough initial workup of the patient during the first admission, evidence of neoplasia was not found. A negative culture found on the first admission was possibly because the patient had been treated with regular topical antibiotics since prior to the admission. Owing to the development of worsening symptoms and the onset of a facial nerve palsy (which could also potentially be attributable to skull base osteomyelitis), further investigation was necessary. Obtaining deeper biopsies from the mastoid was key to diagnosis in this case. A high index of suspicion for neoplasia should be maintained in cases of possible NOE.
9 10 11
12
13 14
15 16
Chandler JR. Malignant external otitis. Laryngoscope 1968;78:1257–94. Nadol JB Jr. Histopathology of Pseudomonas osteomyelitis of the temporal bone starting as malignant external otitis. Am J Otolaryngol 1980;1:359–71. Rubin Grandis J, Branstetter BFt, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infec Dis 2004;4:34–9. Kinney SE, Wood BG. Malignancies of the external ear canal and temporal bone: surgical techniques and results. Laryngoscope 1987;97:158–64. Gloria-Cruz TI, Schachern PA, Paparella MM, et al. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14. Paulus W, Romstock J, Weidenbecher M, et al. Middle ear adenocarcinoma with intracranial extension. Case report. J Neurosurg 1999;90:555–8. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2006;134(4 Suppl):S4–23. Slattery WH III, Brackmann DE. Skull base osteomyelitis. Malignant external otitis. Otolaryngol Clin North Am 1996;29:795–806. Sie KC, Glenn MG, Hillel AH, et al. Osteomyelitis of the skull base, etiology unknown. Otolaryngol Head Neck Surg 1991;104:252–6. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngolo Clin North Am 2008;41:537–49. viii–ix. Shiga K, Ogawa T, Maki A, Concomitant chemoradiotherapy as a standard treatment for squamous cell carcinoma of the temporal bone. Skull Base 2011;21:153–8. Bakhos D, Chenebaux M, Lescanne E, et al. Two cases of temporal bone metastases as presenting sign of lung cancer. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:54–7. Fayemi AO, Toker C. Primary adenocarcinoma of the middle ear. Arch Otolaryngol 1975;101:449–52. McDonald M, Brophy BP, Raymond W. Intracranial invasion from a primary adenocarcinoma arising in the middle and external ear. ANZ J Surg 1995;65:454–6. Zhang T, Dai C, Wang Z. The misdiagnosis of external auditory canal carcinoma. Eur Arch Otorhinolaryngol 2013;270(5):1607–13. Hollis S, Evans K. Management of malignant (necrotising) otitis externa. J Laryngol Otol 2011;125:1212–17.
Learning points ▸ Necrotising otitis externa (NOE) should be considered in immunocompromised or elderly patients and those who do not improve following initial treatment. ▸ Biopsies for histology should always be taken in patients suspected of having NOE in order to exclude neoplastic disease. ▸ CT findings are not pathognomic in cases of skull base osteomyelitis and cannot always rule out a neoplasm. ▸ A failure to improve or worsening symptoms in a patient with NOE warrants further investigation. ▸ Deep tissue samples from the mastoid may be required in some patients in order to make an accurate diagnosis of NOE or neoplasm. Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
3
Reminder of important clinical lesson
Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
CASE REPORT
Concurrent necrotising otitis externa and adenocarcinoma of the temporal bone: a diagnostic challenge Neil Foden,1 Christopher Burgess,1 Stephen Damato,2 James Ramsden1 1
Department of ENT, John Radcliffe Hospital, Oxford, UK Department of Pathology, John Radcliffe Hospital, Oxford, UK
2
Correspondence to Neil Foden, [email protected]
SUMMARY We present a case of an 81-year-old man who was diagnosed with a necrotising (malignant) otitis externa (NOE). Initial biopsies from the external auditory canal showed scanty squamous epithelium but no evidence of malignancy. Despite an initial improvement on intravenous antibiotics and subsequent discharge from hospital, the patient returned with worsening otalgia. Following readmission to the hospital, intravenous antibiotics were restarted. Despite this, the patient developed a lower motor neurone palsy of cranial nerve VII on the ipsilateral side of the pain. He was taken to the theatre for an exploration of the left mastoid with further biopsies. Adenocarcinoma was diagnosed histologically and the patient was started on palliative radiotherapy. This case adds to the known literature on metastatic disease in the temporal bone and highlights the need to exclude malignancy in cases of NOE.
BACKGROUND Malignant (necrotising) otitis externa was first described by Chandler in 1968.1 When otitis externa progresses to an osteomyelitis of the bony ear canal or skull base, it is termed ‘malignant/ necrotising otitis externa.’2 The latter description is preferred to avoid confusion with neoplasia. It is an infective not a neoplastic condition but can be fatal if advanced or inadequately treated. Necrotising otitis externa (NOE) is classically seen in the elderly, patients with diabetes mellitus and those who are immunocompromised.3 Malignancy arising in the temporal bone is rare. Squamous cell carcinoma (SCC) is most commonly seen.4 Adenocarcinoma is rarely seen and when it does, it is usually metastatic5 (usually from primaries in the lungs, breast, liver, kidneys, stomach or prostate) although it has been reported as being primary.6 Adenocarcinoma in the temporal bone with an unknown primary is exceptionally rare. We present a challenging case of concurrent NOE and undiagnosed adenocarcinoma of the temporal bone. It is essential to consider malignancy in all cases of NOE and the identification of infection does not necessarily preclude malignancy. To cite: Foden N, Burgess C, Damato S, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2013-009155
was being treated conservatively. There was no history of immunosuppression or diabetes mellitus. Despite regular aural microsuctioning and topical antibiotics in the clinic over a 2-week period, the condition progressed and otalgia disturbed his sleep. NOE was suspected. Swabs were taken for culture and sensitivity. A Pope wick was inserted into the external auditory canal (EAC), topical antibiotics (Sofradex: dexamethasone 0.05%, framecytin 0.5% and gramicidin 0.005%) were instilled and he was started on intravenous piperacillin/tazobactam. Blood results included a white cell count of 4.22, erythrocyte sedimentation rate 2.0 and a C reactive protein of 4.0. A CT temporal bone was arranged that showed extensive necrotising external otitis and mastoiditis (figure 1). The patient was taken to the theatre for an examination under anaesthetic and biopsy of the EAC. The histology was reported as scanty squamous epithelium, although the sample was superficial. The patient improved clinically with no further otalgia and normal inflammatory markers and was discharged on oral antibiotics. Two weeks after discharge, the patient was re-admitted with increasing otalgia. A further CT showed appearances in keeping with external otitis and mastoiditis with extensive cortical bony erosion of the EAC and mastoid. Intravenous antibiotics were restarted.
CASE PRESENTATION An 81-year-old man was seen in the ENT (ear, nose and throat) emergency clinic and diagnosed with otitis externa in the left ear. He had a history of chronic infection in a total hip replacement that
Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
Figure 1 Axial CT temporal bone showing necrotising external otitis and mastoiditis on the left. 1
Reminder of important clinical lesson Despite treatment, he developed a seventh (VII) cranial nerve palsy on the ipsilateral side. It was decided to proceed with a surgical exploration of the left mastoid, modified radical mastoidectomy and muscle obliteration of the cavity. Surgical findings included a dehiscent middle fossa plate and tegmen tympani with an intact but oedematous dura. The posterior canal wall of the EAC was dehiscent with erosion of the floor of the canal. Tissue samples were sent for microbiology and histology. The culture was positive for a growth of coagulase negative Staphylococcus.
INVESTIGATIONS Thyroid function tests, colorectal tumour markers and prostate specific antigen (PSA) were negative.
Pathological findings Biopsies were taken from the left EAC and deeper samples from the mastoid. Histology from the former revealed a poorly differentiated adenocarcinoma with widespread lymphovascular invasion and focal perineural invasion. The section from the mastoid biopsy section showed amorphous necrotic material with very occasional small clusters of malignant cells at the periphery (figure 2). Immunohistochemistry showed that the tumour cells were diffusely and strongly positive for cytokeratin 7 (CK7). CK20, thyroid transcription factor 1 (TTF1), PSA and CDX2 were negative.
Further imaging MRI of the head and neck with gadolinium contrast showed appearances suggestive of a mix of neoplastic infiltration at the petrous bone particularly at the anterior petrous ridge and a secondary otitis externa (figure 3). Delineation between the two areas was poor. Lymphadenopathy was noted in the parotid along with levels IIa, IIb and V. The level IIb node was more suspicious for neoplastic lymphadenopathy owing to its intermediate diffusion characteristics. A fluorodeoxyglucose-positron emission tomography of the whole body was subsequently performed. This revealed appearances of the temporal bone resection site in keeping with residual tumour and postsurgical inflammation with involved local lymph nodes and bone metastases in C7, T5 and the right
Figure 2 The tumour cells are principally arranged in solid nests with only focal lumen formation. There is marked nuclear pleomorphism and brisk mitotic activity. 2
Figure 3
MRI of the head revealing the tumour.
second rib. No alternative primary tumour site was demonstrated (figure 4).
DIFFERENTIAL DIAGNOSIS ▸ ▸ ▸ ▸ ▸
NOE SCC of the temporal bone Metastatic carcinoma of the temporal bone Fibrous dysplasia Paget’s disease
OUTCOME AND FOLLOW-UP The patient was discussed at a multidisciplinary team meeting. Surgery was not considered to be an option in light of the presence of metastatic disease. The patient subsequently underwent palliative radiotherapy of the affected area for pain relief.
DISCUSSION Diagnosing NOE is based on a thorough history and examination. A history of immunosuppression should alert clinicians. Suspicion should be raised by otalgia out of proportion to uncomplicated otitis externa, otorrhoea and findings of granulomatous tissue in the EAC. Uncomplicated otitis externa tends to respond to aural cleaning and topical antibiotics.7 Cultures must be sent for microbiology, tissue for histology and radiology (usually CT temporal bones) to assess for osteomyelitis or bony erosion. The most common causative organism is Pseudomonas aeruginosa.8 Negative cultures have been found in cases of NOE9 and the absence of a positive culture should not delay antimicrobial treatment. The differential diagnosis includes neoplasm, Paget’s disease, clival lesions and fibrous dysplasia. Biopsies are essential as there is much in common between osteomyelitis (NOE) and neoplasia on radiographic imaging, thus distinguishing the two can be difficult.10 Although neoplasms of the temporal bone are rare, they carry significant morbidity and mortality. Surgical resection can be difficult owing to complex regional anatomy and can often result in damage to the facial nerve and hearing loss.11 Metastatic adenocarcinoma of the temporal bone from a primary in the lung presenting with cranial nerve palsy has been described.12 Although less likely, primary adenocarcinoma of the temporal bone is thought to arise from the ceruminous glands,4 or mucosa of the middle ear, Eustachian tube, mastoid cells or mucous glands of the tympanum.13 They can be slow growing, often without causing metastases, but intracranial extension is possible.14 As Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
Reminder of important clinical lesson Contributors NF was involved in the conception of the idea to write the case report and writing the report. CB was involved in the writing of the report and obtaining radiography images. SD was involved in the histopathology interpretation. JR was involved in the editing of the case report. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
4 5
6
Figure 4 Positron emission tomography CT demonstrating uptake in the left temporal bone and cervical lymph nodes.
7 8
most adenocarcinomas found in the temporal bone are metastatic, it is imperative to try to exclude a primary elsewhere. Diagnostic pitfalls exist. The incidence of neoplasia in the middle ear/temporal bone is so low that many clinicians may not be alerted to the possibility of such a diagnosis; the symptoms are often non-specific (although bloody otorrhoea may be a useful indicator) and biopsies may not always prove adequate.15 This case was made much more challenging by virtue of the concurrent presence of two diagnoses at the same time. Neoplasia is considered a differential diagnosis for patients suspected of having NOE.16 Despite a thorough initial workup of the patient during the first admission, evidence of neoplasia was not found. A negative culture found on the first admission was possibly because the patient had been treated with regular topical antibiotics since prior to the admission. Owing to the development of worsening symptoms and the onset of a facial nerve palsy (which could also potentially be attributable to skull base osteomyelitis), further investigation was necessary. Obtaining deeper biopsies from the mastoid was key to diagnosis in this case. A high index of suspicion for neoplasia should be maintained in cases of possible NOE.
9 10 11
12
13 14
15 16
Chandler JR. Malignant external otitis. Laryngoscope 1968;78:1257–94. Nadol JB Jr. Histopathology of Pseudomonas osteomyelitis of the temporal bone starting as malignant external otitis. Am J Otolaryngol 1980;1:359–71. Rubin Grandis J, Branstetter BFt, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infec Dis 2004;4:34–9. Kinney SE, Wood BG. Malignancies of the external ear canal and temporal bone: surgical techniques and results. Laryngoscope 1987;97:158–64. Gloria-Cruz TI, Schachern PA, Paparella MM, et al. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14. Paulus W, Romstock J, Weidenbecher M, et al. Middle ear adenocarcinoma with intracranial extension. Case report. J Neurosurg 1999;90:555–8. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2006;134(4 Suppl):S4–23. Slattery WH III, Brackmann DE. Skull base osteomyelitis. Malignant external otitis. Otolaryngol Clin North Am 1996;29:795–806. Sie KC, Glenn MG, Hillel AH, et al. Osteomyelitis of the skull base, etiology unknown. Otolaryngol Head Neck Surg 1991;104:252–6. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngolo Clin North Am 2008;41:537–49. viii–ix. Shiga K, Ogawa T, Maki A, Concomitant chemoradiotherapy as a standard treatment for squamous cell carcinoma of the temporal bone. Skull Base 2011;21:153–8. Bakhos D, Chenebaux M, Lescanne E, et al. Two cases of temporal bone metastases as presenting sign of lung cancer. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:54–7. Fayemi AO, Toker C. Primary adenocarcinoma of the middle ear. Arch Otolaryngol 1975;101:449–52. McDonald M, Brophy BP, Raymond W. Intracranial invasion from a primary adenocarcinoma arising in the middle and external ear. ANZ J Surg 1995;65:454–6. Zhang T, Dai C, Wang Z. The misdiagnosis of external auditory canal carcinoma. Eur Arch Otorhinolaryngol 2013;270(5):1607–13. Hollis S, Evans K. Management of malignant (necrotising) otitis externa. J Laryngol Otol 2011;125:1212–17.
Learning points ▸ Necrotising otitis externa (NOE) should be considered in immunocompromised or elderly patients and those who do not improve following initial treatment. ▸ Biopsies for histology should always be taken in patients suspected of having NOE in order to exclude neoplastic disease. ▸ CT findings are not pathognomic in cases of skull base osteomyelitis and cannot always rule out a neoplasm. ▸ A failure to improve or worsening symptoms in a patient with NOE warrants further investigation. ▸ Deep tissue samples from the mastoid may be required in some patients in order to make an accurate diagnosis of NOE or neoplasm. Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
3
Reminder of important clinical lesson
Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Foden N, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009155
