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

Nasopharyngeal and temporal bone abscess following necrotizing otitis externa: a case report

Necrotizing otitis externa (NOE) is a severe infection primarily affecting the external auditory canal, seen mainly in immunocompromised individuals as patients with diabetes mellitus (DM). This case report highlights unusual complications of NOE: temporal bone and nasopharyngeal abscesses. These complications underscore the severity of NOE, particularly when caused by rare pathogens such as Klebsiella species. We detail the case of a 70-year-old male with uncontrolled DM who presented with severe right ear pain, purulent discharge, and significant postauricular swelling. Laboratory investigations revealed elevated inflammatory markers and poorly controlled diabetes. Cultures confirmed Klebsiella pneumoniae, and imaging showed diffuse edema and abscess formation in the temporal bone and nasopharynx. The patient was treated with intravenous Ceftazidime and ciprofloxacin for 6 weeks, followed by oral ciprofloxacin. Effective management of NOE necessitates a comprehensive, multidisciplinary approach. Early intervention, regular monitoring, and imaging are critical for promptly detecting and managing complications.

A systematic review of antimicrobial treatment regimens and their outcomes in necrotising otitis externa

BACKGROUND

Necrotising otitis externa is a serious infection with minimal evidence underpinning its management. This review aims to synthesise published evidence of antimicrobial therapies and their outcomes in necrotising otitis externa.

METHODS

The review was PROSPERO registered (CRD42022353244) and conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses ('PRISMA') guidelines. A robust search strategy filtered 28 manuscripts into the final review. Antimicrobial therapy and clinical outcome data were extracted and analysed.

RESULTS

Published studies are heterogeneous, with high risk of bias and low certainty. Reporting of outcomes is poor and extremely variable. First-line therapy is most commonly in-patient (95 per cent) empiric fluoroquinolone (68 per cent) delivered intravenously (82 per cent). The lack of granular data and poor outcome reporting mean it is impossible to correlate treatment strategies with clinical outcomes.

CONCLUSION

Robust, consistent outcome reporting with reference to treatments administered is mandatory, to inform clinical management and optimise future research. Optimal antimicrobial choices and treatment strategies require clarification through prospective clinical trials.

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.

Exploring theories for the exponential 16-year rise in incidence of necrotising otitis externa in England

Background

Necrotising otitis externa is a severe, life-threatening infection. Epidemiological data demonstrate a dramatic rise in reported cases in England from 2002 to 2017. The reasons for this remain elusive.

Methods

A quantitative descriptive study was undertaken using epidemiological data from the Hospital Episode Statistics database. Cases from 2002 to 2017 were compiled and analysed. Four potential theories were explored to explain the rise in incidence.

Results

Within the 16-year period, 7327 necrotising otitis externa cases were reported. Annual necrotising otitis externa incidence increased 1142 per cent within the 16-year period, from 123 recorded cases in 2002 to 1405 cases in 2017. This correlates with an increasing prevalence of diabetes, an ageing population and likely increased physician awareness of necrotising otitis externa. There is insufficient evidence to support antibiotic resistance as a significant associated factor.

Conclusion

Correlation does not imply causation. It is likely that a combination of factors is contributing to the rise in necrotising otitis externa incidence, including increased physician recognition, diagnosis and accurate clinical coding.

Characteristics, management and outcome of a large necrotising otitis externa case series: need for standardised case definition

Background

Necrotising otitis externa is a severe ear infection for which there are no established diagnostic or treatment guidelines.

Method

This study described clinical characteristics, management and outcomes for patients managed as necrotising otitis externa cases at a UK tertiary referral centre.

Results

A total of 58 (63 per cent) patients were classified as definite necrotising otitis externa cases, 31 (34 per cent) as probable cases and 3 (3 per cent) as possible cases. Median duration of intravenous and oral antimicrobial therapy was 6.0 weeks (0.49–44.9 weeks). Six per cent of patients relapsed a median of 16.4 weeks (interquartile range, 23–121) after stopping antimicrobials. Twenty-eight per cent of cases had complex disease. These patients were older (p = 0.042), had a longer duration of symptoms prior to imaging (p < 0.0001) and higher C-reactive protein at diagnosis (p = 0.005). Despite longer courses of intravenous antimicrobials (23 vs 14 days; p = 0.032), complex cases were more likely to relapse (p = 0.016).

Conclusion

A standardised case-definition of necrotising otitis externa is needed to optimise diagnosis, management and research.

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.

Current management of skull base osteomyelitis

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.

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

OBJECTIVES

There is currently no consensus on the most effective treatment protocol for necrotizing otitis externa (NOE). This article aims to produce a NOE treatment protocol from the literature and clinical experience.

METHODS

A total of 26 case series from the literature were reviewed in combination with a retrospective case series of inpatients from Hull University Teaching Hospitals NHS Trust from 2013-2018. Over 5 years, 40 patients were identified, with only 29 being analysed due to unavailable or incomplete case notes.

RESULTS

In the literature review, the most common bacterial species causing NOE was Pseudomonas aeruginosa. Resistance to ciprofloxacin was prevalent, however multidrug resistance was rare. Ciprofloxacin and ceftazidime were the most widely used antibiotics. No ceftazidime resistance was reported in the literature or in our cohort. The average age of the patients in our cohort was 80 years. Moreover, 62% had either diabetes mellitus or were immunosuppressed. One patient died directly due to NOE-related sepsis. Intravenous ceftazidime monotherapy was mostly used. The duration of treatment was 6-7 weeks, with no relapses documented.

CONCLUSION

Ceftazidime monotherapy was an effective empirical treatment in our cohort, and a total duration of 6-7 weeks of antibiotics was sufficient. We have created a standardised treatment protocol based on our findings that will need to be validated in a larger cohort of patients.

Prognosticating patients with necrotising otitis externa based on response to treatment

INTRODUCTION

Necrotising otitis externa (NOE) is a severe infection of the temporal bone. The traditional severity based staging system does not fully prognosticate all patients with NOE. We hypothesise that a patient response staging system would more accurately capture the disease process and guide prognosis.

METHODS

We carried out a retrospective notes review of patients diagnosed with NOE from January 2017 to December 2018 in a regional tertiary referral centre. Patient outcomes from our proposed patient response staging system were compared to a modified previously published severity based Gleeson staging system with patients requiring prolonged treatment classified as having a poor outcome.

RESULTS

A total of 34 patients were treated for NOE. The majority were male (n=24) and had diabetes (n=25). Patients with the most severe Gleeson staging did not have the worst outcome. Daily delay in resolution of otorrhoea was associated with an increased need for more than six weeks of treatment. Rapid responders are patients who had resolution of otalgia, otorrhoea and C-reactive protein normalisation within 14 days, and all were cured following standard 6 weeks of treatment.

CONCLUSIONS

The Gleeson staging system was valuable in assessing the extent of disease and all early Gleeson staged patients had good outcomes. However, patients with higher severity staging on the Gleeson system did not necessarily require prolonged treatment. There is a role for a joint approach in staging patients based on both modified Gleeson and treatment response, which would subsequently guide prognosis, duration of treatment and early diagnosis of potential fungal NOE.

The challenging diagnosis and follow-up of skull base osteomyelitis in clinical practice

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.

A Rare Case of Fungal Necrotising Otitis Externa Centred on the Left Temporomandibular Joint

INTRODUCTION

Necrotising otitis externa (NOE) is a rare life-threatening complication of simple otitis externa which can be difficult to diagnose and manage. It is very rarely centred on the temporomandibular joint (TMJ). Fungi cause NOE in approximately 5-20% of patients, and a high index of suspicion is required for diagnosis, particularly when there is no improvement with prolonged topical and intravenous antibiotic therapy.

OBJECTIVE

To report a novel case of fungal NOE centred on the left TMJ in an immunocompromised adult male with a focus on investigations and optimal management. Case Report. A 67-year-old male with comorbid chronic renal impairment presented to our otolaryngology department with prolonged left otalgia and otorrhoea. Subsequent cross-sectional imaging demonstrated left NOE centred on the TMJ. Poor resolution with prolonged courses of systemic and topical anti-pseudomonal antibiotics prompted maxillofacial surgical input for left TMJ exploration, washout, and biopsy from the joint capsule. The causative organism was identified as Aspergillus flavus on PCR analysis. The patient was successfully treated with oral posaconazole and repeated topical insertions of amphotericin B-soaked ribbon gauze to the left ear. Discussion. A combination of various imaging modalities including CT, MRI, Tc-99, and gallium-67 are utilised in clinical practice both to diagnose NOE and subsequently monitor disease progression or resolution. Immunocompromised patients with confirmed fungal NOE may require a combination of treatments including surgical debridement and prolonged antifungal therapy for a number of months, if not lifelong, treatment. Initiating empirical antifungal therapy may be justified in some patients. However, this should be judged on a case-by-case basis and guided by discussion with the local microbiology and infectious diseases departments. However, there is no national guideline or consensus regarding treatment of these patients, especially in cases of fungal NOE.

Single Application Cold-Chain Independent Drug Delivery System for Outer Ear Infections

Outer ear infections (OE) affect millions of people annually with significant associated healthcare costs. Incorrect administration or non-compliance with the treatment regimen can lead to infection persistence, recurrence, antibiotic resistance, and in severe cases aggravation to malignant otitis externa. Such issues are particularly pertinent for military personnel, patients in nursing homes, the geriatric population, for patients with head or hand tremors and for those with limited or no access to proper healthcare. With the intent of using traditional material science principles to deconvolute material design while increasing relevance and efficacy, we developed a single application, cold-chain independent thixotropic drug delivery system. This can be easily applied into the ear as a liquid, then gels to deliver effective concentrations of antibiotics against bacterial strains commonly associated with OE. The system maintains thixotropic properties over several stress/no stress cycles, shows negligible swelling and temperature dependence, and does not impact the minimum inhibitory concentration or bactericidal effects of relevant antibiotics. Moreover, the thixogels are biocompatible and are well tolerated in the ear. This drug delivery system can readily translate into a user-friendly product, could improve compliance via a single application by the diagnosing health care provider, is expected to effectively treat OE and minimize the development of antibiotic resistance, infection recurrence or exacerbation.

Malignant Otitis External: Our Experience and Literature Review

BACKGROUND Malignant external otitis (MEO) is an invasive infection that can involve the external auditory canal and the skull base up to the contiguous soft tissues. Considering the changing face of MEO, we reviewed cases of MEO treated in our Ear Nose Throat (ENT) clinic - University Federico II of Naples between 2018 and 2019 to evaluate the current epidemiology of the condition and to assess the state of art on diagnosis, therapeutic and follow-up management in our patients. CASE REPORT We present the cases of three male patients with Type 2 diabetes mellitus who complained of long-lasting otorrhea and pain, with clinical suspicion of MEO. In all cases, ear swab was positive for Pseudomonas aeruginosa. All our patients received a 6-week course of intravenous ciprofloxacin, piperacillin, and tazobactam, with rapid clinical symptoms improvement and complete recovery at 1-year follow-up. CONCLUSIONS MEO is difficult to treat due to the lack of standardized care guidelines. Patients with MEO often present with severe otalgia, edema, otorrhea, and facial nerve paralysis. Clinicians must suspect MEO in elderly diabetic and immunocompromised patients with persistent otalgia after external otitis. Imaging (computed tomography and magnetic resonance imaging) can play synergistic roles in the management of MEO. To evaluate eradication of the disease, clinicians have to assess clinical symptoms and signs as well as radiological imaging and inflammatory markers.

Necrotising otitis externa: A single centre experience

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.

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Necrotising otitis externa has a variable clinical presentation and a relatively high rate of complications.

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The patients were mainly diabetics or aged more than 65 years old.

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The main pathogen isolated was Pseudomonas aeruginosa.

•

A higher median erythrocyte sedimentation rate was associated with fungal infections.

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

BACKGROUND

Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline.

OBJECTIVE

This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management.

METHODS

A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review.

RESULTS

Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately.

CONCLUSION

This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa

OBJECTIVES

To determine independent risk factors for 30-day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.

METHODS

Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013-2014). Overall and disease-specific complication and mortality data were analyzed using chi-squared and multivariate analysis.

RESULTS

There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio [OR] 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65-79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.

CONCLUSIONS

Thirty-day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2220-2228, 2020.

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.

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.

Cotton bud in external ear canal causing necrotising otitis externa and subdural abscess

Necrotising otitis externa (NOE) is an infection originating in the soft tissues of the external auditory canal (EAC) spreading to the surrounding bone and rarely causing intracranial complications. It is usually caused by Pseudomonas aeruginosa and has historically occurred in elderly patients with diabetes or immunodeficiency. EAC foreign body is a risk factor for otitis externa but has not been described in NOE. A healthy 31-year-old man presented with new-onset seizures and worsening left-sided otalgia and otorrhoea. Brain imaging revealed left temporal subdural abscesses superior to the petrous bone. A retained cotton bud was identified in the left EAC, along with osseocartilaginous junction and mastoid granulation tissue. The foreign body was removed; a cortical mastoidectomy performed and intravenous antibiotic administered. At 10 weeks, the patient remained well, with no neurological deficit and no residual ear symptoms, and CT demonstrated complete resolution of the intracranial abscesses.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database

OBJECTIVE

To characterize factors that affect outcomes for patients with malignant otitis externa (MOE).

METHODS

Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed.

RESULTS

A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41).

CONCLUSIONS

This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.

Publishing Trends in Otology and Neurotology

OBJECTIVES

1) Describe publishing trends for otologic/neurotologic disorders over a 35-year span. 2) Compare trends in publishing with disease prevalence. 3) Evaluate changes in topic and journal specific ranking scores over time.

METHODS

PubMed searches were performed on 35 otologic/neurotologic disorders using medical subject headings (MeSH) terms from 1980 to 2015. Searches were limited in scope to the English language. A Mann-Kendall trend analysis evaluated changes in publication frequency as a discrete variable while correcting for total number of articles published per year. Scopus was used to identify SCImago Country and Journal Rank (SJR) indicator scores and weighted-averages used to calculate changes over time.

RESULTS

The total number of publications on the 35 topics increased from 853 in 1980 to a peak of 3,068 in 2013. Otitis media (τ = -0.799, p < 0.001) and Menière's disease (τ = -0.724, p < 0.001) showed strong decreasing publication trends. Temporal bone encephaloceles (τ = 0.743, p < 0.001) and cochlear implants (τ = 0.740, p < 0.001) showed strong increasing publication trends. Rapid rise in publications on superior canal dehiscence and vestibular migraine illustrate novel diagnoses. The weighted-average SJR score increased from 0.816 in 2000 to 1.160 in 2015 (p < 0.001).

CONCLUSION

This study displays trends in the literature over the past 35 years that are often inconsistent with common disorders seen by otologists/neurotologists. Certain diagnoses that are currently being researched less commonly continue to impact patients with the same regularity. Quality of otologic/neurotologic literature has become more reputable with regards to SJR scores.

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.

A Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis: A Large Cohort in Tehran, Iran

AIMS

High rates of negative microbiologic test results highlight the potential role of empiric antimicrobial agents in management of malignant otitis externa (MOE). This study investigates the clinical presentation, laboratory findings, and response to empiric treatment in a large group of patients admitted to a tertiary academic hospital in Tehran, Iran.

METHODS AND MATERIALS

We recruited 224 patients diagnosed with MOE in a prospective observation from 2009 through 2015. All patients received a 2-agent antibacterial regimen at baseline (phase I). Patients with no improvement within 10 days and/or nonresponders to a second course of antibacterials were switched to antifungals (phase II). Response to treatment was observed and documented in both groups.

RESULTS

All patients had physical symptoms for more than 12 weeks before admission. In total, 127 patients responded well to antibacterials. Eighty-seven out of 97 patients who were switched to antifungals had complete response to treatment; patients in the latter group had significantly higher A1C levels at baseline.

CONCLUSION

Our findings provide evidence to develop clinical guidelines that accelerate diagnosis and treatment of MOE to improve patient outcomes.