Necrotizing otitis externa secondary to Scedosporium apiospermum with temporomandibular joint involvement: A case report with diagnostic challenges

Abstract

Introduction Necrotizing otitis externa (NOE) is an aggressive, potentially life-threatening infection of the external auditory canal, most commonly caused by Pseudomonas aeruginosa . Fungal etiologies are increasingly recognized and represent an important diagnostic and therapeutic challenge. Among the fungal pathogens reported, Scedosporium apiospermum remains exceptionally rare. Arthritis of the temporomandibular joint represents an exceedingly rare complication of otitis externa and may lead to joint destruction or ankylosis if not promptly identified and adequately managed. Case presentation We report the case of an 87-year-old Moroccan man with long-standing, poorly controlled diabetes mellitus who presented with persistent right-sided otalgia unresponsive to intravenous antibiotic therapy. Otoscopic examination revealed marked inflammation of the external auditory canal, abundant purulent secretions, and the presence of a friable, contact-bleeding aural polyp. The diagnosis of necrotizing otitis externa was established on the basis of clinical, microbiological, and radiological findings. High-resolution computed tomography of the temporal bone demonstrated ipsilateral extension to the temporomandibular joint. The bacteriological cultures remained sterile. However, fungal culture of polyp biopsy specimens identified Scedosporium apiospermum . Antifungal therapy with intravenous voriconazole followed by oral itraconazole led to marked clinical improvement, in conjunction with meticulous local aural care and optimization of glycemic control. During a five-month follow-up period, he remained clinically stable, with complete resolution of symptoms and no evidence of recurrence. Conclusion This case underscores the importance of considering a fungal etiology in patients who fail to show clinical improvement despite appropriately guided antibiotic therapy, particularly when complicated by temporomandibular joint involvement. It also contributes to the limited literature on Scedosporium apiospermum as a rare cause of necrotizing otitis externa.