Case report:
A 44-year-old diabetic man was hospitalized for the management of a
blackish necrotic lesion in the left auricle with significant
locoregional extension. The history of his disease goes back to ten days
before hospitalization: he had a pretragal swelling, with a bluish zone,
quickly evolving to a blackish necrotic lesion centered on the left
auricle associated with a pretragal fistula. This lesion extended
anteriorly to the parotid region, superiorly to the temporal region and
posteriorly to the retroauricular region (Fig 1). Purulent otorrhea,
otalgia, and left hearing loss were present. Otoscopic examination
revealed a blackish tissue filling the external auditory canal and a
secretion-covered eardrum that was bluish after aspiration. The
rhinological, endobuccal and cervical examinations were normal. The
patient had a left peripheral facial palsy (grade IV of House and
Brackmann classification) associated with a left vocal cord palsy. The
rest of the neurological examination was normal.
Biologically: the blood count showed a hyperleukocytosis of 21240
cells/mm3 (92% neutrophils, with lymphopenia: 3.3% lymphocytes, i.e.
700/mm3), normocytic normochromic anemia with a hemoglobin level of 9.2
gr/dl, and platelets of 233,000/mm3. CRP and blood sugar levels were
high (respectively 254 mg/L and 260 mg/dL).
High‑resolution computed tomography of the temporal bone showed
thickening of the left peri-auricular soft tissues, filling of the left
external auditory canal, middle ear and mastoid cells without bone lysis
or nasosinusal involvement or endocranial extension (Fig 2 - Fig 3).
Magnetic resonance imaging with gadolinium injection showed infiltration
of the subcutaneous soft tissues extending to the homolateral
masticatory, parapharyngeal and parotid spaces with collection in the
left parotid region and the masticatory space communicating with the
homolateral parapharyngeal space, exerting a mass effect on the
pharyngo-laryngeal lumen (Fig 4 - Fig 5).
The patient underwent a biopsy of the auricle. Histopathology showed the
presence of mucormycosis mycelia filaments. The culture was positive
with the presence of Rhisopus
Microspores . Liposomal Amphotericin B was immediately
administered at a dose of 5 mg/kg/d. The collection was drained under
general anesthesia. Bacteriological examination of the drained abscess
isolated Klebsiella Pneumonia confirming bacterial superinfection
and the patient was treated by Vancomycin – Imipenem associated with
Amphotericin B. However, an immediate surgical debridement surgery was
not possible because of poor surgical risk owing to the extensive
inflammation around these necrotic lesions.
A regression of the parotid swelling, local inflammatory signs and
biological inflammatory syndrome were noted. However, the necrotic
lesion extended inferiorly and superiorly to the temporoparietal region
with spontaneous anterior detachment of the necrotic plaque (Fig 6).
This plaque was lined with underlying budding tissue which motivated us
to perform a surgical debridement of the necrotic lesions with total
excision of the left auricle and external auditory canal. (Fig 7). An
informed consent was obtained from the patient before surgery.
After several months, a healing of the substance loss was obtained by
secondary Intention healing (a cover flap was not necessary) (Fig 8).
However, facial and left vagus nerve paralysis persisted without any
real recovery.