老年糖尿病合併惡性外耳炎：病例報告及文獻回顧

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ၡāāࢋ

( Malignant otitis externa ) 84 ( Diabetes mellitus )

14

ᙯᔣෟĈᎤԌঽ ( Diabetes mellitus )

ೋّγ҅ۆ ( Malignant otitis externa )

݈֏

ೋّγ҅ۆ ( malignant otitis externa ) ߏ˘჌

ܬϚγ҅྽ă҅྽य़హ௡ᖐă㝅੻ᄃ֯ࡎᚭ۞͌

֍ͷᚑࢦ۞ຏߖĂ࡭ঽෂ̂кࠎ Pseudomonas aeruginosa

ĂрϚٺҺࠪΑਕצຫ۞ঽଈĂᎤ Ԍঽ ( diabetes mellitus ) ঽଈЯࠎ௟ࡪҺࠪצຫă

຋௟ҕგঽតᄃ҅ݰ pH ࣃ˯̿ĂЯ҃टٽ൴Ϡ ѩ჌ຏߖ

Ąೋّγ҅ۆ۞Ѫ˸த̙ҲĂ༊΍ன ཝৠགྷܬϚॡĂঽଈ۞Ѫ˸தՀ੼Ăтڍਕૉд ѝഇ෧ᕝ֭ග̟ዋ༊۞ڼᒚĂ݋ΞͽࢫҲѪ˸த ᄃ׀൴া

ĄЯࠎೋّγ҅ۆѝഇ۞ᓜԖাېᄃ

˘ਠγ҅ۆᙷҬĂ૱൑ڱٺ়ঽѝഇ෧ᕝĂᓜԖ ᗁरੵ˞ࢋਕૉ੼ޘᘃႷѩ়ঽĂ˵ࢋͽዋ༊۞

၁រވᑭߤᄃᇆညጯᑭߤֽቁؠ෧ᕝĄ

ঽּಡӘ

˘Ҝ 84 ໐ᎤԌঽঽଈٺ 2006 ѐ 7 ͡΍னΠ

҅ূ൭ᄃΠ҅҅႒۞াې̏ѣ׌ฉĂྍঽଈٺা

ې΍னॡӈז҅ᆄಘࡊ෧ٙՐ෧Ăᔵ൒ග̟Ԋొ

҅ᘽăͤ൭ᘽᄃ˾ڇԩϠ৵ڼᒚܕ׌ฉĂ҅൭۞

াې̪ᖞ൑Լච҃ͷؼҩҌ݈҅ొҜĂ֭ͷ႙႙

΍னΠᓚ൑˧۞াېĂЯ҃ҌώੰՐ෧Ąྍঽଈ

࿅ΝѣᎤԌঽঽΫ࿈α˩ѐĂఢ݋ڇϡ˾ڇࢫҕ

ᎤᘽۏڼᒚĂ׎ዶ࿅ΝঽΫΒ߁ᎤԌঽඪঽតˬ ѐă੼ҕᑅ࿈α˩ѐăسܛ഑ͩা˛ѐăᄃབܡ

๫ତצབ̷ੵఙޢˬѐĄଈ۰π૱֭՟ѣ޶҅ݰ

۞௫ၚĂ˵൑ଂְഫڧྻજĂѩѨঽ൴݈۞Ϡ߿

ΞҋநĄҝੰॡ۞நጯᑭߤពϯ֗੼ 152 ̶̳Ă វࢦ 56 ̳͝Ăҕᑅ 130/78 mmHg Ă͕ྯ 67 ྯ/

̶Ăײӛ 18 Ѩ/̶Ăវ໢ 36.4 ƨćΠ઎γ҅྽۞

ͨጀ̙кĂ҅྽ѣࡓཚត̼ҭ൑ځព҅྽̶ک ۏĂ҅ቯϒ૱ćৠགྷጯᑭߤពϯΠ઎ᓚొ΍னฉ ᙝᗞࢬৠགྷ౫༑ćཛొ̚ቢѣ͘ఙࠫஶĂ׎ዶந ጯᑭߤϒ૱Ąҕ୵ᑭߤពϯ white blood cell count

7,800/mm

( N/L:83.4/9.2)Ă hemoglobin 10.9 g/dL Ă platelets 275,000/mm

Ąҕ୻Ϡ̼ᑭߤ glu- cose 125 mg/dL Ă blood urea nitrogen 32 mg/dL Ă

ဦ˘Ĉ८̄ᗁጯବೡពϯΠ઎γ҅ొ̶ᄃΠ઎ج੻ѣព ᇆ (቏ᐝ)Ą

ဦ˟Ĉ㝅੻࿪ཝᕝᆸବೡពϯΠ઎γ҅྽ (௟቏ᐝ) ᄃΠ

઎㝅˭჏హ௡ᖐཚණ (௖቏ᐝ)Ą

ဦˬĈពᇆޢ T1-weighted ჃॎᛷᇆពϯΠ઎γ҅྽ཚ ණͷܬϚ㝅˭჏ (௖቏ᐝ)ᄃݟय़௡ᖐ (௟቏ᐝ)Ą

ဦαĈ੠ᖸ̝ពᇆޢ T1-weighted Ⴣॎᛷᇆពϯγ҅྽

ཚණ̏གྷԼචĂҭߏຏߖܬϚҌ㝅˭჏ (௖቏ᐝ) ᄃݟय़௡ᖐ (௟቏ᐝ) ۞ଐԛݒՀࠎᚑࢦĄ

creatinine 1.6 mg/dL Ă sodium 136.0 mmol/L Ă potassium 4.2 mmol/L Ă alanine aminotransferace ( ALT ) 23 IU/L Ă C-reactive protein ( CRP ) 5.38 mg/dL Ă erythrocyte sediment rate ( ESR ) 94 mm/hr Ă HbA1C 7.0% Ă total cholesterol 132 mg/dL Ąҝੰޢᐌӈົ෧҅ࡊᗁरĂઇγ҅྽۞

ܑϩജഔૈዳඕڍࠎ Aspergillus spp.Ąщଵ Tc-99

̈́ Ga-67 ८̄ᗁጯବೡពϯΠ઎γ҅ొ̶ᄃΠ઎

ج੻ѣពᇆ ( ဦ˘ )Ă㝅੻࿪ཝᕝᆸବೡពϯΠ

઎γ҅྽ᄃΠ઎㝅˭჏ ( subtemporal fossa ) హ௡

ᖐཚණ ( ဦ˟ )ĂჃॎᛷᇆពϯΠ઎㝅ొᐝϩă Π઎҅׹ಛăΠ઎γ҅྽ᄃΠ઎㝅˭჏ᄃΠ઎ݟ य़ ( parapharyngeal space ) ௡ᖐཚණ ( ဦˬ )Ăॲ ፂᓜԖܑனă҅ࡊ૞ࡊᗁरົ෧ᄃᇆညጯᑭߤඕ ڍĂ෧ᕝࠎೋّγ҅ۆЪ׀੻ܬϚĄԸ̟ᐖਔԩ Ϡ৵ڼᒚޢĂΠ҅྽ཚණ۞ଐԛѣԼචĂҭߏ൴ ۆ޽ᇴ֭Ϗ˭ࢫĂҝੰαฉޢ੠ᖸ̝ CRP ̿੼

Ҍ 14.7 mg/dL Ă ESR ̿੼Ҍ 124 mm/hr ĂТॡঽ ଈၙၙ΍னӌᗻӧᙱĂͷटٽ๦ז۞াېĂ੼ޘ ᘃႷ̏ѣௐ˝ᄃௐ˩၆ཝৠགྷܬϚĄᔵ൒޺ᜈֹ

ϡᐖਔԩϠ৵ڼᒚĂͷٺҝੰௐˬฉͽ੼ᑅউڼ ᒚ 3 ͇Ăҭঽଈ႙႙΍னຍᙊ̙୻۞াېĄ੠ᖸ

̝ჃॎᛷᇆពϯΠ઎㝅ొᐝϩăΠ઎҅׹ಛᄃΠ

઎γ҅྽ཚණ̏གྷԼචĂҭߏຏߖܬϚҌ㝅˭჏

ᄃݟय़௡ᖐ۞ଐԛݒՀࠎᚑࢦ ( ဦα )Ąҝੰ࿅

඀̚׀൴۱ۆăԌ྽ۆăײӛ਽აᄃඪ਽აĂͷ Яͅᖬੰ̰ຏߖ۱ۆЪ׀ײӛ਽ა҃ᖼซΐ᜕ঽ

ٗˬѨĂᔵ൒ົ෧ຏߖࡊᗁरޢАޢֹϡᐖਔԩ Ϡ৵ Ciprofloxacin ă Ceftazidime ă Cefpirome В ڼᒚ 14 ฉĂ֭ٺௐ 4 ฉฟؕАޢֹϡ Ticoplanin ᄃ Vancomycin ڼᒚੰ̰ຏߖ۱ۆВ 11 ฉĂঽଈ

̪ᖞЯާّײӛඃ࢝ᄃୀҕّЃҹѪ˸Ą

੅ኢ

ೋّγ҅ۆ఼૱̙ົ΍ன൴፵ٕ͕ຨԣిඈ

૱֍۞ຏߖᇈ࣏

ĂώঽּಡӘ౵ܐ۞ܑனࠎ҅

൭ă҅႒Ăᄃާّγ҅ۆ࠹ТĂͷΠ҅྽ཚණ۞

ଐԛдڼᒚޢѣԼචĂҭߏ̪ᖞᜈ൴к఍ཝৠགྷ ܬϚĄѣֱঽଈдགྷ࿅Ԋొ҅ᘽڼᒚޢĂγ҅྽

۞ຏߖቁ၁ົԼචĂ࡭ֹγ҅྽۞ᑭߤϒ૱Ăҭ ߏѩॡຏߖΞਕ̏གྷܬϚҌஎొ௡ᖐ

Ăӈ֯ࡎ

੻ăམቢă㝅˭ᗠᙯ༼ă㝅੻˭჏ᄃج੻Ă֭ౄ

јཝৠགྷ౫༑ăཝቯۆăཝᓘႹඈ׀൴া

Ąࢋ

ѝഇ෧ᕝೋّγ҅ۆᅮֶያᓜԖᗁर۞੼ޘᛋᛇ

͕ă၁រވ̶ᗓ΍࡭ঽෂă൴ۆ޽ᇾт E S R ˯

̿ă௡ᖐጯᄃᇆညጯᑭߤ

Ą༊ڼᒚγ҅ۆ 4 8 Ҍ 72 ̈ॡޢঽଐ̪ϏԼචĂӈᑕГෞҤঽଈߏ ӎࠎೋّγ҅ۆٕγ҅྽ೋّཚሳ

Ă֭ዋॡщ ଵᇆညጯᑭߤĂтώঽּщଵ̝ Tc-99 ᄃ Ga-67 ବೡពϯѣ㝅੻੻លۆĂӈߏຏߖܬϚඕ቙௡

ᖐăహ੻ᄃർ੻۞ඕڍĄ Tc-99 ବೡΞͽͧ࿪ཝ ᕝᆸବೡՀѝᑭߤ΍੻ܬϚĂ҃ Ga-67 ବೡΞͽ ϡֽෞҤڼᒚ۞ड़ڍ

ćҭߏ८ᗁବೡ۞৿ᕇߏ

̙׍পளّĂ˵൑ڱჟቁ۞ؠҜຏߖొҜĂ֭ͷ

༊Ꭾଈᚑࢦ۞ާّγ҅ۆॡ˵ѣ࠹Т۞ᇆညĂЯ ѩĂ࿪ཝᕝᆸବೡᄃჃॎᛷᇆߏྋ࣠ጯ˯ෞҤೋ

ّγ҅ۆྵָ۞ᇆညጯᑭߤ

Ąώঽּ˵щଵ࿪

ཝᕝᆸବೡᑭߤĂඕڍពϯܧপளّ۞γ҅྽ཚ ණĂᄃྵ׍পளّ۞㝅੻˭਌۹ᆸ̙୻຾Ăҭ൑

֯ࡎ੻ϩኳ৔ᗼ۞ᇆည

Ă҃Ⴣॎᛷᇆੵ˞֍ז γ҅྽ཚණγĂฉᙝ௡ᖐܬϚ۞ଐԛͧ࿪ཝᕝᆸ ବೡՀࠎځពćώঽּ˵ពϯĂ੨Ъ Tc - 9 9 ᄃ Ga-67 ବೡĂᖣϤჃॎᛷᇆᑭߤ㝅੻˭హ௡ᖐ۞

ܬϚĂΞᒔ଀Հָ۞ᇆညҿ᝝

Ą

ቁؠ࡭ঽෂ̝ޢĂֹϡԩϠ৵ܜഇڼᒚೋّ

γ҅ۆྵࠎዋ༊Ăࡶᅮ͘ఙ݋ᑕ่ࢨٺԊొ୻౹

͘ఙ

ćԩϠ৵Ҍ͌ࢋԸ̟̱ฉĂтڍຏߖϏԆ БॲੵӈઃͤԩϠ৵ֹϡĂົጱ࡭Հᚑࢦ۞ຏߖ

7

Ą҃ώঽּҌώੰಶᗁॡ̏΍னཝৠགྷ౫༑া

ېĂពϯ̏གྷߏஎొຏߖĂڼᒚՀ̙टٽĂЯѩ

˵ֹϡ੼ᑅউڼᒚĂҭߏЯࠎঽଈ΍னຍᙊត

̼Ăֹ่ϡˬ͟Ąᔵ൒ѣ͛ᚥಡӘͽ੼ᑅউڼᒚ 16 Ҍ 30 ͟ĂΞͽᒣϒ௡ᖐ৿উĂઇࠎᚑࢦ۞ೋّ

γ҅ۆ۞ᅃӄڼᒚ

Ă൒҃׎ᒚड़̪Ϗѣؠኢ

Ą Pseudomonas aeruginosa ߏೋّγ҅ۆ౵૱֍۞

࡭ঽෂĂ׎΁Ξਕ۞࡭ঽෂΒ߁ Staphylococcus

aureus ă Staphylococcus epidermidis ă Proteus

mirabilis ă Asperugillus spp.

Ąώঽֹּϡ۞ԩ

Ϡ৵ࠎགྷᐖਔԩ P. aeruginosa ̝ԩϠ৵Ă޺ᜈڼ

ᒚ 14 ฉĄᔵ൒Ϥγ҅྽ܑϩૈዳ΍ Aspergillus

spp.Ăҭߏ Aspergillus spp.ߏҜٺγ҅྽۞ВϠ

ෂĂ҃ͷϩቲܑϩജഔૈዳඕڍ૱̙Тٺஎొ௡

ᖐૈዳ

ĂЯѩ൑ڱᕝؠ׎ӈࠎώঽּ̝࡭ঽ ෂĄᔵ൒൑ڱቁؠߏӎࠎឣෂຏߖĂͷд҂ᇋֹ

ϡԩឣෂᘽۏ amphotericin B Ξਕጱ࡭ඪ਽ა۞

̙ ։ ઘ ү ϡ ޢ Ă ԧ ࣇ ̪ ֹ ϡ ˾ ڇ ԩ ឣ ෂ ᘽ Variconazole ڼᒚĂΪߏдڼᒚᇴ͟ޢঽଈ΍ன քΑਕள૱Ăͷ൑ቁ၁ᙋፂពϯώঽּࠎឣෂຏ ߖ҃ઃᘽĄтڍࢋቁؠߏӎࠎឣෂౄј۞எొຏ ߖĂஎొ௡ᖐૈዳٕ੻̷ͯᑕߏ౵׍ѣপளّ۞

͞ڱ

ĄώঽּЯঽଈѐᔙĂ֭Ϗפ଀எొ௡ᖐ

ૈዳĂޙᛉڼᒚѩᙷঽଈॡĂᑕפ଀எొ௡ᖐૈ

ዳͽቁؠ࡭ঽෂĂ֭ॲፂ௟ෂጯᑭߤඕڍܜഇֹ

ϡԩϠ৵ڼᒚć௡ᖐጯᑭߤ۞Ω˘࣎ϫ۞ߏΞͽ ଵੵγ҅྽ೋّཚሳ

Ą

Яࠎγ҅྽۞ຏߖдڼᒚޢົԼචĂ࡭ֹԊ

ొຏߖ࠻Ҭ̏གྷצזଠטĂҭߏஎొຏߖ̪ᖞ޺

ᜈซҖćٙͽ̙ਕ่่Яࠎγ҅྽൴ۆ̏གྷԼච ಶઃͤԩϠ৵ڼᒚĄ E S R ΞͽϡֽෞҤ়ঽ۞

ซणᄃڼᒚ۞ड़ڍ

Ă҃ώঽּͽჃॎᛷᇆઇࠎ

੠ᖸ۞ᇆညጯᑭߤĂᔵ൒੠ᖸ̝Ⴣॎᛷᇆពϯγ

҅྽൴ۆ̏གྷቤྋĂҭ្̰ຏߖݒՀࠎೋ̼ĂЯ ѩԧࣇᚶᜈֹϡԩϠ৵ڼᒚĄܜഇֹϡԩϠ৵Ξ ਕౄјᘽۏ͔൴۞׀൴া

ĂᓜԖᗁरυืણ҂

੠ᖸ̝Ⴣॎᛷᇆٕ८ᗁବೡĂͽҿᕝຏߖߏӎ̏

གྷঐੵĂՙؠߏӎᚶᜈֹϡٕઃͤԩϠ৵Ą

ೋّγ҅ۆ̙ٽॲੵĂೇ൴தࡗࠎ 20%

Ă ᖣϤѝഇ෧ᕝᄃڼᒚΞͽᔖҺຏߖᚶᜈซणĄЯ ࠎڼᒚ۞ซՎĂѩ়ঽ۞Ѫ˸த̏Ϥѝഇ۞ 50%

ࢫҲҌ 10-20%

Ă൒҃ঽଈ۞ཝৠགྷຫच૱൑ڱ

ޭೇĂ҃ͷтڍຏߖొҜܬϚҌϭېᚭăᐚᐖਔ ᚭă្੻ૄొăཝቯٕཝొॡĂঽଈ఼૱࿰ޢ̙

р

Ă Lasisi ඈಡӘҁѐᎤԌঽˠᎮଈೋّγ҅

ۆĂѪ˸த̪੼ا 60% ͽ˯

Ąώঽּᔵ൒޺ᜈ

ֹϡԩϠ৵ڼᒚĂ౵ޢ̪ᖞڼᒚεୀĄ൴ঽ̝ܐ

׌ฉֶ่˘ਠާّγ҅ۆ఍நĂܶҝੰ෧ᕝࠎೋ

ّγ҅ۆĂଳפՀ᎕ໂڼᒚॡĂ̏΍னΠ઎ج

੻ă㝅˭჏హ௡ᖐăݟय़௡ᖐ׶ᗞࢬৠགྷܬϚĂ ͷ˫൑ڱפ଀எొ௡ᖐቁؠ࡭ঽෂĂ׽ࠎ࿰ޢ̙

։۞ࣧЯć൒҃ѩҁѐܜഇᎤԌঽଈ̏ѣᎤԌঽ

׀൴াĂٯԩ˧मĂͅᖬੰ̰ຏߖ۱ۆጱ࡭ײӛ

਽აĂՀߏ౵ޢጱ࡭Ѫ˸۞ࢦࢋࣧЯĄЯѩĂڼ ᒚѩᙷঽଈॡੵ˞ᅮቁؠ࡭ঽෂγĂ˵ืڦຍܜ

ഇҝੰޢ࠹ᙯ۞ੰ̰ຏߖĂ͍׎ߏ۱ొຏߖĄ

༊ᎤԌঽঽଈຏߖγ҅ۆĂͷֹϡԊొ҅ᘽ ڼᒚ 48 Ҍ 72 ̈ॡޢাېϏԼචĂᑕ੼ޘᘃႷߏ

ೋّγ҅ۆĄтڍγ҅ۆᄃᗞࢬৠགྷ౫༑׀х ॡĂᑕጐѝщଵᇆညጯᑭߤߏӎࠎೋّγ҅ۆĂ

֭Ա΍࡭ঽෂĂͽܮග̟ዋ༊۞ڼᒚĄ

ણ҂͛ᚥ

1.Handzel O,Halperin D. Necrotizing ( malignant ) external oti- tis. Am Fam Physician 2003; 68: 309-12.

2.Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face of malignant ( necrotising ) external otitis: clinical, radiologi- cal, and anatomic correlations. Lancet Infect Dis 2004; 4: 34-9.

3.Rene R, Mas A, Villabona CM, Ricart MC, Bassa A, Tolosa F.

Otitis externa maligna and cranial neuropathy. Neurologia 1990;

5: 222-7.

4.Stokkel MP, Takes RP, van Eck-Smit BL, Baatenburg de Jong RJ. The value of quantitative gallium-67 single-photon emis- sion tomography in the clinical management of malignant ex- ternal otitis. Eur J Nucl Med 1997; 24: 1429-32.

5.Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2006; 134(4 Suppl): S4-23.

6.Okpala NC, Siraj QH, Nilssen E, Pringle M. Radiological and radionuclide investigation of malignant otitis externa. J Laryngol Otol 2005; 119: 71-5.

7.Cunningham M, Yu VL, Turner J, Curtin H. Necrotizing otitis externa due to Aspergillus in an immunocompetent patient. Arch Otolaryngol Head Neck Surg 1988; 114: 554-6.

8.Davis JC, Gates GA, Lerner C, Davis MG Jr, Mader JT, Dinesman A. Adjuvant hyperbaric oxygen in malignant exter- nal otitis. Arch Otolaryngol Head Neck Surg 1992; 118: 89-93.

9.Narozny W, Kuczkowski J, Mikaszewski B. Hyperbaric oxygen to treat malignant external otitis. Am Fam Physician 2004; 70:

1860.

10.Rubin Grandis J, Yu VL. Malignant external otitis: insights in- to pathogenesis, clinical manifestations, diagnosis, and therapy.

Am J Med 1988; 85: 391-8.

11.Bhandary S, Karki P, Sinha BK. Malignant otitis externa: a re- view. Pac Health Dialog 2002; 9: 64-7.

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Sci 2001; 30: 221-3.

Malignant Otitis Externa in an Elderly Diabetic Patient Ĉ A Case Report and Literature Review

Por-Wen Yang

, Huei-Fang Wang

, Yu-Fang Chen

, Chia-Chang Huang

, and Hong-Da Lin

A case of malignant otitis externa with multiple cranial nerve deficits is presented. A 84-year-old diabetic male patient presented with severe right otalgia and otorrhea for two weeks and did not respond to ordinary treat- ment. The patient also noticed a progressive facial weakness on the same side. Despite 14-week intravenous antibiotic therapy and hyperbaric oxygen therapy, cranial nerve IX and X deficits followed and the patient died.

Malignant otitis externa should be suspected in diabetic patients presenting with aural discharge not respond to ordinary treatment. Successful treatment depends on early diagnosis and proper therapy. ( J Intern Med Taiwan 2008; 19: 170- 174 )

1

Division of Endocrinology and Metabolism, Department of Medicine, Taipei-Veterans General Hospital, Taipei, Taiwan;

2

Department of Internal Medicine, Tao-Yuan General Hospital, Taoyuan, Taiwan;

3

National Yang-Ming University School of Medicine, Taipei, Taiwan