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

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.

UK consensus definitions for necrotising otitis externa: a Delphi study

OBJECTIVE

To establish consensus definitions for necrotising otitis externa (NOE) to facilitate the diagnosis and exclusion of NOE in clinical practice and expedite future high-quality study of this neglected condition.

DESIGN

The work comprised of a systematic review of the literature, five iterative rounds of consultation via a Delphi process and open discussion within the collaborative. An expert panel analysed the results to produce the final outputs which were shared with and endorsed by national specialty bodies.

SETTING

Secondary care in the UK.

PARTICIPANTS

UK clinical specialists practising in infection, ear nose and throat (ENT) surgery or radiology.

MAIN OUTCOME MEASURES

Definitions and statements meeting the following criteria were accepted: (a) minimum of 70% of respondents in agreement or strong agreement with a definition/statement AND (b) <15% of respondents in disagreement or strong disagreement with a definition/statement.

RESULTS

Seventy-four UK clinicians specialising in ENT, Infection and Radiology with a special interest in NOE took part in the work which was undertaken between 2019 and 2021. The minimum response rate for a Round was 76%. Consensus criteria for all proposed case definitions, outcome definitions and consensus statements were met in the fifth round.

CONCLUSIONS

This work distills the clinical opinion of a large group of multidisciplinary specialists from across the UK to create practical definitions and statements to support clinical practice and research for NOE. This is the first step in an iterative process. Further work will seek to validate and test these definitions and inform their evolution.

The Use of 99mTc-Mononuclear Leukocyte Scintigraphy for Necrotizing External Otitis Diagnosis

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.

Necrotizing Otitis Concealing Carcinomas of the External Auditory Canal

External auditory canal Carcinomas are rare and aggressive tumors and their prognosis depends on early diagnosis. Their clinical similarity to necrotizing otitis is a source of error and therefore of diagnostic delay. Hence the interest of our study which consists in providing ENT specialists and all practitioners with the necessary clinical, evolutionary, radiological, biological and histological elements to avoid diagnostic errors. This is a retrospective study of all patients who were hospitalized for necrotizing otitis in the department of otolaryngology of the hospital of specialties of Rabat spread over a period of 5 years. All patients received an admission CT scan, biological tests, bacteriological sampling and biopsy. As well as initial parenteral antibiotic therapy and surgery for incidentally discovered EAC carcinomas. Clinically, all patients had otalgia and granulation tissue on otoscopic examination under the microscope. 50% had otorrhea. Pseudomonas aeruginosa was isolated in 50% of the cases, staphylococcus aureus in 25% and sterile culture in 25%. From the first biopsy, the diagnosis of tumor was retained in 6/10 patients. A second biopsy was performed in patients who did not show improvement and had a sterile culture. This one allowed the diagnosis in 4 other patients. All our patients had a surgical indication and were operated and then irradiated. The survival at 5 years was 50%. Biopsy must be systematic for every patient hospitalize for necrotizing otitis. Without hesitating to do it again each time the evolution is not good and the culture is sterile.

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.

Diagnostic approach to patients at risk of otogenic skull base osteomyelitis

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.

Necrotising Otitis Externa Antibiotic therapy complications: A retrospective cohort analysis

NOE is a rare but life-threatening condition. Treatment is long-term intravenous antibiotics. However, there is no evidence on the complications of antibiotic treatment in this complex cohort of patients In our study, patients on average are treated with two different antibiotic regimes 63% of these changes in regimen are due to direct adverse effects from treatment including drug intolerance and lack of significant clinical response leading to deterioration and morbid complications Patients requiring multiple antibiotic regimes have a statistically longer duration of treatment. These adverse effects appear to occur more frequently in patients with additional comorbidities. This novel data provides information clinicians can use when initiating treatment for NOE and counsel patients appropriately.

P08 The quality of life and cost benefits of domiciliary 24-hour piperacillin/tazobactam 13.5 g infusion in patients with necrotizing otitis externa

Background

The incidence of necrotizing otitis externa (NOE) is increasing with the rise in the population who are elderly or immunocompromised. Currently there is no consensus on an antibiotic regimen for NOE but in a recent survey of otolaryngologists, 90% recommended using IV antibiotics.1,2 An initial 6 week period of IV antibiotics such as piperacillin/tazobactam has been recommended, this necessitated a prolonged hospital stay in patients who could be managed at home. To enable domiciliary treatment, a patient pathway was set-up, a ‘mid-line’ inserted and once clinically well (after 0–10 days in hospital) home antibiotic treatment was commenced.

Objectives

To evaluate the patient satisfaction, safety and cost benefit of using 6 weeks of domiciliary piperacillin/tazobactam 13.5 g administered with infusion pump in patients with NOE.

Methods

Since September 2017 to present, 11 patients (9 males, 2 females aged 52–91 years) received domiciliary IV antibiotics for NOE, patients completed a patient satisfaction questionnaire [Glasgow Benefit Inventory (GBI), a validated questionnaire that is used to assess the impact of any clinical intervention]. The cost of this service was compared with the traditional 6 week stay in hospital for IV antibiotic therapy. Patients were only asked to complete the GBI to evaluate a recognized treatment.

Results

The GBI scale ranges from −100 (maximal negative benefit) to 0 (no benefit), to +100 (maximal benefit). Table 1 demonstrates that domiciliary IV antibiotics have a positive impact on total and general health but the low scores for social and physical health reflect worsening of quality of life in patients with NOE. All patients expressed they preferred being at home rather than being in hospital. 6 weeks inpatient care (at £250 per night) equates to £10 500 per patient. Piperacillin/tazobactam 4.5 g injection, costing £7.85 per ampoule, given thrice daily for 6 weeks costs £989. Domiciliary treatment using piperacillin/tazobactam 13.5 g infusion device is £98.16 daily, 6 weeks antibiotic costs £4122 per patient. A domiciliary nurse visit is £120 equates to nursing costs of £5040 for antibiotic given by infusion. Domiciliary potentially saves £2327 per patient.

Conclusions

Although studies have assessed community IV antibiotic service;3 this study albeit with limited patient numbers is the first evaluating patient satisfaction and cost benefit of domiciliary antibiotics in patients with NOE. All patients preferred to be treated at home with no safety issues raised. There is a potential saving of £2347 per patient with domiciliary rather than in-patient treatment as well as ‘freeing-up’ beds for other patients requiring admission.

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.

Denosumab and bisphosphonate associated bilateral osteonecrosis of the external auditory canal

We present a case of non-surgically managed bilateral osteonecrosis of the external auditory canal with a history of long-term medical therapy for osteoporosis. A 79-year-old woman with severe osteoporosis and destructive osteoarthritis received >10 years of once weekly bisphosphonate therapy before switching to denosumab. Four months later, the patient presented with bilateral loss of hearing and right-sided otalgia. Necrotising otitis externa, cholesteatoma and malignancy were considered but with histology, microbiological and CT assessment, bilateral osteonecrosis of the external auditory canal was diagnosed. Surgical debridement with canalplasty was avoided due to our patient's comorbidities. Treatment continued for 5 months with regular aural toilet, Terra-Cortril ointment and bismuth-iodine-paraffin paste packing. At 1-year follow-up, bilateral external auditory canals were completely re-epithelialised with no pain or affected hearing. We report the first case of bilateral osteonecrosis of the external auditory canal associated with denosumab and bisphosphonates with successful conservative management.

Diagnosing necrotizing external otitis on CT and MRI: assessment of pattern of extension

BACKGROUND AND PURPOSE

Necrotizing external otitis (NEO) is a serious complication of external otitis. NEO can be classified according to-anterior, medial, posterior, intracranial, and contralateral-extension patterns. Currently there is no consensus on the optimal imaging modality for the identification of disease extension. This study compares NEO extension patterns on MR and CT to evaluate diagnostic comparability.

METHODS

Patients who received a CT and MR within a 3-month interval were retrospectively examined. Involvement of subsites and subsequent spreading patterns were assessed on both modalities by a radiologist in training and by a senior head and neck radiologist. The prevalence of extension patterns on CT and MR were calculated and compared.

RESULTS

All 21 included NEO cases showed an anterior extension pattern on CT and MR. Contrary to MR, medial extension was not recognized on CT in two out of six patients, and intracranial extension in five out of eight patients. The posterior extension pattern was not recognized on MR. Overall, single anterior extension pattern (62%) is more prevalent than multiple extension patterns (38%).

CONCLUSION

All anterior NEO extension pattern were identified on CT as well as MR. However, the medial and intracranial spreading patterns as seen on MR could only be identified on CT in a small number of patients. The posterior spreading pattern can be overlooked on MR. Thus, CT and MR are complimentary for the initial diagnosis and work-up of NEO as to correctly delineate disease extent through the skull base.

Skull Base Osteomyelitis: A Comprehensive Imaging Review

Skull base osteomyelitis is a relatively rare condition, generally occurring as a complication of advanced otologic or sinus infection in immunocompromised patients. Skull base osteomyelitis is generally divided into 2 broad categories: typical and atypical. Typical skull base osteomyelitis occurs secondary to uncontrolled infection of the temporal bone region, most often from necrotizing external otitis caused by Pseudomonas aeruginosa in a patient with diabetes. Atypical skull base osteomyelitis occurs in the absence of obvious temporal bone infection or external auditory canal infection. It may be secondary to advanced sinusitis or deep face infection or might occur in the absence of a known local source of infection. Atypical skull base osteomyelitis preferentially affects the central skull base and can be caused by bacterial or fungal infections. Clinically, typical skull base osteomyelitis presents with signs and symptoms of otitis externa or other temporal bone infection. Both typical and atypical forms can produce nonspecific symptoms including headache and fever, and progress to cranial neuropathies and meningitis. Early diagnosis can be difficult both clinically and radiologically, and the diagnosis is often delayed. Radiologic evaluation plays a critical role in the diagnosis of skull base osteomyelitis, with CT and MR imaging serving complementary roles. CT best demonstrates cortical and trabecular destruction of bone. MR imaging is best for determining the overall extent of disease and best demonstrates involvement of marrow space and extraosseous soft tissue. Nuclear medicine studies can also be contributory to diagnosis and follow-up. The goal of this article was to review the basic pathophysiology, clinical findings, and key radiologic features of skull base osteomyelitis.

In the evaluation of patients with skull base osteomyelitis, does 18F-FDG PET CT have a role?

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.

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.

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.

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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.

Malignant Otitis Externa: Causes for Various Treatment Responses

OBJECTIVES

Malignant (necrotizing) otitis externa (MOE) is an aggressive form of skin inflammation of the external ear with a tendency to spread infection to the temporal bone. The study aimed to evaluate a causal relationship between treatment responses and clinical features in patients with MOE.

MATERIALS AND METHODS

In a retrospective, descriptive section study, the database was analyzed between January 2008 and December 2018 in our department, all patients with diagnosed MOE were identified.

RESULTS

A total of 30 patients were evaluated, of which 27 men and 3 women. The youngest patient was 52 years old while he was eldest 88 years, (mean-71 years old). As the most common comorbidity, diabetes mellitus was found in 23 (76%) subjects. Median duration of symptoms was about 3 months. The most common isolated pathogen was Pseudomonas aeruginosa (47%). Patients with facial nerve palsy and erosion of temporal bone find on computerized tomography affect prolonged stationary treatment (Mean, SD 29.2±8.5 and 26,7±11.6 days), while 80% of patients with facial nerve palsy had recurrence of disease (p=0.005) with mean duration of clinical remission of 60±17.3 days. Overall length of treatment is also increased in the presence of comorbidities as well as in patients with cranial nerve involvement.

CONCLUSION

Patients with cranial nerve involvement, erosion of temporal bone and presence of comorbidities affect prolonged treatment and adverse prognosis. Early diagnosis and initiation of aggressive therapy are essential for stopping the further spread of the disease and prevention of serious complications.

Skull base osteomyelitis secondary to Scedosporium apiospermum infection

Scedosporium apiospermum is a common environmental mold which is increasingly reported in the literature as a cause of infection, particularly in the immunocompromised patient population. We present a case of malignant otitis externa due to S apiospermum, complicated by spread of infection causing skull base osteomyelitis, internal carotid artery vasculitis and subsequent stroke. Despite the multiple complications encountered, prompt diagnosis and initiation of appropriate antifungal treatment resulted in patient survival. Multiple imaging modalities were used to aid the establishment of the diagnosis in this complex case and highlight the radiological findings associated with skull base osteomyelitis and its possible complications.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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