Malignant Otitis Externa Presenting With Nasopharyngeal Hematoma: A Case Report of an Unusual Complication

Objective: Malignant otitis externa (MOE) is a potentially life-threatening infection of the external auditory canal (EAC), often with skull base extension. Vascular complications are exceptionally rare, with only six reports of petrous internal carotid artery (ICA) pseudoaneurysm following MOE. Methods: We present the first reported case of a nasopharyngeal hematoma as a complication of MOE. Results: An 82-year-old male with poorly controlled diabetes presented with 2 months of recurrent left ear otalgia, purulent otorrhea, and facial nerve palsy. He was commenced on 6 weeks of antimicrobial therapy following diagnosis of MOE on imaging. One month post-treatment, an interval scan found a new collection in the left pharyngeal submucosal region expanding into the torus tubarius. Endoscopic examination revealed a left torus tubarius mass effacing the eustachian tube orifice with some blood-stained mucous. The patient was otherwise afebrile and reported only mild trismus with rust-colored sputum. Subsequent computed tomography (CT) imaging revealed that the mass was likely a subacute or evolving nasopharyngeal hematoma, in close proximity to the left petrous and caudal lacerum ICA, with mild luminal irregularities. An angiogram showed no active contrast extravasation or pseudoaneurysm. He was managed conservatively given the absence of active bleeding and a stable airway. A repeat nasoendoscopy 2 weeks later revealed interval decrease in size of the mass, with resolution of symptoms. Conclusion: The pathophysiology of nasopharyngeal hematoma as a complication of MOE may involve direct infection-mediated and inflammatory-induced erosion of arterial walls. Though rare, nasopharyngeal hematomas should be considered in MOE patients with unexplained nasopharyngeal masses. These hematomas, especially when associated with luminal ICA irregularities, may represent a sentinel finding preceding the eventual formation of a carotid pseudoaneurysm. Thus, the presence of nasopharyngeal hematomas warrants vigilant surveillance, with escalation to urgent endovascular intervention in the event of vascular instability.