Letters to the Editor

Hyperbaric Oxygen to Treat Malignant External Otitis

to the editor: We read with interest the article, "Necrotizing (Malignant) External Otitis,"1 by Drs. Handzel and Halperin in the July 15, 2003, issue of American Family Physician, and would like to present our experience in the treatment of malignant external otitis.

Between 1998 and 2003, nine patients (three women and six men) with a mean age of 64.8 years were treated for malignant external otitis at our department of otolaryngology. All treated patients had diseases that could affect their immune system, such as diabetes (seven patients), leukemia (one patient), and bronchial asthma (one patient). Five of the nine patients had palsy of at least one of the cranial nerves. Standard therapy included local treatment of the auditory canal, long-term systemic antibiotic therapy, radical mastoidectomy (two patients), and petrosectomy (one patient). Eight of the nine patients underwent hyperbaric oxygenation. One patient did not qualify for this treatment because of pulmonary contraindications. All eight patients received 100 percent oxygen in a multiplace chamber under 2.5 standard atmospheres of pressure (ATA) for 60 minutes (with two five-minute breaks) once daily, five days a week. The pressure inside the hyperbaric chamber was achieved by compressed air. The total number of sessions depended on clinical status. The mean number of hyperbaric oxygen sessions was 22.1 (range: 16 to 25 sessions). We received good results in all eight patients who were treated with hyperbaric oxygen. Headache and discharge from the ear ceased, bacteriologic examinations of the ear swabs were negative, and changes in bone scintigraphy decreased; however, cranial nerve palsy was still observed. Follow-up ranged from nine months to four years.

Malignant external otitis is not a primary indication for hyperbaric oxygen according to the Undersea and Hyperbaric Medicine Society (UHMS) and the European Committee for Hyperbaric Medicine (ECHM). However, we found hyperbaric oxygen very helpful in the adjunctive treatment of malignant external otitis because it proved to be effective in normalizing oxygen tension, which is necessary for the following: (1) destruction of bacteria by polymorphonuclear leucocytes; (2) stimulation of neovascular formation; and (3) stimulation of osteoclastic and osteoblastic activity. Our clinical observations confirm the experience of other authors.2-6 The rarity of this disease makes it difficult to organize prospective, randomized, double-blind clinical trials that demonstrate the real benefits of hyperbaric oxygen in treating malignant external otitis. For this reason, any clinical experience and observations of this disease are of great value.

Waldemar Narozny, m.d., ph.d.
jerzy kuczkowski, m.d., ph.d.
boguslaw mikaszewski, m.d., ph.d.

Medical University of Gdansk
Department of Otolaryngology
Ul. Debinki 7, bud. 16, 80-211 Gdansk, Poland

REFERENCES

editor's note: This letter was sent to the authors of "Necrotizing (Malignant) External Otitis," who declined to reply.

Pain Relief in Those Recovering from Chemical Dependency

to the editor: I enjoyed the article on the care of patients who are recovering from chemical dependency in the November 15, 2003, issue of American Family Physician.1 This important issue has received little attention in the general medical literature. The article provides an excellent overview of the special factors one should consider when treating recovering persons. Many well-meaning physicians, unaware of these considerations, have unknowingly pushed a recovering person toward relapse by prescribing an avoidable mood-altering medication. The consequences of relapse are often grave, including destroyed relationships, incarceration, and death. Understanding these issues and following the suggestions outlined by the authors can help physicians play an important role in preventing relapses.

In addition to the authors' excellent suggestions about the management of cough in people recovering from chemical dependency, the use of albuterol inhalers should be considered. Albuterol inhalers are not mood altering, and they effectively control cough associated with bronchitis.2 In my experience, albuterol is even more effective for cough in recovering patients than it is in the general population. This is not surprising, because most recovering patients have smoking histories, and many have inhaled a wide variety of potential lung toxins (such as marijuana, cocaine, and toxins from home-made pipes made from aluminum cans).

The authors1 discuss acute pain management, but the topic of postoperative pain deserves additional attention. Following many surgical procedures, patients have no choice but to use medications that have the highest potential for triggering relapse. Recovering patients generally feel trapped between accepting the use of these substances they have worked hard to avoid or suffering unnecessarily. Physicians should reassure the patient that many thousands of persons recovering from chemical dependence have undergone major surgery and remained in recovery. The patient should be encouraged to be as active as possible in recovery effots during the perioperative period (e.g., attending 12-step meetings, meditating).

Following surgery, adequate pain relief should be provided; however, it is important not to overshoot the necessary dose because this will lead to avoidable euphoria. The physician should be attentive for objective signs of uncontrolled pain (such as vital-sign changes, apprehension, difficulty moving) and unnecessarily high doses (such as the patient nodding out during conversation or being difficult to arouse). The patient may require substantially higher doses of medication than usual, and, especially in the early recovery period, may have a very high tolerance. Because of cross-tolerance, this high tolerance may extend to substances the patient never abused .

In my experience, parenteral ketorolac (Toradol) is an effective adjunct that provides adequate relief while using much lower doses of opiates. On discharge, ongoing adequate pain relief should be provided, but the patient should be switched to non-mood-altering medications as soon as possible. Patients should be instructed to adhere precisely to the scheduled dosing of mood-altering drugs and may have someone else keep the bottle and administer the medication. If the dosage is insufficient, the patient should contact the physician to discuss increasing the dose and/or frequency. Following these suggestions can help keep patients on course with their recovery following surgery and allay many of their concerns.

ROBERT L. HATCH, M.D.

University of Florida College of Medicine
Dept. of Community Health and Family Medicine
1600 S.W. Archer Rd.
Room G1-019
Gainsville, FL 32610

REFERENCES

editor's note: This letter was sent to the authors of "Common Problems in Patients Recovering from Chemical Dependency," who declined to reply.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.

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