Necrotizing Otitis Externa Research Articles

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.

A Case of Proliferative and Necrotizing Otitis Externa in a Scottish Fold Shorthair Cat

In this case report, the aim was to contribute to understanding PNOE's clinical presentation, histopathological features, and successful treatment approaches, emphasizing the significance of accurate diagnosis and appropriate management in affected felines. Proliferative necrotic otitis externa (PNOE) is a very rare skin disease of unknown etiology affecting the vertical ear canal and the concave surface of the auricle, which may be accompanied by secondary yeast or bacterial infections. In this case 8-month-old Scottish fold shorthair cat has fragile, papillomatous growths and caseous purulent exudate in the ear canal was presented. The differential diagnosis of this condition includes otoacariasis, plasma cell pododermatitis, papillomavirus and chronic bacterial or yeast otitis externa. Despite antimicrobial and antiparasitic based previous treatments, the lesions persisted. Histopathological examination revealed acanthotic epidermis, necrotic keratinocytes, and inflammatory cell infiltrates. Treatment involved methylprednisolone injection, topical pomades, and systemic antibiotics. The cat showed improvement after initial treatment week, with regression of lesions and cessation of ear discharge. Follow-up visits demonstrated continued improvement, and after two months, minimal sequelae remained. In conclusion, despite the unknown etiology of PNOE, the disease is quite responsive to immunosuppressive therapy, which is beneficial for both diagnosis and treatment.

Diagnostic accuracy of eosinophil-to-lymphocyte ratio and eosinophil-to-neutrophil ratio as biomarkers for differentiating between fungal and bacterial infection in necrotising otitis externa.

Necrotizing otitis externa (NOE) is a serious, progressive, and potentially life-threatening infection of the external auditory canal, affecting soft tissue and bone. The most common organism causing NOE is Pseudomonas Aeruginosa and less common are Fungal infections. When managing a patient with NOE, a culture is taken from the EAC in order to tailor the appropriate antimicrobial treatment, however commonly, the culture is sterile. Inflammation biomarkers may be used as adjuncts to inform on the differential diagnosis and as prognostic markers. To characterize and compare values and ratios of components of the complete blood count (CBC) at admission, at patients with positive swab culture. A retrospective study of NOE patients was conducted. We included all patients admitted between the years 2001-2023, for whom a culture swab tested positive. We compared CBC findings at hospitalization between bacteria and fungi-positive culture patients. Eosinophils-to-Neutrophils Ratio (ENR) was significantly lower in the fungal group compared to the bacterial group 0.023 ± 0.02 and 0.04 ± 0.03, respectively (p-value = 0.025). Eosinophils-to-Leukocyte Ratio (ELR) was significantly lower in the fungal group compared to the bacterial group 0.058 ± 0.04 and 0.12 ± 0.1 respectively (p-value = 0.009). For definition of ELR ≤ 0.1 we found that, sensitivity was 88% (95%CI = 0.679-0.979) and NPV 90% (95%CI = 0.709-0.982). For definition of ENR ≤ 0.03 sensitivity was 88% (95%CI = 0.679-0.979) and NPV 88% (95%CI = 0.679-0.979). Lower values of ELR and ENR in patients with NOE are associated with fungal infection and can serve as a tool in adjusting an appropriate antimicrobial therapy in cases of sterile or when no culture is available.

Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center.

Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE. In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease. A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography. Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.

Research progress of necrotizing otitis externa

Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.