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 neo-vascular 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.

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