An emergency medicine-focused review of malignant otitis externa

Pediatric Necrotizing Otitis Externa: A Scoping Review

OBJECTIVE

This review sought to answer the following research question: What are the characteristics of pediatric necrotizing otitis externa (NOE)? Moreover, we wanted to highlight the clinical importance of the current limitations in the literature.

METHODS

A scoping review was performed to determine what is known about NOE in the pediatric population. Four databases (COCHRANE Library, CINAHL, PubMed, and Scopus) were queried for articles published in English between 1976 to 2022. Variables extracted included comorbidities, demographics, outcomes, and treatment.

RESULTS

A total of 20 studies (N = 439) reported sufficient measures to be included in the review. Patients with NOE had a mean age of 10.0 years (range 2 months to 14 years) with a male-to-female gender ratio of 1.1:1. Mean length of hospital stay was 2.9 days (95%CI: 2.7-3.0). Demographics included 45.4% Caucasian, 6.0% African American, and 2.7% Asian/Pacific Islander. Less than 5% of patients had diabetes, while other reported comorbidities included neutropenia (n = 6), anemia (n = 5), dehydration/malnutrition (n = 4), Stevens Johnson Syndrome (n = 2), some form of immunosuppression/organ transplantation (n = 2), thrombocytopenia (n = 2), and leukopenia (n = 2). There have been no reported deaths from NOE in children.

CONCLUSIONS

In the adult population NOE most commonly affects patients with diabetes, but our review reveals that diabetes does not appear to play as big a role in children. The disease seems to commonly affect patients with immunosuppression or severe health conditions. Complications such as cranial nerve palsies appear to be more common in the pediatric population. Specifically, the role of biopsy and culture in the treatment of pediatric NOE is stressed as they are important in treatment decisions.

The diagnostic conundrum in necrotizing otitis externa

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.

Clinical Spectrum and Treatment Response of Malignant Otitis Externa Patients: A Rural Tertiary Care Centre Experience

INTRODUCTION

Malignant otitis externa (MOE) is an invasive external ear infection that has a tendency to spread through the temporal bone and can further progress to involve intracranial structures. Though the prevalence of MOE is rare, high morbidity and mortality are often associated. Complications of advanced MOE include cranial nerve involvement, most commonly facial nerve, and intracranial infections such as abscesses and meningitis.

MATERIALS AND METHODS

In this retrospective case series of nine patients diagnosed with MOE, demographic data, clinical presentations, laboratory data, and radiological findings were reviewed. All patients were followed up for a minimum period of three months after discharge. Outcomes were measured in terms of reduction in obnoxious ear pain (Visual Analogue Scale), ear discharge, tinnitus, need for re-hospitalization, recurrence of disease, and overall survival.

RESULTS

In our case series of nine patients (seven males and two females), six underwent surgery, and three patients were managed with a medical line of treatment. All patients had a significant reduction in otorrhea, otalgia, random venous blood sugars, and improvement of facial palsy implicating good response to treatment.

CONCLUSION

Prompt diagnosis of MOE warrants clinical expertise and aids in preventing complications. A prolonged course of intravenous anti-microbial agents is the mainstay of treatment, but timely surgical interventions in treatment-resistant cases can prevent complications.

Patients' experience of necrotising otitis externa: a qualitative study

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.

Necrotising otitis externa: a serious condition becoming more frequently encountered

BACKGROUND

Necrotising otitis externa is an aggressive infection of the external ear, which extends to the surrounding bone and soft tissue. In recent years, there has been an apparent increase in the number of patients admitted to our hospital with this condition.

METHODS

A retrospective review was conducted of all patients admitted to our hospital with necrotising otitis externa between July 2012 and June 2020.

RESULTS

Among 39 patients included, only 9 were diagnosed in the first four years, and 30 were diagnosed in the last four years. There were 27 males and 12 females, and the mean age was 78.7 years. There were six non-diabetic immunocompetent patients. Cranial nerve palsies developed in 50 per cent of the patients. Disease-related mortality was 7.7 per cent. A favourable outcome was recorded in 66.7 per cent of the patients.

CONCLUSION

Necrotising otitis externa is associated with high morbidity and mortality. The incidence of the disease is rising in our local geographical area.

Skin manifestations of Pseudomonas aeruginosa infections

PURPOSE OF REVIEW

Pseudomonas aeruginosa is an opportunistic pathogen with considerable morbidity and mortality, particularly in vulnerable hosts. Skin manifestations are common, either representing local inoculation or secondary skin seeding following bloodstream infections. As patients with various predisposing conditions are expanding, we sought to review the most recent published evidence regarding epidemiology, risk factors and diagnosis of skin manifestations of P. aeruginosa.

RECENT FINDINGS

New data exist on epidemiology and diagnosis of skin infections; systemic infections are impacted by multidrug-resistance issues and host immune status.

SUMMARY

Green nail syndrome, toe web infection, hot tub folliculitis, hot hand-foot infection and external otitis are the most common infections originating from the skin per se. Local treatments are the cornerstone and prognosis is favorable in immunocompetent hosts. Ecthyma gangrenosum and P. aeruginosa subcutaneous nodules are usually associated with bloodstream infections and occur primarily in immunocompromised hosts. Necrotizing skin and soft tissue infections occur in diabetic, alcoholic and immunocompromised patients; management requires a multidisciplinary team with surgical approach. Burn wound infections may also be challenging, requiring a specialized team. In all the four latter types of P. aeruginosa skin infections portending significant morbidity and mortality, systemic antibiotics are an integral part of the treatment.

An Organ System-Based Synopsis of Pseudomonas aeruginosa Virulence

Driven in part by its metabolic versatility, high intrinsic antibiotic resistance, and a large repertoire of virulence factors, Pseudomonas aeruginosa is expertly adapted to thrive in a wide variety of environments, and in the process, making it a notorious opportunistic pathogen. Apart from the extensively studied chronic infection in the lungs of people with cystic fibrosis (CF), P. aeruginosa also causes multiple serious infections encompassing essentially all organs of the human body, among others, lung infection in patients with chronic obstructive pulmonary disease, primary ciliary dyskinesia and ventilator-associated pneumonia; bacteremia and sepsis; soft tissue infection in burns, open wounds and postsurgery patients; urinary tract infection; diabetic foot ulcers; chronic suppurative otitis media and otitis externa; and keratitis associated with extended contact lens use. Although well characterized in the context of CF, pathogenic processes mediated by various P. aeruginosa virulence factors in other organ systems remain poorly understood. In this review, we use an organ system-based approach to provide a synopsis of disease mechanisms exerted by P. aeruginosa virulence determinants that contribute to its success as a versatile pathogen.

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.