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.

Detection and characterization of potential virulence determinants in Staphylococcus pseudintermedius and S. schleiferi strains isolated from canine otitis externa in Korea.

BACKGROUND: A recent increase in the occurrence of canine skin and soft tissue infections, including otitis externa and pyoderma, caused by antimicrobial-resistant Staphylococcus pseudintermedius and S. schleiferi has become a significant public and veterinary health issues. OBJECTIVE: We investigated the virulence potentials associated with the occurrence of canine otitis externa in S. pseudintermedius and S. schleiferi. METHODS: In this study, the prevalence of genes encoding leukocidins, exfoliative toxins, and staphylococcal enterotoxins (SEs) was investigated using previously characterized S. pseudintermedius (n = 26) and S. schleiferi (n = 19) isolates derived from canine otitis externa. Susceptibility to cathelicidins (K9CATH and PMAP-36) and hydrogen peroxide (H2O2) was also examined in both staphylococcal species. RESULTS: A high prevalence of genes encoding leukocidins (lukS/F-I, lukS1/F1-S, and lukS2/F2-S), exfoliative toxins (siet, expB, and sset), and SEs was identified in both S. pseudintermedius and S. schleiferi isolates. Notably, S. pseudintermedius isolates possessed higher number of SE genes, especially newer SE genes, than S. schleiferi isolates harboring egc clusters. Although no significant differences in susceptibility to K9CATH and H2O2 were observed between the two isolate groups, S. pseudintermedius isolates exhibited enhanced resistance to PMAP-36 compared to S. schleiferi isolates. CONCLUSIONS: These findings suggest that high a prevalence of various toxin genes together with enhanced resistance to cathelicidins may contribute to the pathogenicity of S. pseudintermedius and S. schleiferi in canine cutaneous infections.

Prevalence of the microbiological causes of canine otitis externa and the antibiotic susceptibility of the isolated bacterial strains.

Otitis externa is a canine disease of multifactorial etiology in which bacteria plays a significant role. Due to the predominant bacterial etiology otitis is usually treated with antibiotics. However, non-prudent use of antibiotics promotes the emergence of antibiotic-resistant bacteria thus compromising the therapy effectiveness. Currently, the increase of antimicrobial resistance (AMR) is one of the biggest threats to global health. For this reason, the aim of the study was to investigate prevalence of the microbiological causes of canine otitis externa and the antibiotic susceptibility of the isolated bacterial strains. The research and sampling were conducted at Veterinary Clinics for small pets in Serbia. Samples were sent to laboratory for bacteriological and mycological testing. Additionally, the sensitivity of the isolated bacteria to antibiotics was evaluated using disc diffusion method. Sixty dogs with otitis externa clinical symptoms were included in the study. Out of a total of 53 positive samples for pathogen presence, bacteria were present in 40. The most prevalent bacteria was Staphylococcus pseudintermedius, followed by Pseudomonas aeruginosa and Proteus spp., while Malassezia pachydermatis was the only isolated yeast pathogen occurring in 36 samples. Generally, the lowest resistance against all bacteria showed enrofloxacin. On the contrary, high resistance to penicillin and amoxicillin was a common finding for G+ and G- bacteria. These results indicate the need for laboratory testing in terms of isolation, identification and antibiotic susceptibility testing, not only in the case of otitis externa in dogs, but in all diseases when it is possible, in order to enhance antimicrobial stewardship and consequently to contribute AMR reduction.

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.

Otomycosis: The foremost aetiological agent causing otitis externa and the antifungal susceptibility pattern in North-Western Iran.

BACKGROUND: Otomycosis is considered a recurring fungal ear infection. The external auditory canal provides an appropriate and optimal situation for fungal growth. OBJECTIVES: The study aimed to identify the causative agents of otomycosis and determine corresponding antifungal drug susceptibility patterns in north-western Iran. METHODS: From October 2020 until November 2021, 200 patients attended an otolaryngology referral centre with otitis externa, and their ear discharge and debris were examined and cultured. The identification of the fungal agents was implemented by polymerase chain reaction-restriction fragment length polymorphism and sequencing. In vitro antifungal susceptibility testing of the isolates was conducted in accordance with the CLSI broth microdilution protocols. RESULTS: The prevalence of otomycosis was measured 50.5% (n = 101/200). The majority of patients were in their forties (n = 35, 34.6%) and female (n = 57, 56.4%), and the most prevalent symptom was otalgia (56.4%). The most underlying factor was remarked manipulation employing a cotton swab (65.3%). Regarding fungus, Aspergillus section Nigri (58.57%) was the foremost isolate, followed by Aspergillus section Flavi (19.23%) and Candida parapsilosis (14.96%). The predominance of Aspergillus isolates had minimal in vitro sensitivity to tioconazole and nystatin. Candida species represented higher geometric mean minimum inhibitory concentrations (MIC) against nystatin. The MIC of three Aspergillus species isolates shown above the epidemiologic cut-off values (ECV) against itraconazole. CONCLUSIONS: Otomycosis incidence surpassed in comparison with the previous study as the most common cause of otitis externa. The MIC distribution of Aspergillus species isolates against triazole antifungals is close to the defined ECVs and likely outrun it over time.

Prevalence of methicillin resistance in Staphylococcus pseudintermedius isolates from dogs with skin and ear infections in South Africa.

ABSTRACT: Staphylococcus pseudintermedius (SP) is an important opportunistic pathogen, frequently associated with pyoderma and otitis in dogs. The emergence and rapid expansion of methicillin-resistant Staphylococcus pseudintermedius (MRSP) is problematic due to multidrug resistance and reduced treatment options. The aim of this study was to determine i) the prevalence of MRSP in dogs with pyoderma or otitis externa, ii) the antimicrobial resistance patterns of MRSP from South African isolates, and iii) the risk factors for MRSP-associated pyoderma or otitis externa in dogs in South Africa (RSA). Sixty-eight presumptive clinical SP isolates (collected from 65 dogs) from five geographically dispersed laboratories in RSA were collected over 2 years. Possible MRSP isolates were flagged when resistance to oxacillin was observed. Thereafter, all isolates were confirmed as SP by polymerase chain reaction (PCR) and further genotyped for the mecA gene. Fifty-seven of 68 isolates were confirmed to be SP (83.8%), while 49/57 (85.9%) carried mecA. Our findings showed that preliminary phenotypic methods supplemented by genotypic methods increased the accuracy of correctly identifying SP. All isolates were resistant to at least one antimicrobial drug. There was a high incidence of amoxicillin (70.1%) and enrofloxacin (65%) resistance. Important risk factors for mecA positive carriage were previous hospital admission, pruritus, and previous antibacterial failure. This study demonstrates a high prevalence of mecA positive carriage (85.9% of samples) in MRSP pyoderma and otitis in dogs in RSA. There is an urgent need for better laboratory diagnosis of MRSP and surveillance of dogs presenting with pyoderma and otitis in South Africa.

A retrospective study of 43 cases of fungal malignant external otitis.

Malignant external otitis (MEO) has a frequent bacterial origin, but we are currently witnessing the emergence of fungal agents, which poses difficulties in diagnosis and management. The aim of our work is to analyze the epidemiological and clinical profile of fungal MEO and to study the antifungal susceptibility of fungi involved. Our study is retrospective collecting 43 patients treated for fungal MEO between 2010 and 2019. Clinical, biological, and radiological data were collected from patient hospitalization records. Identification of yeasts was done by YST vitek®2 card. The antifungal susceptibility testing was performed for yeasts by the AST vitek®2 card and for other fungi by the E-test technique. The average age was 66 (± 12) years. We noted a male predominance in 63 % (n=27). Diabetes was found in 86%. Otalgia was a constant symptom. Cranial nerve palsies were observed in 16% (n=7) of cases. CT showed bone lysis in 74% (n=31>) of cases and Tc99 bone scintigraphy revealed hyperfixation in 100% (n=43) of cases. Candida spp. (n=21), Aspergillus spp. (n=18), and Geotrichum capitatum (n=2) were isolated. No resistance to antifungals has been demonstrated for Candida yeasts. Geotrichum capitatum isolates were resistant to fluconazole and caspofungin. Aspergillus isolates were resistant to amphotericin B and caspofungin in 50% (n=9) and 72% (n=12) of cases, respectively. Our study proves the predominance of Candida yeasts and Aspergillus as the fungal agents involved in MOE. Mycological diagnosis allows the identification and antifungal susceptibility testing. Thus, it allows using of the appropriate antifungal treatment and improves the prognosis of the disease.

Antifungal susceptibility of Malassezia pachydermatis isolated from the external auditive conduct from dogs, in central Chile.

Background: External otitis is common in dogs, and one of the main agents involved is Malassezia pachydermatis, a yeast belonging to the otic microbiota. Empirical treatment can fail; therefore, it is essential to know the antifungal susceptibility profile to prescribe appropriate treatment, a fact scarcely reported in Chile. Aim: This study aimed to determine the antifungal sensitivity of M. pachydermatis isolated from the external auditory canal of dogs in central Chile. Methods: Ear swabs from 30 dogs (15 healthy and 15 with external otitis) were used. Samples were subjected to cytology and fungal culture. The antifungal susceptibility was determined according to clinical and laboratory standards institute (CLSI) document M44A-2 using the disk diffusion test from amphotericin B, Caspofungin, fluconazole, nystatin, clotrimazole, and voriconazole were used. Results: The prevalence of M. pachydermatis was 66.7% from 8 healthy dogs and 12 with otitis. While fungal culture was not associated with the patient's clinical condition (p = 0.24), the yeast count by cytology was significantly higher in dogs with otitis (p = 0.003). The strains were sensitive to all antifungals except for Caspofungin, where 55% of the strains were resistant. Conclusion: Malassezia pachydermatis is isolated more frequently in dogs with otitis, and the ear cytological examination is useful to differentiate colonized dogs versus dogs with otitis. In addition, most antifungals in vitro are active against this yeast, except Caspofungin, an antifungal used in human medicine. This situation should be further monitored in epidemiological programs to evaluate the possible impact on Chilean public health.

Chronic Otitis Externa Secondary to Tympanic Membrane Electrode Placement in Rhesus Macaques (Macaca mulatta).

Otitis externa (OE) is a condition that involves inflammation of the external ear canal. OE is a commonly reported condition in humans and some veterinary species (for example, dogs, cats), but has not been reported in the literature in macaques. Here, we present a case series of acute and chronic OE likely precipitated by abrasion of the ear canal with a tympanic membrane electrode in 7 adult male rhesus macaques (Macaca mulatta). All animals displayed purulent, mucinous discharge from 1 or both ears with 3 macaques also displaying signs of an upper respiratory tract (URT) infection during the same period. A variety of diagnostic and treatment options were pursued including consultation with an otolaryngologist necessitated by the differences in response to treatment in macaques as compared with other common veterinary species. Due to the nature of the studies in which these macaques were enrolled, standard audiological testing was performed before and after OE, including tympanometry, auditory brainstem responses (ABRs), and distortion product otoacoustic emissions (DPOAEs). After completion of study procedures, relevant tissues were collected for necropsy and histopathology. Impaired hearing was found in all macaques even after apparent resolution of OE signs. Necropsy findings included abnormalities in the tympanic membrane, ossicular chain, and middle ear cavity, suggesting that the hearing impairment was at least partly conductive in nature. We concluded that OE likely resulted from mechanical disruption of the epithelial lining of the ear canal by the ABR electrode, thereby allowing the development of opportunistic infections. OE, while uncommon in macaques, can affect them and should be included as a differential diagnosis of any macaque presenting with otic discharge and/or auricular discomfort.

One year on: assessing the impact of coronavirus disease 2019 on demand for semi-urgent ENT services.

OBJECTIVE: This study investigated how the coronavirus disease 2019 pandemic has impacted on presentations to ENT first-on-call services. METHODS: All appointments to a rapid access triage clinic from 1 June to 31 August in 2019 and 2020 were reviewed retrospectively and their reasons for consultation classified. A binomial proportion test was used to determine whether the proportions of consultations per presentation differed significantly between years. This analysis was repeated with the number of unique patients per presenting complaint. RESULTS: The proportions of nine reasons for consultation differed significantly between 2019 and 2020, including an increase in otitis media and nasal trauma presentations, and a decrease in otitis externa and tonsillitis presentations. Reattendances caused some variation in the frequency of certain diagnoses. CONCLUSION: Our data suggest a shift in the presentations to first-on-call services, which may be a result of changes in patient behaviour and access to healthcare services.

[External otitis: clinical diagnostics and treatment tactics]. / Naruzhnyi otit: klinicheskaya diagnostika i lechebnaya taktika.

OBJECTIVE: To summarize modern data about the epidemiology, etiology, clinical course and diagnosis of otitis externa. MATERIAL AND METHODS: Materials of scientific publications included in the Cochrane Library, information bases of the RSCI, MEDLINE, PubMed were used as a data source. The choice of material was carried out according to the keywords: otitis externa, etiology, diagnosis, treatment, local treatment. RESULTS: The role of combined drugs in the main etiopathogenetic mechanisms of the external ear inflammatory process is shown. CONCLUSION: Analysis of published data from clinical trials indicates the importance of a fixed antibacterial agents and anesthetic combination in increasing the effectiveness of topical therapy for otitis externa.

Otodectic and bacterial etiology of feline otitis externa in Tripoli, Libya.

Background: Feline otitis externa is a dermatological disorder with a multifactorial complex etiology. Aim: This study aimed to investigate the prevalence of different etiological agents, particularly the parasitic and bacterial, responsible for the cases of feline otitis externa in Tripoli, Libya, and to assess the antimicrobial susceptibility of the bacterial isolates from those cases. Methods: Cerumen and otic discharges of the suspected cats were collected for parasite detection and bacterial culture. Kirby-Bauer's disk diffusion method was used for antimicrobial susceptibility testing. Results: The results showed that otodectic mites and bacterial causes were equally the most prevalent in those cases, with a prevalence of 47.1% each. Otodectes cynotis infestation was more frequently bilateral and severe. Staphylococcus spp. were the most prevalent among bacterial causes (75%), followed by Proteus spp. (16.6%) and Pseudomonas spp. (8.4%). Norfloxacin and gentamicin were the most effective antimicrobials against bacterial isolates, as they were effective against 83.3% and 70.8% of isolates, respectively. Conclusion: Otodectes cynotis infestation and staphylococcal infections constituted the most common etiology of feline otitis externa in Tripoli, Libya, and norfloxacin represented a cogent antibacterial for the treatment of otitis externa.

Malignant otitis externa: An updated review.

Malignant otitis externa is a progressive infection of the external auditory canal and skull base. Pseudomonas aeruginosa is the most isolated microorganism and it affects mostly to diabetic, elderly, and immunocompromised individuals. Non-resolving otalgia and chronic otorrhea are the clinical manifestations presented. Facial nerve palsy is a common and well recognized complication. (Computed tomography) CT scan is useful for initial assessment, Technetium-99m is highly sensitive and is part of the protocol for diagnosis. Treatment should be individualized, with multidisciplinary cooperation among specialties. Management involves systemic antipseudomonal antibiotics and monitoring with radiologic techniques, it also involves the strict control of diabetes. It is essential to follow up the patients for at least a year post-treatment. In refractory malignant otitis externa and affection of facial nerve, surgical management is recommended. We reviewed the most recent studies on epidemiology, clinical manifestations, diagnosis, and treatment to provide an update on Malignant Otitis Externa that can offer an overview for clinical practice and future research.

Increased incidence of otitis externa in covid-19 patients.

OBJECTIVE: The current study showed the relation between otitis externa and COVID-19 infection and compared otitis externa with other symptoms of COVID-19 as anosmia. METHODS: 257 cases who were confirmed positive for COVID-19, were examined otoscopic and endoscopic for otitis externa, onset of starting symptoms of otitis externa and its relation to days of infection with COVID-19 were documented and the prevalence of otitis externa with anosmia in the study group were estimated. RESULTS: Increased incidence of otitis externa in COVID-19 patients (18% of study group) and symptoms starting mainly between the 5th to 8th day of COVID-19 infection. Combined otitis externa and anosmia occurred in 13% of study group. CONCLUSIONS: Otitis externa has a relation to COVID-19 infection. Further research needed to study its pathogenesis and mechanisms.

Pediatric acute otitis externa: Characteristics and predictors for hospital admission.

BACKGROUND: Acute otitis externa (AOE), is a common infectious disease affecting children and adults. Its peak prevalence is around the summer months, it involves the external auditory canal and in most cases is due to bacterial agents. METHODS: This is a retrospective observational analytical case-based study involving all consecutive patients under the age of 18 years old presenting with AOE to a pediatric emergency department. RESULTS: We collected data from 337 patients under 18 years of age with 344 visits to the Emergency Department, between the years 2011-2018. Nearly half of the visits presented during the summer months. Children were divided into two subgroups: hospitalized and non-hospitalized. Median hospitalization time was 3 days. The hospitalized sub-group had higher rates of failed treatment, as well as higher rates of external ear canal edema, systemic fever, canal discharge and auricular edema. On multivariable analysis the following variables had the strongest correlation for hospital admission: auricular edema (OR 27.98), otorrhea (OR 1.82), narrowing of the ear canal by more than 50% (OR 1.91), fever (OR 2.92), and previous systemic treatment (OR 2.53). Pseudomonas aeruginosa (PA) was isolated in 78% of cultures in the hospitalized sub-group. All PA strains were sensitive to ciprofloxacin. CONCLUSIONS: This study highlights the main clinical variables which may predict hospitalization among children with AOE as well as the dominant role of sensitive strains of PA in the pathogenesis of this condition in children.

Evidence of new sequence types of methicillin-resistant Staphylococcus pseudintermedius in Italy.

Staphylococcus pseudintermedius (SP) and methicillin-resistant SP (MRSP) is one of the most important veterinary pathogens in the dog. Herein, from a total of 126 S. pseudintermediusstrains, 23 MRSP (18%) were identified. Multi-Locus Sequence Typing (MLST) revealed that most of MRSP strains belonged to ST71 (26%), which have been already reported in Italy and other countries. Interestingly, nine new sequence types (39%), from 1053 up to 1061, were described for the first time. Moreover, the isolated MRSP strains showed relevant antibiotic resistance profiles. This report highlights the circulation of new sequence types of MRSP in Italy and underlines the need of a global epidemiological surveillance to limit the increasing spread of multidrug-resistant MRSPstrains worldwide, since they may represent a considerable concern for dog's health.

Occurrence of various pathogenic and opportunistic fungi in skin diseases of domestic animals: a retrospective study.

BACKGROUND: Fungal infection of animals or humans are common all over the world. Some of microorganisms like fungi, exist on the skin and can be transmitted onto other individuals, other animal species or even humans and cause skin infections. Moreover, they can be the causative agents of severe generalized infections especially in immunocompromised individuals. The study aimed to evaluate the most frequent etiological agents of skin diseases and to compare the prevalence of animal fungal infections in Poland, and to discuss the possibility of transmission to humans in Poland. RESULTS: The obtained results are culture based. The fungi most frequently isolated from group of animals with skin lesions were Malassezia pachydermatis (29.14%), and Candida yeasts (27.07%), and dermatophytes (23.5%), including Microsporum canis as majority of them (59.25%), and Trichophyton genus (40.7%), most of them T. mentagrophytes, while Malassezia pachydermatis represented (80%) of isolates in animals with otitis externa. In over 19% of positive fungal cultures obtained from external ear canals Candida yeasts, mainly C. albicans, were identified. CONCLUSIONS: Dermatomycoses in companion animals are caused by both, mycelial fungi and yeasts. Most frequently isolated were Malassezia pachydermatis and Candida spp. Dermatophytes (Trichophyton, Microsporum), were also cultured, but the total number of these isolates seems to decrease. We have not found Cryptococcus neoformans in tested clinical samples.

Association of Comorbid Conditions with Six-month Survival and Disease Outcome in Patients of Necroinflammatory Otitis Externa.

OBJECTIVE: To determine association of gender, causative organisms, control of diabetes, facial paralysis, infectious agent, and hearing loss with disease outcome, in terms of six-month improvement of symptoms, static condition or expiry of patients presenting with necroinflammatory otitis externa (NOE). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: ENT Department in collaboration with Pathology Department, KEMU/Mayo Hospital, Lahore from 2016 to 2019.  Methodology: Patients with NOE were inducted. Studied variables included age at presentation, gender, diabetes, glycated hemoglobin (HbA1c) levels, comorbid conditions, facial nerve involvement, hearing loss, CT and biopsy findings, and causative organisms; and their association with outcome was observed with significance at p<0.05. RESULTS: Out of 28 patients, there were 17 males (60.7%) and 11 females (39.3%). Association between gender and survival showed that 41.2% (7) males and 27.3% (3) females survived; and 23.5% (4) males and 1 (9.1%) female expired within six months of diagnosis. Thinning of temporal bone (2/5=40%) was common among the expired patients. Twenty percent (1/5) patients diagnosed with squamous cell carcinoma and 80% (4/5)with granulation tissue (GT) expired (p=0.543) All ten patients (100%) that improved had mild to moderate hearing loss (p <0.001). Among expired group, 80% (4/5) had HBA1c of more than 7 and 20% (1/5) had good control of diabetes. Aspergillus (2/5=40%) and Pseudomonas (1/5=20%) were the commonest among expired patients; Staphylococcus (6/10=60%) and Pseudomonas (3/10=30%) infections were more frequent among the survived (p=0.005). CONCLUSION: Previously pseudomonal infection was described as the only causative agent of NOE. This study showed a rising community-acquired disease with Staphylococcus aureus 6/10 (60%) and Pseudomonas 3/10 (30%) infection. Fungal infection is associated with poor survival and death, thus requiring aggressive management. Thinning of temporal bone on CT, uncontrolled diabetes, sever hearing loss and facial paralysis score V/VI were associated with poor outcome of disease. Key Words: Necroinflammatory otitis externa, Pseudomonas aeruginosa. Diabetes, Hearing loss, Facial paralysis, Temporal bone thinning, CT scan.

Necrotizing Otitis Externa: A Systematic Review and Analysis of Changing Trends.

OBJECTIVE: To assess for changes in trends of the disease process, management, and outcomes of necrotizing otitis externa (NOE) over the last decade. DATA SOURCES: Articles in English, published between January 2011 and June 2019, were searched in PubMed, Scopus, Web of Science, ScienceDirect, and the Cochrane Database. STUDY SELECTION: Inclusion criteria: 1) reported evidence of NOE, 2) details on patient demographic and underlying medical disorder, 3) details on treatments, 4) documented outcomes, and 5) greater than 10 cases. DATA EXTRACTION: Study demographics, underlying conditions, infectious etiology, treatments, signs and symptoms, and outcomes. DATA SYNTHESIS: Ten studies, totalling 284 patients with a mean age of 67.8 years, were included. The time period of collected patient data ranged from 2000 to 2018. Temporal subgroup analysis was conducted before and after 2009. Cure rate was lower in the post-2009 group (76.0 versus 94.1%, p < 0.01) while disease-specific mortality remained stable. Increases in proportions of diabetes and culture negative results (p < 0.01) were also observed in this latter group. Rate of extensive surgery and the use of ciprofloxacin decreased (p < 0.01), while the use of ceftazidime increased in the post-2009 group (p < 0.01). CONCLUSION: A decrease in cure rate of NOE patients was observed in the setting of an increase in prevalence of diabetes. Various antipseudomonal agents are being used and an increase in culture negative results is seen.

A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa.

BACKGROUND: Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline. OBJECTIVE: This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management. METHODS: A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review. RESULTS: Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately. CONCLUSION: This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.