Endocrine Abstracts

Background: Fungal necrotizing external otitis (NEO) is a serious and potentially life-threatening infection that is challenging to manage. It affects almost exclusively elderly diabetic patients. The diagnosis is often delayed and it is a rare disease, although its frequency has increased over the last few years. We aim through this study to share our experience in the management of a case of fungal NEO complicated by a retropharyngeal abscess in a diabetic patient and discuss its diagnosis tools, anti-fungal treatment choice, and outcomes.

Methods: We report a rare case of invasive necrotizing external otitis caused by Aspergillus flavus in a diabetic patient without other underlying immunosuppression. A review of Aspergillus spp. malignant external otitis since voriconazole became the first line for invasive aspergillosis was performed.

Case Presentation: We present a case of a 77 year old man with a history of type 2 diabetes, dyslipidemia and an ischemic cerebrovascular accident. He was admitted to our department 8 months ago for the management of bilateral NEO, which was treated with optimal antimicrobial therapy and cured. The reason for his consultation was facial palsy associated with odynophagia for two days. Physical examination revealed a right peripheral facial paralysis grade V and a swelling in the posterior pharyngeal wall. The rest of the examination was normal. Laboratory tests indicated a biological inflammatory syndrome. A computed tomography scan was performed, revealing a retropharyngeal collection measuring 4 cm with osteitis of the skull base. The patient was treated with empiric courses of antibiotics until a fungal infection was diagnosed and he underwent endoscopic endonasal drainage of the abscess under general anesthesia. Proven Apsergillus infection was based on culture and serologic test. The equilibration of diabetes was obtained. Treatment was based on a combination of ceftazidime and fluoroquinolone for several weeks, associated with voriconazole during 3 months. After a follow-up of one year, he had been cured with normalization of the biological, and imaging features, but with persistent facial palsy.

Conclusions: Given our experience and the literature review, fungal NEO is an aggressive and potentially fatal infection. A fungal etiology should be considered early in the course of invasive necrotizing external otitis unresponsive to a conventional broad spectrum antibiotic therapy or in case of complications, with the need for positive culture swabs and/or positive serologic test to a fungal pathogen to confirm the diagnosis.