A 61-year-old man presented with severe otalgia and otorrhea. He had a 35-year history of right-sided intermittent otorrhea, aural fullness, and tinnitus and a 3-month history of decreased balance. Topical and systemic antibiotic therapy was initiated, but his symptoms persisted, and new symptoms of severe facial pain and fever developed. He had no history of immunocompromise. Physical examination revealed an edematous, mildly erythematous right external auditory canal, with purulent discharge obscuring the tympanic membrane. There was no pain with movement of the pinna. Temperature, light touch, and sharp and dull stimuli were reduced in the right trigeminal distribution. Audiometric testing showed a down-sloping, moderate to profound mixed hearing loss in the patient's right ear. Computed tomography of the temporal bone with intravenous contrast showed opacification of the right middle ear, sclerotic mastoid with erosion of the carotid canal adjacent to the eustachian tube, and a peripherally enhancing low-density petrous apex collection (Figure 1). Gadolinium-enhanced magnetic resonance imaging also demonstrated a low-signal focus in the right petrous apex, with enhancement and thickening of the cisternal portion of the right trigeminal nerve and meninges of the posterior clivus and sphenoid wing (Figure 2). View LargeDownload Figure 1. View LargeDownload Figure 2. Hematoxylin-eosin staining of biopsy specimens of granulomatous tissue from the protympanum and petrous apex demonstrated acute and chronically inflamed ciliated columnar epithelium and granulation tissue (Figure 3). Grocott-Gomori methenamine-silver nitrate staining (Figure 4) showed aggregates of gram-positive filamentous bacteria in entangled masses focally breaking up into coccoid and bacillary forms. Cultures identified Proteus mirabilis, Enterococcus avium, and multiple strains of Corynebacterium species with sensitivity to ciprofloxacin. View LargeDownload Figure 3. View LargeDownload Figure 4. What is your diagnosis?
Archives of Otolaryngology - Head & Neck Surgery
– American Medical Association
Published: Feb 1, 2012
Keywords: nitrate,magnetic resonance imaging,enterococcus,edema,computed tomography,biopsy,ciprofloxacin,physical examination,fever,audiometry,corynebacterium,ear,external auditory canal,middle ear,earache,eosine yellowish-(ys),eustachian tube,facial pain,gadolinium,gram-positive bacteria,gram-positive bacterial infections,gram-positive cocci,gram-positive rods,granulation tissue,hematoxylin,mastoid process,methenamine,pain,patient rights,proteus mirabilis,sphenoid bone,temporal bone,therapeutic touch,tinnitus,trigeminal nerve,tympanic membrane,bacteria,body temperature,meninges,silver,temperature,antibiotic therapy,pinna,balance impairment,hearing loss, mixed conductive-sensorineural,clivus,otorrhea,erosion,opacification,touch sensation,columnar epithelium