Hyperbaric oxygen therapy in malignant otitis externa: a retrospective analysis.

PURPOSE: Malignant otitis externa (MOE) is a rare form of invasive osteomyelitis of the external ear canal. It is typically caused by Pseudomonas aeruginosa in immunocompromised patients. The diagnosis is clinical, and the initial treatment involves systemic antibiotics or antifungal therapy. Surgery is usually only considered when medical treatment has failed. Although hyperbaric oxygen therapy (HBOT) is recommended for refractory osteomyelitis, there are no specific guidelines for MOE. METHODS: This is a retrospective study that evaluates clinical data, treatment, and results obtained in patients diagnosed with MOE treated with HBOT at the Pedro Hispano Hospital between 2007 and 2022. RESULTS: During the study period, fifteen patients diagnosed with MOE were admitted for treatment with HBOT. All patients received antibiotic and/or antifungal therapy, and three required surgical intervention before starting HBOT. The pathology was successfully managed on all patients. CONCLUSIONS: HBOT may be an effective adjuvant treatment option in patients with MOE but it lacks robust scientific evidence. However, its therapeutic value should not be underestimated due to the good results and few adverse effects reported in recent retrospective studies and case reports.

Skull Base Osteomyelitis- Marauders of the Skull.

Skull base osteomyelitis is a vicious infection of temporal bone associated with very high morbidity and mortality. But few studies have been undertaken recently for eliciting its increasing incidence. Hence this study aims to describe the clinical profile of skull base osteomyelitis and changes noted in the post-covid period, and encourage a uniform treatment policy globally. This descriptive study was conducted among 140 patients diagnosed with skull base osteomyelitis. Data was collected using semi-structured proforma, HRCT temporal bone findings, microbiological reports, histopathology of granulation tissue, ESR and House-Brackmann grading. Male patients in 61-70 age group were most commonly affected and all patients had uncontrolled diabetes mellitus, usually presenting with nocturnal otalgia, ear canal granulation and cranial nerve palsy. Pseudomonas aeruginosa was the most common isolate followed by Staphylococcus aureus. Among fungal pathogens, candida albicans were the most common. 29.3% patients had extensive disease according to Thakar et al. staging and on follow up, 43.75% patients showed a satisfactory response. Coronary artery disease and cerebrovascular accidents were the leading cause of death. More atypical organisms, extensive disease and changes in antibiotic sensitivity were noted in the post-covid period. Prolonged treatment with culture sensitive antibiotic is the main stay of treatment. A uniform treatment guideline is needed for proper management of such patients. Level of Evidence 4.

Epidemiology and risk factors for extension of necrotizing otitis externa.

PURPOSE: Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension? METHODS: French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone. RESULTS: Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%). CONCLUSION: Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.

Rare Cause of Skull Base Osteomyelitis: A Challenging Diagnosis and Management With a Literature Review.

This is a case of skull base osteomyelitis (SBO) caused by a rare fungal species, Scedosporium apiospermum. This is a clinical case report with a review of the literature. SBO is a potentially life-threatening infection of the temporal bone. The patient presented to our hospital with a two-month history of left otalgia, otorrhea and reduced hearing, after failed initial intravenous antibiotic therapy. Thorough examination and further investigation confirmed the diagnosis of SBO caused by a rare fungal species, S. apiospermum. The patient was subsequently started on a long-term course of antifungals which led to an improvement of symptoms. This case highlights the importance of early recognition and considering early antifungal treatment in patients with persistent otalgia and otorrhea, particularly in those who have failed to respond to intravenous antibiotics. Further research is needed to better understand the optimal timing and duration of antifungal therapy in these patients.

[Research progress of necrotizing otitis externa].

Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.

Fungal Infections of the External Auditory Canal and Emerging Pathogens.

Fungal infections of the external auditory canal can range from common (otomycosis) to life threatening (necrotizing otitis externa). Proper identification of fungal pathogens is necessary to guide appropriate therapy, and a high index of suspicion for fungal causes of ear canal disease is critical. Fungal pathogens may be an especially important cause of ear canal disease in certain populations, including patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients. Opportunistic fungal infections of the ear canal are an emerging concern.

[Current diagnosis and treatment of skull base osteomyelitis].

Skull base osteomyelitis is a rare, refractory, and potentially fatal disease primarily caused by otogenic and sino rhinogenic infections. At times, it can mimic neoplasia complicating the diagnosis. With the use of antibiotics, advancements in diagnostic methods, and skull base surgical techniques, the mortality rate has significantly improved. However, the successful diagnosis and treatment of the disease is still challenging due to delayed diagnosis, lengthy treatment course, a tendency for relapse and lack of guidelines. Therefore, this article aims to review the progress in the diagnosis and treatment of skull base osteomyelitis.

Cranial nerve palsy prevalence and associated factors in patients with malignant otitis externa.

Objective: To identify the prevalence of cranial nerve (CN) palsy and its associated factors in malignant otitis externa (MOE). Methods: In a retrospective study, records of MOE patients from 2011 to 2014 were reviewed. MOE and CN involvement were evaluated based on patient demographics, clinical, and paraclinical data. Results: Overall, 119 MOE patients with a mean age of 65.9 ± 11.3 were included. 69.7% were male, and 63.0% had a history of diabetes. The most common symptoms and signs were otalgia (97.5%), otorrhea (44.5%), and ear canal erythema/edema (24.4%). Thirty-three patients (27.7%) had CN involvement. The facial nerve was mostly involved (26.1%). Skull base osteomyelitis (SBO) was present in 59 patients. When excluding patients younger than 30 and older than 80, age decade was correlated with CN palsy. 66.9% of patients with CN palsy and 65.6% without CN palsy were male, which was significantly different. The following factors were not significantly different between patients with and without CN palsy: Comorbidities, signs and symptoms, diagnostic delay, erythrocyte sedimentation rate level, fasting blood sugar, hemoglobin A1c level, antifungal therapy, hospitalization duration, and SBO on imaging. Tinnitus was correlated with SBO evidence on imaging (specificity: 96.7%). Conclusion: CN involvement occurs in about three out of 10 MOE patients. Male gender and advanced age may be related to a higher incidence rate of CN palsy. Tinnitus can be a specific indicator of SBO. These findings could help in better decision-making for early interventions. Level of Evidence: 4.

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.

CT findings in temporal bone sites in skull base osteomyelitis from malignant otitis externa.

OBJECTIVES: To identify the earliest sites and spread patterns of bony erosions on high-resolution temporal bone computerized tomographic (HRTBCT) scans and conjugate the radiological findings with clinical/laboratory data for guiding the interpretation of CT images of skull base osteomyelitis (SBOM) from malignant otitis externa (MOE). STUDY DESIGN: Retrospective and prospective medical records analysis. METHODS: The medical records of all patients who presented to a referral medical center during 2015-2022 and initially diagnosed with SBOM. Radiological assessment of each sub-site was performed by 2 qualified neuro-radiologist, who were blind to the clinical data. RESULTS: 33 patients were enrolled. All patients suffered edema and exudates of the external auditory canal (EAC). The most common osseous markers for SBOM were dehiscence or irregularity of the anterior EAC wall and temporomandibular joint (TMJ) medial wall (21/33, 64% patients, each), followed by a fistula from the TMJ to the EAC (20/33, 61% patients). Eustachian tube bony walls and condylar irregularity and/or dehiscence were as prevalent as 16/33, 48% of patients, each. EAC inferior and posterior walls of the EACs were irregular or dehiscent in patients with more advanced disease. CONCLUSIONS: The high symptomatologic overlap between SBOM and other aural pathologies might cause diagnostic (and subsequent treatment) delay and result in dire complications. EAC edema and irregularity or dehiscence of the anterior EAC wall are the most common early CT findings associated with SBOM caused by MOE.

Otitis externa maligna. Experiencia a lo largo de 25 años en un hospital de tercer nivel / Malignant external otitis. Experience over 25 years at a tertiary referral hospital

Introducción y objetivo: La otitis externa maligna (OEM) es una infección agresiva de los tejidos blandos del oído externo y estructuras circundantes, que puede diseminarse e involucrar la base del cráneo y la articulación temporomandibular (ATM). Afecta fundamentalmente a pacientes inmunodeprimidos mayores de 65 años. El objetivo de este trabajo ha sido conocer las características de los pacientes diagnosticados de OEM en nuestro hospital durante los últimos años y establecer los criterios diagnóstico-terapéuticos de esta rara enfermedad. Método: Se realizó un estudio descriptivo, observacional y retrospectivo, de los pacientes ingresados en el Hospital Clínico Universitario de Valladolid por OEM entre los años 1996 y 2021. Resultados: En los últimos 25 años fueron ingresados por OEM nueve pacientes, 78% varones (7/9) y con una edad media de 76,8 años. Todos manifestaron precozmente la enfermedad, con otalgia, otorrea y tejido de granulación en el conducto auditivo externo (CAE). Ninguno tuvo afectación de pares craneales, pero cuatro sufrieron invasión de la ATM y dos fallecieron. Discusión y Conclusiones: Actualmente el diagnóstico de OEM se establece a partir de una variedad de hallazgos clínicos, de laboratorio y radiográficos. El tratamiento antibiótico depende de la severidad de la infección. Desde la aparición de los antibióticos antipseudomónicos, el tratamiento quirúrgico inicial de esta patología no está indicado, realizándose únicamente biopsia o desbridamiento para el diagnóstico diferencial con patología tumoral. Conclusión: La OEM continúa siendo una enfermedad con grave morbilidad y potencialmente mortal, especialmente en pacientes ancianos y con otras comorbilidades. (AU)

Introduction and objective: Malignant external otitis (MEO) is an aggressive infection of the soft tissues of the external canal and surrounding structures, which can spread and involve the skull base and the temporomandibular joint (TMJ). It mainly affects immunocompromised patients over 65 years of age. The objective of this study has been to know the characteristics of patients diagnosed with MEO in our hospital in recent years and to establish the diagnosis and therapeutic criteria for this rare disease. Method: A descriptive, observational, and retrospective study of patients diagnosed with MEO at the University Clinical Hospital (Valladolid, Spain) between 1996 and 2021 was carried out. Results: Nine patients were diagnosed with MEO in the last 25 years, 78% male (7/9), and with a mean age of 76.8 years. All patients manifested the disease early with otalgia, otorrhea and granulation tissue in the external auditory canal (EAC). None had cranial nerve involvement, but four had TMJ invasion and two of the nine patients in the sample died. Discussion: Currently the diagnosis of MEO is established from a variety of clinical, laboratory and radiographic findings. Antimicrobial therapy depends on the severity of the infection. Since the availability of systemic antipseudomonal antibiotics, surgical treatment of this pathology is not indicated initially, performing only biopsy or debridement for differential diagnosis with tumor pathology. Conclusion: MEO continues to be a disease with serious morbidity and maximum mortality, especially in elderly patients and with other comorbidities. (AU)

Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center.

Objectives: Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE. Methods: In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease. Results: A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography. Conclusion: Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.

Current diagnosis and treatment of skull base osteomyelitis / 临床耳鼻咽喉头颈外科杂志

Skull base osteomyelitis is a rare, refractory, and potentially fatal disease primarily caused by otogenic and sino rhinogenic infections. At times, it can mimic neoplasia complicating the diagnosis. With the use of antibiotics, advancements in diagnostic methods, and skull base surgical techniques, the mortality rate has significantly improved. However, the successful diagnosis and treatment of the disease is still challenging due to delayed diagnosis, lengthy treatment course, a tendency for relapse and lack of guidelines. Therefore, this article aims to review the progress in the diagnosis and treatment of skull base osteomyelitis.

Research progress of necrotizing otitis externa / 临床耳鼻咽喉头颈外科杂志

Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis.

OBJECTIVE: To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections. METHODS: Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results. RESULTS: Of 48 patients with NOE, the mean age is 73±11.6 years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9 days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2 days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders. CONCLUSION: The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

Imaging of Acute and Chronic Skull Base Infection.

Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.

Hyperbaric oxygen therapy in malignant otitis externa: A systematic review of the literature.

OBJECTIVE: To review the role of adjuvant hyperbaric oxygen therapy (HBOT) in the treatment of malignant otitis externa (MOE). DATA SOURCES: PubMed, Scopus, Web of Science, Science Direct, and Cochrane Library were searched for the following concepts: "hyperbaric oxygen" and "malignant or necrotizing otitis externa." METHODS: Studies were included if they contained (1) patients with reported evidence of MOE, (2) employment of adjuvant HBOT, (3) details on patients' medical condition, and (4) documented survival outcomes. Extracted information included patient demographics, underlying medical conditions, infectious etiology, signs and symptoms, medical and surgical treatments, duration of medical treatment, mean follow up time, HBOT setting, number of HBOT sessions, complications, survival rate, and all-cause mortality. RESULTS: A total of 16 studies comprising 58 patients (mean age 68.0 years) were included. Diabetes was present in 94.7% of cases and Pseudomonas spp (64.3%) was the most common infectious agent. Cranial nerve VII was involved in 55.2% of cases. Overall, the disease cure rate with adjuvant HBOT was 91.4% and all-cause mortality was 8.6%. Among those who had cranial nerve VII involvement, 72.0% had return of function and 93.8% of them survived. CONCLUSION: HBOT may be an effective treatment option for refractory or advanced MOE but its efficacy remains unproven due to lack of strong scientific evidence. However, its therapeutic value should not be underestimated given good results and few adverse events reported in this study.

Standardised treatment protocol for necrotizing otitis externa: retrospective case series and systematic literature review.

OBJECTIVES: There is currently no consensus on the most effective treatment protocol for necrotizing otitis externa (NOE). This article aims to produce a NOE treatment protocol from the literature and clinical experience. METHODS: A total of 26 case series from the literature were reviewed in combination with a retrospective case series of inpatients from Hull University Teaching Hospitals NHS Trust from 2013-2018. Over 5 years, 40 patients were identified, with only 29 being analysed due to unavailable or incomplete case notes. RESULTS: In the literature review, the most common bacterial species causing NOE was Pseudomonas aeruginosa. Resistance to ciprofloxacin was prevalent, however multidrug resistance was rare. Ciprofloxacin and ceftazidime were the most widely used antibiotics. No ceftazidime resistance was reported in the literature or in our cohort. The average age of the patients in our cohort was 80 years. Moreover, 62% had either diabetes mellitus or were immunosuppressed. One patient died directly due to NOE-related sepsis. Intravenous ceftazidime monotherapy was mostly used. The duration of treatment was 6-7 weeks, with no relapses documented. CONCLUSION: Ceftazidime monotherapy was an effective empirical treatment in our cohort, and a total duration of 6-7 weeks of antibiotics was sufficient. We have created a standardised treatment protocol based on our findings that will need to be validated in a larger cohort of patients.

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.

Facial nerve palsy in otitis externa: A red flag?

Otitis externa is an infection of the external auditory canal. It rarely results in facial palsy except in severe cases such as necrotizing otitis externa, which is a life-threatening invasive infection of the external auditory canal. Early recognition with prompt and appropriate treatment of necrotizing otitis externa is crucial to prevent more sinister complications. Here we report a case of an elderly gentleman who presented with otitis externa and developed facial palsy a month later. We identified possible problems that may have led to the complication so that such an occurrence can be prevented in the future.