Malignant Otitis Externa: A Novel Stratification Protocol for Predicting Treatment Outcomes.

OBJECTIVES: 1) Stratify malignant otitis externa into severe and nonsevere disease categories. 2) Predict treatment courses and outcomes based on this stratification. SETTING: Tertiary center. PATIENTS: Retrospective review 2004 to 2014; 28 patients. Inclusion criteria are a diagnosis by senior authors, radiographic evidence of disease, admission for intravenous antibiotics/debridement, minimum 1 year of follow-up. INTERVENTIONS: Severe group stratification if two or more of the following: cranial nerve VII palsy, fungal positive culture, relapse, surgery performed, major radiographic findings. All other patients stratified to nonsevere group. MAIN OUTCOME MEASURES: Cure, alive/refractory disease, death by disease, death by other cause. Secondary measures are antibiotic duration and number of disease-related admissions. RESULTS: Forty-three percent (12 of 28) and 57% (16 of 28) of patients stratified into the severe and nonsevere groups. The severe group had significantly more adverse disease-specific outcomes than the nonsevere group (7 of 12 versus 0 of 16; p = 0.002). Disease-specific mortality was 42% and 0% in the severe and nonsevere groups, respectively. The severe group had longer antibiotic courses (12.8 versus 6.9 wk; p = 0.01) and more disease-related admissions/relapses (1.6 versus 1, p < 0.001). Only four of 12 severe group patients achieved cure. All but two nonsevere patients achieved cure, with those two dying of other causes. CONCLUSION: A subgroup of malignant otitis externa may exist that is not as susceptible to parenteral antibiotics and local debridement. A combination of clinical and radiographic findings may be useful for stratifying patients into severe/nonsevere categories. Patients with severe disease may be more likely to die of their disease and have worse treatment courses such that additional surgical intervention may be indicated.

[Exostoses of the external auditory canal in professional diving. A case for the German Social Accident Insurance Institution]. / Berufstaucher mit Gehörgangsexostosen. Ein Fall für die Berufsgenossenschaft.

Exostoses of the external auditory canal are often diagnosed incidentally but may also cause complications, e.g., conductive hearing loss and/or recurrent inflammations of the external ear canal due to stenosis. This paper presents current scientific data on the pathogenesis of ear canal exostoses, which obviously focus on the cold water hypothesis. We present a case of an expert opinion on occupational illness and discuss whether the legal preconditions for recognition "like an occupational disease" according to article 9(2) Social Code Book VII are met. A systematic reporting of suspected cases is recommended in order to obtain reliable data on the epidemiology and the clinical course of external auditory exostoses among individuals occupationally exposed to cold water and to enter an expert discussion on the reasonability of an inclusion in the list of occupational diseases.

Malignant external otitis: analysis of severe cases.

OBJECTIVE: To study the effect of specific clinical, laboratory, and imaging parameters on the course of severe (type 1) malignant external otitis (MEO). STUDY DESIGN: Case series with chart review. SETTING: Tertiary, university-affiliated medical center. SUBJECTS AND METHODS: Fifty-seven patients hospitalized with severe MEO were followed for disease course and survival in a tertiary center between 1990 and 2008. RESULTS: In 20% of patients, disease was persistent and/or aggressive despite prolonged and extensive treatment. Of this subgroup, 45% died of the disease. Prognostic factors of persistent/aggressive disease were facial nerve paralysis, bilateral disease, and significant major computed tomography findings (temporomandibular joint destruction, infratemporal fossa or nasopharyngeal soft tissue involvement). Cultures grew fungi in 5 patients, and follow-up imaging revealed disease progression. The overall 5-year survival was 55% for patients with short-term disease and 40% for patients with persistent/ aggressive disease (P = .086). By age, 5-year survival was 75% in patients younger than 70 years old and 44% in older patients (P = .029). CONCLUSIONS: A significant subset of patients with MEO has a prolonged, aggressive, and highly fatal disease that needs to be identified early. These patients more frequently have bilateral disease, cranial nerve paralysis, and positive computed tomography findings. Their follow-up should routinely include imaging studies to evaluate disease progression, and every effort should be made to identify and treat underlying fungal infection.

[External otitis in children: etiology and principles of therapy].

External otitis accounts for 21 to 25% of all inflammatory ear diseases. This paper presents the original data providing a deeper insight into etiology of this disease taking into consideration the great variety of its pathogenic agents, the possibility of development of mixed forms, and changes of whether conditions at the peak of morbidity. In addition, the results of assessment of the efficacy of Pimafucort designed for both mono- and combined therapy of the disease of interest are reported.

Granular myringitis: is it a surgical problem?

OBJECTIVE: An attempt to settle the controversies associated with granular myringitis (GM) including incidence, etiology, pathology, presentation, relation to chronic otitis media, and treatment. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center and private otology practice. PATIENTS: 94 patients presenting with GM over 28 years. INTERVENTION: Diagnosis by otoscopy, audiometry, radiology, and bacteriology; long-term follow-up (6 months to 12 years); assessment of treatment results. MAIN OUTCOME MEASURES: The pathologic states of the affected tympanic membranes were studied in both active and quiescent stages. The results of conservative versus surgical management were evaluated. RESULTS: The disease presents with chronic painless otorrhea, normal hearing and mastoid pneumatization, and granular areas, which may be patchy, diffuse, or segmental. The latter is the most frequent and is most commonly posterosuperior. The infecting organism is Pseudomonas aeruginosa. The pathologic process affects all drum layers and can cause a perforation. The most important predisposing factor is disturbed epithelial migration, which may be exaggerated by eustachian tube dysfunction. Of 26 cases treated conservatively, none healed without recurrence. Of 48 cases treated surgically, there were 2 recurrences. CONCLUSIONS: Pathologically, the disease affects all drum layers. It presents with an active stage, which may be misdiagnosed as chronic otitis media or cholesteatoma, and a quiescent stage when it may be overlooked. Although distinct from chronic otitis media, it can cause a perforation. The disease responds readily to medical treatment, but recurrence is common. Radical surgery offers a curative measure in refractory cases.

Malignant external otitis: a radiographic-clinical correlation.

Malignant external otitis is an infectious process of the ear which may cause marked destruction of the surrounding bony structures. After evaluation of the plain skull films, mastoid series, temporal bone tomography, arteriography, and venography in nine cases of malignant external otitis, we divided the disorder into an early stage and late stage. The early stage is manifested by a soft tissue mass within the external canal or clouding of the mastoid air cells with no bone destruction. In the late stage, bone destruction may extend to the middle ear cavity, temporomandibular joint, and/or base of the skull. A correlation can be made between the clinical findings and these radiographic stages. Complex motion tomography is essential to appreciate the bone destruction in patients with late stage disease.