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Go BC, Wong K, Eliades SJ, Brant JA, Bigelow DC, Ruckenstein MJ, Hwa TP. Reassessing the Utility of Surgical Intervention for Skull Base Osteomyelitis: A 16-Year Experience. Otolaryngol Head Neck Surg 2024; 171:197-204. [PMID: 38344847 DOI: 10.1002/ohn.661] [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: 11/13/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE The role of surgery in lateral skull base osteomyelitis (SBO) is controversial. Surgical intervention is often requested by consulting services in the interest of additional culture data to inform medical management. However, whether surgery alters subsequent antibiotic treatment or modifies disease outcome remains unknown. The aim of this study was to investigate the role of surgical intervention in the treatment of SBO by (1) comparing nonsurgical and surgical culture data and (2) assessing clinical outcomes and treatment course following surgical intervention. STUDY DESIGN Retrospective. SETTING Tertiary care center. METHODS The electronic record was queried for all patients with SBO who presented to a single institution over a 16-year period (2007-2023). Information recorded included history and exam, bedside and intraoperative culture data, antibiotic course, and disease outcomes. Primary outcome measures included change in medical management based on intraoperative cultures, recurrence rates, and mortality rates. RESULTS Forty patients (41 ears, average age 73 ± 13 years) met inclusion criteria. Out of 13 (32%) patients who underwent surgical intervention, one intraoperative culture changed the antibiotic course due to identification of resistance to the original antibiotic used. Surgery did not demonstrate a benefit in overall mortality (23% vs 18%, P = 0.36) or facial nerve function (33% vs 50%, P = 0.56) compared to medical management, and was associated with increased recurrence rates (54% vs 11%, P = 0.05). CONCLUSION Surgical cultures rarely changed antibiotic selection. Surgical debridement in treatment-refractory SBO was also not associated with improvement in recurrence or mortality rates, though this may reflect underlying differences in disease severity.
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Affiliation(s)
- Beatrice C Go
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Wong
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven J Eliades
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason A Brant
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Douglas C Bigelow
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tiffany P Hwa
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Faizal B, Abraham RM, Blessan M, Nair AS, Menon U, Pavithran J. Serum Galactomannan as a Minimally Invasive Diagnostic Tool for Fungal Skull Base Osteomyelitis. Indian J Otolaryngol Head Neck Surg 2024; 76:2583-2589. [PMID: 38883534 PMCID: PMC11169188 DOI: 10.1007/s12070-024-04563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/15/2024] [Indexed: 06/18/2024] Open
Abstract
Multidrug resistant strains and fungi add to treatment conundrums in skull base osteomyelitis (SBO). Deep tissue culture in these patients is challenging due to their advanced age and co-morbidities. Besides, fungal culture positivity is seen only in 60% of invasive aspergillosis. To determine the efficacy of a minimally invasive test-Serum Galactomannan (sGM)-for diagnosing fungal SBO. Prospective observational study. Thirty- three patients, clinically diagnosed with SBO were included in this study. Baseline ESR (Erythrocyte Sedimentation Rate), CRP (C- Reactive Protein), pain score, and sGM were noted for all patients. Antifungal Voriconazole was initiated on patients if the sGM values were more than 0.8. At the 12th week of treatment, all parameters were repeated and compared with the baseline values. A significant reduction was noted in ESR, CRP, and pain scores at the 12th week of treatment compared to the baseline values in patients with raised sGM values who were started on Voriconazole. For a culture-proven fungal skull base osteomyelitis with a cut-off value of sGM > / = 0.8, the obtained sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 81.82, 36.36, 39.13, 80 and 51.52% respectively. At a cut-off value of sGM > / = 01.6, the values of sensitivity/specificity, PPV, NPV and accuracy were 81.82/72.73%, 60%, 88.89% and 75.76%. Culture-negative patients in SBO with sGM value > 0.8 were more likely to be fungal SBO. An sGM cut-off of 1.6 was observed to give maximum accuracy for diagnosing fungal SBO.
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Affiliation(s)
- Bini Faizal
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Remita Mary Abraham
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Merlin Blessan
- Department of Internal Medicine, Infectious Diseases Division, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Anjali S Nair
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Unnikrishnan Menon
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Jayanty Pavithran
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
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Rocha LA, Costa T, Silva L, Veríssimo R. Exploring Suspected Diagnoses in Elderly Patients: A Case Study of Potential Necrotizing Otitis Externa. Cureus 2023; 15:e49801. [PMID: 38161550 PMCID: PMC10757833 DOI: 10.7759/cureus.49801] [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] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
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.
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Affiliation(s)
- Luís A Rocha
- Internal Medicine, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, PRT
| | - Tiago Costa
- Internal Medicine, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, PRT
| | - Luciana Silva
- Internal Medicine, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, PRT
| | - Rafaela Veríssimo
- Internal Medicine and Geriatrics, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, PRT
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Azeez TA, Adeagbo AK. The Association Between Malignant Otitis Externa and Diabetes Mellitus in Africa: A Systematic Review. Indian J Otolaryngol Head Neck Surg 2023; 75:3277-3287. [PMID: 37974885 PMCID: PMC10645783 DOI: 10.1007/s12070-023-03939-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/06/2023] [Indexed: 11/19/2023] Open
Abstract
Diabetes mellitus is one of the risk factors for malignant otitis externa. There are very few studies on the disease in Africa and there is a need to pool the prior studies to highlight the characteristics of the disease. The study type is a systematic review and the PRISMA guidelines were followed. Using the appropriate terms, relevant medical databases were systematically searched. Thirty-two studies met the eligibility criteria with a total sample size of 848, who were mainly elderly. Diabetes mellitus was present in 94% of the participants. Average duration of diabetes diagnosis in the participants was 12.4 years. The pooled HbA1c was 9.8%. The most common symptoms were otalgia (96.1%), otorrhoea (75.8%) and hearing loss (56.1%). Pseudomonas was the most common isolate (72%). Fluoroquinolones and the 3rd-generation cephalosporins were the preferred antibiotics. The pooled cure rate from antimicrobial usage was 76.2%. In addition to medications, 24.6% of the affected individuals required debridement. About 1.6% of the participants died from malignant otitis externa. Malignant otitis externa is associated with poorly controlled diabetes. Pseudomonas is the most common cause and a significant proportion gets cured with prolonged antibiotherapy.
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Affiliation(s)
- Taoreed Adegoke Azeez
- Department of Medicine, Reddington Multi-Specialist Hospital, 12, Idowu Martins Street, Victoria Island, Lagos, Nigeria
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5
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Costa MB, Onishi ET. Necrotizing Otitis Externa: A Proposal for Diagnostic and Therapeutic Approach. Int Arch Otorhinolaryngol 2023; 27:e706-e712. [PMID: 37876706 PMCID: PMC10593509 DOI: 10.1055/s-0042-1758719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/04/2022] [Indexed: 10/26/2023] Open
Abstract
Introduction Necrotizing otitis externa has a high impact on the quality of life of patients and has shown a significant increase in its incidence in recent years. There has been a change in the profile of affected patients and a lack of consensus on the management of these patients. Objective To develop a practical and effective care protocol to standardize the diagnostic and therapeutic management of necrotizing otitis externa. Methods A retrospective cohort study of necrotizing otitis externa patients between January 2015 and December 2020. Results There were 34 patients with two bilateral cases, totaling 36 ears. The mean age was 68.5, with a higher prevalence of males (76%). Diabetes was present in 97% of the samples. The involvement of cranial pairs was identified in 35% of the sample. Pseudomonas aeruginosa was the most frequent pathogen isolated, found in 50% of the cases. Among the cultures with bacterial agents isolated, 35% showed resistance to ciprofloxacin. The most frequent exam was computed tomography (94%). Hospital admission was indicated for 31 patients (91%), and ceftazidime was the most prescribed drug (35.5%). There were 11 recurrences (32%), and 12 patients (35%) had complications during treatment. Among the unfavorable outcomes, 12% persisted with some degree of peripheral facial paralysis, 6% maintained dysphagia, and 9% died of the disease. Conclusions The present study developed a diagnostic and therapeutic protocol for the effective management of necrotizing otitis externa. This protocol is a dynamic tool and should be revised and updated as new demands emerge during its implementation.
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Affiliation(s)
- Marília Batista Costa
- Department of Otorhinolaryngology - Head and Neck Surgery, Universidade Federal de São Paulo, Escola Paulista de Medicina, Sao Paulo, SP, Brazil
| | - Ektor Tsuneo Onishi
- Department of Otorhinolaryngology - Head and Neck Surgery, Universidade Federal de São Paulo, Escola Paulista de Medicina, Sao Paulo, SP, Brazil
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Owen E, Abrar R, Stapleton E. Patients' experience of necrotising otitis externa: a qualitative study. J Laryngol Otol 2023; 137:356-362. [PMID: 35343410 DOI: 10.1017/s0022215122000858] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- E Owen
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Abrar
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
| | - E Stapleton
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
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7
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Tsilivigkos C, Avramidis K, Ferekidis E, Doupis J. Malignant External Otitis: What the Diabetes Specialist Should Know-A Narrative Review. Diabetes Ther 2023; 14:629-638. [PMID: 36897495 PMCID: PMC10064349 DOI: 10.1007/s13300-023-01390-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
AIMS Malignant external otitis (MEO) is a special type of external otitis associated with extensive inflammation and osteomyelitis. It is believed to originate from the external auditory meatus and advance regionally to the soft tissues and the bone, eventually involving the skull base. Pseudomonas aeruginosa and diabetes mellitus are factors commonly involved in the pathogenesis of MEO. Although its treatment has changed considerably during the last decades, morbidity and mortality of the disease remain high. Our aim was to review basic aspects of MEO, a disease unknown until 1968, which attracts great interest among Ears, Nose and Throat (ENT), diabetes and infectious diseases specialists. METHODS AND RESULTS In this narrative review we mainly include relevant papers written in English or with an English abstract. We searched PubMed and Google Scholar, using the keywords malignant external otitis, malignant otitis externa, necrotizing external otitis, skull base osteomyelitis, diabetes mellitus and surgery up to July 2022. Some of the most recent articles, with specific references to earlier articles and a book reference regarding the pathophysiology, diagnosis and treatment of MEO and its relationship to diabetes mellitus, were included. CONCLUSION MEO is not an uncommon disease and is principally treated by ENT surgeons. Nevertheless, diabetes specialists should be aware of the disease presentation and management, since they will often encounter patients with undiagnosed MEO or will need to manage glucose levels in patients hospitalized with the disease.
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Affiliation(s)
- Christos Tsilivigkos
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece.
| | - Konstantinos Avramidis
- Second Department of Internal Medicine, Hippokration General Hospital, 15772, Athens, Greece
| | - Eleftherios Ferekidis
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - John Doupis
- Department of Internal Medicine and Diabetes, Salamis Naval and Veterans Hospital, Salamis Naval Base, 18900, Salamis Island, Greece
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8
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Zonnour A, Shahnazar R, Jamshidi A, Dabiri S, Saedi E, Emami H, Yazdani N. Cranial nerve palsy prevalence and associated factors in patients with malignant otitis externa. Laryngoscope Investig Otolaryngol 2023; 8:538-545. [PMID: 37090887 PMCID: PMC10116972 DOI: 10.1002/lio2.1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/29/2022] [Accepted: 02/19/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To identify the prevalence of cranial nerve (CN) palsy and its associated factors in malignant otitis externa (MOE). Methods In a retrospective study, records of MOE patients from 2011 to 2014 were reviewed. MOE and CN involvement were evaluated based on patient demographics, clinical, and paraclinical data. Results Overall, 119 MOE patients with a mean age of 65.9 ± 11.3 were included. 69.7% were male, and 63.0% had a history of diabetes. The most common symptoms and signs were otalgia (97.5%), otorrhea (44.5%), and ear canal erythema/edema (24.4%). Thirty-three patients (27.7%) had CN involvement. The facial nerve was mostly involved (26.1%). Skull base osteomyelitis (SBO) was present in 59 patients. When excluding patients younger than 30 and older than 80, age decade was correlated with CN palsy. 66.9% of patients with CN palsy and 65.6% without CN palsy were male, which was significantly different. The following factors were not significantly different between patients with and without CN palsy: Comorbidities, signs and symptoms, diagnostic delay, erythrocyte sedimentation rate level, fasting blood sugar, hemoglobin A1c level, antifungal therapy, hospitalization duration, and SBO on imaging. Tinnitus was correlated with SBO evidence on imaging (specificity: 96.7%). Conclusion CN involvement occurs in about three out of 10 MOE patients. Male gender and advanced age may be related to a higher incidence rate of CN palsy. Tinnitus can be a specific indicator of SBO. These findings could help in better decision-making for early interventions. Level of Evidence 4.
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Affiliation(s)
- Alireza Zonnour
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Reza Shahnazar
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Abolfazl Jamshidi
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Sasan Dabiri
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Elham Saedi
- Department of Internal Medicine (Neurology Division) Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Hamed Emami
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Nasrin Yazdani
- Otorhinolaryngology Research Center, Department of Otorhinolaryngology‐Head and Neck Surgery Amir Alam Hospital, Tehran University of Medical Sciences Tehran Iran
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Freeman MH, Perkins EL, Tawfik KO, O'Malley MR, Labadie RF, Haynes DS, Bennett ML. Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management. Laryngoscope 2023; 133:179-183. [PMID: 35546515 DOI: 10.1002/lary.30161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 02/02/2023]
Abstract
TITLE Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management. OBJECTIVE To compare outcomes of surgical and nonsurgical management in cases of facial paresis secondary to skull base osteomyelitis. METHODS A 14 patients presenting with skull base osteomyelitis complicated by facial nerve paresis at a single tertiary referral center from 2009 to 2019 were retrospectively reviewed. Patients were treated with medical therapy with or without surgical intervention, consisting of mastoidectomy and debridement with or without facial nerve decompression. House-Brackmann (HB) Grade was the main outcome measure. RESULTS A 14 patients (average age 68 years, range 58-82 years, 71% male) were analyzed, with 5 undergoing facial nerve decompression (36%), 5 undergoing mastoidectomy without facial nerve decompression (36%), and 4 undergoing medical management alone (28%). Of the 4 patients who underwent medical therapy alone, none experienced significant improvement in facial function. Of the 5 patients who underwent facial nerve decompression, 3 patients experienced improved facial function. Of the 5 patients who underwent mastoidectomy without decompression, 4 experienced improved facial function. There was no clear link between the severity of infection and the severity of facial paresis. When comparing HB score changes before and after treatment across groups, there was no statistically significant difference seen (p = 0.47). CONCLUSIONS Mastoidectomy and debridement with or without facial nerve decompression may improve facial nerve outcomes when compared to isolated medical management, although differences were not of statistical significance. The best facial nerve recoveries occurred in patients undergoing surgery within 14 days of the onset of paralysis. LEVEL OF EVIDENCE 4 - Case Series Laryngoscope, 133:179-183, 2023.
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Affiliation(s)
- Michael H Freeman
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth L Perkins
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kareem O Tawfik
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R O'Malley
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert F Labadie
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David S Haynes
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc L Bennett
- The Otology Group, Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Macias D, Jeong SS, Van Swol JM, Moore JD, Brennan EA, Raymond M, Nguyen SA, Rizk HG. Trends and Outcomes of Fungal Temporal Bone Osteomyelitis: A Scoping Review. Otol Neurotol 2022; 43:1095-1107. [PMID: 36351221 DOI: 10.1097/mao.0000000000003714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- David Macias
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina
| | - Seth S Jeong
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina
| | | | - Jeremy D Moore
- College of Medicine, Medical University of South Carolina
| | - Emily A Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, South Carolina
| | - Mallory Raymond
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina
| | - Shaun A Nguyen
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina
| | - Habib G Rizk
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina
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11
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CT findings in temporal bone sites in skull base osteomyelitis from malignant otitis externa. Eur Arch Otorhinolaryngol 2022; 280:2687-2694. [PMID: 36416973 DOI: 10.1007/s00405-022-07749-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify the earliest sites and spread patterns of bony erosions on high-resolution temporal bone computerized tomographic (HRTBCT) scans and conjugate the radiological findings with clinical/laboratory data for guiding the interpretation of CT images of skull base osteomyelitis (SBOM) from malignant otitis externa (MOE). STUDY DESIGN Retrospective and prospective medical records analysis. METHODS The medical records of all patients who presented to a referral medical center during 2015-2022 and initially diagnosed with SBOM. Radiological assessment of each sub-site was performed by 2 qualified neuro-radiologist, who were blind to the clinical data. RESULTS 33 patients were enrolled. All patients suffered edema and exudates of the external auditory canal (EAC). The most common osseous markers for SBOM were dehiscence or irregularity of the anterior EAC wall and temporomandibular joint (TMJ) medial wall (21/33, 64% patients, each), followed by a fistula from the TMJ to the EAC (20/33, 61% patients). Eustachian tube bony walls and condylar irregularity and/or dehiscence were as prevalent as 16/33, 48% of patients, each. EAC inferior and posterior walls of the EACs were irregular or dehiscent in patients with more advanced disease. CONCLUSIONS The high symptomatologic overlap between SBOM and other aural pathologies might cause diagnostic (and subsequent treatment) delay and result in dire complications. EAC edema and irregularity or dehiscence of the anterior EAC wall are the most common early CT findings associated with SBOM caused by MOE. LEVEL OF EVIDENCE: 4
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12
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Durojaiye OC, Slucka A, Kritsotakis EI. Retrospective analysis of outcomes of outpatient parenteral antimicrobial therapy (OPAT) for necrotising otitis externa. Eur J Clin Microbiol Infect Dis 2022; 41:941-949. [PMID: 35556187 DOI: 10.1007/s10096-022-04455-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/05/2022] [Indexed: 11/03/2022]
Abstract
Necrotising otitis externa (NOE) is an uncommon but life-threatening infection that requires prolonged systemic antimicrobial therapy. This study aims to identify factors associated with treatment response and outcome in patients with NOE treated through outpatient parenteral antimicrobial therapy (OPAT). We performed a retrospective analysis of patients with NOE treated over a 4-year period (January 2018-January 2022) at a tertiary referral hospital in Derbyshire, UK. We defined OPAT failure as unplanned readmission within 30 days of discontinuation of OPAT. Prolonged duration of therapy was defined as length of parenteral antimicrobial treatment of more than 8 weeks. A total of 46 cases of NOE were reviewed. OPAT failure and prolonged therapy were recorded in 9 (19.6%) and 23 (50.0%) episodes respectively. Facial nerve involvement (odds ratio [OR], 14.54; 95% confidence interval [CI], 2.76-76.60; p = 0.002), dementia (OR, 7.65; 95% CI, 1.23-47.46; p = 0.029), Charlson comorbidity score (OR, 1.41 per unit increase; 95% CI, 1.00-2.00; p = 0.049) and peak CRP level (OR, 1.03 per unit increase; 95% CI, 1.00-1.06; p = 0.027) were associated with increased risk of treatment failure. Facial nerve involvement (OR, 16.30; 95% CI, 2.60-102.31; p = 0.003) and peak CRP level (OR, 1.04; 95% CI, 1.01-1.07; p = 0.016) were also associated with an increased need for prolonged antimicrobial therapy. In addition, extent of disease (based on imaging findings) was linked to prolonged therapy (OR, 22.89; 95% CI, 3.62-144.76; p = 0.001). NOE could be effectively managed as outpatient via OPAT. However, vigorous antimicrobial treatment and close monitoring of patients with pre-existing comorbidities, facial nerve paralysis, extensive disease and markedly elevated inflammatory markers are essential to optimise clinical outcomes.
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Affiliation(s)
- Oyewole Chris Durojaiye
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK. .,Department of Microbiology, Royal Derby Hospital, Derby, DE22 3NE, UK.
| | - Augustinas Slucka
- Department of Pharmacist, Royal Derby Hospital, Derby, DE22 3NE, UK.,Present Address: NHS Sheffield Clinical Commissioning Group, Sheffield, S9 4EU, UK
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, 71003, Heraklion, Greece.,School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, S1 4DA, Sheffield, UK
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13
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Bigdeli R, Jabbour J, Noor A, Bradshaw K, North H, Singh N, Sritharan N. Cotton bud foreign body associated necrotising otitis externa – a case series and literature review. OTOLARYNGOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.xocr.2022.100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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14
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Emerging themes in necrotising otitis externa: a scoping review of the literature 2011-2020 and recommendations for future research. The Journal of Laryngology & Otology 2021; 136:575-581. [PMID: 34666847 DOI: 10.1017/s0022215121003030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Abstract
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.
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16
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Dwivedi R, Rasquinha M, Harwood R. Dysphagia due to necrotizing otitis externa. Age Ageing 2021; 50:1004-1005. [PMID: 33951146 DOI: 10.1093/ageing/afab034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Indexed: 11/13/2022] Open
Abstract
An 88-year-old man presented with delirium, and subsequently developed hoarseness and oropharyngeal dysphagia. This was due to skull-based osteomyelitis from necrotizing otitis externa (NOE), causing lower cranial nerve (X, XII) palsies and venous sinus thrombosis. Diagnosis was delayed as the patient reported no otalgia, had an almost normal looking external auditory canal and was not diabetic. He deteriorated and died despite intravenous antibiotics. We need a high index of suspicion for NOE and its complications in patients presenting with otolaryngeal symptoms.
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Affiliation(s)
| | | | - Rowan Harwood
- University of Nottingham School of Health Sciences, Nottingham, UK
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17
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Cho WS, Bonduelle Q, Ghasemi A, Baskaran V, O'Connor R, Shah J, Andrewartha F, Fergie N. Prognosticating patients with necrotising otitis externa based on response to treatment. Ann R Coll Surg Engl 2021; 103:285-290. [PMID: 33682472 DOI: 10.1308/rcsann.2020.7133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- W S Cho
- Nottingham University Hospitals NHS Trust, UK
| | - Q Bonduelle
- Nottingham University Hospitals NHS Trust, UK
| | - A Ghasemi
- Nottingham University Hospitals NHS Trust, UK
| | - V Baskaran
- Nottingham University Hospitals NHS Trust, UK
| | - R O'Connor
- Nottingham University Hospitals NHS Trust, UK
| | - J Shah
- Nottingham University Hospitals NHS Trust, UK
| | | | - N Fergie
- Nottingham University Hospitals NHS Trust, UK
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18
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Treviño González JL, Reyes Suárez LL, Hernández de León JE. Malignant otitis externa: An updated review. Am J Otolaryngol 2021; 42:102894. [PMID: 33429178 DOI: 10.1016/j.amjoto.2020.102894] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/27/2020] [Indexed: 11/18/2022]
Abstract
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.
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19
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Guimaraes GC, de Freitas PP, da Silva VAR, Castilho AM. Conservative management of petrous apex abscess and Gradenigo's syndrome in a diabetic patient: Case report and literature review. Clin Case Rep 2021; 9:742-746. [PMID: 33598237 PMCID: PMC7869396 DOI: 10.1002/ccr3.3625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022] Open
Abstract
The case reported evidences the possibility of nonsurgical treatment in patients with abscesses located in regions difficult to reach surgically due to surgical limitations or possible sequelae related to surgical procedure.
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20
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Devaraja K, Nayak DR. Malignant otitis externa with subsequent internal jugular vein thrombosis and hypoglossal palsy: a report and review of literature. J Otol 2020; 15:112-116. [PMID: 32884563 PMCID: PMC7451676 DOI: 10.1016/j.joto.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 11/29/2022] Open
Abstract
Inflammation of a part or whole of the temporal bone and surrounding soft tissue is termed as malignant otitis externa, which typically spreads to skull base to involve cranial nerves VII. Rarely can it also effect one or more of cranial nerves IX, X, XI, and XII. We present a case of malignant otitis externa which presented with symptomatic palsy of IX and XII nerves sparing the VII cranial nerve. The patient though later on had internal jugular vein thrombosis, which we presume is due to the involvement of the parapharyngeal space that prompted us to reconsider the diagnosis, and later on, to aggravate the therapy. With proper blood sugar control and appropriate long term antibiotics, not only that the patient is disease free at one year follow up, but the cranial nerve deficits also recovered. Apart from sharing the clinical and management details of this patient, we have reviewed the relevant literature in the discussion, which has shed some light onto some of the interesting facts about this condition and its prognosis.
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Affiliation(s)
- K Devaraja
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, 576104, India
| | - Dipak Ranjan Nayak
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, 576104, India
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21
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Hasnaoui M, Ben Mabrouk A, Chelli J, Larbi Ammari F, Lahmar R, Toumi A, Mighri K. Necrotising otitis externa: A single centre experience. J Otol 2020; 16:22-26. [PMID: 33505446 PMCID: PMC7814081 DOI: 10.1016/j.joto.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Abstract
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. Necrotising otitis externa has a variable clinical presentation and a relatively high rate of complications. The patients were mainly diabetics or aged more than 65 years old. The main pathogen isolated was Pseudomonas aeruginosa. A higher median erythrocyte sedimentation rate was associated with fungal infections.
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Affiliation(s)
- Mehdi Hasnaoui
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Asma Ben Mabrouk
- Department of Infectious Diseases, Fattouma Bourguiba Hospital, Monastir, 5000, Tunisia
| | - Jihene Chelli
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Fatma Larbi Ammari
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Rihab Lahmar
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
| | - Adnene Toumi
- Department of Infectious Diseases, Fattouma Bourguiba Hospital, Monastir, 5000, Tunisia
| | - Khalifa Mighri
- Department of Otolaryngology-Head and Neck Surgery, Tahar Sfar Hospital, Mahdia, 5100, Tunisia
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22
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Di Lullo AM, Russo C, Grimaldi G, Capriglione P, Cantone E, Del Vecchio W, Motta G, Iengo M, Elefante A, Cavaliere M. Skull Base Fungal Osteomyelitis: A Case Report and Review of the Literature. EAR, NOSE & THROAT JOURNAL 2020; 100:1089S-1094S. [PMID: 32584614 DOI: 10.1177/0145561320936006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Skull base osteomyelitis (SBO) is an invasive infection refractory to therapy, closely linked with malignant otitis externa (MOE). It is characterized by a mild clinical presentation that can delay cross-sectional imaging considered as the key to revealing it. Skull base osteomyelitis typically affects elderly diabetics and immunocompromised patients (>70 years). It most commonly has an otogenic origin due to an extension of MOE. The prognosis can be very poor without the administration of adequate and timely therapy at an early disease stage. Nowadays, Pseudomonas aeruginosa remains the most common pathogen associated with SBO. Fungi are a rare cause of MOE. This report documents a rare case of otogenic SBO caused by Candida parapsilosis in a diabetic patient, with persistent otologic symptoms as clinical onset and resistance to medical treatment. Fungal MOE has more subtle symptoms and is more aggressive than its bacterial counterpart. When MOE is resistant to antibacterial drugs, this should raise the suspicion of a fungal etiology of MOE. The current guidelines do not exhaustively describe the diagnosis, antifungal drugs of choice, and optimum duration of treatment. The description of these rare clinical cases should help with the multidisciplinary management of this disease in order to optimize the diagnosis and therapeutic protocol.
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Affiliation(s)
- Antonella M Di Lullo
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy.,CEINGE-Advanced Biotechnology, Naples, Italy
| | - Camilla Russo
- Department of Advance Biomedical Sciences, Neuroradiology Unit, University of Naples Federico II, Italy
| | - Giusy Grimaldi
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy
| | - Pasquale Capriglione
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy
| | - Elena Cantone
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy
| | - Walter Del Vecchio
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
| | - Gaetano Motta
- Department of Mental and Physical Health and Preventive Medicine, Otorhinolaryngology-Head and Neck Surgery Unit, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Maurizio Iengo
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy
| | - Andrea Elefante
- Department of Advance Biomedical Sciences, Neuroradiology Unit, University of Naples Federico II, Italy
| | - Michele Cavaliere
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Otorhinolaryngology-Head and Neck Surgery Unit, University of Naples Federico II, Italy
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23
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Prediction of skull base osteomyelitis in necrotising otitis externa with diffusion-weighted imaging. The Journal of Laryngology & Otology 2020; 134:404-408. [PMID: 32498734 DOI: 10.1017/s0022215120001073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To predict skull base osteomyelitis in patients with necrotising otitis externa using diffusion-weighted imaging. METHODS A retrospective analysis was conducted of 25 necrotising otitis externa patients with skull base osteomyelitis (n = 10) or without skull base involvement (n = 14) who underwent a single-shot diffusion-weighted imaging of the skull base. RESULTS The respective mean apparent diffusion coefficient values of the skull base, as determined by two reviewers, were 0.851 ± 0.15 and 0.841 ± 0.14 ×10-3mm2/s for the skull base osteomyelitis patients, and 1.065 ± 0.19 and 1.045 ± 0.20 ×10-3mm2/s for the necrotising otitis externa patients without skull base involvement. The difference in apparent diffusion coefficients between the groups was significant, for both reviewers (p = 0.008 and 0.012). The optimal threshold apparent diffusion coefficient for predicting skull base osteomyelitis in necrotising otitis externa patients was 0.945 ×10-3mm2/s and 0.915 ×10-3mm2/s, with an area under the curve of 0.825 and 0.800, accuracy of 87.5 and 83.3 per cent, sensitivity of 85.7 and 90.0 per cent, and specificity of 90.0 and 78.6 per cent, for each reviewer respectively. CONCLUSION Apparent diffusion coefficient is a non-invasive imaging parameter useful for predicting skull base osteomyelitis in necrotising otitis externa patients.
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24
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Arsovic N, Radivojevic N, Jesic S, Babac S, Cvorovic L, Dudvarski Z. Malignant Otitis Externa: Causes for Various Treatment Responses. J Int Adv Otol 2020; 16:98-103. [PMID: 32209516 PMCID: PMC7224427 DOI: 10.5152/iao.2020.7709] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/06/2019] [Accepted: 12/13/2019] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Nenad Arsovic
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Nemanja Radivojevic
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Snezana Jesic
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Snezana Babac
- Clinic of ENT, Clinical and Hospital Centre Zvezdara, Belgrade, Serbia
| | - Ljiljana Cvorovic
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Zoran Dudvarski
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia
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25
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Yang TH, Xirasagar S, Cheng YF, Wu CS, Kao YW, Shia BC, Lin HC. Malignant Otitis Externa is Associated with Diabetes: A Population-Based Case-Control Study. Ann Otol Rhinol Laryngol 2020; 129:585-590. [DOI: 10.1177/0003489419901139] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Despite studies reporting a possible association between malignant otitis externa (MOE) and diabetes, there are no large-scale population-based empirical studies. This nationwide, population-based case-control study explored the association of MOE occurrence with previously diagnosed diabetes. Methods: Data were retrieved from Taiwan’s National Health Insurance Research Database, 753 patients with MOE (cases) and 2 259 propensity score-matched patients without MOE (controls). Multiple logistic regressions were conducted to examine the association of MOE with previously diagnosed diabetes. Results: In total, 728 (24.2%) out of 3 012 sample patients had diabetes prior to the index date. Chi-square test revealed a significant difference in diabetes prevalence among cases and controls (54.8% vs 13.9%, p < 0.001). Simple logistic regression showed the odds ratio for prior diabetes among cases versus controls was 7.50 (95% CI, 6.22~9.03). The adjusted odds ratio of prior diabetes for cases versus controls was 10.07 (95% CI, 8.15~12.44) after adjusting for patient demographics and medical co-morbidities. Conclusions: This study found an association between MOE and diabetes. One clinical practice implication of our study is that when a patient with diabetes complains of otalgia or otorrhea, and physical examination shows swelling of the ear canal or granulation growth, physicians should consider the possibility of MOE.
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Affiliation(s)
- Tzong-Hann Yang
- Department of Otorhinolaryngology, Taipei City Hospital, Taipei
- Department of Speech, Language and Audiology, National Taipei University of Nursing and Health
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Sudha Xirasagar
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Yen-Fu Cheng
- Department of Speech, Language and Audiology, National Taipei University of Nursing and Health
- Department of Medical Research, Taipei Veterans General Hospital, Taipei
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, National Yang-Ming University, Taipei
| | - Chuan-Song Wu
- Department of Otorhinolaryngology, Taipei City Hospital, Taipei
| | - Yi-Wei Kao
- Big Data Research Center, Taipei Medical University, Taipei
| | - Ben-Chang Shia
- Big Data Research Center, Taipei Medical University, Taipei
| | - Herng-Ching Lin
- Sleep Research Center, Taipei Medical University Hospital, Taipei
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei
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26
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Cheng Y, Yang T, Wu C, Kao Y, Shia B, Lin H. A population‐based time trend study in the incidence of malignant otitis externa. Clin Otolaryngol 2019; 44:851-855. [DOI: 10.1111/coa.13387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/08/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Yen‐Fu Cheng
- Department of Medical Research Taipei Veterans General Hospital Taipei Taiwan
- Department of Otolaryngology‐Head and Neck Surgery Taipei Veterans General Hospital Taipei Taiwan
- Department of Otolaryngology‐Head and Neck Surgery, School of Medicine National Yang‐Ming University Taipei Taiwan
- Department of Speech, Language and Audiology National Taipei University of Nursing and Health Sciences Taipei Taiwan
- Research Center of Sleep Medicine, College of Medicine Taipei Medical University Taipei Taiwan
| | - Tzong‐Han Yang
- Department of Otolaryngology Taipei City Hospital Taipei Taiwan
| | - Chuan‐Song Wu
- Research Center of Sleep Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- Department of Otolaryngology Taipei City Hospital Taipei Taiwan
| | - Yi‐Wei Kao
- Big Data Research Center Taipei Medical University Taipei Taiwan
| | - Ben‐Chang Shia
- Big Data Research Center Taipei Medical University Taipei Taiwan
| | - Herng‐Ching Lin
- Research Center of Sleep Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- School of Health Care Administration Taipei Medical University Taipei Taiwan
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27
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Chaudhary HA, Ibrahim WH, Yousaf Z, Abubeker IY, Kartha A. Fungal Malignant Otitis Externa Involves a Cascade of Complications Culminating in Pseudoaneurysm of Internal Maxillary Artery: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:562-566. [PMID: 31005959 PMCID: PMC6489412 DOI: 10.12659/ajcr.913469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patient: Male, 66 Final Diagnosis: Pseudoaneurysm of internal maxillary artery secondary to fungal malignant otitis externa Symptoms: Epistaxis Medication: — Clinical Procedure: Functional endoscopic sinus surgery, endovascular embolization Specialty: Infectious Diseases
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Affiliation(s)
| | - Wanis H Ibrahim
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Anand Kartha
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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28
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Das S, Iyadurai R, Gunasekaran K, Karuppusamy R, Mathew Z, Rajadurai E, John AO, Mani S, George T. Clinical characteristics and complications of skull base osteomyelitis: A 12-year study in a teaching hospital in South India. J Family Med Prim Care 2019; 8:834-839. [PMID: 31041210 PMCID: PMC6482749 DOI: 10.4103/jfmpc.jfmpc_62_19] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Context: Skull base osteomyelitis (SBO) is an uncommon disease with substantial morbidity and mortality. Aims: The aim of this study is to characterize clinical features, outcomes, and complications of SBO. We also looked at differences in clinical profile in otogenic and non-otogenic SBO. Materials and Methods: This is a single-center retrospective observational study. Patients aged more than 15 years of age with clinical and radiological diagnosis of SBO admitted in general medicine department in a teaching hospital in South India from March 2006 to February 2018 were recruited. Results: A total of 41 patients with SBO were identified and included. Mean age was 56.9 ± 10.7 years. In all, 90% of patients (37/41) had diabetes mellitus and 29% (12/41) had recent head/neck surgery. Only 19% (8/41) needed ICU care, and mortality was 21% (9/41). Most common symptom was headache seen in 73% (30/41) of patients. Majority, 61% (25/41), had otogenic infections. Otogenic infections were associated with longer duration of diabetes mellitus (mean = 11.5 vs. 5 years, P = 0.01), higher creatinine levels (mean = 1.66 vs. 0.9 mg/dL, P = 0.014, odds ratio [OR] = 3.8), and higher incidence of cranial nerve palsy (92% vs. 56%; OR = 8.9) compared to non-otogenic SBO. Cranial nerve palsy (78%), meningitis (63%), and cerebral venous thrombosis (43%) were frequent complications of SBO in this study. The causative organisms for SBO in our cohort was bacterial in 60% (15/25) and fungal in 40% (10/25) of the patients. Surgical debridement for source control was done in 54% of patients (22/41) and was associated with survival at discharge (P = 0.001). Conclusions: Bacterial infections are the most common cause of SBO. Otogenic SBO is associated with longer duration of diabetes mellitus and higher incidence of cranial nerve palsy. Therapeutic surgical debridement plays an important role in treatment of SBO and is associated with improved survival.
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Affiliation(s)
- Sohini Das
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ramya Iyadurai
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Gunasekaran
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Reka Karuppusamy
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Zacharia Mathew
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ebenezer Rajadurai
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajoy O John
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tina George
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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The significance of tissue biopsy for fungi in necrotizing otitis externa. Eur Arch Otorhinolaryngol 2018; 275:2941-2945. [PMID: 30291437 DOI: 10.1007/s00405-018-5151-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The conventional treatment for necrotizing otitis externa (NOE) is prolonged anti-pseudomonas therapy, with surgical treatment in non-responsive patients. The aim of the present study is to describe the course of management of patients with non-responsive NOE undergoing hyperbaric oxygen therapy (HBOT), and to investigate the importance of tissue biopsy for fungi in this group of patients. MATERIALS AND METHODS A retrospective study conducted between January 2010 and December 2013 at an Otolaryngology Head and Neck Surgery Department. Included were all 52 patients with NOE referred to our Medical Centre for further treatment including HBOT. RESULTS Fifty-two consecutive patients, 29 men and 23 women, with a mean age of 70.6 years, were included in our study. Twenty seven (51.9%) underwent surgical debridement. No significant difference was found between the group having surgical intervention, and those who did not, with regard to sex, age, comorbidities, cranial nerve involvement or laboratory results. However, those who had surgical intervention had a statistically significant higher rate of fungal infection (P = 0.049). After completing 7 weeks of HBOT, a significantly lower WBC count was observed in the fungus-infected group (7000 vs 7.800, P = 0.03), and a tendency towards lower CRP levels in the fungus-infected group (16 vs 58, P = 0.087). CONCLUSION Patients with NOE should have a comprehensive surgical intervention when delayed healing is observed, because proper fungal culturing might change the course of treatment and improve prognosis. LEVEL OF EVIDENCE 4.
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