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Lodhi S, Dodgson K, Dykes M, Vishwanath V, Bazaz R, Mathur S, Watson G, Cartwright K, Pearson A, Wearmouth D, List R, Yates P, Dixon J, Puveendran A, Wilson M, Watson K, Cullinan M, Mentias Y, Capper R, Jewes L, Wallis S, Hamilton D, Adams B, Khalid-Raja M, Faris B, Khan M, Linton S, Abrar R, Owen E, Bisbinas V, Ijaz A, Lau K, Timms S, Bruce J, Stapleton E. Diagnostic criteria and core outcome set development for necrotising otitis externa: the COSNOE Delphi consensus study. J Laryngol Otol 2024:1-8. [PMID: 38644734 DOI: 10.1017/s0022215124000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS). METHODS The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting. RESULTS The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research. CONCLUSION The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.
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Affiliation(s)
- Sirat Lodhi
- Department of Otolaryngology, Manchester Royal Infirmary, UK
| | - Kirsty Dodgson
- Department of Microbiology, Manchester Royal Infirmary, UK
| | - Michael Dykes
- Department of Radiology, Manchester Royal Infirmary, UK
| | | | - Rohit Bazaz
- Department of Microbiology Wythenshawe Hospital, Manchester, UK
| | | | - Glen Watson
- Department of Otolaryngology, Sheffield Teaching Hospitals, UK
| | | | - Amy Pearson
- Department of Otolaryngology, Hull University Teaching Hospitals, UK
| | | | - Richard List
- Department of Radiology, Hull University Teaching Hospitals, UK
| | - Phillip Yates
- Department of Otolaryngology, Newcastle Upon Tyne NHS Hospitals, UK
| | - Joanna Dixon
- Department of Radiology, Newcastle Upon Tyne NHS Hospitals, UK
| | | | | | | | - Milo Cullinan
- Department of Microbiology, Sunderland Royal Hospital, UK
| | | | - Ruth Capper
- Department of Otolaryngology, Doncaster Royal Infirmary, UK
| | - Linda Jewes
- Department of Microbiology, Doncaster Royal Infirmary, UK
| | | | | | | | | | - Barzo Faris
- Department of Microbiology, Stepping Hill Hospital, Stockport, UK
| | - Maha Khan
- Department of Otolaryngology, Manchester Royal Infirmary, UK
| | - Stefan Linton
- Department of Otolaryngology, St John's Hospital, Livingston, UK
| | - Rohma Abrar
- Department of Otolaryngology, Doncaster Royal Infirmary, UK
| | - Eloise Owen
- Department of Otolaryngology, University of Manchester, UK
| | | | - Ali Ijaz
- Department of Otolaryngology, University of Sheffield, UK
| | - Kimberley Lau
- Department of Otolaryngology, Sheffield Teaching Hospitals, UK
| | - Sara Timms
- Department of Otolaryngology, Preston Royal Hospital, UK
| | - Jack Bruce
- Department of Otolaryngology, University of Manchester, UK
| | - Emma Stapleton
- Department of Otolaryngology, Manchester Royal Infirmary, UK
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Grau-van Laak C, Ruiz-García C, Lassaletta L, Morales-Puebla JM. Chronic otorrhea and osteomyelitis of the external auditory canal by Achromobacter xylosoxidans: an uncommon diagnosis. Eur Arch Otorhinolaryngol 2024; 281:2031-2035. [PMID: 38367073 PMCID: PMC10942891 DOI: 10.1007/s00405-024-08465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/08/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE Achromobacter xylosoxidans is an emerging pathogen mainly associated with resistant nosocomial infections. This bacteria had been isolated in the ear together with other pathogens in cultures from patients with chronic otitis media, but it had never been reported as a cause of osteomyelitis of the external auditory canal. CASE PRESENTATION We present a unique case of a healthy 81-year-old woman who presented with left chronic otorrhea refractory to topical and oral antibiotic treatment. Otomicroscopy revealed an erythematous and exudative external auditory canal (EAC) with scant otorrhea. The tympanic membrane was intact, but an area of bone remodeling with a small cavity anterior and inferior to the bony tympanic frame was observed. Otic culture isolated multi-drug-resistant A. xylosoxidans, only sensitive to meropenem and cotrimoxazole. Temporal bone computed tomography showed an excavation of the floor of the EAC compatible with osteomyelitis. Targeted antibiotherapy for 12 weeks was conducted, with subsequent resolution of symptoms and no progression of the bone erosion. CONCLUSIONS Atypical pathogens such as A. xylosoxidans can be the cause of chronic otitis externa. Early diagnosis and specific antibiotherapy can prevent the development of further complications, such as osteomyelitis. In these cases, otic cultures play an essential role to identify the causal germ. This is the first case of EAC osteomyelitis due to A. xylosoxidans reported to date.
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Affiliation(s)
- Coloma Grau-van Laak
- PhD Program in Medicine and Surgery, Autonomous University of Madrid, Madrid, Spain.
- Department of Otolaryngology, La Paz University Hospital, Paseo de la Castellana, 261, 28046, Madrid, Spain.
- IdiPAZ Research Institute, Madrid, Spain.
| | - Carmen Ruiz-García
- PhD Program in Medicine and Surgery, Autonomous University of Madrid, Madrid, Spain
- Department of Otolaryngology, La Paz University Hospital, Paseo de la Castellana, 261, 28046, Madrid, Spain
- IdiPAZ Research Institute, Madrid, Spain
| | - Luis Lassaletta
- PhD Program in Medicine and Surgery, Autonomous University of Madrid, Madrid, Spain
- Department of Otolaryngology, La Paz University Hospital, Paseo de la Castellana, 261, 28046, Madrid, Spain
- IdiPAZ Research Institute, Madrid, Spain
- Biomedical Research Networking Centre on Rare Diseases (CIBERER), Institute of Health Carlos III, Madrid, Spain
| | - J Manuel Morales-Puebla
- Department of Otolaryngology, La Paz University Hospital, Paseo de la Castellana, 261, 28046, Madrid, Spain
- IdiPAZ Research Institute, Madrid, Spain
- Biomedical Research Networking Centre on Rare Diseases (CIBERER), Institute of Health Carlos III, Madrid, Spain
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3
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Ahmed AA, Rashid S, Gupta VK, Molony NC, Gupta KK. The diagnostic conundrum in necrotizing otitis externa. World J Otorhinolaryngol Head Neck Surg 2024; 10:59-65. [PMID: 38560038 PMCID: PMC10979047 DOI: 10.1002/wjo2.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/23/2023] [Accepted: 04/10/2023] [Indexed: 04/04/2024] Open
Abstract
Necrotizing otitis externa (NOE) is an aggressive and fast-evolving infection of the external auditory canal. Late diagnoses and untreated cases can lead to severe, even fatal consequences and so early diagnosis and treatment are paramount. NOE is a notoriously challenging diagnosis to make. It is therefore important to understand what diagnostic modalities are available and how otolaryngologists can use them to accurately treat such an aggressive disease. This review aims to evaluate the different diagnostic options available in NOE and discuss their advantages and limitations, thus, providing an up-to-date picture of the multimodal approach required in the diagnosis of this disease.
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Affiliation(s)
- Abiya A. Ahmed
- Bradford Royal InfirmaryBradford Teaching Hospitals NHS Foundation TrustWest BromwichWest YorkshireUK
| | - Shaan Rashid
- Bradford Royal InfirmaryBradford Teaching Hospitals NHS Foundation TrustWest BromwichWest YorkshireUK
| | - Vinay K. Gupta
- Sandwell and West Birmingham Hospitals NHS TrustWest BromwichUK
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4
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Vaca M, Medina MM, Cordero AI, Polo R, Pérez C, Domínguez S, de Los Santos G. Necrotizing external otitis: diagnostic clues in the emergency department. Eur Arch Otorhinolaryngol 2024; 281:737-742. [PMID: 37548705 DOI: 10.1007/s00405-023-08178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/04/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE The assessment of necrotizing external otitis requires a high index of suspicion by the attending physician. The purpose of the study is to determine the accuracy of parameters available at the Emergency Department for the diagnosis of this pathology. METHODS Retrospective diagnostic accuracy study. Patients consulting at the Emergency Department for longstanding ear swelling, severe otalgia, and failure to respond to topical treatment were included. Otoscopy, physical examination, CT appearance, and analytical results were tested for the diagnosis of necrotizing external otitis, using nuclear imaging as gold standard. Sensitivity, specificity, likelihood ratios and ROC curves were calculated. RESULTS 24 patients were included; 13 cases were necrotizing external otitis, and 11 cases were other external ear pathologies. Erythrocyte sedimentation rate and C-reactive protein levels were significantly associated with necrotizing external otitis (AUC 0.92 p < 0.001, and 0.8 p < 0.001). Positive likelihood ratios were 10.15 for values of erythrocyte sedimentation rate over 26 mm/h, and 8.25 for C-reactive protein levels over 10 mg/L. Negative likelihood ratios were 0.08 and 0.28, respectively. These results were significant. The rest of clinical and radiological parameters were less accurate. CONCLUSIONS Erythrocyte sedimentation rate and C-reactive protein are useful parameters in the evaluation of a case of longstanding otitis with clinical suspicion of necrotizing external otitis. If any of them is elevated, the probability of suffering this condition is significantly increased. If they are within normal ranges, an alternative diagnosis should be sought.
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Affiliation(s)
- Miguel Vaca
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain.
| | - María M Medina
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
| | - Adela I Cordero
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
| | - Rubén Polo
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
| | - Cecilia Pérez
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
| | - Sandra Domínguez
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
| | - Gonzalo de Los Santos
- Department of Otolaryngology, Hospital Universitario Ramón Y Cajal, Ctra. Colmenar Km 9.100, 28034, Madrid, Spain
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Telli T, Desaulniers M, Pyka T, Caobelli F, Forstmann S, Umutlu L, Fendler WP, Rominger A, Herrmann K, Seifert R. What Role Does PET/MRI Play in Musculoskeletal Disorders? Semin Nucl Med 2023:S0001-2998(23)00091-0. [PMID: 38044175 DOI: 10.1053/j.semnuclmed.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023]
Abstract
Musculoskeletal disorders of nononcological origin are one of the most frequent reasons for consultation. Patients suffering from musculoskeletal disorders also consult more than once for the same reason. This results in multiple clinical follow-ups after several radiological and serum examinations, the main ones including X-rays targeting the painful anatomical region and inflammatory serum parameters. As part of their work up, patients suffering from musculoskeletal disorders often require multisequence, multi-parameter MRI. PET/MRI is a promising imaging modality for their diagnosis, with the added advantage of being able to be performed in a single visit. PET/MRI is particularly useful for diagnosing osteomyelitis, spondylodiscitis, arthritis, many pediatric pathologies, and a wide range of other musculoskeletal pathologies. PET/MRI is already used to diagnose malignant bone tumors such as osteosarcoma. However, current knowledge of the indications for PET/MRI in nononcological musculoskeletal disorders is based on studies involving only a few patients. This review focuses on the usefulness of PET/MRI for diagnosing nononcological musculoskeletal disorders.
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Affiliation(s)
- Tugce Telli
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, Essen, Germany.
| | - Mélanie Desaulniers
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, Essen, Germany; Department of Nuclear Medicine and Radiobiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Thomas Pyka
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Federico Caobelli
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sophia Forstmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
| | - Lale Umutlu
- Department of Radiology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Ken Herrmann
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, Essen, Germany; Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
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Vosbeek EGM, Straatman LV, Braat AJAT, de Keizer B, Thomeer HGXM, Smit AL. Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center. OTOLOGY & NEUROTOLOGY OPEN 2023; 3:e042. [PMID: 38516544 PMCID: PMC10950167 DOI: 10.1097/ono.0000000000000042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/09/2023] [Indexed: 03/23/2024]
Abstract
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.
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Affiliation(s)
- Eleonora G M Vosbeek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Louise V Straatman
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Hans G X M Thomeer
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Adriana L Smit
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
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7
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Vatakara A, Damle NA, Khurana A, Sagar S, Kumar R, Verma H. 99mTechnetium-Ubiquicidin Scan with Single-Photon Emission Computed Tomography/Computed Tomography in Skull Base Osteomyelitis. Indian J Nucl Med 2023; 38:297-300. [PMID: 38046968 PMCID: PMC10693375 DOI: 10.4103/ijnm.ijnm_192_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 12/05/2023] Open
Abstract
Malignant otitis externa (MOE) with skull base osteomyelitis (SBO) is an aggressive infection that predominantly affects elderly, diabetic, or immunocompromised patients, and is associated with high disease-specific mortality. Pseudomonas aeruginosa is the most isolated microorganism. External otitis associated with granulation tissue and pain is the most common presenting feature; a biopsy is obtained to rule out malignancy. A proper consensus is lacking regarding the best imaging modality for early initial diagnosis and follow-up. 99mTechnetium (99mTc)-labeled ubiquicidin (UBI) 29-41 is a bacterial attaching peptide that does not bind to activated leukocytes. We report a case of SBO initially misdiagnosed as a chronic otitis media, but later proved to be a case of MOE. 99mTc methylene diphosphonate bone scan and 99mTc-UBI 29-41 scan with single-photon emission computed tomography/computed tomography scans were performed to corroborate the clinical diagnosis. SBO remains a great challenge due to its increasing prevalence and high morbidity are difficult to diagnose and are often confused with cholesteatoma and neoplastic process. The UBI scan could be an auxiliary noninvasive diagnostic alternative in early diagnosis.
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Affiliation(s)
- Arunraj Vatakara
- Department of ENT, All India Institute of Medical Sciences, New Delhi, India
| | | | - Aditi Khurana
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sambit Sagar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Kumar
- Department of ENT, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Verma
- Department of ENT, All India Institute of Medical Sciences, New Delhi, India
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8
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Owen E, Abrar R, Stapleton E. Patients' experience of necrotising otitis externa: a qualitative study. J Laryngol Otol 2023; 137:356-362. [PMID: 35343410 DOI: 10.1017/s0022215122000858] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Necrotising otitis externa is a serious infective condition. Patients are typically frail, diagnostic delay is common and severe pain is a key feature. This study aimed to qualitatively analyse patient-centred data to identify key themes in the patient's experience. METHODS Open-ended questionnaires were sent to 28 patients. Responses were qualitatively analysed using a grounded theory approach. Iterative cycles were used to develop codes using a constant comparison technique. Emerging categories were refined to identify core themes. RESULTS Four main themes emerged: severe pain, mental health, quality of life and diagnostic delays. CONCLUSION This is the first study to explore patients' perspectives in necrotising otitis externa. It indicates a need to raise awareness of necrotising otitis externa, and to improve symptom management, pain control and quality of life. This valuable information can be used to identify research priorities, guide service improvements, improve clinical care and feed into the development of a Core Outcome Set for necrotising otitis externa.
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Affiliation(s)
- E Owen
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Abrar
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
| | - E Stapleton
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
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9
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Tsilivigkos C, Avramidis K, Ferekidis E, Doupis J. Malignant External Otitis: What the Diabetes Specialist Should Know-A Narrative Review. Diabetes Ther 2023; 14:629-638. [PMID: 36897495 PMCID: PMC10064349 DOI: 10.1007/s13300-023-01390-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
AIMS Malignant external otitis (MEO) is a special type of external otitis associated with extensive inflammation and osteomyelitis. It is believed to originate from the external auditory meatus and advance regionally to the soft tissues and the bone, eventually involving the skull base. Pseudomonas aeruginosa and diabetes mellitus are factors commonly involved in the pathogenesis of MEO. Although its treatment has changed considerably during the last decades, morbidity and mortality of the disease remain high. Our aim was to review basic aspects of MEO, a disease unknown until 1968, which attracts great interest among Ears, Nose and Throat (ENT), diabetes and infectious diseases specialists. METHODS AND RESULTS In this narrative review we mainly include relevant papers written in English or with an English abstract. We searched PubMed and Google Scholar, using the keywords malignant external otitis, malignant otitis externa, necrotizing external otitis, skull base osteomyelitis, diabetes mellitus and surgery up to July 2022. Some of the most recent articles, with specific references to earlier articles and a book reference regarding the pathophysiology, diagnosis and treatment of MEO and its relationship to diabetes mellitus, were included. CONCLUSION MEO is not an uncommon disease and is principally treated by ENT surgeons. Nevertheless, diabetes specialists should be aware of the disease presentation and management, since they will often encounter patients with undiagnosed MEO or will need to manage glucose levels in patients hospitalized with the disease.
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Affiliation(s)
- Christos Tsilivigkos
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece.
| | - Konstantinos Avramidis
- Second Department of Internal Medicine, Hippokration General Hospital, 15772, Athens, Greece
| | - Eleftherios Ferekidis
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - John Doupis
- Department of Internal Medicine and Diabetes, Salamis Naval and Veterans Hospital, Salamis Naval Base, 18900, Salamis Island, Greece
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10
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Baba A, Kurokawa R, Kurokawa M, Reifeiss S, Policeni BA, Ota Y, Srinivasan A. Advanced imaging of head and neck infections. J Neuroimaging 2023. [PMID: 36922159 DOI: 10.1111/jon.13099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023] Open
Abstract
When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.
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Affiliation(s)
- Akira Baba
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryo Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mariko Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Reifeiss
- Department of Radiology, Roy Caver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Bruno A Policeni
- Department of Radiology, Roy Caver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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Takata J, Hopkins M, Alexander V, Bannister O, Dalton L, Harrison L, Groves E, Kanona H, Jones GL, Mohammed H, Andersson MI, Hodgson SH. Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research. Clin Otolaryngol 2023; 48:381-394. [PMID: 36759416 DOI: 10.1111/coa.14041] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/30/2022] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES To present a systematic review and critical analysis of clinical studies for necrotising otitis externa (NOE), with the aim of informing best practice for diagnosis and management. DESIGN Medline, Embase, Cochrane Library and Web of Science were searched from database inception until 30 April 2021 for all clinical articles on NOE. The review was registered on PROSPERO (ID: CRD42020128957) and conducted in accordance with PRISMA guidelines. RESULTS Seventy articles, including 2274 patients were included in the final synthesis. Seventy-three percent were retrospective case series; the remainder were of low methodological quality. Case definitions varied widely. Median patient age was 69.2 years; 68% were male, 84% had diabetes and 10% had no reported immunosuppressive risk factor. Otalgia was almost universal (96%), with granulation (69%) and oedema (76%) the commonest signs reported. Pseudomonas aeruginosa was isolated in 62%, but a range of bacterial and fungal pathogens were reported and 14% grew no organism. Optimal imaging modality for diagnosis or follow-up was unclear. Median antimicrobial therapy duration was 7.2 weeks, with no definitive evidence for optimal regimens. Twenty-one percent had surgery with widely variable timing, indication, or procedure. One-year disease-specific mortality was 2%; treatment failure and relapse rates were 22% and 7%, respectively. CONCLUSION There is a lack of robust, high-quality data to support best practice for diagnosis and management for this neglected condition. A minimum set of reporting requirements is proposed for future studies. A consensus case definition is urgently needed to facilitate high-quality research.
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Affiliation(s)
- Junko Takata
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK.,Infectious Diseases Data Observatory, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Michael Hopkins
- Department of Ear, Nose and Throat Surgery, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Victoria Alexander
- Department of Ear, Nose and Throat Surgery, St George's University Hospital NHS Trust, London, UK
| | - Oliver Bannister
- Department of Infection, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Modernising Medical Microbiology, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lucy Dalton
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Laura Harrison
- Department of Ear, Nose and Throat Surgery, Royal Berkshire Hospital, Reading, UK
| | - Emily Groves
- Department of General Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Hala Kanona
- Department of Ear, Nose and Throat Surgery, The Royal National Ear Nose and Throat and Eastman Dental Hospital, University College London Hospitals NHS Trust, London, UK
| | | | - Hassan Mohammed
- Department of Ear, Nose and Throat, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Monique I Andersson
- Department of Infection, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Division of Clinical Laboratory Science, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Susanne H Hodgson
- Department of Infection, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Biochemistry, University of Oxford, Oxford, UK
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de Souza SAL, Laurindo RSS, Gutfilen-Schlesinger G, Felix F, Amarante Junior JLDM, Gutfilen B. The Use of 99mTc-Mononuclear Leukocyte Scintigraphy for Necrotizing External Otitis Diagnosis. Diagnostics (Basel) 2023; 13:diagnostics13030570. [PMID: 36766675 PMCID: PMC9914623 DOI: 10.3390/diagnostics13030570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Necrotizing external otitis (NEO) is a severe infectious disease in the external acoustic meatus (EAM) and mastoid that may extend to the cranial base. Due to the lack of a gold standard examination technique, the diagnosis is often difficult and delayed. This study aimed to evaluate the sensitivity and specificity of 99mTc-mononuclear leukocyte scintigraphy associated with 99mTc-phytate in suspected NEO compared to 99mTc-MDP and 67Ga-citrate. METHODS A prospective study (32 patients) was conducted between 2011 and 2016. RESULTS At the end, twenty-four patients remained for the study conduction; nineteen had confirmed NEO diagnosis, one had sarcoma, one had EAM cholesteatoma, one had diffuse simple external otitis, and two had an inconclusive diagnosis. 99mTc-mononuclear leukocyte scintigraphy plus 99mTc-phytate was as sensitive as 99mTc-MDP bone scintigraphy (19/19X9/19), and more sensitive than 67Ga scintigraphy (19/19 x 17/19). Regarding specificity, it was superior to bone scintigraphy, 100% × 40% (5/5 × 2/5), and 67Ga scintigraphy, 100% × 20% (5/5 × 1/5). After the infection resolution, all NEO patients had their leukocyte scintigraphy negativized. To the best of our knowledge, this is the first study that evaluates this technique in patients with suspected NEO. CONCLUSIONS 99mTc-mononuclear leukocyte was revealed to be the best option for NEO because of its specificity.
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Affiliation(s)
- Sergio Augusto Lopes de Souza
- Serviço de Otorrinolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Correspondence:
| | - Roberta Silveira Santos Laurindo
- Serviço de Otorrinolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Gabriel Gutfilen-Schlesinger
- Serviço de Otorrinolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Felippe Felix
- Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | | | - Bianca Gutfilen
- Serviço de Otorrinolaringologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
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13
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PET-Computed Tomography in Bone and Joint Infections. PET Clin 2023; 18:49-69. [DOI: 10.1016/j.cpet.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Arslan IB, Pekcevik Y, Cukurova I. Management and long-term comorbidities of patients with necrotizing otitis externa. Eur Arch Otorhinolaryngol 2022; 280:2755-2761. [PMID: 36528642 PMCID: PMC9759449 DOI: 10.1007/s00405-022-07784-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Ilker Burak Arslan
- Department of Head Neck Surgery, Tepecik Training and Research Hospital, Health Science University, Izmir Tepecik SUAM Gaziler Bulvarı No:468, Yenisehir, Konak Izmir, Turkey
| | - Yeliz Pekcevik
- Department of Radiology, Tepecik Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ibrahim Cukurova
- Department of Head Neck Surgery, Tepecik Training and Research Hospital, Health Science University, Izmir Tepecik SUAM Gaziler Bulvarı No:468, Yenisehir, Konak Izmir, Turkey
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15
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Could [18F]FDG PET/CT or PET/MRI Be Useful in Patients with Skull Base Osteomyelitis? Diagnostics (Basel) 2022; 12:diagnostics12092035. [PMID: 36140437 PMCID: PMC9497608 DOI: 10.3390/diagnostics12092035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/19/2022] [Indexed: 11/24/2022] Open
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16
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Althawadi N, Hussein AEM, Sabra O. Skull Base Osteomyelitis With Bilateral Acute Otitis Media. Cureus 2022; 14:e24144. [PMID: 35582563 PMCID: PMC9107316 DOI: 10.7759/cureus.24144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 12/26/2022] Open
Abstract
Skull base osteomyelitis is an inflammatory process that usually occurs secondary to necrotizing otitis externa or chronic mastoid infections. The involvement of the external auditory canal is typical of this condition and aids in its diagnosis. The treatment of skull base osteomyelitis is often complex and involves long-term intravenous antibiotics. Skull base osteomyelitis originating from the middle ear is a rare entity. We report a case of skull base osteomyelitis originating from the bilateral otitis media.
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Margulis I, Cohen-Kerem R, Roitman A, Gez-Reder H, Aviram A, Bitterman-Fisher S, Kugelman N, Doweck I. Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis. EAR, NOSE & THROAT JOURNAL 2022:1455613221080973. [PMID: 35311376 DOI: 10.1177/01455613221080973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Itai Margulis
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Raanan Cohen-Kerem
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ariel Roitman
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Hadar Gez-Reder
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ariel Aviram
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Sivan Bitterman-Fisher
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Nir Kugelman
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ilana Doweck
- Department of Otolaryngology Head and Neck Surgery, 37255Lady Davis Carmel Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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18
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Lim JWJ, Hill FCE, Kerr S, Briggs R, McLean T. Diagnostic approach to patients at risk of otogenic skull base osteomyelitis. Acta Otolaryngol 2022; 142:272-279. [PMID: 35382682 DOI: 10.1080/00016489.2022.2057586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Otogenic skull base osteomyelitis (OSBO) is rare and potentially fatal sequelae of otitis externa. Accurate and timely diagnosis is important due to rising incidence, morbidity and costs associated with treatment. Consensus on the diagnostic approach for OSBO has yet to be reached, in particular the utility of imaging modalities. AIMS/OBJECTIVES This study reviews a single institution's high-volume experience of OSBO, with the aim of analysing clinicopathologic features and imaging studies to develop a diagnostic algorithm. MATERIAL AND METHODS A retrospective review of patients admitted with OSBO from 2009 to 2019, was performed. After applying inclusion and exclusion criteria, 103 patients with 106 unique episodes of suspected OSBO were selected. De-identified information including patient demographics, clinicopathologic features and imaging outcomes was recorded and analysed. RESULTS HbA1c ≥ 7% significantly predicted for OSBO in univariate (OR 7.83, 95% CI 1.85-33.16, p = 0.01) and multivariate analyses (OR 5.21, 95% CI 1.05-25.81, p = 0.04). The CT/technetium-99m/gallium-67 combination produced better diagnostic accuracy for OSBO (AUROC 0.96, 95% CI 0.92-1), when compared to a CT/MRI combination (AUROC 0.86, 95% CI 0.79-0.93). CONCLUSIONS AND SIGNIFICANCE Once there is a clinical suspicion for OSBO, diagnosis is established by synthesising results from clinical assessment, pathologic investigations and imaging modalities. The imaging utilised to diagnose OSBO should vary according to the clinical situation and limitations of each modality.
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Affiliation(s)
- Jason Wei Jun Lim
- Department of Otolaryngology, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Fiona C. E. Hill
- Department of Otolaryngology, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Stephen Kerr
- The Kirby Institute, The University of New South Wales, Sydney, Australia
| | - Robert Briggs
- Department of Otolaryngology, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Tim McLean
- Department of Otolaryngology, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
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Noroozbeigi N, Dabbagh VR, Pakdin Parizi Z, Soltani S, Sadeghi R. Malignant External Otitis in a Patient With Diabetes Mellitus: Comparison of Bone Scan SPECT/CT and 68Ga-Citrate PET/CT. Clin Nucl Med 2022; 47:e287-e288. [PMID: 35025801 DOI: 10.1097/rlu.0000000000004004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT We reported a 66-year-old woman with malignant external otitis who was referred to our department for evaluation of disease extension. Both 99mTc-MDP bone SPECT/CT and 68Ga-citrate PET/CT were done for the patient. Both studies showed concordant areas of increased uptake in the petrous bone. In addition, 68Ga-citrate PET/CT showed soft tissue infection in the nasopharyngeal wall. Our case showed the potential of 68Ga-citrate PET/CT for evaluation of malignant external otitis.
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Affiliation(s)
- Nasim Noroozbeigi
- From the Nuclear Medicine Department, Razavi Hospital, Imam Reza International University
| | - Vahid Reza Dabbagh
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Pakdin Parizi
- From the Nuclear Medicine Department, Razavi Hospital, Imam Reza International University
| | - Samira Soltani
- From the Nuclear Medicine Department, Razavi Hospital, Imam Reza International University
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Khan HA. Necrotising Otitis Externa: A Review of Imaging Modalities. Cureus 2021; 13:e20675. [PMID: 34966623 PMCID: PMC8710300 DOI: 10.7759/cureus.20675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/25/2022] Open
Abstract
Necrotising Otitis Externa (NOE) has often posed some challenges in view of diagnosis and management by clinicians. One such challenge is the appropriate and timely use of imaging techniques since its use is critical not only in diagnosis but also in determining the extent and resolution of the disease. Hence, doctors in both primary and secondary health care need to be familiar with presenting symptoms while specialists need to be appraised of advances in imagining techniques in diagnosis and management of NOE. Whilst there is a general consensus amongst clinicians on some aspects of management of NOE, there is very limited consensus on the use of imaging modalities. There is no single modality of imaging that can provide a complete picture of diagnosis, disease progression and resolution. This review aims to highlight the strengths and weaknesses of various imaging techniques used in the diagnosis and management of NOE over the years and whether a multi-modal imaging technique at particular stages of the disease may provide better management outcomes.
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Affiliation(s)
- Hammaad A Khan
- Otolaryngology - Head and Neck Surgery, Aintree University Hospital, Liverpool, GBR
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21
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Necrotising otitis externa: the increasing financial burden on the National Health Service. The Journal of Laryngology & Otology 2021; 136:730-733. [PMID: 34753526 DOI: 10.1017/s0022215121003443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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22
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Kim DH, Kim SW, Hwang SH. Predictive value of radiologic studies for malignant otitis externa: a systematic review and meta-analysis. Braz J Otorhinolaryngol 2021; 89:66-72. [PMID: 34799270 PMCID: PMC9874358 DOI: 10.1016/j.bjorl.2021.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/06/2021] [Accepted: 08/31/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine the diagnostic accuracy of Necrotizing Otitis Externa (NOE) based on radiologic studies. METHODS The PubMed, Cochrane, Embase, Web of Science, SCOPUS, and Google Scholar databases were searched. True-positive and false-negative results were extracted for each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. RESULTS The included studies contained data on 37 studies diagnosed with NOE. The sensitivity of gallium-67, technetium-99m, and Magnetic Resonance Imaging (MRI) was 0.9378 (0.7688-0.9856), 0.9699 (0.8839-0.9927), and 0.9417 (0.6968-0.9913), respectively. For Computed Tomography (CT), the positive criteria consisted of bony erosion alone and bony erosion plus any soft tissue abnormality. The sensitivity of CT based only on bony erosion was 0.7062 (0.5954-0.7971); it was higher 0.9572 (0.9000-0.9823) when based on bony erosion plus any soft tissue abnormality. CONCLUSION The diagnostic sensitivity of technetium-99m, gallium-67, and MRI was favorable. On CT, the presence of bony erosion may be a useful diagnostic marker of NOE, but the diagnostic sensitivity will be even higher if the criterion of any soft tissue abnormality is also included; however, care should be taken when interpreting the results. Our study demonstrates the potential utility of radiology studies for diagnosing NOE, but their lack of specificity must be considered, and standardized anatomic criteria are still needed. LEVEL OF EVIDENCE 2A.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea,Corresponding author.
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Emerging themes in necrotising otitis externa: a scoping review of the literature 2011-2020 and recommendations for future research. The Journal of Laryngology & Otology 2021; 136:575-581. [PMID: 34666847 DOI: 10.1017/s0022215121003030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
PURPOSE OF REVIEW Skull base osteomyelitis (SBO) is a challenging entity to diagnose and treat. The goal of this review is to summarize the imaging findings of SBO and present these in the context of recent studies on imaging of SBO. RECENT FINDINGS This review discusses the clinical presentation, pathophysiology and imaging appearances of SBO. The review further emphasizes the results of latest studies on imaging of SBO, and the role of different modalities in diagnosis and evaluation of disease course and treatment response. Brief discussion on differential diagnoses from an imaging standpoint is also included. SUMMARY Various imaging modalities play different and complimentary roles in diagnosis and management of SBO, which are discussed in this review.
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Abstract
PURPOSE OF REVIEW Skull base osteomyelitis (SBO) is a life-threatening condition. Due to an aging and increasingly multimorbid population, clinicians are more often challenged with this disease. Yet, there is no consensus on the optimal diagnostic and follow-up management. This review should aid clinicians in decision-making for their patients. RECENT FINDINGS Treatment-resistant otalgia or headache is suspicious of SBO. Pseudomonas aeruginosa remains the most common pathogen but clinicians are challenged with increasing rates of sterile or fungal cultures due to previously applied antibiotics/steroids. No single imaging modality is able to detect the full extent of the disease. Whereas functional nuclear imaging with gallium-67 or methylene diphosphonate-technetium-99m was once advocated, its actual benefit is questionable. Newer modalities such as fluoro-D-glucose-positron emission tomography (PET)/computed tomography, PET/magnetic resonance imaging (MRI), or diffusion-weighted MRI seem to be promising in diagnosis and follow-up. Finding the causative pathogen is of utmost importance followed by long-term intravenous antibiotics until the disease has completely resolved. Surgery plays a minor role in treatment but can be helpful in selected cases. SUMMARY The numerous challenges in SBO render management difficult, but with a clear work-up including regular clinical, laboratory and imaging examinations, outcome can be improved.
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Affiliation(s)
- Alice B Auinger
- Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
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The Role of 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) in Management of Nocardiosis: A Retrospective Study and Review of the Literature. Infect Dis Ther 2021; 10:2227-2246. [PMID: 34283408 PMCID: PMC8572926 DOI: 10.1007/s40121-021-00495-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction 18-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is a well-established tool for managing metastatic infections. Nocardiosis, a primarily pulmonary infection, disseminates at high rates. Routine imaging includes chest CT and brain imaging. We examined the use of FDG-PET/CT in nocardiosis and assessed its contribution to diagnosis and management. Methods A retrospective study in two tertiary medical centers during 2011–2020. Individuals with nocardiosis for whom FDG-PET/CT was implemented for any reason were included and their medical records were reviewed. A board-certified nuclear medicine physician independently reviewed all scans. Additionally, a systematic review was conducted according to the PRISMA guidelines, to extract data from publications reporting FDG-PET/CT use for the management of nocardiosis. Results FDG-PET/CT contributed to the management of all seven patients who met inclusion criteria. It assisted in ruling out an underlying malignancy (29%, 2/7); establishing a wide infection extent (57%, 4/7); and affecting decisions regarding treatment (57%, 4/7), including drug regimen, oral step-down, and duration of therapy. We identified 20 published case reports on this topic. In 80% (16/20), FDG-PET/CT contributed to the management of nocardiosis similar to our study. In addition, in most of the literature cases, FDG-PET/CT guided the diagnostic biopsy. Conclusion FDG-PET/CT is valuable in the diagnosis and management of individuals with nocardiosis. The contribution of incorporating FDG-PET/CT to the management of individuals with nocardiosis and its role in monitoring treatment response and shortening treatment duration should be evaluated in prospective studies.
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Ringrose T, Biggs TC, Hilton JM, Crossley E, Basil M, Graham-Hart L, Megadmi H, Buckland J, Pringle MB. Examining the utility of nuclear medicine imaging in the diagnosis and management of necrotising otitis externa. Clin Otolaryngol 2021; 46:1159-1163. [PMID: 33966334 DOI: 10.1111/coa.13799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/04/2021] [Accepted: 04/18/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas Ringrose
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Timothy C Biggs
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Jennifer M Hilton
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Eleanor Crossley
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Malik Basil
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Louis Graham-Hart
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Hakim Megadmi
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Jonathan Buckland
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Mike B Pringle
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Cosham, UK
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Treviño González JL, Reyes Suárez LL, Hernández de León JE. Malignant otitis externa: An updated review. Am J Otolaryngol 2021; 42:102894. [PMID: 33429178 DOI: 10.1016/j.amjoto.2020.102894] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/27/2020] [Indexed: 11/18/2022]
Abstract
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.
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In the evaluation of patients with skull base osteomyelitis, does 18F-FDG PET CT have a role? Nucl Med Commun 2021; 41:550-559. [PMID: 32282638 DOI: 10.1097/mnm.0000000000001187] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of regional fluorine-18 fluorodeoxyglucose (F-FDG) positron emission tomography-computed tomography (PET-CT) in patients with skull base osteomyelitis (SBO) and to compare with magnetic resonance imaging (MRI) whenever available. MATERIALS AND METHODS A total of 77 patients (male:female = 56:21; mean age 66.4 ± 9.4 years) with clinically suspected SBO, who underwent regional F-FDG PET-CT were included in this retrospective study. F-FDG PET-CT images were analyzed for presence, localization and intensity of FDG uptake. Diagnostic performance of F-FDG PET-CT was analyzed based on histopathology, culture, and clinical/imaging follow-up. The agreement analysis between F-FDG PET-CT and MRI findings was performed in 56 patients. RESULTS The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of F-FDG PET-CT for diagnosing SBO were 96.7, 93.3, 98.3, 87.5, and 96.1%, respectively. The average SUVmax of the lesions was 5.9 ± 3.5. The SUVmax of the fungal lesions was lower than that of bacterial lesions with P-value of <0.001. On comparing variables like C-reactive protein, erythrocyte sedimentation rate, and SUVmax for prediction of recurrence/progression, by plotting an ROC curve, the SUVmax was found to be an independent prognostic marker. 56 out of 77 patients had undergone both F-FDG PET-CT and MRI. The agreement analysis between the modalities showed almost perfect agreement for delineation of soft tissue and bony involvement with κ values of 0.82 and 0.81, respectively. CONCLUSION F-FDG PET-CT is a sensitive tool in evaluation of patients with SBO. It shows a very good agreement with the MRI. It plays a critical role in treatment response evaluation.
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Auinger AB, Dahm V, Stanisz I, Schwarz-Nemec U, Arnoldner C. The challenging diagnosis and follow-up of skull base osteomyelitis in clinical practice. Eur Arch Otorhinolaryngol 2021; 278:4681-4688. [PMID: 33511482 PMCID: PMC8553694 DOI: 10.1007/s00405-020-06576-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/15/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE The disease activity of skull base osteomyelitis can be challenging to assess by means of conventional imaging methods and renders monitoring of the disease difficult, especially in areas with restricted access to nuclear medicine imaging. Here, we provide clinically relevant data on the management of skull base osteomyelitis including assessment, treatment, and follow-up strategies with regards to the role of imaging. METHOD A chart review was performed including 30 patients treated for SBO from 1993 to 2015. Clinical findings, treatment procedures, and complication rates were assessed. Special attention was paid to imaging procedures. RESULTS The overall mortality rate was 36.7% and increased to 45% when cranial nerve palsies were present. An initial computed tomography (CT) scan was performed in all patients, MRI in 60% and nuclear imaging in 33%. CT scans failed to detect progression or regression in up to 80% after four to nine months. MRI examinations could reveal changes at a higher rate compared to CT. Nuclear medicine functional imaging was most likely to assess disease activity. CONCLUSION A combination of different imaging modalities is recommended for diagnosing SBO. For the follow-up, MRI is preferable to CT as changes can be detected more readily with MRI. If available, nuclear medicine imaging should guide the decision of treatment discontinuation.
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Affiliation(s)
- Alice B Auinger
- Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Valerie Dahm
- Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Isabella Stanisz
- Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ursula Schwarz-Nemec
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Hasnaoui M, Ben Mabrouk A, Chelli J, Larbi Ammari F, Lahmar R, Toumi A, Mighri K. Necrotising otitis externa: A single centre experience. J Otol 2020; 16:22-26. [PMID: 33505446 PMCID: PMC7814081 DOI: 10.1016/j.joto.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Necrotising otitis externa (NOE) is a rare infection of the ear canal with frequent bone erosion. This study’s objective is to describe the different features of NOE as well as its management in an ear-nose-throat department. We also tried to identify the particularities of the fungal infection. Patients and methods It is an observational cohort that included all the patients hospitalised for the management of NOE. The study was carried out in the ear-nose-throat Department of Mahdia University Hospital in Tunisia between January 2006 and december 2019. Results A total of 40 patients were included. The mean age was 65 ± 12.9 years and the sex ratio was 0.9. Ninety percent of the patients included were diabetics. The most common signs found were oedema of the external canal (97.5%) and auricular discharge (92.5%). The main pathogen isolated was Pseudomonas aeruginosa (61.7%). Fungi were isolated in 9 cases (26.47%). Computed tomography was performed for 32 patients (80%). Bone erosion was seen in 26 cases (81.3%). The main complications were cerebral venous thrombosis, retropharyngeal abscess and cerebral empyema. Thirty one patients received only antibiotics, 2 received only antifungal treatment, and 7 received both antibiotics and antifungal treatment. All patients had a favorable outcome. Univariate analysis showed a higher median erythrocyte sedimentation rate was associated with fungal infections. No other differences were noted. Conclusion Our management protocol seems to be efficient since all patients had initial favorable outcome. A higher median erythrocyte sedimentation rate was associated with fungal infections. Necrotising otitis externa has a variable clinical presentation and a relatively high rate of complications. The patients were mainly diabetics or aged more than 65 years old. The main pathogen isolated was Pseudomonas aeruginosa. A higher median erythrocyte sedimentation rate was associated with fungal infections.
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Affiliation(s)
- Mehdi Hasnaoui
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Asma Ben Mabrouk
- Department of Infectious Diseases, Fattouma Bourguiba Hospital, Monastir, 5000, Tunisia
| | - Jihene Chelli
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Fatma Larbi Ammari
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Rihab Lahmar
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Adnene Toumi
- Department of Infectious Diseases, Fattouma Bourguiba Hospital, Monastir, 5000, Tunisia
| | - Khalifa Mighri
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
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Abstract
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.
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What is the Best Test for Diagnosis and Monitoring Treatment Response in Malignant Otitis Externa? Laryngoscope 2020; 130:2516-2517. [DOI: 10.1002/lary.28609] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 01/04/2023]
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Affiliation(s)
- Robert E Morales
- Department of Diagnostic Radiology and Nuclear Medicine, Division of Neuroradiology, University of Maryland School of Medicine, Baltimore, MD.
| | - David J Eisenman
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, Division of Neuroradiology, University of Maryland School of Medicine, Baltimore, MD
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