Managing emergency department patients with otalgia.

Though the vast majority of conditions associated with otalgia are not life-threatening, there are nuances and controversies in the diagnosis and management of even the most common diseases, such as acute otitis media and otitis externa. For more severe disease processes, such as necrotizing otitis externa, acute mastoiditis, and perichondritis, early recognition and timely management are paramount in reducing morbidity and mortality. A systematic approach to the evaluation of these patients is key to establishing an accurate diagnosis, identifying patients who are at high risk for dangerous etiologies or complications, and providing optimal patient care. This issue summarizes the most recent guidelines and presents a systematic, evidence-based approach to the emergency department evaluation and management of patients with otalgia.

Predictive role of facial nerve palsy improvement in malignant external otitis.

PURPOSE: To evaluate the effects of different factors on facial nerve palsy improvement in patients with malignant external otitis (MEO) and the predictive role of improvement on MEO. METHODS: Data were collected from all MEO patients with facial paralysis who were hospitalized between 2012 and 2017 at a tertiary referral center. We contacted patients at least 6 months after their admission to evaluate their facial nerve function and survival rate. RESULTS: In a study of 19 samples with a mean age of 69.1 years, 9 patients (47.7%) had some or complete improvement, while 10 (52.6%) had no or very minimal improvement. In this study, there was no statistically significant difference between patients with and without facial nerve palsy improvement in terms of age, sex, usage of antifungal treatment alongside antibiotics, duration of hospital stays, HbA1c level, presentation of hearing loss and vertigo, the severity of facial palsy, comorbidity score, mean of fasting blood sugar, leukocytosis, first ESR and ESR drop, CRP and physiotherapy. We found a positive correlation between improving facial palsy and patients' survival rates. CONCLUSION: Considering the possible influence of facial paralysis improvement prognosis on MEO patients' survival, it could affect our approach to the disease.

A case of fungal otitis externa caused by coinfection of Candida auris and Aspergillus flavus.

Fungal otitis externa is a disease encountered occasionally and is caused mostly by Aspergillus or Candida spp. We report a woman with fungal otitis externa who also had typical findings in the external auditory canal. The results of a culture showed coinfection with Candida auris and Aspergillus flavus. Identification of both species was performed by sequencing analysis of the 26S rDNA (D1/D2) and ß-tubulin regions. Additionally, the newly developed CHROMagar™ Candida Plus medium was a useful tool for the easy and rapid identification of C. auris. To the best of our knowledge, this is the first report of fungal otitis externa caused by coinfection with C. auris and A. flavus. This case showed good susceptibility to many antifungal drugs and fortunately had a good clinical course with 1% bifonazole cream, which was applied to the fungal coinfection. Notably, C. auris is a multidrug-resistant yeast-like fungus. The increase in drug-resistant fungi and co-infections caused by these pathogens can make the diagnosis and treatment more complex and difficult. To solve these problems, performing rapid and accurate identification and susceptibility testing using chromogenic medium and molecular biological analysis would be useful.

Management and long-term comorbidities of patients with necrotizing otitis externa.

PURPOSE: We aimed to present the management of the patients with necrotizing otitis externa (NOE) and its comorbidities in early and long-term follow-up. METHODS: Between 2011 and 2022, 30 patients with the diagnose of NEO, who had cortical bone erosion or trabecular demineralization in temporal bone computed tomography and administered at least 6-week antimicrobial therapy were included in the study. Clinical, laboratory and imaging findings of patients, and comorbidities during follow-up were analysed. NOE extending further from the petro-occipital fissure on magnetic resonance imaging was accepted as medial skull base (MSB) involvement. RESULTS: 30 patients, (8 women, 22 men, mean age 66.2 ± 1.7), with NOE were followed 36.4 ± 29.6 months. The mortality rate was 23.33% and the mean survival time was 12.37 ± 11.35 months. Repeated cultures reveal a new or second pathogen in 5 patients (20%). Severe and profound sensorineural hearing loss (SNHL) were observed in 4 and 12 patients, respectively. Labyrinthitis ossificans emerged in 3 of 6 surviving patients with profound SNHL during follow-up. Chronic disease anemia (CDA) (66.66%), cerebrovascular disease (CVD) (43.33%), chronic renal failure (CRF) (30%), and retinopathy (26.66%) were the most frequent comorbidities in patients with NOE. Cranial nerve paralysis (CNP) (P < 0.001), SNHL (P < 0.04), CDA (P < 0.005), and mortality (P < 0.022) were significantly associated with the presence of MSB involvement. CONCLUSIONS: NOE is a disease that requires long-term follow-up, causes severe morbidity, and has a high mortality rate. MSB involvement is associated with CNP, SNHL and labyrinthitis ossificans. Moreover, CDA, CVD, CRF and retinopathy are the most common comorbitidies needed to be managed.

[A man in his fifties with pain in the head, neck and ear canal] / En mann i 50-årene med smerter i hode, nakke og øregang.

BACKGROUND: A man in his fifties, originally from a Middle Eastern country, presented with left-sided otalgia and neck pain which worsened over several months. He had pre-existing hypertension, diabetes mellitus type 2 and end stage renal disease requiring dialysis. CASE PRESENTATION: His presenting complaints started whilst on a long stay in his country of origin. Symptoms progressively worsened over the coming months while he underwent extensive medical examinations and investigations. This revealed opacifications in the mastoid cavities, raised inflammatory markers, and finally a CT scan revealed osteolytic lesions in his cervical spine. The lesions continued to progress, and his clinical condition deteriorated to the point that he required surgery. Culture was obtained through perioperative biopsies and showed growth of Aspergillus flavus. INTERPRETATION: The patient had initially received topical treatment for an assumed infectious external otitis. Later culture from his outer ear also showed growth of A. flavus, the same pathogen that was found in a biopsy from his cervical spine. He was diagnosed with cervical mycotic osteomyelitis, probably secondary to a chronic external otitis. Long term antimycotic therapy and three neurosurgical operations were required to treat the patient.

A Case of Adult Clival Osteomyelitis.

Clival osteomyelitis is a potentially life-threatening skull base infection. It is rare and generally challenging to diagnose and treat. Clival osteomyelitis is typically seen in the pediatric population and is very rare in the adult population. It occurs as a complication of recurring paranasal infections and malignant otitis externa. The exact pathophysiology of osteomyelitis of the clivus is relatively uncertain. Here, we describe a case of a 36-year-old man with medical history significant for hypertension and poorly controlled type 1 diabetes mellitus who experienced recurrent paranasal sinus infection for 2 years. He received multiple antibiotic treatments and underwent adenoidectomy without substantial improvement of symptoms. Ultimately, a diagnosis of the clival osteomyelitis through the help of a computed tomography (CT) scan of the paranasal sinus and neck was made. This diagnosis allowed for adequate intervention and treatment of our patient with subsequent resolution of his presenting symptoms. This case highlights the importance of high suspicion for clival osteomyelitis in patients with recurring sinus infections.

Diagnostic approach to patients at risk of otogenic skull base osteomyelitis.

BACKGROUND: Otogenic skull base osteomyelitis (OSBO) is rare and potentially fatal sequelae of otitis externa. Accurate and timely diagnosis is important due to rising incidence, morbidity and costs associated with treatment. Consensus on the diagnostic approach for OSBO has yet to be reached, in particular the utility of imaging modalities. AIMS/OBJECTIVES: This study reviews a single institution's high-volume experience of OSBO, with the aim of analysing clinicopathologic features and imaging studies to develop a diagnostic algorithm. MATERIAL AND METHODS: A retrospective review of patients admitted with OSBO from 2009 to 2019, was performed. After applying inclusion and exclusion criteria, 103 patients with 106 unique episodes of suspected OSBO were selected. De-identified information including patient demographics, clinicopathologic features and imaging outcomes was recorded and analysed. RESULTS: HbA1c ≥ 7% significantly predicted for OSBO in univariate (OR 7.83, 95% CI 1.85-33.16, p = 0.01) and multivariate analyses (OR 5.21, 95% CI 1.05-25.81, p = 0.04). The CT/technetium-99m/gallium-67 combination produced better diagnostic accuracy for OSBO (AUROC 0.96, 95% CI 0.92-1), when compared to a CT/MRI combination (AUROC 0.86, 95% CI 0.79-0.93). CONCLUSIONS AND SIGNIFICANCE: Once there is a clinical suspicion for OSBO, diagnosis is established by synthesising results from clinical assessment, pathologic investigations and imaging modalities. The imaging utilised to diagnose OSBO should vary according to the clinical situation and limitations of each modality.

Brachycephaly in French bulldogs and pugs is associated with narrow ear canals.

BACKGROUND: Brachycephalic dog breeds have multiple skull malformations which may lead to anatomical changes in the external auditory canal. It is our frequent observation that in the otoscopic examination of the external ear in these breeds we are unable to visualise the tympanic membrane as a consequence of extreme narrowing of the proximal ear canal. Additionally brachycephalic dogs reportedly are predisposed to otitis externa (OE) and otitis media. OBJECTIVES: To characterizse the transition of the cartilaginous ear canal to the bony meatus acusticus externus using computed tomography (CT) and to investigate a possible association with OE in brachycephalic dogs. MATERIALS AND METHODS: Seventy-five client-owned dogs [pugs (n = 20), French bulldogs (n = 55)] were included and assessed for OE using an owner questionnaire and otoscopic and cytological examinations. In dorsal plane CT scans, the diameter of the porus acusticus externus was measured using novel methodology. The results were compared with a normocephalic control group without preexisting otological disorders. RESULTS: Brachycephalic dogs had a significantly smaller porus acusticus externus diameter (2.6 mm) than normocephalic dogs (5.0 mm). Of the brachycephalic dogs, 32% had OE yet this was not statistically significantly related to the diameter of the porus acusticus externus. Middle ear effusion (44%) and narrowing of the external ear canal (82.6%) were significantly more frequent in brachycephalic dogs. Only five of 150 eardrums could be visualised otoscopically. CONCLUSIONS AND CLINICAL RELEVANCE: Malformation of the porus acusticus externus causes severe stenosis of the proximal ear canal in brachycephalic dogs. A connection between stenosis of the external auditory canal and OE could not be confirmed.

Contexte - Les races de chiens brachycéphales présentent de multiples malformations crâniennes qui peuvent entraîner des modifications anatomiques du conduit auditif externe. Nous observons fréquemment que lors de l'examen otoscopique de l'oreille externe chez ces races, nous sommes incapables de visualiser la membrane tympanique en raison d'un rétrécissement extrême du conduit auditif proximal. De plus, les chiens brachycéphales seraient prédisposés à l'otite externe (OE) et à l'otite moyenne. Objectifs - Caractériser la transition du conduit auditif cartilagineux au méat osseux externe par tomodensitométrie (TDM) et étudier une éventuelle association avec l'OE chez les chiens brachycéphales. Matériels et méthodes - Soixante-quinze chiens de propriétaires [carlins (n = 20), bouledogues français (n = 55)] ont été inclus et évalués pour l'OE à l'aide d'un questionnaire du propriétaire et d'examens otoscopiques et cytologiques. Dans les tomodensitogrammes du plan dorsal, le diamètre du porus acusticus externus a été mesuré à l'aide d'une nouvelle méthodologie. Les résultats ont été comparés à un groupe témoin normocéphale sans trouble otologique préexistant. Résultats - Les chiens brachycéphales avaient un diamètre de porus acusticus externus significativement plus petit (2,6 mm) que les chiens normocéphales (5,0 mm). Parmi les chiens brachycéphales, 32 % avaient une OE, mais cela n'était pas statistiquement lié de manière significative au diamètre du porus acusticus externus. L'épanchement de l'oreille moyenne (44 %) et le rétrécissement du conduit auditif externe (82,6 %) étaient significativement plus fréquents chez les chiens brachycéphales. Seuls cinq des 150 tympans ont pu être visualisés par otoscopie. Conclusions et pertinence clinique - La malformation du porus acusticus externus provoque une sténose sévère du conduit auditif proximal chez le chien brachycéphale. Un lien entre la sténose du conduit auditif externe et l'OE n'a pas pu être confirmé.

Contexto - Raças de cães braquicefálicos apresentam múltiplas malformações cranianas que podem levar a alterações anatômicas no conduto auditivo externo. Frequentemente, observamos que na avaliação otoscópica da orelha externa destas raças não conseguimos visualizar a membrana timpânica como uma consequência do estreitamento extremo do conduto auditivo proximal. Além disso, cães braquicefálicos são sabidamente predispostos à otite externa (OE) e otite média. Objetivos - Caracterizar a transição do conduto auditivo cartilaginoso para o meato acústico ósseo externo utilizando tomografia computadorizada (TC) e investigar uma possível associação com OE em cães braquicefálicos. Materiais e métodos - Setenta cães de clientes [pugs (n=20), buldogues franceses (n = 55)] foram inclusos e avaliados para OE utilizando um questionário para os proprietários, citologia e otoscopia. Nas TCs em plano dorsal, o diâmetro do poro acústico externo foi mensurado utilizando uma metodologia nova. Os resultados foram comparados com um grupo de cães normocefálicos controle sem alterações otológicas pré-existentes. Resultados - Os cães braquicefálicos apresentaram o diâmetro do poro acústico externo (2,6mm) significativamente menor que os cães normocefálicos (5,0mm). Dos cães braquicefálicos, 32% apresentavam OE, mas não houve relação significativa com o diâmetro do poro acústico externo. Presença de efusão na orelha média (44%) e estreitamento do conduto auditivo externo (82,6%) foram significativamente mais frequentes em cães braquicefálicos. Apenas cinco de 150 tímpanos puderam ser visualizados por otoscopia. Conclusões e relevância clínica - Malformações do poro acústico externo causa estenose grave do conduto auditivo proximal em cães braquicefálicos. Não foi possível comprovar a conexão entre a estenose do conduto auditivo externo e OE.

Introducción- las razas de perros braquicéfalos tienen múltiples malformaciones craneales que pueden provocar cambios anatómicos en el conducto auditivo externo. Con frecuencia observamos que en el examen otoscópico del oído externo en estas razas no podemos visualizar la membrana timpánica como consecuencia del estrechamiento extremo del conducto auditivo proximal. Además, según la literatura al respecto, los perros braquicéfalos están predispuestos a padecer otitis externa (OE) y otitis media. Objetivos - Caracterizar la transición del canal auditivo cartilaginoso al meato acusticus externus óseo mediante tomografía computerizada (CT) e investigar una posible asociación con OE en perros braquicefálicos. Materiales y métodos- setenta y cinco perros de propietarios particulares [carlinos (n = 20), bulldogs franceses (n = 55)] fueron incluidos y evaluados por posible OE mediante un cuestionario para propietarios y exámenes otoscópicos y citológicos. En tomografías computerizadas del plano dorsal, el diámetro del porus acusticus externus se midió utilizando una metodología novedosa. Los resultados se compararon con un grupo control normocefálico sin trastornos otológicos preexistentes. Resultados- los perros braquicefálicos tenían un diámetro del porus acusticus externus significativamente más pequeño (2,6 mm) que los perros normocefálicos (5,0 mm). De los perros braquicefálicos, el 32 % tenía OE, pero esto no se relacionó estadísticamente de manera significativa con el diámetro del porus acusticus externus. La efusión del oído medio (44 %) y el estrechamiento del conducto auditivo externo (82,6 %) fueron significativamente más frecuentes en perros braquicefálicos. Solo cinco de 150 tímpanos pudieron visualizarse por otoscopia. Conclusiones y relevancia clínica - La malformación del porus acusticus externus causa estenosis severa del canal auditivo proximal en perros braquicefálicos. No se pudo confirmar una conexión entre la estenosis del conducto auditivo externo y la OE.

Malignant External Otitis in a Patient With Diabetes Mellitus: Comparison of Bone Scan SPECT/CT and 68Ga-Citrate PET/CT.

ABSTRACT: We reported a 66-year-old woman with malignant external otitis who was referred to our department for evaluation of disease extension. Both 99mTc-MDP bone SPECT/CT and 68Ga-citrate PET/CT were done for the patient. Both studies showed concordant areas of increased uptake in the petrous bone. In addition, 68Ga-citrate PET/CT showed soft tissue infection in the nasopharyngeal wall. Our case showed the potential of 68Ga-citrate PET/CT for evaluation of malignant external otitis.

Diabetes and glycemic control in necrotizing otitis externa (NOE).

PURPOSE: Although the association between necrotizing otitis externa (NOE) and diabetes mellitus (DM) is well known, there is little knowledge in regards to the effects of DM and glycemic control on the outcome of NOE. The aim of the study was to determine the effects of DM duration and glycemic control, and in-hospital glycemic control on NOE severity. METHODS: A retrospective case series analysis, including all patients hospitalized between 1990 and 2018 due to NOE were included. Data collected included NOE disease characteristics, duration of DM, DM-associated comorbidities, glycated hemoglobin (HbA1c), urine microalbumin and in-hospital blood glucose measurements. Disease severity was defined based on duration of hospitalization (above or below 20 days) and need for surgery. RESULTS: Eighty-nine patients were included in the study. Eighty-three patients (94.3%) had DM. Preadmission HbA1c was 8.13% (5.8-12.6%). Forty-nine patients (65.5%) had mean blood glucose of ≥ 140 mg/dL and 26 (34.5%) had ≤ 140 mg/dL. DM duration was 157.88 months among NOE patients who required surgery, and 127.6 months among patients who were treated conservatively (p value 0.25). HbA1c in patients hospitalized < 20 days was 7.6%, and 8.7% among NOE hospitalized ≥ 20 days (p value 0.027). Seven patients with mean blood glucose of ≤ 140 mg/dL had Pseudomonas Aeruginosa (PA-NOE) (26.7%), in comparison to 25 (51.0%) with mean blood glucose measurement of ≥ 140 mg/dL (p = 0.045). CONCLUSIONS: HbA1c at admission is associated with longer hospitalization duration among NOE patients. Mean blood glucose during hospitalization was associated with a higher likelihood of PA infection, however, it had no effect on disease outcome.

Necrotising otitis externa and how to reduce length of hospital stay: a complete audit cycle of 77 hospital admissions.

BACKGROUND: Necrotising otitis externa is a serious condition that requires hospital admission. Longer hospital stays are associated with increased complications. METHOD: This was a closed audit cycle in a tertiary ENT centre of patients presenting with necrotising otitis externa to the ENT department between 2015 and 2019. The aim was to audit the length of hospital stay in comparison to national figures as well as the time needed for investigations. RESULTS: The number of patients with necrotising otitis externa is increasing in England. Length of stay, however, appears to be more stable. A total of 66 admissions occurred over the study period for 48 patients in total, and mean length of stay was 12.4 days. After implementation of a new protocol, length of stay was reduced to 7.1 days. CONCLUSION: Patients with necrotising otitis externa require prompt diagnosis and management in order to shorten length of stay in hospital and avoid serious complications. Multi-disciplinary protocol development and implementation could help in reducing length of stay of necrotising otitis externa patients.

Paralysis from an ear infection: a severe case of otitis externa leading to acute complete cervical cord syndrome.

We report a case of a generally fit and well 54-year-old man who presented with a 2-day history of worsening left-sided otorrhea, headache, neck stiffness, vomiting and fever on the background of a 7-week history of otitis externa (OE). His condition progressed dramatically as he developed symptoms consistent with acute complete cervical cord syndrome with radiological evidence of skull base osteomyelitis, parapharyngeal, retropharyngeal and paravertebral abscesses and sigmoid sinus thrombus. Ultimately, he made a significant, although not complete, recovery. This case is unique in demonstrating how OE can develop into a potentially life threatening condition. It emphasises the importance of early diagnosis and treatment of OE, the recognition of 'red flag' symptoms and highlights the importance of a multidisciplinary team approach when managing complex complications of OE.

Methicillin-resistant Staphylococcus schleiferi subspecies coagulans associated with otitis externa and pyoderma in dogs.

Background: Dermatological infections are the most common cases in the daily pet clinic. Since its discovery in 1990, Staphylococcus schleiferi subspecies coagulans have been reported more frequently in canine otitis externa and pyoderma and even in cases of zoonoses. Aim: Detect the presence of S. schleiferi subsp. coagulans of canine otitis externa and pyoderma, its antimicrobial resistance, and the presence of mecAgen. Methods: Three-hundred-thirty-one swabs from dogs with otitis externa and pyoderma were cultured on bacteriological agar for bacterial isolation and subsequent biochemical and molecular identification. The identified S. schleiferi subsp. coagulans were evaluated for their antimicrobial susceptibility using the Kirby-Bauer technique, including an oxacillin disk, and subsequently, a PCR was run to identify which ones had the mecA gene. Results: Thirty-four (22.97%) and twelve (6.56%) isolates were identified as S. schleiferi subspecies coagulans from otitis externa and pyoderma, respectively. Fluoroquinolones, the most widely used group of antibiotics in Peru, showed a susceptibility of 58.82% (20/34) in cases of otitis externa and 50% (6/12) in cases of canine pyoderma. Meanwhile, nitrofurantoin was the antibiotic with the best efficacy in both cases, with 97% (33/34) in otitis externa and 83% (10/12) in pyoderma. Furthermore, 40% (13/34) of S. schleiferi subsp. coagulans isolated from otitis externa were resistant to methicillin, and 85.29% (29/34) had the mecA gene. On the other hand, the only methicillin-resistant isolate from pyoderma was also the only one with a mecA gene. Conclusion: This study is the first report of S. schleiferi subsp. coagulans in Peru, finding a higher percentage than reported in other South American countries.

Lemierre's Syndrome Due to Malignant Otitis Externa: Imaging Studies Revealed Its Systemic Dissemination.

Lemierre's syndrome is characterized by internal jugular vein thrombosis and systemic septic embolism; it is a fatal complication of upper respiratory tract infections. To date, it has not been demonstrated how the upper respiratory tract inflammation spreads from the primary infection site to internal jugular vein and systemic thrombosis. We report a very rare case of Lemierre's syndrome derived from malignant otitis externa in which the spread of infection and thrombosis process were identified by imaging. A 61-year-old man with severe diabetes mellitus visited our hospital with consciousness disturbance and right posterior neck pain. He complained of right ear pain and otorrhea several days prior to the neck pain. Contrast-enhanced computed tomography demonstrated thrombosis in internal jugular vein and multiple lung abscesses. Temporal bone images revealed continuous lesions from skull base osteomyelitis to suboccipital abscess and sigmoid sinus thrombosis. We diagnosed the patient as having Lemierre's syndrome secondary to skull base osteomyelitis following malignant otitis externa. The patient clinically recovered with a combination of drainage of suboccipital abscess and long-term administration of antibiotics, which is the standard treatment of malignant otitis externa. Considering the details of imaging and bacterial examination is very useful for understanding the pathophysiology and determining appropriate treatment in Lemierre's syndrome pathophysiology and determining appropriate treatment in Lemierre's syndrome.

Dysphagia due to necrotizing otitis externa.

An 88-year-old man presented with delirium, and subsequently developed hoarseness and oropharyngeal dysphagia. This was due to skull-based osteomyelitis from necrotizing otitis externa (NOE), causing lower cranial nerve (X, XII) palsies and venous sinus thrombosis. Diagnosis was delayed as the patient reported no otalgia, had an almost normal looking external auditory canal and was not diabetic. He deteriorated and died despite intravenous antibiotics. We need a high index of suspicion for NOE and its complications in patients presenting with otolaryngeal symptoms.

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida! / Aneurisma micótico da aorta em paciente debilitado com imunidade comprometida - um alerta para Cândida

Abstract Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

Resumo A cândida é uma causa rara de aneurismas da aorta infecciosos. Relatamos o caso de um paciente diabético com doença renal terminal, que foi submetido a reparo de aneurisma da aorta abdominal com vazamento. Ele estava em tratamento de longo prazo com antibióticos para otite externa maligna. A Candida albicans foi isolada da cultura da parede do aneurisma que sofreu a excisão. Não há relatos prévios de aneurisma da aorta infeccioso causado por cândida em pacientes com otite externa maligna. Este relato de caso visa reforçar que a cândida deve ser uma das suspeitas de causa de aneurisma da aorta infeccioso em pacientes debilitados e com imunossupressão crônica. O manejo desses casos pode ser extremamente desafiador, principalmente em contextos em que os recursos são escassos, e mencionaremos as vantagens e desvantagens das diversas opções de tratamento.

Facial nerve paralysis in malignant otitis externa: comparison of the clinical and paraclinical findings.

BACKGROUND: Malignant otitis externa is an uncommon but critical challenging disease with some degree of cranial nerve involvement. AIM/OBJECTIVE: to examine the factors leading to facial paralysis in these patients and clarify indications for aggressive treatment in the group most at risk. MATERIAL AND METHODS: In a case-control study, demographic, clinical, laboratory, audiometric, imaging, and treatment characteristics of 139 patients in groups with and without facial paralysis were analysed. RESULTS: 45 patients (32.4%) had facial paralysis. Compared to patients without facial nerve involvement, patients with facial palsy had a higher rate of inflammatory markers (mean erythrocyte sedimentation rate on admission [67.71 vs 51.16 mm/h], and the average of total ESR [64.27 vs 54.46 mm/h], as well as the mean C-reactive protein [38.96 vs 27.53 mg/L]). Also, the involvement of the facial canal (p < .01) and nasopharyngeal space (p < .05) were related to the incidence of facial paralysis. CONCLUSION: Nasopharyngeal extension of the inflammation and facial nerve canal erosion might be useful as predictors of facial nerve dysfunction. The elevated erythrocyte sedimentation rate is correlated with the increased risk of facial paralysis, and aggressive medical management is more crucial. SIGNIFICANCE: Improvement in predicting the outcome of patients with malignant otitis externa.

Prediction of skull base osteomyelitis in necrotising otitis externa with diffusion-weighted imaging.

OBJECTIVE: To predict skull base osteomyelitis in patients with necrotising otitis externa using diffusion-weighted imaging. METHODS: A retrospective analysis was conducted of 25 necrotising otitis externa patients with skull base osteomyelitis (n = 10) or without skull base involvement (n = 14) who underwent a single-shot diffusion-weighted imaging of the skull base. RESULTS: The respective mean apparent diffusion coefficient values of the skull base, as determined by two reviewers, were 0.851 ± 0.15 and 0.841 ± 0.14 ×10-3mm2/s for the skull base osteomyelitis patients, and 1.065 ± 0.19 and 1.045 ± 0.20 ×10-3mm2/s for the necrotising otitis externa patients without skull base involvement. The difference in apparent diffusion coefficients between the groups was significant, for both reviewers (p = 0.008 and 0.012). The optimal threshold apparent diffusion coefficient for predicting skull base osteomyelitis in necrotising otitis externa patients was 0.945 ×10-3mm2/s and 0.915 ×10-3mm2/s, with an area under the curve of 0.825 and 0.800, accuracy of 87.5 and 83.3 per cent, sensitivity of 85.7 and 90.0 per cent, and specificity of 90.0 and 78.6 per cent, for each reviewer respectively. CONCLUSION: Apparent diffusion coefficient is a non-invasive imaging parameter useful for predicting skull base osteomyelitis in necrotising otitis externa patients.