A 65-year-old man with poorly controlled diabetes and hypertension reported progressive otalgia and otorrhea in his left ear for 8 months. He was only treated with symptomatic medications in the emergency services during this time. Five months later, he noticed loss of visual acuity in the left eye and hearing loss in the left ear, progressing soon after with left peripheral facial palsy. During the next two months, he evolved with left eye proptosis (Figs. 1 and 2 ), complete visual loss and ophthalmoplegia (Figs. 1 and 2), in addition to hearing loss in the right ear. He was initially evaluated by a primary care otorhinolaryngologist, who suspected the diagnosis of MEO and initiated ciprofloxacin 500 mg twice a day. After 7 days he was referred to our tertiary hospital for additional specialized diagnostic and therapeutic evaluations. On physical examination, there was a clear left eye proptosis and blindness, with absent direct photomotor reflex and preserved consensual reflex, impairment of left oculomotor, trochlear and abducent nerves, determining complete ophthalmoplegia, left peripheral facial palsy, complete hearing loss on the left and partial hearing on the right.
Considering the severity of the case, the high risk of infectious spread to the brain parenchyma and meninges and the microbiological profile of the hospital, it was opted to switch the antibiotic therapy to meropenem 2 g intravenous infusion every 8 h and vancomycin 1 g intravenous infusion twice a day.
Initial computed tomography (CT) of the head showed erosion of the anterior wall of the left external ear conduct and of the left mandible condyle and dehiscence of the external auditory canal, without other bone changes. (Fig. 3). Besides, there was a bilateral veiling of the mastoid air cells, more pronounced on the left. The magnetic resonance image (MRI) of the brain revealed a tissue occupying the left superior orbital fissure intraconal fat, with invasion of the left orbit, determining nerve compression (Figs. 4 and 5 ). There was involvement of the left optic, oculomotor, trochlear and abducent nerves, enhancement of the extrinsic ocular muscles and proptosis. Superior ophthalmic veins were preserved bilaterally and there was no evidence of cavernous sinus thrombosis. There was also heterogeneity of the whole sphenoid bone with hyperintensity on T2/FLAIR images and contrast enhancement (Figs. 4 and 5), tissue thickening and enhancement around the left temporo-mandibular articulation, besides contrast enhancement on the trajectory of the left facial nerve.
Ten days after initiation of antibiotics (7 days of oral ciprofloxacin and 3 days of meropenem and vancomycin), the patient underwent left canal wall-up mastoidectomy, with removal of tissue samples for microbiological evaluation, including Mycobacterium tuberculosis and fungus. During the surgical procedure, the mastoid cavity was cleaned, an integral ossicular chain was observed, as well as the tympanic membrane and disease-free middle ear. It was also opted for the insertion of ear ventilation tube bilaterally. The external ear canal skin fragments revealed mixed inflammatory infiltrate content with necrosis areas and multinucleated giant cells; the mastoid bone material showed chronic inflammatory infiltrate content. All microbiological tests performed were negative, and this was interpreted as a possible consequence of the early use of antibiotics.
The patient had no surgical complications, presented good recover of the right ear hearing capacity after 2 days, but showed no improvements of the neurological deficits nor the left ear hearing function, probably because of the chronicity of the case. Due to clinical stability and normal laboratory parameters, after 7 days of the surgical procedure the antibiotic therapy was switched to ciprofloxacin 400 mg intravenous infusion twice a day with a further objective of oral domiciliar ciprofloxacin, in order to totalize 6 week treatment period. Unfortunately, we have been facing dramatic months of COVID-19 pandemic, causing great apprehension specially over the hospitalized patients. Although the patient in case was not in the COVID-19 hospital section, on the 14th day of hospitalization, he initiated fever, dry cough and evolved after 2 days with dyspnea, motivating oral intubation and transfer to COVID-19 intensive care unit. The reverse transcription polymerase chain reaction (RT-PCR) confirmed Sars-CoV-2 infection. As an elderly man, with poorly controlled diabetes and in current malignant external otitis treatment, the patient had a poor outcome on this new coronavirus infection and sadly passed away after 10 days. This reflects the actual reality of the world and the difficulty of managing hospitalized patients during this COVID-19 pandemic.