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Kaminer BM, El-Saied S, Lasry B, Kaplan DM. Diagnostic accuracy of eosinophil-to-lymphocyte ratio and eosinophil-to-neutrophil ratio as biomarkers for differentiating between fungal and bacterial infection in necrotising otitis externa. Clin Otolaryngol 2024; 49:343-348. [PMID: 38263617 DOI: 10.1111/coa.14142] [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: 07/15/2023] [Revised: 11/27/2023] [Accepted: 12/17/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Necrotizing otitis externa (NOE) is a serious, progressive, and potentially life-threatening infection of the external auditory canal, affecting soft tissue and bone. The most common organism causing NOE is Pseudomonas Aeruginosa and less common are Fungal infections. When managing a patient with NOE, a culture is taken from the EAC in order to tailor the appropriate antimicrobial treatment, however commonly, the culture is sterile. Inflammation biomarkers may be used as adjuncts to inform on the differential diagnosis and as prognostic markers. AIM To characterize and compare values and ratios of components of the complete blood count (CBC) at admission, at patients with positive swab culture. METHODS A retrospective study of NOE patients was conducted. We included all patients admitted between the years 2001-2023, for whom a culture swab tested positive. We compared CBC findings at hospitalization between bacteria and fungi-positive culture patients. RESULTS Eosinophils-to-Neutrophils Ratio (ENR) was significantly lower in the fungal group compared to the bacterial group 0.023 ± 0.02 and 0.04 ± 0.03, respectively (p-value = 0.025). Eosinophils-to-Leukocyte Ratio (ELR) was significantly lower in the fungal group compared to the bacterial group 0.058 ± 0.04 and 0.12 ± 0.1 respectively (p-value = 0.009). For definition of ELR ≤ 0.1 we found that, sensitivity was 88% (95%CI = 0.679-0.979) and NPV 90% (95%CI = 0.709-0.982). For definition of ENR ≤ 0.03 sensitivity was 88% (95%CI = 0.679-0.979) and NPV 88% (95%CI = 0.679-0.979). CONCLUSION Lower values of ELR and ENR in patients with NOE are associated with fungal infection and can serve as a tool in adjusting an appropriate antimicrobial therapy in cases of sterile or when no culture is available.
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Affiliation(s)
- Benyamin M Kaminer
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Sabri El-Saied
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Batel Lasry
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Daniel M Kaplan
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
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Krawiec E, Brenet E, Truong F, Nguyen Y, Papthanassiou D, Labrousse M, Dubernard X. Epidemiology and risk factors for extension of necrotizing otitis externa. Eur Arch Otorhinolaryngol 2024; 281:2383-2394. [PMID: 38499694 DOI: 10.1007/s00405-024-08549-5] [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: 11/30/2023] [Accepted: 02/12/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension? METHODS French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone. RESULTS Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%). CONCLUSION Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.
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Affiliation(s)
- Elise Krawiec
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Esteban Brenet
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - France Truong
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Yohan Nguyen
- Department of Internal Medicine, Infectious Diseases and Clinical Immunology, University Hospital of Reims, Reims, France
| | | | - Marc Labrousse
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Xavier Dubernard
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France.
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Lodhi S, Timms S, Stapleton E. A systematic review of antimicrobial treatment regimens and their outcomes in necrotising otitis externa. J Laryngol Otol 2024; 138:120-129. [PMID: 37767726 DOI: 10.1017/s0022215123001664] [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] [Indexed: 09/29/2023]
Abstract
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.
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Affiliation(s)
- Sirat Lodhi
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Sara Timms
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Emma Stapleton
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
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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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McCarty Walsh E, Hanson MB. Fungal Infections of the External Auditory Canal and Emerging Pathogens. Otolaryngol Clin North Am 2023; 56:909-918. [PMID: 37553272 DOI: 10.1016/j.otc.2023.06.010] [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] [Indexed: 08/10/2023]
Abstract
Fungal infections of the external auditory canal can range from common (otomycosis) to life threatening (necrotizing otitis externa). Proper identification of fungal pathogens is necessary to guide appropriate therapy, and a high index of suspicion for fungal causes of ear canal disease is critical. Fungal pathogens may be an especially important cause of ear canal disease in certain populations, including patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients. Opportunistic fungal infections of the ear canal are an emerging concern.
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Affiliation(s)
- Erika McCarty Walsh
- Department of Otolaryngology, Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Matthew B Hanson
- Department of Otolaryngology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Hamiter M, Amorosa V, Belden K, Gidley PW, Mohan S, Perry B, Kim AH. Skull Base Osteomyelitis: Historical Perspective, Diagnosis and Management Update. Otolaryngol Clin North Am 2023; 56:987-1001. [PMID: 37479637 DOI: 10.1016/j.otc.2023.06.004] [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] [Indexed: 07/23/2023]
Abstract
SBO is a life-threatening disease that requires a high index of suspicion based on these patients complex underlying medical co-morbidities and clinician's acumen. Once a diagnosis is made, is it critical to communicate and work closely with other multidisciplinary teams (neuroradiology for appropriate choice of imaging study and interpretation; infectious disease for appropriate medical treatment and duration; internist to properly manage their underlying medical co-morbidities). Despite advances in imaging, the diagnosis is first made based on clinical judgment, appropriate culture, and tissue biopsy.
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Affiliation(s)
- Mickie Hamiter
- Department of Otolaryngology, Columbia University Irving Medical Center, New York, NY, USA
| | - Valerianna Amorosa
- Module E, First floor, Corporal Michael J. Crescenz VA Medical Center, University and Woodlawn Avenue, Philadelphia, PA 19104, USA
| | - Katherine Belden
- Division of Infectious Diseases, Thomas Jefferson University Hospital, 1101 Market Street, Suite 2720, Philadelphia, PA 19107, USA
| | - Paul W Gidley
- Department of Head and Neck Surgery, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1445, Houston, TX 77030, USA
| | - Suyash Mohan
- Department of Radiology, 219 Dulles Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19004, USA
| | - Brian Perry
- Department of OTO-HNS, UT Health San Antonio, Joe R. and Teresa Lozano Long School of Medicine, 7703 Floyd Curl Drive, MC 7777, San Antonio, TX 78229-3900, USA
| | - Ana H Kim
- Department of Otolaryngology, Columbia University Irving Medical Center, New York, NY, USA.
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Pugliese G, Maccari A, Felisati E, Felisati G, Giudici L, Rapolla C, Pisani A, Saibene AM. Are artificial intelligence large language models a reliable tool for difficult differential diagnosis? An a posteriori analysis of a peculiar case of necrotizing otitis externa. Clin Case Rep 2023; 11:e7933. [PMID: 37736475 PMCID: PMC10509342 DOI: 10.1002/ccr3.7933] [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: 06/22/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
Key Clinical Message Large language models have made artificial intelligence readily available to the general public and potentially have a role in healthcare; however, their use in difficult differential diagnosis is still limited, as demonstrated by a case of necrotizing otitis externa. Abstract This case report presents a peculiar case of necrotizing otitis externa (NOE) with skull base involvement which proved diagnostically challenging. The initial patient presentation and the imaging performed on the 78-year-old patient suggested a neoplastic rhinopharyngeal lesion and only after several unsuccessful biopsies the patient was transferred to our unit. Upon re-evaluation of the clinical picture, a clinical hypothesis of NOE with skull base erosion was made and confirmed by identifying Pseudomonas aeruginosa in biopsy specimens of skull base bone and external auditory canal skin. Upon diagnosis confirmation, the patient was treated with culture-oriented long-term antibiotics with complete resolution of the disease. Given the complex clinical presentation, we chose to submit a posteriori this NOE case to two large language models (LLM) to test their ability to handle difficult differential diagnoses. LLMs are easily approachable artificial intelligence tools that enable human-like interaction with the user relying upon large information databases for analyzing queries. The LLMs of choice were ChatGPT-3 and ChatGPT-4 and they were requested to analyze the case being provided with only objective clinical and imaging data.
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Affiliation(s)
- Giorgia Pugliese
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Alberto Maccari
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Elena Felisati
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Giovanni Felisati
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Leonardo Giudici
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Chiara Rapolla
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Antonia Pisani
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Alberto Maria Saibene
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
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