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Haleem AH, Shahidi S, Hilton JM, Pringle M, Biggs TC, Buckland J. Refining necrotising otitis externa management: A follow-up study on a departmental algorithm and the role of nuclear medicine imaging. Am J Otolaryngol 2025; 46:104659. [PMID: 40344787 DOI: 10.1016/j.amjoto.2025.104659] [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: 04/14/2025] [Accepted: 04/24/2025] [Indexed: 05/11/2025]
Abstract
OBJECTIVE This study evaluates the effectiveness of a departmental diagnostic and treatment algorithm for necrotising otitis externa (NOE), with a particular focus on the role of nuclear medicine imaging in improving diagnostic accuracy and patient outcomes. METHODS A retrospective cohort analysis was conducted on patients admitted with suspected NOE to a major UK general hospital over a two-year period. Clinical presentation, imaging modalities, and treatment outcomes were reviewed to assess the algorithm's impact, with a focus on the diagnostic yield of CT, Technetium scans, and MRI, as well as treatment success rates and recurrence. RESULTS Among 33 patients (mean age: 77 years), 28 were diagnosed with necrotising otitis externa (NOE). Diabetes was present in 41 %, and Pseudomonas aeruginosa was identified in 70 % of cases. CT confirmed NOE in 21 patients (64 %), including two with skull base erosion. Among 12 patients with negative CT findings, 9 underwent Technetium bone scintigraphy, with 5 (56 %) yielding positive results. Two patients underwent MRI, confirming NOE in one case. One patient was diagnosed clinically. Overall, 6 of 12 patients (50 %) with negative CT results were ultimately diagnosed with NOE following further imaging. All 28 diagnosed patients received prolonged intravenous or oral antibiotic therapy based on microbiological sensitivity. Of these, 24 had follow-up (mean: 5.6 weeks), with clinical resolution observed in 20 patients (83 %). Additional imaging was performed in 13 cases, including MRI (n = 4), CT (n = 5), Gallium scan (n = 1), PET-CT (n = 1), and combined CT/MRI (n = 2), primarily for persistent symptoms. Four patients were diagnosed with alternative conditions, including canal cholesteatoma and squamous cell carcinoma. Overall, the cure rate within the cohort was 83 %, with no NOE recurrences or NOE-related mortality recorded during the follow-up period. CONCLUSION This study validates the efficacy of the department's updated NOE diagnostic and treatment algorithm, reinforcing the utility of technetium bone scans in cases where CT results are inconclusive. Findings highlight the importance of combining advanced imaging with clinical assessment for optimal NOE management, ensuring high-resolution rates and preventing unnecessary interventions.
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Affiliation(s)
- A H Haleem
- Bolton NHS Foundation Trust, United Kingdom.
| | - S Shahidi
- Southampton General Hospital, ENT - Head & Neck Directorate, United Kingdom
| | - J M Hilton
- Portsmouth University Hospitals NHS Trust · ENT - Head & Neck Directorate, United Kingdom
| | - M Pringle
- Portsmouth University Hospitals NHS Trust · ENT - Head & Neck Directorate, United Kingdom
| | - T C Biggs
- Portsmouth University Hospitals NHS Trust · ENT - Head & Neck Directorate, United Kingdom
| | - J Buckland
- Portsmouth University Hospitals NHS Trust · ENT - Head & Neck Directorate, United Kingdom
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Rampinelli V, Testa G, Arosio AD, Piazza C. Skull base osteoradionecrosis: from pathogenesis to treatment. Curr Opin Otolaryngol Head Neck Surg 2025; 33:65-73. [PMID: 39903654 DOI: 10.1097/moo.0000000000001036] [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: 02/06/2025]
Abstract
PURPOSE OF REVIEW This review aims to provide a comprehensive analysis of skull base osteoradionecrosis (ORN), a severe and rare complication of radiotherapy for head and neck malignancies. It explores pathogenesis, clinical presentation, diagnostic strategies, and management approaches, emphasizing the importance of multidisciplinary care in addressing this challenging condition. RECENT FINDINGS Skull base ORN results from radiotherapy-induced tissue damage, characterized by hypovascularity, hypoxia, and necrosis, often compounded by secondary infections. Advances in radiotherapy techniques, such as intensity-modulated radiotherapy and heavy particles, have reduced ORN incidence, though cases persist, particularly in high-dose radiotherapy fields. Emerging treatments, including hyperbaric oxygen therapy and the pentoxifylline-tocopherol protocol, show promise but lack robust evidence for standardized use. Surgical interventions, especially those incorporating vascularized tissue reconstruction, have demonstrated favorable outcomes in refractory cases. Recent studies underscore the utility of multimodal imaging techniques, including MRI and PET/CT, for distinguishing ORN from tumor recurrence. SUMMARY Skull base ORN represents a complex and potentially life-threatening condition requiring tailored, multidisciplinary management. Although advancements in diagnostics and therapeutics have improved outcomes, significant challenges remain, particularly in developing standardized protocols. Further research is needed to refine treatment strategies and improve evidence-based practices for this entity.
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Affiliation(s)
- Vittorio Rampinelli
- Unit of Otorhinolaryngology - Head and Neck Surgery, ASST Spedali Civili, Department of Surgical and Medical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia
| | - Gabriele Testa
- Unit of Otorhinolaryngology - Head and Neck Surgery, ASST Spedali Civili, Department of Surgical and Medical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia
| | - Alberto Daniele Arosio
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology - Head and Neck Surgery, ASST Spedali Civili, Department of Surgical and Medical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia
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Chiavarini E, Cerritelli L, Caranti A, Ciorba A, Malagutti N, Borin M, Pelucchi S. Scedosporium Apiospermum: A Rare Cause of Necrotizing Otitis Externa. Our Experience and A Review of the Current Literature. Indian J Otolaryngol Head Neck Surg 2025; 77:1884-1890. [PMID: 40226283 PMCID: PMC11985874 DOI: 10.1007/s12070-025-05395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Accepted: 02/13/2025] [Indexed: 04/15/2025] Open
Abstract
Necrotizing otitis externa (NOE) is a severe and progressive infection of the external auditory canal that poses significant diagnostic and therapeutic challenges, particularly when caused by rare pathogens such as Scedosporium apiospermum. This case report details an 84-year-old diabetic male with NOE treated with a combination of oral and topical Voriconazole after multiple ineffective antibiotic therapies. The consequent literature review identifies and analyzes 8 cases of NOE caused by S. apiospermum, revealing significant challenges in diagnosis and management. Diagnostic delays in NOE caused by Scedosporium apiospermum were common, leading to prolonged empirical antibiotic therapy in most cases. The follow-up duration was very long, with high rates of morbidity and mortality, including serious complications. Voriconazole emerged as the most effective antifungal treatment, though its use is associated with substantial risks, necessitating careful monitoring. Our findings underscore the importance of considering fungal etiologies in persistent NOE and emphasize the need for repeated ear swabs and targeted therapy to improve patient outcomes. The results highlight a critical gap in standardized diagnostic and therapeutic protocols, advocating for more rigorous evaluation and management strategies in cases of suspected Scedosporium infections.
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Affiliation(s)
- Eleonora Chiavarini
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
| | - Luca Cerritelli
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
| | - Alberto Caranti
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
- Gruppo Otorinolaringoiatrico Della Romagna, Primus Medical Center, via Punta di Ferro, 2/c, 47122 Forlì, FC Italy
| | - Andrea Ciorba
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
| | - Nicola Malagutti
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
| | - Michela Borin
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
| | - Stefano Pelucchi
- ENT & Audiology Department, University Hospital of Ferrara, via Aldo Moro 8, 44124 Cona, FE Italy
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Karthat AG, Regi S, Thomas H, Sara KB, Beula Subashini P, Sundaresan R, Thomas R. Diffusion-Weighted Imaging Does Not Differentiate Between Bacterial and Fungal Skull Base Osteomyelitis. Clin Otolaryngol 2025; 50:300-306. [PMID: 39533393 DOI: 10.1111/coa.14256] [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: 06/04/2024] [Revised: 09/19/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Abstract
OBJECTIVE Apparent diffusion coefficient (ADC) value helps in differentiating infections from neoplasms on magnetic resonance imaging (MRI). We investigate the diffusion-weighted images in skull base osteomyelitis (SBO) to evaluate if ADC values can differentiate fungal and bacterial SBO and to analyse the microbiology of all SBO patients. DESIGN Retrospective observational study. SETTING Quaternary care referral centre. PARTICIPANTS A retrospective review of 142 patients diagnosed and treated for SBO patients from January 2010 to May 2023 was done. MAIN OUTCOME MEASURE Chi-square or Fisher's exact test was used to compare ADC values of bacterial and fungal SBO. RESULTS The most common pathogens isolated were Pseudomonas (42.2%), Aspergillus (30.98%), and S. aureus (23.94%). The average ADC value of affected soft tissues among patients was 1.13 ± 0.26 × 10-3 mm2/s compared to the average ADC value of normal soft tissue, 1.34 ± 0.31 × 10-3 mm2/s. There was no statistical significance when comparing the average ADC values of bacterial and fungal SBO patients (p value = 0.142). CONCLUSION This study suggests that though infection due to Pseudomonas was the commonest, it was detected only in 42.2% of patients. More than half of the cases had organisms other than Pseudomonas, demanding the clinician to obtain deeper biopsies early in the course of the disease for microbiological analysis. DWI does not help differentiate bacterial and fungal SBO, again emphasising the need for deeper tissue biopsies in all these patients to assist in the early identification of the pathogen.
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Affiliation(s)
- Arun G Karthat
- Department of Otolaryngology, Christian Medical College, Vellore, India
| | - Soumya Regi
- Department of Radiology, Christian Medical College, Vellore, India
| | - Habie Thomas
- Department of Otolaryngology, Christian Medical College, Vellore, India
| | - Katti B Sara
- Department of Otolaryngology, Christian Medical College, Vellore, India
| | - P Beula Subashini
- Department of Microbiology, Christian Medical College, Vellore, India
| | - Rajan Sundaresan
- Department of Otolaryngology, Christian Medical College, Vellore, India
| | - Regi Thomas
- Department of Otolaryngology, Christian Medical College, Vellore, India
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Jansen RW, Kemp P, Wiegers SE, de Graaf P, van Schie A, Martens RM, Boellaard R, Zwezerijnen GJC, Goderie T. Treatment Response Evaluation in Necrotizing Otitis Externa Using 18 F-FDG-PET Imaging. Otol Neurotol 2025; 46:295-302. [PMID: 39794893 DOI: 10.1097/mao.0000000000004402] [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: 01/13/2025]
Abstract
OBJECTIVE This study aims to identify 18 F-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. STUDY DESIGN Retrospective cohort study. SETTING Tertiary hospital. PATIENTS Patients diagnosed with NOE between 2011 and 2022. NOE criteria included otalgia, otorrhea, granulation, and radiological features consistent with osteomyelitis. INTERVENTION 18 F-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. MAIN OUTCOME MEASURES Recurrent disease of NOE after end-of-treatment 18 F-FDG-PET scans. RESULTS This study comprised 20 NOE patients, including 5 (25%) experiencing recurrent disease after the end-of-treatment scan. The end-of-treatment 18 F-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. CONCLUSIONS SUVpeak on 18 F-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.
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Affiliation(s)
| | - Pieter Kemp
- Department of Otolaryngology-Head and Neck Surgery
| | - Sanne E Wiegers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pim de Graaf
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annelies van Schie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roland M Martens
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ronald Boellaard
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerben J C Zwezerijnen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Tabashiri A, Allahverdi Nazhand H, Fathy M, Mortazavi SM, Javandoust Gharehbagh F, Haghighi-Morad M, Mokhtarinejad F, Alavi Darazam I. Evaluation of the clinical and radiological features of patients with Malignant otitis externa (MOE). BMC Infect Dis 2025; 25:277. [PMID: 40000962 PMCID: PMC11863464 DOI: 10.1186/s12879-025-10637-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
INTRODUCTION Malignant otitis externa (MOE) is a life-threatening infection of the external auditory canal and temporal bone. OBJECTIVE This study is designed to identify the clinical features, predisposing factors, radiological findings, complications, diagnoses, and management of MOE patients. STUDY DESIGN Retrospective cross-sectional study. SETTING Loghman-e-Hakim Hospital, Tehran, Iran. METHODS The study included 40 patients diagnosed with MOE from 2011 to 2023. The data extracted from medical records included demographic data, clinical signs and symptoms, radiological findings, laboratory data, predisposing factors, complications, treatments, and outcomes. Out of 37 patients, 21 were followed up. RESULTS The study found that the mean age of patients was 62.24 ± 11.44 years, with 62.2% being male. Otalgia and otorrhea were the most commonly reported symptoms, and mastoiditis was the most common radiological finding. Bone erosions and osteomyelitis were other important complications. Vascular complications were also observed in 7 patients. The study also found that most patients had underlying conditions such as diabetes mellitus, hypertension, ischemic heart disease, and renal disease. One patient passed away during hospitalization, while others improved and were discharged. Then, at follow-up, 11 patients died, mainly due to the progression of underlying disorders including cardiac, and renal manifestations. CONCLUSION Based on our findings, although MOE most commonly occurs in poorly-controlled diabetic or immunocompromised patients, it can also occur in individuals without known conditions. Furthermore, increasing the age and severity of DM could lead to more complications. In terms of medical therapy, coverage of gram-positive bacteria and an antipseudomonal regimen would be an effective treatment.
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Affiliation(s)
- Arefeh Tabashiri
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mobin Fathy
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Farid Javandoust Gharehbagh
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Haghighi-Morad
- Department of Radiology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Kamali St, Tehran, Iran
| | - Farhad Mokhtarinejad
- Department of Otorhinolaryngology, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Tehran University of Medical Sciences, Tehran, Iran.
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Kaminer BM, El-Saied S, Lasry B, Kaplan DM. Diagnostic accuracy of eosinophil-to-lymphocyte ratio and eosinophil-to-neutrophil ratio as biomarkers for differentiating between fungal and bacterial infection in necrotising otitis externa. Clin Otolaryngol 2024; 49:343-348. [PMID: 38263617 DOI: 10.1111/coa.14142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/27/2023] [Accepted: 12/17/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Necrotizing otitis externa (NOE) is a serious, progressive, and potentially life-threatening infection of the external auditory canal, affecting soft tissue and bone. The most common organism causing NOE is Pseudomonas Aeruginosa and less common are Fungal infections. When managing a patient with NOE, a culture is taken from the EAC in order to tailor the appropriate antimicrobial treatment, however commonly, the culture is sterile. Inflammation biomarkers may be used as adjuncts to inform on the differential diagnosis and as prognostic markers. AIM To characterize and compare values and ratios of components of the complete blood count (CBC) at admission, at patients with positive swab culture. METHODS A retrospective study of NOE patients was conducted. We included all patients admitted between the years 2001-2023, for whom a culture swab tested positive. We compared CBC findings at hospitalization between bacteria and fungi-positive culture patients. RESULTS Eosinophils-to-Neutrophils Ratio (ENR) was significantly lower in the fungal group compared to the bacterial group 0.023 ± 0.02 and 0.04 ± 0.03, respectively (p-value = 0.025). Eosinophils-to-Leukocyte Ratio (ELR) was significantly lower in the fungal group compared to the bacterial group 0.058 ± 0.04 and 0.12 ± 0.1 respectively (p-value = 0.009). For definition of ELR ≤ 0.1 we found that, sensitivity was 88% (95%CI = 0.679-0.979) and NPV 90% (95%CI = 0.709-0.982). For definition of ENR ≤ 0.03 sensitivity was 88% (95%CI = 0.679-0.979) and NPV 88% (95%CI = 0.679-0.979). CONCLUSION Lower values of ELR and ENR in patients with NOE are associated with fungal infection and can serve as a tool in adjusting an appropriate antimicrobial therapy in cases of sterile or when no culture is available.
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Affiliation(s)
- Benyamin M Kaminer
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Sabri El-Saied
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Batel Lasry
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Daniel M Kaplan
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel
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Krawiec E, Brenet E, Truong F, Nguyen Y, Papthanassiou D, Labrousse M, Dubernard X. Epidemiology and risk factors for extension of necrotizing otitis externa. Eur Arch Otorhinolaryngol 2024; 281:2383-2394. [PMID: 38499694 DOI: 10.1007/s00405-024-08549-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/12/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension? METHODS French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone. RESULTS Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%). CONCLUSION Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.
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Affiliation(s)
- Elise Krawiec
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Esteban Brenet
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - France Truong
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Yohan Nguyen
- Department of Internal Medicine, Infectious Diseases and Clinical Immunology, University Hospital of Reims, Reims, France
| | | | - Marc Labrousse
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France
| | - Xavier Dubernard
- Departments of Oto-Rhino-Laryngology, University Hospital of Reims, Rue du Général Koenig, 51100, Reims, France.
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Lodhi S, Timms S, Stapleton E. A systematic review of antimicrobial treatment regimens and their outcomes in necrotising otitis externa. J Laryngol Otol 2024; 138:120-129. [PMID: 37767726 DOI: 10.1017/s0022215123001664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Necrotising otitis externa is a serious infection with minimal evidence underpinning its management. This review aims to synthesise published evidence of antimicrobial therapies and their outcomes in necrotising otitis externa. METHODS The review was PROSPERO registered (CRD42022353244) and conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses ('PRISMA') guidelines. A robust search strategy filtered 28 manuscripts into the final review. Antimicrobial therapy and clinical outcome data were extracted and analysed. RESULTS Published studies are heterogeneous, with high risk of bias and low certainty. Reporting of outcomes is poor and extremely variable. First-line therapy is most commonly in-patient (95 per cent) empiric fluoroquinolone (68 per cent) delivered intravenously (82 per cent). The lack of granular data and poor outcome reporting mean it is impossible to correlate treatment strategies with clinical outcomes. CONCLUSION Robust, consistent outcome reporting with reference to treatments administered is mandatory, to inform clinical management and optimise future research. Optimal antimicrobial choices and treatment strategies require clarification through prospective clinical trials.
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Affiliation(s)
- Sirat Lodhi
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Sara Timms
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Emma Stapleton
- Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
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Vosbeek EGM, Straatman LV, Braat AJAT, de Keizer B, Thomeer HGXM, Smit AL. Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center. OTOLOGY & NEUROTOLOGY OPEN 2023; 3:e042. [PMID: 38516544 PMCID: PMC10950167 DOI: 10.1097/ono.0000000000000042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/09/2023] [Indexed: 03/23/2024]
Abstract
Objectives Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE. Methods In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease. Results A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography. Conclusion Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.
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Affiliation(s)
- Eleonora G M Vosbeek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Louise V Straatman
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Hans G X M Thomeer
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Adriana L Smit
- Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
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McCarty Walsh E, Hanson MB. Fungal Infections of the External Auditory Canal and Emerging Pathogens. Otolaryngol Clin North Am 2023; 56:909-918. [PMID: 37553272 DOI: 10.1016/j.otc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Fungal infections of the external auditory canal can range from common (otomycosis) to life threatening (necrotizing otitis externa). Proper identification of fungal pathogens is necessary to guide appropriate therapy, and a high index of suspicion for fungal causes of ear canal disease is critical. Fungal pathogens may be an especially important cause of ear canal disease in certain populations, including patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients. Opportunistic fungal infections of the ear canal are an emerging concern.
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Affiliation(s)
- Erika McCarty Walsh
- Department of Otolaryngology, Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Matthew B Hanson
- Department of Otolaryngology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Hamiter M, Amorosa V, Belden K, Gidley PW, Mohan S, Perry B, Kim AH. Skull Base Osteomyelitis: Historical Perspective, Diagnosis and Management Update. Otolaryngol Clin North Am 2023; 56:987-1001. [PMID: 37479637 DOI: 10.1016/j.otc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
SBO is a life-threatening disease that requires a high index of suspicion based on these patients complex underlying medical co-morbidities and clinician's acumen. Once a diagnosis is made, is it critical to communicate and work closely with other multidisciplinary teams (neuroradiology for appropriate choice of imaging study and interpretation; infectious disease for appropriate medical treatment and duration; internist to properly manage their underlying medical co-morbidities). Despite advances in imaging, the diagnosis is first made based on clinical judgment, appropriate culture, and tissue biopsy.
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Affiliation(s)
- Mickie Hamiter
- Department of Otolaryngology, Columbia University Irving Medical Center, New York, NY, USA
| | - Valerianna Amorosa
- Module E, First floor, Corporal Michael J. Crescenz VA Medical Center, University and Woodlawn Avenue, Philadelphia, PA 19104, USA
| | - Katherine Belden
- Division of Infectious Diseases, Thomas Jefferson University Hospital, 1101 Market Street, Suite 2720, Philadelphia, PA 19107, USA
| | - Paul W Gidley
- Department of Head and Neck Surgery, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1445, Houston, TX 77030, USA
| | - Suyash Mohan
- Department of Radiology, 219 Dulles Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19004, USA
| | - Brian Perry
- Department of OTO-HNS, UT Health San Antonio, Joe R. and Teresa Lozano Long School of Medicine, 7703 Floyd Curl Drive, MC 7777, San Antonio, TX 78229-3900, USA
| | - Ana H Kim
- Department of Otolaryngology, Columbia University Irving Medical Center, New York, NY, USA.
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Pugliese G, Maccari A, Felisati E, Felisati G, Giudici L, Rapolla C, Pisani A, Saibene AM. Are artificial intelligence large language models a reliable tool for difficult differential diagnosis? An a posteriori analysis of a peculiar case of necrotizing otitis externa. Clin Case Rep 2023; 11:e7933. [PMID: 37736475 PMCID: PMC10509342 DOI: 10.1002/ccr3.7933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
Key Clinical Message Large language models have made artificial intelligence readily available to the general public and potentially have a role in healthcare; however, their use in difficult differential diagnosis is still limited, as demonstrated by a case of necrotizing otitis externa. Abstract This case report presents a peculiar case of necrotizing otitis externa (NOE) with skull base involvement which proved diagnostically challenging. The initial patient presentation and the imaging performed on the 78-year-old patient suggested a neoplastic rhinopharyngeal lesion and only after several unsuccessful biopsies the patient was transferred to our unit. Upon re-evaluation of the clinical picture, a clinical hypothesis of NOE with skull base erosion was made and confirmed by identifying Pseudomonas aeruginosa in biopsy specimens of skull base bone and external auditory canal skin. Upon diagnosis confirmation, the patient was treated with culture-oriented long-term antibiotics with complete resolution of the disease. Given the complex clinical presentation, we chose to submit a posteriori this NOE case to two large language models (LLM) to test their ability to handle difficult differential diagnoses. LLMs are easily approachable artificial intelligence tools that enable human-like interaction with the user relying upon large information databases for analyzing queries. The LLMs of choice were ChatGPT-3 and ChatGPT-4 and they were requested to analyze the case being provided with only objective clinical and imaging data.
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Affiliation(s)
- Giorgia Pugliese
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Alberto Maccari
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Elena Felisati
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Giovanni Felisati
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Leonardo Giudici
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Chiara Rapolla
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Antonia Pisani
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Alberto Maria Saibene
- Otolaryngology UnitSanti Paolo e Carlo HospitalMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
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