A population‐based time trend study in the incidence of malignant otitis externa

Skull Base Osteomyelitis- Marauders of the Skull

Skull base osteomyelitis is a vicious infection of temporal bone associated with very high morbidity and mortality. But few studies have been undertaken recently for eliciting its increasing incidence. Hence this study aims to describe the clinical profile of skull base osteomyelitis and changes noted in the post-covid period, and encourage a uniform treatment policy globally. This descriptive study was conducted among 140 patients diagnosed with skull base osteomyelitis. Data was collected using semi-structured proforma, HRCT temporal bone findings, microbiological reports, histopathology of granulation tissue, ESR and House-Brackmann grading. Male patients in 61-70 age group were most commonly affected and all patients had uncontrolled diabetes mellitus, usually presenting with nocturnal otalgia, ear canal granulation and cranial nerve palsy. Pseudomonas aeruginosa was the most common isolate followed by Staphylococcus aureus. Among fungal pathogens, candida albicans were the most common. 29.3% patients had extensive disease according to Thakar et al. staging and on follow up, 43.75% patients showed a satisfactory response. Coronary artery disease and cerebrovascular accidents were the leading cause of death. More atypical organisms, extensive disease and changes in antibiotic sensitivity were noted in the post-covid period. Prolonged treatment with culture sensitive antibiotic is the main stay of treatment. A uniform treatment guideline is needed for proper management of such patients. Level of Evidence 4.

Exploring Suspected Diagnoses in Elderly Patients: A Case Study of Potential Necrotizing Otitis Externa

Necrotizing otitis externa (NOE) is a rare invasive infection affecting the EAC and the base of the skull. This condition is more prevalent in the elderly, diabetics, and immunocompromised individuals, often attributed to the bacterium Pseudomonas aeruginosa. In this case report, we present the clinical scenario of a 90-year-old woman with a history of diabetes and epilepsy. Initially admitted with acute pyelonephritis, fever, and prostration, she subsequently developed left facial paralysis during treatment. Cranial computed tomography (CT) revealed inflammation in the middle ear and bone erosion of the facial nerve canal. The examination by the Department of Ear, Nose, and Throat (ENT) describes that NOE would be the most likely diagnosis. Given the patient's comorbidities and the severity of the disease, the treatment was initiated empirically and later adjusted based on the culture and sensitivity results with ceftazidime. NOE is a critical condition requiring early diagnosis and interdisciplinary collaboration due to the associated risk of complications. Adequate glycemic control is imperative, and the judicious use of antibiotics is crucial in light of escalating resistance.

Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research

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.

Trends and Outcomes of Fungal Temporal Bone Osteomyelitis: A Scoping Review

INTRODUCTION

Temporal bone osteomyelitis is an invasive infection most often caused by bacteria and associated with high mortality. Fungal etiologies are rare and little is known of the predictors of disease severity and outcomes in fungal temporal bone osteomyelitis.

MATERIALS AND METHODS

A scoping review was performed to determine what is known from the literature on how clinical, diagnostic, and treatment characteristics relate to patient outcomes in fungal temporal bone osteomyelitis. Using PRISMA guidelines, three databases were searched to identify all published cases of fungal temporal bone osteomyelitis. Data were extracted from each study, including clinical, diagnostic, and treatment characteristics, and outcomes.

RESULTS

Sixty-eight studies comprising 74 individual cases of fungal temporal bone osteomyelitis were included. All studies were case reports. There were high rates of diabetes, facial nerve palsy, infectious complications, and need for surgical intervention, as well as a significant delay in the evaluation and diagnosis of fungal temporal bone osteomyelitis. Disease recovery was greater in patients presenting with otorrhea, comorbid diabetes, and in those without facial nerve palsy.

DISCUSSION

Many of the defining characteristics of fungal temporal bone osteomyelitis remain unknown, and future reports should focus on determining factors that improve timely diagnosis and treatment of fungal TBO in addition to identifying prognostic indicators for outcomes and survival.

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.

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.

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.