Aspergillus necrotizing otitis externa with temporomandibulozygomatic involvement.

INTRODUCTION: Aspergillus necrotizing otitis externa (NOE) is a rare disease, often associated with delayed diagnosis, the management of which is poorly defined. SUMMARY: The authors report a case of Aspergillus flavus necrotizing otitis externa with temporomandibular arthritis and temporozygomatic osteomyelitis with Staphylococcal coinfection in a diabetic patient. The diagnosis and discontinuation of treatment were guided by PET-CT scan. A favourable course without sequelae was observed after repeated surgical curettage and 3 months of antifungal therapy. DISCUSSION: Aspergillus flavus is the agent most commonly incriminated in NOE. Indirect diagnostic tests (serology) may be negative. The diagnosis is based on imaging-guided surgical biopsy with histological examination and standard and fungal microbiological culture. Treatment requires a combination of surgery and antifungal therapy. The duration of antifungal therapy is poorly defined and discontinuation of therapy can be guided by PET-CT scan.

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.

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.

Malignant otitis externa: an Asian perspective on treatment outcomes and prognostic factors.

OBJECTIVE: Malignant otitis externa (MOE) is a severe disease with varying outcomes. Despite advances in antibiotic treatment, a significant proportion still succumbs to this disease. We aimed to analyze the effect of clinical factors on prognosis and to review treatment outcomes in our institution. STUDY DESIGN: Case series with retrospective chart review of MOE cases from 2006 to 2011. SETTING: Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore, a tertiary referral center. SUBJECTS AND METHODS: Patients with MOE admitted for treatment were studied and divided into 2 outcome groups depending on response to a 6-week course of intravenous antibiotics. Demographic and disease factors were analyzed with regard to outcome. RESULTS: Nineteen cases were analyzed. Disease resolved in 63.2% after 6 weeks of antibiotics. Mortality was 21.1%. Age, diabetic control, duration of diagnostic delay, cranial nerve involvement, and inflammatory markers were not found to predict prognosis. Erythrocyte sedimentation rate and C-reactive protein levels correlated with disease activity and can be used to monitor progress. Clival involvement was associated with persistent disease (P = .002). Only 63.2% of cases had positive cultures. Pseudomonas aeruginosa was the main organism, and 33.3% of isolates were multidrug resistant. Outcome was not different in cases where culture-directed therapy was employed vs those where empirical ceftazidime and fluoroquinolone were used (P = .650). CONCLUSION: Malignant otitis externa remains an insidious disease with significant mortality. Involvement of the clivus portends a poorer prognosis. Combination therapy with intravenous ceftazidime and oral fluoroquinolone remains relevant despite concerns of culture-negative cases and multidrug-resistant Pseudomonas.

Initial management of necrotizing external otitis: errors to avoid.

OBJECTIVES: Diagnostic and therapeutic practice guidelines have been established for classical forms of benign otitis externa. However, these guidelines do not include unusual forms of the disease, especially "invasive" otitis externa. No consensual diagnostic flow diagram has been published in the literature, which frequently results in delayed diagnosis and inappropriate primary care management. The objective of this study was to analyse the primary care management practices of malignant otitis externa (MOE). MATERIAL AND METHODS: Retrospective study of 22 cases of MOE managed in our tertiary care centre over a 6-year period (2004-2010). RESULTS: All but one of the patients presented a systemic or local predisposing factor. The mean interval between onset of the first symptoms and referral to our tertiary care centre was 13weeks (range: 1 to 12months); 77% of patients were referred by a private ENT specialist, 14% were referred by a an emergency department and 9% were referred by a hospital department. Seventeen patients (81%) had received one or more courses of inappropriate systemic antibiotics during this interval (oral in 15 cases, parenteral in two cases, multiple treatments in 13 cases). The mean duration of each course of antibiotics was 12days (range: 7 to 21days). All patients also received local antibiotic ear drops (aminoglycosides or fluoroquinolones). CONCLUSIONS: The practice audit constantly revealed delayed management of MOE, often resulting in inappropriate antibiotic prescriptions. Publication of practice guidelines for primary and secondary care practitioners therefore appears to be essential.

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.

Antioxidant effect of pomegranate extract in reducing acute inflammation due to myringotomy.

OBJECTIVE: To assess the effect of pomegranate extract on acute inflammation due to myringotomy. DESIGN: Prospective, randomised study. SUBJECTS: Thirty Sprague-Dawley rats were divided into three groups. Group one constituted controls. Group two underwent myringotomy. Group three underwent myringotomy and also received 100 µl/day pomegranate extract, via gavage, one day before and two days after surgery. Following sacrifice 48 hours after myringotomy, the animals' right ears were used to determine the concentration of reactive oxygen species, using the chemiluminescence method; left ears were used for histological study. RESULTS: Reactive oxygen species levels were significantly decreased in group three compared with group two (p < 0.01). The density of inflammatory cells in group three was significantly less than that in group two (p < 0.01). Lamina propria thickness and vessel density were also significantly decreased in group three compared with group two (p < 0.01). CONCLUSION: Our results indicate that oral pomegranate extract decreases reactive oxygen species concentration and acute inflammation in the tympanic membrane after myringotomy.

Fungal malignant external otitis.

OBJECTIVE: To investigate the clinical characteristics and outcome of fungal malignant external otitis (MEO). METHODS: The files of 60 patients treated for MEO in 1990-2008 at a tertiary medical center were reviewed for clinical characteristics and outcome, and findings were compared between patients with fungal and nonfungal infection. RESULTS: Mean duration of follow-up was 4 years. Nine patients (15%) had fungal disease; the main pathogen was Candida spp. Compared with the nonfungal MEO group, patients with a fungal infection were younger at diagnosis (average 68 vs. 74 years, p = 0.01) and had more facial nerve palsies (55% vs. 14%, p = 0.01), fewer positive bacterial cultures at presentation (33% vs. 75%, p = 0.02), and higher rates of surgery (78% vs. 18%, p = 0.0008) and hyperbaric treatment (78% vs. 4%, p = 0.0001). Eighty-nine percent had persistent infection (>2 courses of systemic antibiotics before antifungal treatment) compared with 12% in the nonfungal group (p = 0.0001). Fungal disease was associated with more persistently positive imaging findings (87.5% vs. 25%, p = 0.0001). There was no significant between-group difference in survival. CONCLUSION: Fungal MEO probably occurs secondary to prolonged antibiotic treatment for bacterial MEO. The fungal disease is more invasive than the bacterial disease, although survival is the same. Treatment should be aggressive and hyperbaric oxygen therapy should be considered.

Malignant otitis externa: case series.

BACKGROUND: In the light of current concerns regarding ciprofloxacin resistance and the changing face of malignant otitis externa, we reviewed cases of malignant otitis externa treated in our centre, in order both to evaluate the current epidemiology of the condition and to assess the status of drug resistance in our patient population. METHOD: Retrospective case review of all malignant otitis externa cases managed in a tertiary referral centre in the north-east of England between 2000 and 2009. RESULTS: Forty-one patients were identified, but the required data were available for only 37 cases. Patients' ages ranged from 51 to 101 years (median, 81 years). Diabetes was present in 51 per cent of patients (19/37), facial nerve palsy in 40 per cent (15/37) and multiple cranial nerve palsy in 24 per cent (9/37). Pseudomonas aeruginosa was the most commonly isolated organism (54 per cent), sensitive to ciprofloxacin in all cases. CONCLUSIONS: The incidence of cranial nerve palsy in our study was higher than in previous reports. The incidence of diabetes and Pseudomonas aeruginosa in our cohort was much lower than previously reported. The Pseudomonas aeruginosa strains isolated were all sensitive to ciprofloxacin, despite recent reports on emerging resistance.

Anti-inflammatory activity of seed essential oil from Zizyphus jujuba.

This study was undertaken to evaluate the effect of essential oil from seeds of Zizyphus jujuba on TPA-induced skin inflammation in experimental mice. Exposure of TPA on the ear of the BALB/c mice caused a marked increase in both ear thickness and skin water content. The ear thickness was measured for TPA-induced ear was 0.54 mm, as compared to control (0.23 mm). Treatment with 1% and 10% of essential oil caused significant decrease in ear thicknesses which were measured to be 0.30 and 0.35 mm, as well as reduce the water content about 51% and 53% in the TPA-induced skin inflammation model, respectively. Furthermore, histological analysis clearly confirmed that Z. jujuba essential oil inhibited the inflammatory responses of skin inflammation in animal model. Therefore, our findings demonstrate that the essential oil of Z. jujuba seeds might accelerate the development of new drugs for various inflammatory diseases.

Invasive fungal and bacterial infections of the temporal bone.

OBJECTIVES/HYPOTHESIS: Objectives were to highlight the importance of surgical therapy in treating invasive polymicrobial infections of the temporal bone, to discuss the importance of antifungal therapy, and to review the differential diagnosis of ear canal granulomatous disorders. STUDY DESIGN: Retrospective case review at a tertiary care medical center. METHODS: A retrospective chart review of all patients diagnosed with invasive polymicrobial temporal bone infections was performed. Four patients were identified. All patients required surgical therapy for definitive management. All patients were followed for at least 1 year or until death. RESULTS: Three of four patients had invasive fungi as pathogens. One patient had an occult squamous cell carcinoma. At the time of writing, one patient was free of disease, two were dead of disease, and one was alive with disease. CONCLUSION: Invasive polymicrobial temporal bone infections can occur in immunocompromised patients and can possibly harbor an occult malignancy. Surgical debridement may be necessary to arrive at a correct diagnosis. Modified radical mastoidectomy with parenteral antibiotic therapy and other adjunctive measures may be necessary for disease resolution.

A new assay for antiphlogistic activity: zymosan-induced mouse ear inflammation.

A new model of local inflammation has been developed: intradermal zymosan-induced mouse ear edema. The symptoms of inflammation induced by injecting zymosan into one of the ears were followed up for 72 h. The ear edema and the local accumulation of polymorphonuclear leukocytes' (PMN) marker enzyme, myeloperoxidase (MPO), were determined. Edema peaked at 4-6 h, while MPO activity peaked at 24 h after zymosan application. The correlation between inflammatory response and concentration of zymosan was also tested. Of the various concentrations tested, 1% suspension has been found optimal. Anti-inflammatory drugs and mediator antagonists were examined in order to establish the selectivity and sensitivity of the assay. A glucocorticoid (dexamethasone), two cyclooxygenase inhibitors (indomethacin, piroxicam) and an interleukin-1 (IL-1) release inhibitor (IX 207-887, Sandoz) all reduced edema and MPO activity as well. However, a lipoxygenase inhibitor (phenidone), a serotonin receptor antagonist (methysergide) and H1 and H2 receptor antagonists (clemastine and cimetidine, respectively) all failed to inhibit the reaction.

Otitis externa: clinical comparison of local ciprofloxacin versus local oxytetracycline, polymyxin B, hydrocortisone combination treatment.

Thirty patients with otitis externa were included in a prospective, randomized, parallel group comparison study. Treatment regimens used were ciprofloxacin (2 mg/ml) as ear drops twice daily or drops containing oxytetracycline (5 mg/ml) polymyxin B (10,000 units/ml) and hydrocortisone (15 mg/ml) twice daily for 7 days. Evaluation was by clinical signs and symptoms and bacteriological findings from ear swabs prior to and 3 and 8 days after start of therapy, together with long-term follow-up if necessary. Sixteen patients were included in the ciprofloxacin and 14 in the combined antibiotic group. Six of 16 and 7 of 14 initial swabs, respectively, contained Pseudomonas aeruginosa. Mixed Gram-negative and Gram-positive pathogens were found in 3 patients in the ciprofloxacin group. All Gram-negative isolates were sensitive to ciprofloxacin. Microbiological evaluation showed rapid eradication of all bacterial pathogens in the ciprofloxacin group with 1 persistence of Candida albicans but eradication of Staphylococcus aureus in the same ear with marked clinical improvement. There was 1 case of supercolonization in the ciprofloxacin group with Candida parapsilosis. In the combined antibiotic group, there were 7 persistencies of which 5 were P. aeruginosa. No adverse effects were noted in either group. Treatment was assessed as a complete success in 14/16 and 5/14 cases, partial success in 2/16 and 4/14 cases and unsuccessful or indeterminate in 0/16 and 5/14 cases, respectively. Ciprofloxacin thus appears to be a useful and effective agent in the local therapy of otitis externa.

Hyperbaric oxygenation for necrotizing (malignant) otitis externa.

Two patients with extensive necrotizing otitis externa have been treated by hyperbaric oxygenation. One patient had facial nerve palsy and the other suffered from skull base involvement. Due to severe side effects, the preferred combined intravenous antibiotic therapy was changed to monotherapy in one case and completely withdrawn in the second. This was done before the commencement of hyperbaric oxygenation, while the necrotizing infection was still active. Hyperbaric oxygenation therapy was followed by complete resolution of the necrotizing otitis externa, which did not recur. The pathogenesis of the disease and mechanisms by which hyperbaric oxygenation might be of benefit are described. We conclude that hyperbaric oxygenation should be considered as adjuvant therapy for necrotizing otitis externa whenever a therapeutic pressure chamber is available.

Necrotizing external otitis treated with ciprofloxacin. A case report.

Necrotizing (malignant) external otitis is a severe infection caused by Pseudomonas aeruginosa which occurs mainly in elderly diabetics or in immuno-depressed patients (Chandler, 1968). The management of this condition requires the association between an aminoglycoside antibiotic and an antipseudomonal beta-lactamic, given parenterally during a 4 to 6 week period. Sometimes it is necessary to continue the therapy for months until there is no evidence of residual disease (Strauss et al., 1982). Ciprofloxacin is a quinolone with antipseudomonal activity which can be taken orally, and it is a useful alternative to the current treatment. The authors report a case of necrotizing external otitis which was successfully treated with ciprofloxacin.