A Listening Ear 2017-05-18T12:59:27+00:00

A little known complication of long term diabetes is Malignant Otitis Externa which requires diagnosis and treatment very promptly on presentation.  Adults who have had diabetes for a long time will likely have a weakened immune system and are prone to infection.  Researchers in Italy in 2001 started to explore the effect that diabetes may have on hearing loss and 47 patients treated with insulin were noted to have impairments in the spinal canal in the ear.  Problems often began with a lesion in the inner ear possibly caused by neuropathy.  Studies have shown that hearing loss in the high frequency area of the ear can lead to progressive hearing loss.  442 cases of malignant otitis externa were recorded in England in 2013/14 and seen in hospital and more treated by GP’s at home. Diabetes is flagged up as an underlying cause.  Pain associated with Malignant Otitis Externa often starts around 7 – 8 pm in the evening and becomes worse until 2.00 – 3.00am leading to difficulty in sleeping.  Pain experienced during the day is usually manageable with prescribed pain management.

Otitis externa is a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum.  Otitis externa is often referred to as “swimmer’s ear” because repeated exposure to water can make the ear canal more vulnerable to inflammation. Symptoms include:

  • ear pain, which can be severe
  • itchiness in the ear canal
  • a discharge of liquid or pus from the ear
  • some degree of temporary hearing loss

Only one ear is usually affected and with treatment symptoms should clear up in a few days.  Some cases can persist for several months or longer.  Malignant Otitis Externa is a serious but rare complication of Otitis Externa where the infection spreads to the bone surrounding the ear canal.

When to see your GP   You should see your GP promptly if you think you may have otitis externa.

Your GP will ask about your symptoms and whether you regularly use any items that are inserted into your ears, such as hearing aids or ear plugs. They may also examine inside your ear using an otoscope.  If you have recurring episodes of otitis externa that haven’t responded to treatment, your GP may take a swab of the inside of your ear. This will be tested to help determine what type of infection you have, if any, so appropriate medication can be prescribed and treatment effected.

What causes otitis externa?  Most cases of otitis externa are caused by a bacterial infection but can also be caused by:

  • irritation
  • fungal infections
  • allergies

There are a number of things that can make you more likely to develop otitis externa, including:

  • damaging the skin inside your ear
  • regularly getting water in your ear

Getting water in your ear is particularly significant, because this can cause you to scratch inside your ear, and the moisture also provides an ideal environment for bacteria to grow.

Who is affected?  Otitis externa is relatively common. It’s estimated that around 1 in 10 people will be affected by it at some point in their lives.

The condition is slightly more common in women than men and is most often diagnosed in adults aged 45 to 75.

People with certain long-term (chronic) conditions are at greater risk of developing the condition including:

How otitis externa is treated:  Otitis externa sometimes gets better without treatment, but it can take several weeks. Your GP can prescribe ear drop medication that usually improves the symptoms within a few days.

There are a number of different types of ear drops or spray that may be used to treat otitis externa, which tend to be used several times a day for about a week.   Your GP may refer you to a specialist for further treatment and advice if symptoms are severe or you fail to respond to treatment.

Preventing otitis externa:  To help reduce your chances of developing otitis externa, you should avoid inserting cotton wool buds and other things into your ears (including your fingers), as this can damage the sensitive skin in your ear canal.  If you’re a regular swimmer, consider using ear plugs when swimming or wearing a swimming cap to cover your ears and protect them from water.  You should try to avoid getting water, soap or shampoo into your ears when you have a shower or bath.

Complications   of otitis externa are uncommon, but can be very serious. One rare complication of otitis externa is malignant otitis externa, which is where an infection spreads from the ear canal into the surrounding bone.  This requires prompt treatment with antibiotics and sometimes surgery.  It can be fatal if left untreated.

Weak immune system   You may be at higher risk of developing otitis externa if you have a condition that can weaken your immune system, such as long term Type 1 Diabetes.  There are a number of things that can make you more likely to develop otitis externa, including:

  • damaging the skin inside your ear
  • regularly getting water in your ear

Getting water in your ear is particularly significant, because this can cause you to scratch inside your ear, and the moisture also provides an ideal environment for bacteria to grow.

Common causes of otitis externa can include:

  • a bacterial infection – usually by bacteria called Pseudomonas aeruginosa or Staphylococcus aureus
  • seborrheic dermatitis – a common skin condition where the naturally greasy areas of your skin become irritated and inflamed, which can sometimes affect the ears
  • middle ear infection (otitis media) – discharge produced by an infection deeper in the ear can sometimes lead to otitis externa
  • a fungal infection – such as from the Aspergillus variety and the Candida albicans variety (which also causes thrush); fungal infections are more common if antibacterial or steroid ear drops are used for a long time
  • irritation or an allergic reaction – otitis externa can occur because of a reaction to something that comes into contact with your ears, such as ear medication, ear plugs, shampoo or sweat

Otitis externa can also return after previous treatment if you don’t complete the full course.

Possible triggers   The following are not direct causes but may make the condition more likely to develop.

Excessive moisture Liquid in your ear canal can make you more likely to develop an infection. Moisture provides an ideal environment for bacteria – and to a lesser degree, fungi – to grow.   Risk may be increased by:

  • swimming – particularly in dirty or polluted water
  • sweating
  • being exposed to humid environments

Water can also wash away earwax inside your ears, which can make them itchy.

Ear damage   The ear canal is very sensitive and may become damaged through:

  • scratching inside your ears
  • excessive cleaning
  • inserting cotton buds
  • wearing ear plugs or in-ear headphones for long periods
  • Using a hearing aid may also increase your risk of developing otitis externa.

Chemicals

The chances of getting otitis externa are increased if you use certain products in or near your ears, such as:

  • hair sprays
  • hair dyes
  • earwax softeners

Underlying skin conditions   As well as seborrheic dermatitis, certain underlying skin conditions can increase the risk of otitis externa. These include:

Allergic conditions   Allergic rhinitis or asthma, can lead to a higher risk of developing otitis externa.

Weak immune system   You are likely to be at higher risk of developing otitis externa if you have a condition that can weaken your immune system, such as: diabetes HIV or AIDS.  Certain cancer treatments, such as chemotherapy, may also increase your risk of otitis externa.

Malignant  Osteomyelitis

Osteomyelitis is the medical term for a bone infection, usually caused by bacteria.  Osteomyelitis most commonly affects the long bones in the legs, but other bones, such as those in the back or arms can also be affected.

Symptoms of osteomyelitis may include:

  • a high temperature (fever) of 38C (100.4F) or above
  • bone pain, which can often be intense
  • swelling, redness and a warm sensation in the affected area

The condition is often referred to as either:

  • acute osteomyelitis – when the infection develops following an injury, infection or underlying condition
  • chronic osteomyelitis – when the condition regularly returns

When to see your GP

Osteomyelitis can affect people of any age, so visit your GP if you or your child experiences persistent bone pain with a fever.

Very young children do not always develop a fever when they have osteomyelitis and they may not be able to communicate any bone pain. You should see your GP if your child becomes irritable has a reduced appetite and is reluctant to use a certain part of their body (most often an arm or leg).

Why does osteomyelitis happen?

Osteomyelitis develops when the bone becomes infected. In most cases bacteria is responsible for the infection although it can also be caused by fungi.  Blood tests and a biopsy may be used to determine whether you have an infection and what caused it.

There are two ways the infection can occur:

  • following an injury (known as contiguous osteomyelitis)  such as a fractured bone, animal bite or during surgery or following surgery.
  • via the bloodstream (known as haematogenous osteomyelitis)

Contiguous osteomyelitis is more common in adults, whereas haematogenous osteomyelitis is more common in children.

Certain things can increase your chances of developing osteomyelitis. For example, if you have a condition that affects the blood supply to certain parts of your body, such as diabetes, or a condition that weakens the immune system, such as rheumatoid arthritis.  Osteomyelitis is also known to be a common complication of certain health conditions. For example:

  • 30-40% of people with diabetes who experience a puncture injury to their foot will develop osteomyelitis
  • less than one in every 200 people with sickle cell anaemia will develop osteomyelitis in any given year

Malignant Osteomyelitis can become chronic osteomyelitis if not treated quickly, as the bones can become permanently damaged, resulting in persistent pain and loss of function.

How is osteomyelitis treated?

If diagnosed early, osteomyelitis can be treated with antibiotics for at least four to six weeks. At first, you may have to stay in hospital to receive IV antibiotics, but it may be possible to receive IV treatment at home when you start to feel better.

In severe or chronic cases of osteomyelitis, surgery may be used in combination with antibiotics. Surgery is most often used to remove damaged bone and drain pus from wounds.

Complications

Although osteomyelitis is usually treated successfully with antibiotics, chronic and severe cases can lead to other problems.

Recurring osteomyelitis

If you’ve had a previous episode of osteomyelitis, there’s a chance of it returning. This is because underlying conditions that often cause osteomyelitis, such as poor circulation or a weakened immune system can be difficult to treat.

Gangrene

If the blood supply to the bone is severely reduced, this can cause the tissue to die (gangrene).  Amputation may be used as a last resort if gangrene develops.  The condition can usually be treated before it reaches this stage.

Preventing osteomyelitis

It’s not always possible to avoid getting osteomyelitis. But there are steps you can take to reduce your chances.

Cleaning wounds thoroughly with water and dressing them in a clean bandage will reduce the chances of getting an infection from an injury.  Improving general health will help reduce the risk of developing conditions that can lead to osteomyelitis.

Diabetes and the Ear

When Otitis Externa occurs in the ear canal in the event correct ear drop antibiotic treatment is not commenced promptly and the infection cause is not diagnosed within a week for patients with a weakened immune system, such as patients with long term diabetes.  This can lead to the infection quickly spreading onto the bone behind the ear leading to extreme pain and discharge especially if the moist environment within the ear canal is not kept dry.  When this occurs IV antibiotic treatment is obligatory up to 3 – 4 times a day for 6 weeks to treat the condition with regular follow up including hearing test on completion of treatment.  Diagnosis by Ultrasound and CT may be helpful however an MRI scan will likely show how far the infection has spread with follow up CT scan after 6 weeks and again after 3 months to ensure stabilisation and ensure less chance of reoccurrence.

Saliva Gland and Dental Link

Insulin link – Researchers have recently analysed findings from previous research and found that reducing inflammation of the gums in people with diabetes can help lower the risk of serious complications such as eye problems and heart disease. It is thought that when bacteria infect the mouth and cause inflammation, the resulting chemical changes reduce the effectiveness of insulin and raise the levels of blood sugar.

Plaque with bacteria can build up when otitis externa develops and could lead to serious gum disease known as periodontal disease.  Dental treatment to reduce inflammation may therefore help to reduce blood sugar levels.  Researchers have suggested findings highlight the need for doctors and dentists to work together in the treatment of people with diabetes.

‘This research confirms that there may be a link between serious gum disease and diabetes. It highlights the role dentists can play in managing the condition, given that gum disease is very treatable.

The findings were published as part of the international Cochrane Collaboration.’

BMC Endocr.Disord..September  2014; 14: 75.  Published online 2014 Sep 16. doi:  10.1186/1472-6823-14-75

A study from South Sweden with 196 patients published in 2014 with helpful clinical information raises a number of questions by showing people with long term diabetes seem to show elevated calcium in saliva and reduced magnesium zinc and potassium levels in saliva which is interesting.  Type 1 and Type 2 diabetic patients secrete significantly less resting and stimulated salivary protein concentration compared the healthy participants.  Secretary capacity (stimulated minus resting values) was markedly reduced compared to controls.  Is this a diet issue associated with diabetes?

The study also investigated depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in type 1 diabetes.  Patient experience with excessive saliva secretion late at night and during the night suggests very little understanding exists.   The timing is also associated with extreme pain experienced from about 8.00pm till 5.00am with malignant otitis externa.

This suggests the need to review diet issues for patients with Type 1 and Type 2 Diabetes where use of Aspartame instead of sugar in drinks and food especially in tea, coffee and diet sugar free lemonade drinks may be detrimental to patient wellbeing especially if the long term use of such drinks and foods lead to electrolyte imbalance in saliva secretion in patients with long term diabetes and excessive saliva secretion associated with midnight salivary cortisol (MSC) changes.

Eva O Melin,1,2,3,7 Maria Thunander,1,3,4 Mona Landin-Olsson,1,5 Magnus Hillman,1 and Hans O Thulesius2,3,6

http://advancedotolaryngology.com/patient-education/malignant-otitis-externa/

Necrotizing (Malignant) External Otitis


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OPHIR HANDZEL, M.D., LL.B., and DORON HALPERIN, M.D., Kaplan Medical Center, Rehovot, Israel

Am Fam Physician. 2003 Jul 15;68(2):309-312.

Further research is needed to identify potential benefits for the average patient with long term Type 1 Diabetes who may have experienced a little known complication of the condition Malignant Otitis Externa possibly leading to Osteomyelitis.  Any research is not intended to question generally accepted principles in diabetes care in Primary and Secondary Care environments and is not designed in any way to potentially put patients’ health or wellbeing at risk.  Research should be particularly designed to support new ways of thinking and treating a long term complication of the condition by way of patient experience and expertise when patients with diabetes are consumers of the NHS throughout the UK.  This view is extended to create more awareness of the complication amongst professional diabetes clinicians, dental clinicians and nurses in both Primary and Secondary Care and assist in prompt diagnosis of patients presenting with the complication to enable early diagnosis and treatment to prevent and minimise extended treatment requirement or poor treatment outcomes and enhance patient wellbeing.

Early diagnosis of disease – It is commonly acknowledged that the earlier a disease or condition is diagnosed the better the prognosis for the patient and the lower the costs generally for the healthcare provider, for example, reducing the need for costly treatments or expensive hospital stays.   Diagnostics can increasingly assist in determining the likely effectiveness of different therapies and in helping patients monitor their own long term condition.

Saliva Gland and Ear Infection, Link to Depression, Physical Inactivity, Smoking

Ref: Mol Cell Biochem 2004 June 261 – Effects of diabetes mellitus on salivary secretion and its composition in the human.  Mata AD et al

Abstract  The study investigated the effects of diabetes mellitus (types 1 and 2) on human salivary gland function compared to healthy matched controls.  The results have shown that both type 1 and type 2 diabetic patients secrete significantly (p< 0.05) less resting and stimulated saliva compared to healthy age-matched protein concentration compared to healthy participants.  However, the secretary capacity (stimulated minus resting values) was markedly reduced compared to controls.  The level of calcium (Ca2+) in the saliva of diabetic patients was significantly (p>0.05) elevated compared to the AMC.  In contrast, the levels of magnesium (Mg2+) , zinc(Zn2+) and potassium (K+) in the saliva of diabetic patients were significantly (p<0.05) reduced compared to the values obtained in AMC.   These results indicate that diabetes mellitus can lead to marked dysfunction of the secretary capacity of the salivary glands.  In these patients a modified fluid, organic and inorganic salivary secretion may be responsible for the increased susceptibility to oral infections and impaired wound healing described by others in the literature.  Ref www.ncbi.nlm.nih.gov/pubmed

  • Can a slight diet modification correct this?
  • There are many papers about aspartate and as patients with diabetes tend to use artificial sweeteners is this an issue?
  • Is high midnight salivary cortisol (MSC) a contributory factor in saliva gland secretion?
  • The Swedish study ‘Depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in Type 1 diabetes’ by Eva O Melin et al published September 2014 looked at regular tongue saliva swabs taken at 23.00 and 00.30 hours.   The pain experience starts around 7 – 8 pm and becomes worse until 2.00 – 3.00am leading to difficulty with sleeping at night.
  • Does salivary gland difference between patients with diabetes, Type 1 and Type 2, or pre diabetes suggest that such patients may experience more hunger and thirst leading to weight gain requiring diet program and exercise correction and if not checked may lead to massive weight gain and possible bariatric surgery?

Presentation at GP Practice

Any patient suffering from long term Type 1 Diabetes treated with insulin on presentation at the GP practice with Otitis externa  (Ear Infection) and  Osteomyelitis (Bone Infection) and pain should be treated immediately with antibiotic tablets, ear drops, an ear swab taken at first presentation and pain relief discussed with the patient and prescribed.  If symptoms persist after one week the patient should promptly be referred to a specialist ENT centre for further diagnosis and treatment.  An urgent CT and MRI scan should be ordered to assess the extent of the infection in the inner ear and whether the condition may have spread onto the bone behind the ear.

Blood test profile – Reduced Sodium (Na+) and Magnesium (Mg+) may be observed and require monitoring.

Ear Structure

The inner ear is a fluid filled bone structure with around 30,000 hair cells (sensing cells) which are activated by wave like movement in the fluid.  The movement in the hair cells transforms into electric impulses which via the hearing nerve are transmitted to the brain.  Magnesium helps maintain a normal function of calcium in the channel to the fine hair cells which register sound frequencies in the inner ear.  Lack of magnesium may damage the function of the hair cells and hearing nerve.  This may result in hearing strange noises or reduced hearing ability.  The older a person becomes the less magnesium is produced in the body.  With age the ability to absorb magnesium from the diet is reduced and at the same time the body’s elimination of magnesium is increased.

Magnesium is very important for hearing and magnesium has an influence on the nervous transmission and the function of the nervous system.  A magnesium supplement may be helpful to contribute to a normal electrolyte balance and help restore hearing loss.

Pain Relief

Otitis externa (Ear Infection) and Osteomyelitis (Bone Infection) is likely to cause extreme pain for the patient especially late at night and during the night.  If patients are allergic to strong prescribed pain killers this can make pain management very difficult.  A suggested pain management and treatment plan might be:

  • Paracetamol 500mg – up to 8 tablets per day (4 times / day x 2) plus
  • Ibuprofen 200mg – up to 1 – 2 tablets 3 times / day plus
  • DL – Phenylalanine 500mg – 1 tablet per day with food at breakfast
  • Ear – Tone Magnesium 320mg with Ginkgo biloba extract 100mg and pine bark 125mg – 1 tablet daily

Pain killers tend to cause constipation and irregular bowel function.  DL – Phenylalanine may be found to stabilise bowel function and help stabilise BG levels.

Caution

IV delivered antibiotics may be found to reduce BG levels sometimes significantly especially during the night and late morning.  This tends to be the opposite of a Type 1 patient with infection and treated with antibiotics when BG levels may fluctuate and may tend to rise.  Regular BG monitoring is very important and especially a night time snack before bed to prevent risk of low night time BG or carryover to next morning.

Hygiene

Hygiene when IV antibiotics are delivered is very important to prevent sepsis or other complications.  Symptoms of sepsis can be similar to hypoglycaemia.  When IV antibiotics are delivered by cannula it is important to keep the cannula protected and clean by wearing a loose sleeve shirt and loose clothes, tops and sweaters and a plastic sleeve during showering.

Derek C Beatty, BSc, DipM ©                  Aston Clinton Scientific Ltd. Edinburgh                                July 2016 Rev April 2017

References

 Effects of diabetes mellitus on salivary secretion and its composition in the human.  Mata AD et al, Mol Cell Biochem 2004 June 261  Biomed Chromatogr. 2012 May;26(5):571-82. doi: 10.1002/bmc.1677. Epub 2011 Sep 6.

Salivary peptidome in type 1 diabetes mellitus.

Caseiro A1Vitorino RBarros ASFerreira RCalheiros-Lobo MJCarvalho DDuarte JAAmado F.

Copyright © 2011 John Wiley & Sons, Ltd.   Diabet Med. 1986 Nov-Dec;3(6):537-40.

The effects of diabetes and autonomic neuropathy on parotid salivary flow in man.

Lamey PJFisher BMFrier BM.

Arch Oral Biol. 2015 Mar;60(3):425-31. doi: 10.1016/j.archoralbio.2014.07.010. Epub 2014 Jul 24.

Selected antibacterial factors in the saliva of diabetic patients.

Malicka B1Kaczmarek U2Skośkiewicz-Malinowska K2. Copyright © 2014. Published by Elsevier Ltd.

BMC Endocr Disord. 2014 Sep 16;14:75. doi: 10.1186/1472-6823-14-75.

Depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in type 1 diabetes.

Melin EO1Thunander MLandin-Olsson MHillman MThulesius HO. Swed Dent J Suppl. 1995;107:1-68.

Periodontal disease in adult insulin-dependent diabetics.

Thorstensson H1. PMID: 7638766  [PubMed – indexed for MEDLINE] Acta Odontol Scand. 1989 Jun;47(3):175-83.

Some salivary factors in insulin-dependent diabetics.

Thorstensson H1Falk HHugoson AOlsson J.

 

BMC Endocr.Disord..September  2014; 14: 75.  Published online 2014 Sep 16. doi:  10.1186/1472-6823-14-75

Biomed Chromatogr. 2012 May;26(5):571-82. doi: 10.1002/bmc.1677. Epub 2011 Sep 6.

Treatment of Periodontal Disease for Glycaemic Control in People with Diabetes

Dr Terry C Simpson  International Cochrane Collaboration  Dentistry – postgraduate study  Apr 14, 2016