Presentation
Right ear pain and pus discharge for two weeks. Known case of diabetes mellitus.
Patient Data
Ill-defined enhancing soft tissue at the right pharyngeal mucosal space and right parapharyngeal space, associated with bony erosions at the petrous apex of the right temporal bone, right pterygoid bone, greater wing of the right sphenoid bone, right carotid canal, right Vidian canal, the roof of right external auditory canal, right tegmen tympani and right temporomandibular joint. The right scutum is sharp.
Rim enhancing collection was noted at the condyle of the right mandible in keeping with abscess formation.
Enhancing soft tissue at the nasopharynx obliterating bilateral fossa of Rossenmueller.
The petrous portion of the right internal carotid artery is encased by the soft tissue where it is still opacified.
The right internal jugular vein is patent.
Fluid opacification at the right middle ear cavity and right mastoid air cells. Right middle ear ossicles are intact.
Swelling and convexity at the right cavernous sinus are suspicious of infiltration.
Enhancing smooth thickened dura was noted at the right temporal fossa.
No focal brain parenchymal lesion. No hydrocephalus. The right sigmoid sinus is well opacified.
Left EAC, middle ear, and mastoid air cells are clear.
Case Discussion
The patient has a background history of poorly controlled type II diabetes mellitus. Initially treated as right acute suppurative otitis media with two different courses of oral antibiotics (cefuroxime and clarithromycin), but symptoms were not resolved.
Pus swab culture isolated Pseudomonas Aeruginosa.
Correlating with a background of diabetes mellitus (immunocompromise) and culture of pseudomonas, CT features are in keeping with right necrotizing otitis externa with skull base osteomyelitis.
Enhancing right temporal dura and possible right cavernous sinus enlargement suggest intracranial extension.
Right temporomandibular joint abscess formation.
The patient was treated aggressively with an intravenous antibiotic (Cetazidime).
Necrotizing otitis externa usually requires a prolonged course of antibiotic (6 weeks).