Aspergillus infections of lateral skull base: a case series.

PURPOSE: While extensive research with accurate classification has been done in mycoses of the paranasal sinuses and anterior skull base, a similar understanding of lateral skull base fungal pathologies is lacking due to relative rarity and diagnostic difficulties. We introduce a series of eleven cases and two different invasive entities of Aspergillus temporal bone diseases-fungal skull base osteomyelitis (SBO)/malignant otitis externa (MOE) and chronic invasive granulomatous fungal disease (CIGFD). METHODOLOGY: A retrospective observational study was conducted at the neuro-otology unit of a tertiary care referral center between July 2017 and November 2022. Diagnosed cases of lateral skull base osteomyelitis with atypical symptoms and lack of response to culture-directed antibiotics were evaluated for fungal origin. Patient data, including history, laboratory findings, serum galactomannan assay, CT and MRI imaging findings, clinical examination findings, and co-morbidities, were analyzed. The treatment course and response were assessed. RESULTS: A total of 11 cases were included in the study. Of these, 9 were cases of Aspergillus-induced skull base osteomyelitis (SBO) and 2 of Aspergillus-induced chronic invasive granulomatous fungal disease (CIGFD). CIGFD presented with persistent ear discharge and slowly progressive post-aural swelling, while all patients of fungal SBO had lower cranial nerve palsies. CIGFD responded to excision and antifungals, while SBO responded well to conservative anti-fungal treatment. CONCLUSION: In cases of lateral SBO not responding to antibiotic therapy, the possibility of fungal etiology should be considered. Aspergillus spp. seems to be the major fungal pathogen.

Bilateral pyogranulomatous otitis externa with putative cartilage destruction in a dog: A severe case of auricular chondritis?

Auricular chondritis of unknown cause was suspected in a 10-year-old male Bolognese dog with a five-month history of painful bilateral nodular and ulcerative pyogranulomatous dermatitis of the pinnae with putative auricular cartilage destruction. Pain and lesions resolved with immunosuppressive doses of prednisolone, yet the condition resulted in deformity of both pinnae and external canals.

Une chondrite auriculaire d'étiologie inconnue est suspectée chez un bichon bolonais mâle de 10 ans qui présente depuis 5 mois une dermatite pyogranulomateuse nodulaire et ulcéreuse bilatérale douloureuse du pavillon de l'oreille avec une destruction présumée du cartilage auriculaire. La douleur et les lésions disparaissent avec des doses immunosuppressives de prednisolone, mais l'affection entraîne une déformation des deux pavillons et des conduits auriculaires externes.

Suspeitou­se de condrite auricular de causa desconhecida em um cão macho Bolonhês de 10 anos de idade com um histórico de cinco meses de dermatite piogranulomatosa ulcerativa e nodular bilateral no pavilhão auricular com suposta destruição de cartilagem auricular. A dor e as lesões resolveram com doses imunossupressoras de prednisolona apesar de a etiologia ter resultado na deformidade de ambas as orelhas e condutos auditivos.

Se sospechó la existencia de una condritis auricular de causa desconocida en un perro boloñés de 10 años con historia de 5 meses de duración de una dermatitis nodular ulcerativa piogramulomatosa y bilateral en las orejas con posible destrucción del cartílago auricular. El dolor y las lesiones se resolvieron con dosis inmunosupresoras de prednisolona pero la enfermedad produjo deformación de ambas orejas y de los canales auriculares externos.

Malignant (necrotizing) externa otitis: the experience of a single hyperbaric centre.

INTRODUCTION: Malignant otitis externa (MOE) is a potentially life-threatening infection of the soft tissues of the external ear, quickly spreading to involve the periosteum and bone of the skull base. Treatment includes antibiotics and eventually surgery. Hyperbaric oxygen treatment (HBOT) has been proposed as an adjunctive therapy. However, in the tenth consensus conference, this disease was considered as a non-indication for HBOT. The aim of this study was to evaluate the effectiveness of HBOT in MOE treatment. METHODS: Retrospective and observational study was conducted of patients with MOE treated in our centre. Staging of the disease was made according to the clinicopathological classification system. RESULTS: From March 1998 to November 2016, 16 patients were referred. 6% patients were on stage 1 of the disease at the time they were referred, 20% in stage 2, 7% in stage 3a, 13% in stage 3b and 53% in stage 4. Seven (43.75%) patients had VII nerve palsy and three (18.75%) patients had multiple nerve palsy. Average length of symptoms of disease was 5 months (maximum 11 months). Average number of sessions was 33 and the length of hospitalization prior to HBOT (median 90 days) was significantly longer than the time between beginning HBOT and cure (p = 0.028, Wilcoxon signed rank test). There were no fatalities due to MOE and all patients were considered free of disease after HBOT. CONCLUSION: HBOT was well tolerated and revealed to be a helpful adjuvant treatment in MOE. According to our data, HBOT should be considered for patients who failed conventional treatments and in severe cases.

Isolation of Candida auris from Ear of Otherwise Healthy Patient, Austria, 2018.

The emerging pathogen Candida auris is isolated mostly from hospitalized patients and often shows multidrug resistance. We report on the isolation of this yeast in Austria from an outpatient's auditory canal. The isolate showed good susceptibility against antifungals except for echinocandins; the patient was treated successfully with topical administration of nystatin.

Malignant external otitis: The shifting treatment paradigm.

IMPORTANCE: Malignant external otitis (MEO) is an aggressive infection occurring in immunocompromised hosts. Increasing antimicrobial resistance is making the disease more difficult to treat. OBJECTIVE: Determine if there has been a shift in the microbiology and outcomes of MEO. DESIGN: A retrospective case series at a tertiary care institution. SETTING: Inpatient and outpatient tertiary care hospital. PARTICIPANTS: 12 cases of recent MEO were reviewed. MAIN OUTCOMES AND MEASURES: The primary outcome was progression of disease. Secondary outcomes were drug resistance and complications of MEO. RESULTS: Only 4 patients were cured of MEO. Four patients expired during the study period and at least one of these deaths was a direct result of the MEO. 7 patients developed Cranial nerve palsies, and 3 patients developed abscesses. CONCLUSIONS: Select cases of MEO now require multi-drug and long-term parenteral antibiotic therapy with extended hospital stays.

Comparison of two ear cytological collection techniques in dogs with otitis externa.

BACKGROUND: Canine otitis externa is a common disease. Cytological evaluation of otic exudate is a useful diagnostic test to direct and monitor treatment for otitis externa. One method of collecting ear cytological specimens utilizes a cotton-tipped swab inserted into the vertical ear canal. A proposed alternative method is to aspirate exudate from the deep horizontal canal using a rubber tube. HYPOTHESIS/OBJECTIVES: To compare cytological findings between two different collection techniques by evaluating the numbers of bacteria, Malassezia yeast and inflammatory cells. ANIMALS: Thirty client-owned dogs with otitis externa. METHODS AND MATERIALS: A prospective, randomized, blinded comparison study. Ear canals from each dog were sampled using cotton swab and rubber tube. Ear cytological preparations were evaluated independently by two investigators for polymorphonuclear leucocytes (PMN), monocytes/lymphocytes, macrophages, yeast, intracellular (IC) cocci, extracellular (EC) cocci, IC bacilli and EC bacilli. RESULTS: A paired Student's t-test was used to compare the two techniques. The inter-investigator reliability for PMN, EC bacilli and yeast was good, and for EC cocci was moderate. There were significantly higher numbers of PMNs obtained by the tube method (P = 0.0024) than by the cotton swab method. There were no statistically significant differences between cotton swab and rubber tube methods for monocytes/lymphocytes (P = 0.7780), macrophages (P = 0.1751), EC cocci (P = 0.1262), EC bacilli (P = 0.1162), yeast (P = 0.5371), IC cocci (P = 0.6606) or IC bacilli (P = 0.6761). The technique was well tolerated. CONCLUSION: An alternative ear cytological collection technique was identified which enables sampling of the deep horizontal canal.

Analysis of the otic mycobiota in dogs with otitis externa compared to healthy individuals.

BACKGROUND: Otitis externa is a common multifactorial disease with a prevalence in dogs as high as 10-20%. In humans, the diversity of the cutaneous mycobiota appears to increase in diseased states, whereas one canine study identified a decrease in diversity of the cutaneous mycobiota in atopic dogs compared to healthy individuals. HYPOTHESIS/OBJECTIVES: To describe the otic mycobiota in dogs with otitis externa compared to healthy dogs. ANIMALS: Samples were collected from six dogs with clinical and cytological evidence of otitis externa and five clinically normal dogs. METHODS AND MATERIALS: Swabs were collected from the ears of six dogs with fungal otitis externa. DNA from each sample was isolated and Illumina sequencing was performed targeting the internal transcribed spacer region. Sequences were processed using the bioinformatics software MOTHUR. RESULTS: Fungi from ten different phyla were identified. The mycobiota of all affected ears was dominated by the genera Malassezia, which accounted for 55.7-98.4% of sequences (median 96.8%). Affected ears had significantly decreased observed richness, estimated richness and inverse Simpson's diversity index compared to controls (P = 0.008). Linear discriminant analysis effect size (LEfSe) analysis identified 42 operational taxonomic units (OTUs) that were differentially abundant (P < 0.05). Three OTUs were over-represented in the affected ears, including M. pachydermatis, whereas 39 OTUs were over-represented in healthy ears. CONCLUSIONS: Reduced fungal richness and diversity was present in affected ears, with markedly higher relative abundances of Malassezia. The otic fungal mycobiota is much more complex than has been identified with culture-based studies.

Skull base osteomyelitis secondary to malignant otitis externa mimicking advanced nasopharyngeal cancer: MR imaging features at initial presentation.

PURPOSE: Skull base osteomyelitis (SBOM) is an inflammatory process which often arises from malignant otitis externa (MOE); the diffuse skull base and adjacent soft tissue involvement may be mistaken at initial imaging for advanced nasopharyngeal carcinoma (NPC), especially if there is no prior knowledge of MOE, direct spread from the sphenoid sinus or in atypical presentations of MOE. This study aims to evaluate imaging features on MR that may differentiate SBOM from NPC. MATERIALS AND METHODS: The MR examinations of 26 patients diagnosed with SBOM between January 1996 and January 2013 were retrospectively reviewed. Comparison was also made with the MR images of 22 consecutive patients with newly diagnosed advanced T3 and T4 NPC between July 2011 and August 2012. Imaging features in both conditions were compared, including the presence of a nasopharyngeal bulge, nasopharyngeal mucosal irregularity, lateral extension, architectural distortion (or lack thereof), increased T2 signal and enhancement patterns. RESULTS: The most prevalent findings in SBOM were lateral extension, increased T2 signal in adjacent soft tissues, lack of architectural distortion and enhancement greater than or equal to mucosa. The combination of these 4 findings was found to best differentiate SBOM from advanced NPC, and found to be statistically significant (p<0.001). CONCLUSION: We suggest that the combination of lateral extension, increased T2 signal, lack of architectural distortion and enhancement greater than or equal to mucosa is helpful in differentiating SBOM from advanced NPC.

[Malignant externa otitis: the modern principles of diagnostics and treatment]. / Zlokachestvennyi naruzhnyi otit: sovremennye printsipy diagnostiki i lecheniia.

The objective of the present study was to elucidate the specific features of the clinical course of malignant externa otitis in the context of the present-day concepts. A total of 5 patients presenting with the confirmed diagnosis of malignant external otitis were available for the examination. The analysis of the clinical observations provided the basis for the characteristic of pathogenesis of this condition, diagnostic principles, and treatment modalities for the management of the pathology in question. It is concluded that the patients suffering from malignant externa otitis must remain under medical care and observation during a long period and the strategy for the treatment of each concrete patient should be chosen on an individual basis taking into consideration the presence of concomitant pathologies and their adequate therapy.

The impact of topical and systemic enoxaparin sodium use on traumatic tympanic membrane perforation and myringosclerosis.

The objective of this study is to investigate the effect of topical and systemic enoxaparin sodium on the healing pattern of experimentally induced tympanic membrane perforation and formation of myringosclerosis. A total of 24 Wistar-Albino strain rats were included in the study. Standard myringotomies were performed on each rat. In the first group, isotonic serum physiologic was dropped on external ear canal (control group). Topical enoxaparin was dropped on external ear canal and daily topical doses of enoxaparin were dropped on external ear canal of the rats for 14 days (topical treatment group). Third group received subcutaneous injections of enoxaparin for 14 days (systemic treatment group). Five micrometer thick sections of the bullae of the rats were stained with H&E. Inflammation, edema and sclerotic lesions and neovascularization observed in the lamina propria layer of the tympanic membrane, and total thickness of the tympanic membrane were evaluated. In intergroup comparisons, significant difference in the distribution pattern of severity of inflammation in all three groups was not observed (p = 0.784, p > 0.05). Total TM thickness differed among all three groups (p = 0.028, p < 0.05). A statistically significant difference was observed between the systemic enoxaparin and the control groups (p = 0.022, p < 0.05). A statistically significant difference was observed between the topical enoxaparin and the control groups (p = 0.037, p < 0.05). However, comparison between the topical and systemic treatment groups could not reveal any statistically significant intergroup difference (p = 0.682, p > 0.05). A significant difference was not observed among three groups as for the distribution of myringosclerotic plaques, severity of edema and neovascularization in the lamina propria (p = 0.539, p > 0.05), (p = 0.063, p > 0.05), (p = 0.152, p > 0.05). Topical and systemic enoxaparin treatment did not prevent formation of sclerotic plaques; however, it decreased TM thickness significantly in comparison with the control group.

Is there a real benefit of hyperbaric oxygenotherapy in the treatment of necrotizing otitis externa?

INTRODUCTION: Necrotizing otitis externa remains a severe and sometimes life-threatening disease in diabetic patient. Many therapeutic approaches have been described but what about the real benefit of hyperbaric oxygenotherapy in the management of this disease? METHODS: The authors reported a retrospective study about 42 patients treated for necrotizing external otitis over a period of 9 years (2006 to 2014). The patients were treated either by only antibiotherapy (23 cases) or with both antibiotherapy and hyperbaric oxygenotherapy (19 cases). The evolution under treatment was appreciated in the two groups through clinical, biological and radiological parameters. RESULTS: The study included 42 diabetic patients with a mean age of 67 years (50 to 84 years). The sex-ratio M/F was 0.82. The diagnosis of necrotizing otitis externa was assessed through clinical and bacteriologic criteria in diabetic patients. A temporal bone CT-scan and a technetium scintigraphy were performed in order to precise the topography of the disease and the level of bone lysis. Antibiotherapy was prescribed intravenously and then orally for a mean period of 8 weeks (5 to 15 weeks). Hyperbaric oxygenotherapy was given for 19 patients (average: 20 sessions). The recovery was affirmed on clinical, biological and radiological features. Otalgia disappeared at the 11th day of treatment without HOT and at the 5th day with HOT. Otorrhea disappeared at the 6th day of treatment by HOT and at the 13th day without HOT. The recovery or the regression of facial palsy occurred in 75% of the cases when HOT was given. The total recovery from the disease was diagnosed in 36 patients (86%). The rate of recovery was 100% in the group treated by HOT and 74% in the group treated by only antibiotics. The recurrence of the disease was noted in 6 patients that haven't benefited from HOT. The end of the oral therapy was guided by the results of the Gallium bone scintigraphy. CONCLUSION: Hyperbaric oxygenotherapy must be associated in the treatment of necrotizing otitis externa. The results of our study suggest a real benefit of this therapy regarding clinical, biological and radiological parameters of this severe affection.

Protective effect of small molecule analogues of the Acanthocheilonema viteae secreted product ES-62 on oxazolone-induced ear inflammation.

ES-62 is the major secreted protein of the rodent filarial nematode Acanthocheilonema viteae. The molecule contains covalently attached phosphorylcholine (PC) residues, which confer anti-inflammatory properties on ES-62, underpinning the idea that drugs based on this active moiety may have therapeutic potential in human diseases associated with aberrant inflammation. Here we demonstrate that two synthetic small molecule analogues (SMAs) of ES-62 termed SMA 11a and SMA 12b are protective in the oxazolone-induced acute allergic contact dermatitis mouse model of skin inflammation, as measured by a significant reduction in ear inflammation following their administration before oxazolone sensitisation and before oxazolone challenge. Furthermore, it was found that when tested, 12b was effective at reducing ear swelling even when first administered before challenge. Histological analysis of the ears showed elevated cellular infiltration and collagen deposition in oxazolone-treated mice both of which were reduced by treatment with the two SMAs. Likewise, the oxazolone-induced increase in IFNγ mRNA in the ears was reduced but no effect on other cytokines investigated was observed. Finally, no influence on the mast cell populations in the ear was observed.

Two cases of lupus vulgaris in childhood and review of the clinical challenges.

BACKGROUND: Lupus vulgaris (LV) is the most common form of cutaneous tuberculosis (TB) in Europe, nevertheless the overall incidence is low. It constitutes about 1.5% of all extra-pulmonary cases worldwide. A slight raise in TB incidence rates among children was recently registered in Germany, which can be explained by the increased immigration. PATIENTS AND METHODS: We present 2 cases of immigrated children who were diagnosed with Lupus vulagris, both clinically and histopathologically. Although the symptoms and the duration of the skin lesions were very different, both patients had a non-healing skin ulceration.In our cases cultures of the skin biopsy were positive for Mycobacterium tuberculosis and the lesions showed marked improvement in response to antituberculous treatment. In the first patient, it took 6 years between occurrence of skin lesions and final diagnosis. The second patient had an extracutaneous focus, namely abdominal TB. CONCLUSION: We report our experience and emphasize on recent advances in the diagnosis and treatment of paediatric skin TB.

Lessons learnt from the diagnosis and antimicrobial management of necrotising (malignant) otitis externa: our experience in a tertiary referral centre.

Necrotising otitis externa is an uncommon and aggressive infection of the external auditory canal with a tendency to present in the elderly and immunocompromised patient. We report a series of twenty-five patients admitted to our institution over a four-year period with this diagnosis. We review the diagnosis and antimicrobial management of these cases, and propose a treatment algorithm based on our experience.

An investigation of ear necrosis in pigs.

Porcine ear necrosis was investigated in 23 conveniently chosen farms, consisting of 14 case farms and 9 control farms. Biopsies of lesions and oral swabs from pigs on 11 case farms were examined by histology and bacterial culture. All farms were visited for observations and a survey on management, housing, and the presence of other clinical signs or behavioral vices. Histological examination revealed that the lesions began on the surface and progressed to deeper layers, and that vascular damage did not appear to be the initiating cause. Spirochetes were only rarely observed in histological examination and were not cultured from biopsies and oral swabs. Staphylococcus aureus and Staphylococcus hyicus were cultured from 91% and 66% of samples, respectively. Ear biting and a humid environment were associated with ear necrosis. On some farms large numbers of pigs were affected and lesions were sometimes extensive. The condition appears to be an infectious disease beginning on the surface of the skin; contributing environmental and management factors are likely.

Enquête sur la nécrose des oreilles chez les porcs. La nécrose des oreilles porcines a fait l'objet d'une enquête dans un échantillonnage de convenance de 23 fermes, composé de 14 fermes de cas et de 9 fermes témoins. Les biopsies de lésions et des prélèvements oraux faits chez des porcs dans 11 fermes de cas ont été examinés par histologie et culture bactérienne. Toutes les fermes ont été visitées pour recueillir des observations et effectuer un examen de la gestion, du logement et de la présence d'autres signes cliniques ou vices de comportement. L'examen histologique a révélé que les lésions commençaient sur la surface et progressaient vers des couches plus profondes et que les dommages vasculaires ne semblaient pas être la cause initiale. Des spirochètes ont été rarement observés à l'examen histologique et n'ont pas été cultivés dans les biopsies et les prélèvements oraux. Staphylococcus aureus et Staphylococcus hyicus ont été cultivés dans 91 % et 66 % des échantillons, respectivement. Les morsures d'oreilles et un environnement humide étaient associés à la nécrose des oreilles. Dans certaines fermes, un grand nombre de porcs étaient affectés et les lésions étaient parfois importantes. L'affection semble être une maladie infectieuse qui commence à la surface de la peau; des facteurs contributifs liés à l'environnement et à la gestion sont probables.(Traduit par Isabelle Vallières).

Neoplasms of the Ear Canal.

Primary EAC neoplasms include benign and malignant lesions of bony, glandular or cutaneous origin. Small, benign slow growing bony neoplasms are often asymptomatic, diagnosed incidentally and might not require intervention. Both malignant and benign neoplasms of cutaneous and glandular origin can present with symptoms of chronic otitis externa, leading to delays in diagnosis. Prompt biopsy of soft tissue lesions associated with non-resolving otitis externa are warranted. Local and regional imaging is helpful to understand disease extent and origin, but even early-stage malignant neoplasms require aggressive surgical treatment.

Antibiotic therapy in necrotising external otitis: case series of 32 patients and review of the literature.

Necrotising external otitis (NEO) is a rare but severe bone infection, usually due to Pseudomonas aeruginosa, the management of which is not standardised. Systemic antibiotic therapy is usually prescribed for at least 6 weeks, but no review has been published on this topic. We report our experience and have reviewed the literature regarding antibiotic therapy in NEO. Here we describe a case-series of consecutive NEO cases seen over an 8-year period (2004-2011) in a French tertiary-care teaching hospital. Since 2009 we have shortened the duration of antibiotic therapy to 6 weeks. We also present a review of the literature regarding antibiotic therapy in NEO. We include 32 NEO cases, with positive microbiological cultures in 30 cases. Among the 30 patients with suspected or proven P. aeruginosa infections, 27 received an initial combination therapy of ceftazidime and ciprofloxacin. The duration of antibiotic therapy and length of hospital stay were significantly reduced after 2009 (9.4 ± 3.2 weeks versus 5.8 ± 0.7, P < .0.001; and 18.2 ± 8.7 days versus 11.6 ± 6.9, P = .0.03, respectively). Patient outcomes were favorable in all cases, with a 14-month median duration of follow-up. Our literature review (30 case series) shows that initial combination therapy is associated with better outcomes as compared with single therapy (97 % versus 83 %, P < .0.001). We suggest 3 weeks of initial combination therapy (ceftazidime + ciprofloxacin, high doses) followed by 3 weeks single therapy with ciprofloxacin in susceptible P. aeruginosa NEO. A close collaboration between ear, nose and throat and infectious diseases specialists is needed.

Single photon emission computed tomography/computed tomography of the skull in malignant otitis externa.

Malignant otitis externa is a severe, rare infective condition of the external auditory canal and skull base. The diagnosis is generally made from a range of clinical, laboratory, and imaging findings. Technetium 99m methylene diphosphonate bone scintigraphy is known to detect osteomyelitis earlier than computed tomography. The authors present a patient with bilateral malignant otitis externa where the extent of skull base involvement was determined on 3-phase bone scintigraphy with single photon emission computed tomography/computed tomography.