Necrotizing Otitis Externa Research Articles

When tuberculosis makes you deaf

Tuberculous otomastoiditis is a rare and serious infection that most often occurs in association with pulmonary involvement. It is easy to diagnose when the two pathologies are associated and isolated. We herein report the case of a patient initially hospitalized for Pseudomonas aeruginosa necrotising otitis externa (NOE), which delayed the diagnosis of tuberculous otomastoiditis. The 50-year-old patient was hospitalized for NOE and concurrently presented with pulmonary tuberculosis. NOE was associated with temporal bone lysis with carotid canal involvement. Despite appropriate treatment, NOE evolution was unfavourable. Two months later, the patient underwent a mastoidectomy to evacuate a mastoid abscess. In a deep tissue sample, tuberculosis complex was detected by PCR assay. For 12months, the patient underwent for pulmonary and osseous tuberculosis. While the clinical course was favourable but deafness occurred subsequently. An association of P.aeruginosa NOE and tuberculous otomastoiditis is a highly exceptional event.

Treatment Response Evaluation in Necrotizing Otitis Externa Using 18F-FDG-PET Imaging.

This study aims to identify 18F-FDG-PET imaging features for improving treatment response evaluation in patients with necrotizing otitis externa (NOE), aiding in the difficult differentiation between sterile inflammation and active infection. Retrospective cohort study. Tertiary hospital. Patients diagnosed with NOE between 2011 and 2022. NOE criteria included otalgia, otorrhea, granulation, and radiological features consistent with osteomyelitis. 18F-FDG-PET/computed tomography (CT) parameters were derived from manually delineated regions of interest and were evaluated on both pretreatment and end-of-treatment scans. Recurrent disease of NOE after end-of-treatment 18F-FDG-PET scans. This study comprised 20 NOE patients, including 5 (25%) experiencing recurrent disease after the end-of-treatment scan. The end-of-treatment 18F-FDG-PET parameters of maximal and peak standardized uptake value (SUVmax and SUVpeak) were significantly higher in recurrent cases (p = 0.025 and p = 0.025, respectively). Both parameters demonstrated good discrimination ability in predicting recurrence, with optimal cutoffs yielding 100% sensitivity and 67% specificity. Other parameters, including mean SUV and total lesion glycolysis (TLG), did not yield significant results, neither did the calculated difference in uptake between end-of-treatment and pretreatment scans. SUVpeak on 18F-FDG-PET was the preferred parameter for treatment response evaluation of NOE at the end-of-treatment scan. A high residual SUVpeak may adequately detect patients at risk for recurrent disease, which may necessitate prolonged treatment, while low SUVpeak is found in patients with low risk for recurrent disease permitting safe treatment cessation.

Unusual Presentation of a Rare Disease: A Case Report of Fungal Necrotizing Otitis Media and Mastoiditis.

Acute necrotizing otitis media is a severe middle ear infection which causes necrosis of the tympanic cavity. A 54-year-old female was presented who suffered from diabetes mellitus and end-stage renal disease presenting with severe otalgia, initially thought to be necrotizing otitis externa. She rapidly progressed to total necrosis of the tympanic membrane. Further assessments confirmed a fungal disease caused by Candida tropicalis and Aspergillus flavus. Immediate antifungal therapy with amphotericin B and subsequent radical mastoidectomy managed to control the disease with no sign of necrosis after 3 months. Early diagnosis, aggressive systemic antifungal treatment, and surgical debridement are vital components for successful management of such cases.

C-reactive protein (CRP) and otorrhoea as prognosticate markers for necrotising otitis externa treatment response: based on a retrospective cohort study of 62 patients

Background Recurrence rate of necrotising otitis externa (NOE) after treatment is 15-20%. This is mainly due to a lack of reliable clinical indicator for the resolution of disease. Aims We aim to assess the predictability of the otalgia, otorrhoea and C-reactive protein (CRP) levels in a large cohort of sixty-two patients for treatment outcome. Methods Consecutive patients treated for NOE in our Nottingham tertiary ENT referral unit were retrospectively reviewed from January 2017 to June 2020. Diagnoses were made based on clinical findings and imaging. Good response to treatment was defined as those who required treatment of not longer than the standard six weeks of systemic antibiotics. Results Average age at presentation was 78.4 years. 75.8% of patients were male. 62.9% had diabetes. Ten patients received more than the standard six weeks of systemic antibiotics. Complications from disease progression included cranial nerve neuropathies (14.5%), meningitis (3.2%), and sigmoid sinus thrombosis (3.2%). Two patients had recurrent or persistent NOE and died while on treatment. Delays in normalization of CRP (p = 0.015) and resolution of otorrhoea (p = 0.014) were associated with an increased need for prolonged antibiotic treatment. Conclusion Normalisation of CRP and resolution of otorrhea can assist in identifying patients who will likely benefit from a prolonged course of systemic antibiotics.

Temporal Bone Myeloid Sarcoma Presenting as Necrotizing Otitis Externa: A Case Report and Literature Review.

Myeloid sarcoma (MS) is a proliferation of immature myeloid cells that occurs extramedullary, often accompanying acute myeloid leukemia (AML). It typically presents in areas such as lymph nodes, skin, and the head and neck regions. The emergence of MS within the temporal bone is rare, and it can manifest through nonspecific symptoms. In this paper, we reported a case of A 47-year-old female presented with right-sided otalgia, otorrhea, tinnitus, reduced hearing, and ear fullness, and developed facial asymmetry. She was initially diagnosed with necrotizing otitis externa and was treated accordingly. Further investigations were conducted, leading to the diagnosis of MS. She began treatment with induction chemotherapy followed by consolidation therapy. And we reviewed the literature and included 14 MS cases with the same anatomical localization, discussing the primary presentation, immunohistochemistry, and treatment approaches of these patients. In conclusion, temporal bone MS should be considered in patients with a history of AML presenting with nonspecific symptoms. Diagnostic modalities for MS include computed tomography and magnetic resonance imaging scans. Systemic chemotherapy remains the preferred treatment approach. The complexity and diversity of temporal bone MS presentations necessitate further comprehensive research to enhance understanding and improve management strategies for this rare condition.

Deciding treatment end point in necrotizing otitis externa: validation of a standardized clinical response assessment strategy with positron emission tomography findings.

Primary: To explore criteria for treatment endpoint in NOE. Secondary: To study correlation of inflammatory markers, Erythrocyte sedimentation Rate (ESR) and C-reactive protein (CRP) with disease status. Prospective cohort study conducted in a tertiary care hospital over two years (2021-2023) consisted 28 patients with NOE. Treatment culmination point was decided based on symptoms control and correlated with PET-scan findings. Clinical response was analysed with respect to the serum inflammatory markers and PET Scan findings. There was fair degree of agreement between clinical resolution and resolution of findings on PET scan (kappa coefficient - 0.76 [95% CI; 0.40,1.00]). Inflammatory markers showed statistically significant decline with clinical resolution but failed to return to normal. Decision to terminate treatment of NOE can be reliably made on clinical grounds in patients remaining asymptomatic for three weeks. Resolution of inflammation on PET scan is in congruity with the clinical remission .

Approach to otitis externa.

To provide family physicians with a practical evidence-based approach to management of otitis externa. The approach described is based on MEDLINE and PubMed literature published between 1993 and 2023. Otitis externa is diffuse inflammation of the external auditory canal and typically occurs from moisture exposure and trauma. Management focuses on eliminating infection, pain management, education, and preventing recurrence. The primary treatment of uncomplicated otitis externa is topical. Complicated presentations may require additional systemic therapy. History taking and physical examination can help differentiate among acute, chronic, and necrotizing otitis externa. At-risk populations, typically those who are immunosuppressed, are more likely to develop necrotizing otitis externa and should be carefully monitored.

Preliminary evidence supporting use of UK consensus definitions for necrotising otitis externa

BackgroundInfections of the external ear canal (EAC) exist as a spectrum of disease from severe otitis externa (SOE) to necrotising otitis externa (NOE), but distinguishing between these is challenging. The UK consensus case definition (UKCCD) was established in 2022, but had not yet been assessed in clinical practice. MethodsAll consecutive adult patients undergoing CT to investigate a diagnosis of possible NOE between November 2018 and October 2019 were prospectively included in the cohort. Clinical diagnosis at baseline and the end of 12 months follow-up were compared to the diagnosis defined by UKCCD. Results55 patients were included in the analysis. 27 % (15/55) had an initial clinical diagnosis of NOE, of which 47 % (7/15) did not have changes on CT consistent with NOE. Only 9 % (5/55) patients had an MRI scan performed within 7 days of the baseline CT. At the end of 12 months, 9 % (5/55) patients had a change in diagnosis to or from NOE. All cases diagnosed as NOE by UKCCD had a clinical diagnosis of ‘NOE’ at baseline, while no cases clinically diagnosed as NOE were mislabelled by UKCCD as ‘not NOE’. All cases that had a change of diagnosis in the 12-month period or had an initial CT with no changes consistent with NOE, were captured by the UKCCD category of ‘possible NOE’. Median duration of antibiotics of clinically defined NOE cases were 14 days of intravenous (IQR: 7.3–23.8), 28 days of oral (IQR: 21.0–40.3), and 49.5 days combined (IQR: 29.8–67.3). ConclusionUKCCD has excellent clinical concordance with clinical diagnosis. Further work is warranted to assess its utility for risk stratification of patients presenting with severe infections of the EAC in a larger cohort.

Pediatric Necrotizing Otitis Externa: A Scoping Review.

This review sought to answer the following research question: What are the characteristics of pediatric necrotizing otitis externa (NOE)? Moreover, we wanted to highlight the clinical importance of the current limitations in the literature. A scoping review was performed to determine what is known about NOE in the pediatric population. Four databases (COCHRANE Library, CINAHL, PubMed, and Scopus) were queried for articles published in English between 1976 to 2022. Variables extracted included comorbidities, demographics, outcomes, and treatment. A total of 20 studies (N = 439) reported sufficient measures to be included in the review. Patients with NOE had a mean age of 10.0 years (range 2 months to 14 years) with a male-to-female gender ratio of 1.1:1. Mean length of hospital stay was 2.9 days (95%CI: 2.7-3.0). Demographics included 45.4% Caucasian, 6.0% African American, and 2.7% Asian/Pacific Islander. Less than 5% of patients had diabetes, while other reported comorbidities included neutropenia (n = 6), anemia (n = 5), dehydration/malnutrition (n = 4), Stevens Johnson Syndrome (n = 2), some form of immunosuppression/organ transplantation (n = 2), thrombocytopenia (n = 2), and leukopenia (n = 2). There have been no reported deaths from NOE in children. In the adult population NOE most commonly affects patients with diabetes, but our review reveals that diabetes does not appear to play as big a role in children. The disease seems to commonly affect patients with immunosuppression or severe health conditions. Complications such as cranial nerve palsies appear to be more common in the pediatric population. Specifically, the role of biopsy and culture in the treatment of pediatric NOE is stressed as they are important in treatment decisions.

External Auditory Canal Erosion at the 6 O'clock Spot.

To report a common site of external ear canal erosion in multiple pathologies, located inferiorly at 6 o'clock. Otology patients who came in 2023 for treatment of external auditory canal erosions. This clinical capsule is an observational report of the external canal's propensity to erosion at the 6 o'clock location. Patient treatments were canalplasty, mastoidectomy, and medical management. Documentation of the propensity to erosion at the 6 o'clock location in the external auditory canal. Locations of the niduses of prior series of external auditory canal pathologies are documented. Eight patients are presented with external auditory canal erosion in 10 ears originating at the 6 o'clock position medial to the bony-cartilaginous junction. No other patient with spontaneous canal erosion presented with their nidus of pathology in another canal location. (A review of 42 case series of 291 patients found that keratosis obturans and bisphosphonate-induced osteonecrosis tended to arise from the same 6 o'clock lateral bony canal location, while 26% of necrotizing otitis externa cases arose there.). The "6 o'clock spot" in the external canal is a common location of canal erosion for spontaneous wax and keratin collections and may be the precursor to keratosis obturans, bisphosphonate-induced osteonecrosis of the ear canal, and necrotizing otitis externa.

Diagnostic criteria and core outcome set development for necrotising otitis externa, symptomatic evaluation in patients awaiting septoplasty and early versus late tracheostomy in critically ill patients.

Diagnostic criteria and core outcome set development for necrotising otitis externa, symptomatic evaluation in patients awaiting septoplasty and early versus late tracheostomy in critically ill patients.

185 Examining the Efficiency of Diagnosing and Managing Necrotising Otitis Externa (NOE) Using a Departmental Management Algorithm

185 Examining the Efficiency of Diagnosing and Managing Necrotising Otitis Externa (NOE) Using a Departmental Management Algorithm

Clinical outcomes in OPAT patients treated with ceftriaxone 4 g and ceftazidime 6 g extended interval dosing regimens.

New dosing regimens for ceftriaxone 4 g/24 hours and ceftazidime 3 g/12 hours are convenient for patients receiving OPAT. To date, these have not been clinically validated. To assess the tolerability, toxicity and effectiveness of once daily ceftriaxone (4 g) and 12 hourly ceftazidime regimens (3 g twice a day) in the OPAT setting. From April 2018 until March 2023; demographic, clinical, microbiological and outcome data were collected on all adult patients discharged to a community-based OPAT team in East London. There were 487 OPAT episodes. Fifty-three (10.9%) patients received ceftriaxone 4 g once a day and 20 (4.1%) ceftazidime 3 g twice a day. In the ceftriaxone group, the commonest conditions treated were orthopaedic, neurosurgical or diabetic foot infections. OPAT was used to expedite the discharge of 45 (84.9%) patients, the remainder were admission avoidance episodes. The commonest isolate causing infection was MSSA 23 (43.4%). There were no tolerability or toxicity episodes recorded. All patients were cured and bed days saved were 1266.In the smaller twice-daily ceftazidime cohort, seven (35%) patients were treated for necrotizing otitis externa, six (30%) for bronchiectasis and six (30%) for urinary tract infections. The commonest cause of infection was P. aeruginosa, 18 (90%). One case of nephrotoxicity was recorded. All patients were cured and bed days saved were 896. Regimens of ceftriaxone 4 g once a day and ceftazidime 3 g twice a day were well tolerated and highly effective. If widely adopted, these regimens will save OPAT and nursing time and enable more patients to be treated.

Necrotizing otitis externa in diabetic patients: clinical features and out come

Necrotizing otitis externa in diabetic patients: clinical features and out come

Bacteriological and mycological profile of necrotizing otitis externa in diabetics

Bacteriological and mycological profile of necrotizing otitis externa in diabetics

Diagnostic criteria and core outcome set development for necrotising otitis externa: the COSNOE Delphi consensus study.

Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS). The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting. The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research. The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.

Value of Hyperbaric oxygen as an adjuvant treatment for necrotizing otitis externa

Value of Hyperbaric oxygen as an adjuvant treatment for necrotizing otitis externa

Epidemiology and risk factors for extension of necrotizing otitis externa.

Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension? 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. Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2years 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 22days 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%). 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.

Head-to-Head Comparison Between 18F-FDG PET and Leukocyte Scintigraphy to Monitor Treatment Responses in Necrotizing Otitis Externa.

Necrotizing otitis externa (NOE) is a rare disease associated with high morbidity and mortality, and there is currently no available accurate biomarker to assess treatment responses. The aim of the current study was to evaluate and directly compare the diagnostic performances of 18-Fluoro-deoxyglucose positron emission tomography (18F-FDG PET) and labeled leukocyte scintigraphy (LS) to monitor treatment responses in NOE. Consecutive patients with NOE who underwent 18F-FDG PET at the end of antibiotic therapy and planar as well as single photon emission computed tomography-labeled leukocyte scintigraphy after completing the initial antibiotic treatment were retrospectively included. Semiquantitative analyses were performed to determine the ratios of affected/nonaffected sides for PET and 4 hour and 24 hour LS acquisitions as well as the kinetic PET ratios (at diagnosis and post-treatment) and LS (4 and 24 hours). The final treatment responses were assessed by 2 experienced ENT physicians based on clinical, otoscopic, and biological data and subsequent 3-month follow-up. Seventeen patients (74.0 ± 10.6 years old, 5 women) were included. The best diagnostic performances were obtained with the PET maximum standardized uptake value (SUVmax)-lesion-to-background ratio and the tomographic LS lesion-to-background ratio at the 4-hour acquisition timepoint (thresholds of 4.1 and 1.19, yielding accuracies of 100% and 88%, respectively). In the multivariate analysis, the PET SUVmax-lesion-to-background ratio was the only predictive factor of recovery when associated with all clinical parameters (P < .001). 18F-FDG PET is the first-line imaging modality for evaluating NOE treatment responses, with excellent diagnostic performances. LS with only 4-hour acquisitions appeared to suffice to evaluate NOE treatment responses. Both biomarkers constitute early prognostic biomarkers for predicting antibiotic treatment response in patients with NOE. The institutional ethics committee (Comité d'Ethique du CHRU de Nancy) approved the evaluation of retrospective patient data, and the trial was registered at ClinicalTrials.gov (n°2023PI003-404).

Necrotising otitis externa, epistaxis first aid advice, laterality in otolaryngology and what medical students want from ENT teaching.

Necrotising otitis externa, epistaxis first aid advice, laterality in otolaryngology and what medical students want from ENT teaching.