Necrotizing otitis externa: a systematic review

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.

Fungal Malignant Otitis Externa Involves a Cascade of Complications Culminating in Pseudoaneurysm of Internal Maxillary Artery: A Case Report

Patient: Male, 66

Final Diagnosis: Pseudoaneurysm of internal maxillary artery secondary to fungal malignant otitis externa

Symptoms: Epistaxis

Medication: —

Clinical Procedure: Functional endoscopic sinus surgery, endovascular embolization

Specialty: Infectious Diseases

Malignant otitis externa, an increasing burden in the twenty-first century: review of cases in a UK teaching hospital, with a proposed algorithm for diagnosis and management

Background

Malignant otitis externa is a potentially fatal infection of the skull base. With an ageing population and increasing prevalence of diabetes, the incidence of malignant otitis externa in the British population is rising. To date, there remain no accepted diagnostic criteria, few prognostic indicators and no consensus treatment pathways.

Method

A prospective case series was conducted at a tertiary referral teaching hospital.

Results

A cohort of susceptible individuals predominates (elderly, male, with immunosuppression and diabetes), with 25 per cent reporting a preceding incident. Otorrhoea, otalgia and canal granulation were the commonest presenting features, alongside positive pseudomonas cultures. No clear markers for predicating disease severity were isolated; however, a high initial haemoglobin A1c level demonstrated a significant moderately positive correlation with length of treatment.

Conclusion

A treatment pathway designed to provide a standardised approach to investigation and treatment is proposed, which aims to increase earlier diagnosis, streamline care and facilitate the development of best practice.

Diagnosis and treatment of necrotising otitis externa and diabetic foot osteomyelitis - similarities and differences

OBJECTIVE

Necrotising otitis externa is a severe inflammatory process affecting soft tissue and bone, mostly in diabetic patients. Diabetic patients are also at risk of diabetic foot osteomyelitis, another inflammatory condition involving soft tissue and bone. This review aimed to describe the similarities and differences of these entities in an attempt to further advance the management of necrotising otitis externa.

METHOD

A PubMed search was conducted using the key words 'otitis externa', 'necrotising otitis externa', 'malignant otitis externa', 'osteomyelitis' and 'diabetic foot'.Results and conclusionThe similarities regarding patient population and pathophysiology between necrotising otitis externa and diabetic foot osteomyelitis raise basic questions concerning the effects of long-standing diabetes on the external ear. The concordance between local swabs and bone cultures in diabetic foot osteomyelitis is less than 50 per cent. If this holds true also to necrotising otitis externa, the role of deep tissue cultures should be strongly considered. Similar to diabetic foot osteomyelitis, magnetic resonance imaging should be considered in selected necrotising otitis externa subgroups.

Acute external otitis as debut of acute myeloid leukemia - A case and review of the literature

Acute leukemia is a well known childhood cancer. The relation between leukemia and otological symptoms has long been established but is highly rare as a debut symptom of leukemia. External otitis is a common condition affecting many children, and most cases are successively treated with topical medicine. Here we present a child with acute external otitis later shown to be the debut symptom of acute myeloid leukemia, to our knowledge the first specific case described. We have reviewed the literature to find red flags for suspicion of severe disease in case of acute external otitis.

Advanced Imaging Techniques in Skull Base Osteomyelitis Due to Malignant Otitis Externa

PURPOSE OF REVIEW

To give an up-to-date overview of the strengths and weaknesses of current imaging modalities in diagnosis and follow-up of skull base osteomyelitis (SBO).

RECENT FINDINGS

CT and MRI are both used for anatomical imaging, and nuclear techniques aid in functional process imaging. Hybrid techniques PET-CT and PET-MRI are the newest modalities which combine imaging strengths.

SUMMARY

No single modality is able to address the scope of SBO. A combination of functional and anatomical imaging is needed, in the case of newly suspected SBO we suggest the use of PET-MRI (T1, T2, T1-FS-GADO, DWI) and separate HRCT for diagnosis and follow-up.

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 malignant otitis externa on the increase? A retrospective review of cases

We performed a retrospective review of all patients with malignant otitis externa (MOE) treated in our center between July 2004 and December 2012 to evaluate the current epidemiology in our region and to ascertain causative factors associated with the perceived increase in the number of cases diagnosed. Eleven patients were identified (5 men and 6 women), with a mean age of 77 years (range: 38 to 97 years). Diabetes was present in 36%. Pseudomonas aeruginosa was the causative organism in 64% of cases; all pathogens were sensitive to ciprofloxacin. We noted a significant increase in the diagnostic frequency of MOE during the study period (p = 0.0027) No obvious causative factors were identified. Due to the mortality associated with this condition, further studies are required to establish national trends.

Current management of necrotising otitis externa in the UK: survey of 221 UK otolaryngologists

INTRODUCTION

Necrotising otitis externa (NOE) is a rare infection causing skull base osteomyelitis. The evidence regarding NOE consists mostly of case series. Hence, there is a limited evidence base to guide decision-making. This survey aims to report the experience of 221 otolaryngologists in this condition.

MATERIALS AND METHODS

Internet survey administered to the membership of the British Association of Otorhinolaryngology - Head and Neck Surgery (ENT UK).

RESULTS

Respondents' detailed replies on diagnosis, treatment and follow up are presented. One third of respondents reported increasing incidence of NOE. Over 80% diagnosed NOE based on pre-existing risk factors, severe pain, non-resolution of infection and CT scan. Most respondents managed NOE with intravenous antibiotics (90%) and blood sugar control (82%). There was less agreement in certain aspects of management including the role of surgery and the nature and duration of follow up.

CONCLUSIONS

Our survey provides a picture of NOE management in the UK. While there is consensus in some aspects of NOE management, other aspects attract widely differing answers. This may reflect the lack of strong evidence in the literature. Future work should aim to address this.

Technetium-99m (⁹⁹mTc)-labelled sulesomab in the management of malignant external otitis: is there any role?

We report two cases of malignant external otitis (MEO) evaluated with Technetium-99m((99m)Tc)-labelled sulesomab. Two patients affected by MEO are presented, together with a literature review. Both patients were studied with clinical examination, ear discharge culture, radiological imaging, blood exams, (99m)Tc Sulesomab, and treated with antibiotic therapy. (99m)Tc-Sulesomab would appear to be an useful tool for diagnosis and follow-up of MEO, highlighting the site and extension of the inflammatory process, and evaluating course and treatment efficacy. (99m)Tc-Sulesomab shows promise as a rapid, effective and safe imaging agent for treatment response evaluation and follow-up of patients with MEO. Further studies are warranted to validate the inclusion of (99m)Tc-Sulesomab scan in the imaging follow-up of patients with MEO.

Necrotising (malignant) otitis externa in the UK: a growing problem. Review of five cases and analysis of national Hospital Episode Statistics trends

Background:

Necrotising (malignant) otitis externa is a severe infection causing temporal bone osteomyelitis. Although rare, our experience (reported herein) shows local doubling of cases in 2013. Hospital Episodes Statistics data for England over 14 years also indicate increased incidence nationally. Specific learning points in management are also discussed.

Methods:

A retrospective review was conducted of patients admitted in 2013 to Wexham Park Hospital, Slough, UK (catchment population, 450 000). In addition, the UK Government Hospital Episodes Statistics data were interrogated.

Results:

There were five cases of necrotising (malignant) otitis externa in 2013, representing a local doubling on previous years. The mean age of patients was 82 years. All cultures grew Pseudomonas aeruginosa; no isolates were antibiotic resistant. All patients responded to systemic anti-pseudomonals on clinical, biochemical and radiological parameters. Hospital Episodes Statistics data showed a six-fold increase in the number of cases from 1999 (n = 67) to 2013 (n = 421).

Conclusion:

Our experience suggests increasing necrotising (malignant) otitis externa incidence, and retrospective analysis of Hospital Episodes Statistics data supports this observation. Necrotising (malignant) otitis externa poses challenges in management, as exemplified in our cases, requiring a high index of suspicion and early aggressive treatment to achieve cure.