Koninklijke Bibliotheek, National Library of the Netherlands
IP1491214940416
A 70-year-old man with severe deep paroxysmal ear pain
Oliveira, Aleli T.
Ferreira, Natália R.
Marques, Marise P.C.
Cunha Jr., Ricardo
Bahia, Paulo R.V.
Carvalho, Antônio C.P.
DosSantos, Marcos F.
Monteiro, André A.
text
article
monographic
Interdisciplinary neurosurgery : advanced techniques and case management
continuing
22147519
0000000013588
7
C
text
Born digital tijdschriften
KB collectiekavel
text
Elektronische Wetenschappelijke Tijdschriften
EWTIJ
10.1016/j.inat.2016.11.006
urn:nbn:nl:kb-1491214940160
Automatisch gegenereerd op basis van de EWTIJ XML in release 1.5 van het digitaal magazijn.
INAT
157
S2214-7519(16)30102-5
10.1016/j.inat.2016.11.006
The Authors
Fig. 1
Sagittal (A), axial (B) and coronal (C) T1-weighted head MRI images.
Fig. 1
Letter to the Editor
A 70-year-old man with severe deep paroxysmal ear pain
Aleli T.
Oliveira
D.D.S.
a
b
⁎
aleli.torres@yahoo.com.br
Natália R.
Ferreira
D.D.S.
a
b
Marise P.C.
Marques
M.D., M.S. Ph.D.
c
Ricardo
Cunha
Jr.
d
Paulo R.V.
Bahia
M.D., Ph.D.
b
Antônio C.P.
Carvalho
M.D., Ph.D.
b
Marcos F.
DosSantos
D.D.S., M.S., Ph.D
e
André A.
Monteiro
D.D.S., M.S.
Odont. Dr.
a
a
Departamento de Clínica, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro (UFRJ), Brazil
Departamento de Clínica
Faculdade de Odontologia
Universidade Federal do Rio de Janeiro (UFRJ)
Brazil
b
Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Brazil
Departamento de Radiologia
Faculdade de Medicina
Universidade Federal do Rio de Janeiro (UFRJ)
Brazil
c
Serviço de Otorrionolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Serviço de Otorrionolaringologia
Hospital Universitário Clementino Fraga Filho
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
d
Clínica de Dor e Cuidados Paliativos, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Clínica de Dor e Cuidados Paliativos
Hospital Universitário Clementino Fraga Filho
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
e
Laboratório de Morfogênese Celular (LMC), Insituto de Ciências Biomédicas (ICB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Laboratório de Morfogênese Celular (LMC)
Insituto de Ciências Biomédicas (ICB)
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
⁎
Corresponding author at: Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho, 373, Centro de Ciências da Saúde, Bloco K, 2° andar, Sala 56, Ilha da Cidade Universitária, Rio de Janeiro, RJ CEP: 21.941-902, Brazil.
Faculdade de Odontologia
Universidade Federal do Rio de Janeiro
Av. Carlos Chagas Filho, 373
Centro de Ciências da Saúde
Bloco K, 2° andar, Sala 56
Ilha da Cidade Universitária
Rio de Janeiro
RJ
CEP: 21.941-902
Brazil
1
Clinical background
A 70year-old man was admitted to the orofacial pain clinic with a 6months history of severe, paroxysmal episodes of stabbing pain in the depth of the left ear canal. According to the patient's self-report, a previous neurological examination had not found abnormalities. Also, three months before, he had been successfully treated for a left external otitis. Nonetheless, the pain persisted. Upon the clinical examination, no signs of peripheral lesions (face and oral mucosa) or scar tissues were identified. However, several attacks of very intense pain (10/10 on the visual analogue scale) on the left ear canal and radiating to the ipsilateral temporal region were observed. The pain was either spontaneous or elicited by light tactile stimulation of the ipsilateral concha but not by pressure stimuli or mandibular movements. Cranial nerve examination was normal, except for a left anacusis, right hypoacusis and a discrete paresis of the left orbicularis. Past medical history included type II diabetes mellitus and a left otosurgery several years later. A head MRI was obtained (Fig. 1
) and laboratorial tests were requested.
2
What is the most likely diagnosis?
A.
Symptomatic trigeminal neuralgia.
B.
Postherpetic neuralgia.
C.
Nervus intermedius neuralgia due to malignant otitis externa.
D.
Ramsay Hunt syndrome.
E.
Nervus intermedius neuralgia due to nasopharyngeal tumor.
3
Answer
C.
Nervus intermedius neuralgia due to malignant otitis externa.
4
Discussion
MRI revealed an infiltrative tissue, with intermediate signal intensity in T1, extending from the left pharyngeal recess to the petrous part of the temporal bone and left internal acoustic meatus. The left facial nerve exhibited contrast-enhancement into the geniculate ganglion, tympanic and mastoid segments. A suspicious area lateral to the nasopharynx was also identified. Blood tests showed increased ESR, high levels of PCR and hyperglycemia. Gallium-67 scintigraphy suggested an ongoing inflammatory/infectious process in the left mastoid process, which as confirmed by an open mastoid biopsy. Such findings led to a diagnosis of nervus intermedius neuralgia due to malignant otitis externa. Antibiotic therapy with ciprofloxacin was initiated, based on the gram stain and culture results, collected by a swab of the external acoustic meatus and further confirmed by the biopsy specimens. This treatment was associated with carbamazepine for pain control. The patient improved and became stable after six weeks of the therapy applied. However, the pain recurred after six months. In addition, MRI and 67-gallium scintigraphy revealed that the disease was advancing. Therefore, it was necessary to return to intra-venous antibiotic therapy (piperacillin and tazobactam), based on the biopsy results. The disease is currently under control.
Osteomyelitis affecting the temporal bone (often referred to as malignant otitis externa) is not common. Diabetes mellitus is the most frequent predisposing factor [1] and one possible explanation is the presence of a more alkaline pH of the cerumen in the ears of diabetic patients, that could create a favorable environment for bacterial proliferation [2]. Mastoid involvement can produce facial nerve palsy, while the IX, X and XI cranial nerves can be compromised when the lesion spreads to the jugular foramen. Nonetheless, the occurrence of nervus intermedius neuralgia as an initial symptom of a malignant otitis externa is extremely rare.
Conflict of interest/disclosures
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
References
[1]
S.C.
Prasad
K.C.
Prasad
A.
Kumar
Osteomyelitis of the temporal bone: terminology, diagnosis, and management
J. Neurol. Surg. B Skull Base
75
2014
324
331
[2]
P.V.
Driscoll
A.
Ramachandrula
D.A.
Drezner
Characteristics of cerumen in diabetic patients: a key to understanding malignant external otitis?
Otolaryngol. Head Neck Surg.
109
1993
676
679
INAT
157
S2214-7519(16)30102-5
10.1016/j.inat.2016.11.006
The Authors
Letter to the Editor
A 70-year-old man with severe deep paroxysmal ear pain
Aleli T.
Oliveira
D.D.S.
a
b
⁎
aleli.torres@yahoo.com.br
Natália R.
Ferreira
D.D.S.
a
b
Marise P.C.
Marques
M.D., M.S. Ph.D.
c
Ricardo
Cunha
Jr.
d
Paulo R.V.
Bahia
M.D., Ph.D.
b
Antônio C.P.
Carvalho
M.D., Ph.D.
b
Marcos F.
DosSantos
D.D.S., M.S., Ph.D
e
André A.
Monteiro
D.D.S., M.S.
Odont. Dr.
a
a
Departamento de Clínica, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro (UFRJ), Brazil
Departamento de Clínica
Faculdade de Odontologia
Universidade Federal do Rio de Janeiro (UFRJ)
Brazil
b
Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Brazil
Departamento de Radiologia
Faculdade de Medicina
Universidade Federal do Rio de Janeiro (UFRJ)
Brazil
c
Serviço de Otorrionolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Serviço de Otorrionolaringologia
Hospital Universitário Clementino Fraga Filho
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
d
Clínica de Dor e Cuidados Paliativos, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Clínica de Dor e Cuidados Paliativos
Hospital Universitário Clementino Fraga Filho
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
e
Laboratório de Morfogênese Celular (LMC), Insituto de Ciências Biomédicas (ICB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
Laboratório de Morfogênese Celular (LMC)
Insituto de Ciências Biomédicas (ICB)
Universidade Federal do Rio de Janeiro (UFRJ)
Rio de Janeiro
Brazil
⁎
Corresponding author at: Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho, 373, Centro de Ciências da Saúde, Bloco K, 2° andar, Sala 56, Ilha da Cidade Universitária, Rio de Janeiro, RJ CEP: 21.941-902, Brazil.
Faculdade de Odontologia
Universidade Federal do Rio de Janeiro
Av. Carlos Chagas Filho, 373
Centro de Ciências da Saúde
Bloco K, 2° andar, Sala 56
Ilha da Cidade Universitária
Rio de Janeiro
RJ
CEP: 21.941-902
Brazil
KBJ00000000006166
2017-04-01T23:22:01
S300.2
S300
S2214-7519(16)30102-5
10.1016/j.inat.2016.11.006
INAT
2214-7519
157
COR
NON-CRC
UNLIMITED
2016-11-23T15:37:35Z
22147519/v7sC/S2214751916301025/main.xml
14838
MAIN
JA 5.4.0 SIMPLE-ARTICLE
FULL-TEXT
22147519/v7sC/S2214751916301025/main.assets/gr1.sml
15834
IMAGE-THUMBNAIL
22147519/v7sC/S2214751916301025/main.assets/gr1.jpg
33868
IMAGE-DOWNSAMPLED
22147519/v7sC/S2214751916301025/main.pdf
229964
MAIN
1.7 6.5
DISTILLED OPTIMIZED BOOKMARKED
22147519/v7sC/S2214751916301025/main.raw
6323
S2214-7519(16)X0005-9
INAT
2214-7519
7
C
201703
1
78
S2214-7519(16)30102-5
10.1016/j.inat.2016.11.006
73
74
main.pdf
PDF
1.7
local
1491214940160
collectiebehoudsniveau 1
2017-04-03T10:44:44.120+02:00
local
1491214940672
0
SHA-512
ffe8157d189a940355a71d9dd9c21e1634df633f22fcc9069193fedf752abbd64e33ed3a0b322de0f66b4987b868c630710cf42b69afd2401e3d788114f42c92
java.security.MessageDigest
12625
not checked
metadata.xml
local
1491214940673
0
SHA-512
3beb788854dfcd9bbdece445a4d12b24c201ebd65d5e9b2157acc7f5fc61a5eb3810475aecb4b9460281d9544b2eebebf51a6bce49b699c637dfac8b80a75602
java.security.MessageDigest
15834
not checked
gr1.sml
local
1491214940674
0
SHA-512
25aa3be38022c94dc8d31436af3d000d5da329cae49f0e992b5e6c2f1c8741ce3d6e72f05f6549ebcb42c3821123ceb1f2e01d5d8df0a05a28f3ce98d3adaf7c
java.security.MessageDigest
33868
not checked
gr1.jpg
local
1491214940675
0
SHA-512
46e81b4a869ed1789b7b3a4bcc49975af996e5375f70329116ee03f09b6b7a102b7c2e2e0d17daff857ddc364c93e3618476c221152a9309bd0cec2c34a23d57
java.security.MessageDigest
6323
not checked
main.raw
local
1491214940676
0
SHA-512
b8c6493f96947dc728e4f1fbcb85004eb417f8c74f7ad82d5e28515954ea393a24dfde5c9f184092627a76699adfdf99e28539f0046d9542c1f134522af39d87
java.security.MessageDigest
229964
Adobe Acrobat Document
1.7
DIAS
62
DIAS tentative identification
main.pdf
local
1491214940677
0
SHA-512
821fed6b771bd4e97b25bb5e0bdee905546418a617668479226bb6f06dabc6d05bbb1459f6c5f8e094e1f8982fb5e88812d824a6c2dbd9a7e2e79669b26e2926
java.security.MessageDigest
14838
not checked
main.xml
free
00001
The Authors
KB-agent-id
1
supplier
KB-owner-id
00001
KB-agent-id
1
Elsevier
organization
The Authors
ingestion
2017-04-03T10:44:44.120+02:00
Connector
software
Digitaal Magazijn release 1.5
ejournals_esp_1
streamprofile
ingestion2017-04-03T12:43:55.357+01:00Generic IngestsoftwareDigitaal Magazijn release 1.5