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

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.

[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.

Rare Cause of Skull Base Osteomyelitis: A Challenging Diagnosis and Management With a Literature Review

This is a case of skull base osteomyelitis (SBO) caused by a rare fungal species, Scedosporium apiospermum. This is a clinical case report with a review of the literature. SBO is a potentially life-threatening infection of the temporal bone. The patient presented to our hospital with a two-month history of left otalgia, otorrhea and reduced hearing, after failed initial intravenous antibiotic therapy. Thorough examination and further investigation confirmed the diagnosis of SBO caused by a rare fungal species, S. apiospermum. The patient was subsequently started on a long-term course of antifungals which led to an improvement of symptoms. This case highlights the importance of early recognition and considering early antifungal treatment in patients with persistent otalgia and otorrhea, particularly in those who have failed to respond to intravenous antibiotics. Further research is needed to better understand the optimal timing and duration of antifungal therapy in these patients.

[Current diagnosis and treatment of skull base osteomyelitis]

Skull base osteomyelitis is a rare, refractory, and potentially fatal disease primarily caused by otogenic and sino rhinogenic infections. At times, it can mimic neoplasia complicating the diagnosis. With the use of antibiotics, advancements in diagnostic methods, and skull base surgical techniques, the mortality rate has significantly improved. However, the successful diagnosis and treatment of the disease is still challenging due to delayed diagnosis, lengthy treatment course, a tendency for relapse and lack of guidelines. Therefore, this article aims to review the progress in the diagnosis and treatment of skull base osteomyelitis.

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis

OBJECTIVE

To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections.

METHODS

Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results.

RESULTS

Of 48 patients with NOE, the mean age is 73±11.6 years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9 days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2 days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders.

CONCLUSION

The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

Dysphagia due to necrotizing otitis externa

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.

Facial nerve palsy in otitis externa: A red flag?

Otitis externa is an infection of the external auditory canal. It rarely results in facial palsy except in severe cases such as necrotizing otitis externa, which is a life-threatening invasive infection of the external auditory canal. Early recognition with prompt and appropriate treatment of necrotizing otitis externa is crucial to prevent more sinister complications. Here we report a case of an elderly gentleman who presented with otitis externa and developed facial palsy a month later. We identified possible problems that may have led to the complication so that such an occurrence can be prevented in the future.

Conservative management of petrous apex abscess and Gradenigo's syndrome in a diabetic patient: Case report and literature review

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.

From Uncommon Infection to Multi-Cranial Palsy: Malignant External Otitis Insights

Purpose:

The progression of the otitic infectious process toward diseases of particular severity is often unpredictable, just as it is challenging to manage the patient over time, even after the apparent resolution of the disease. We aim to define a radiological reading key that allows us to correctly and promptly treat the disease, avoiding the possible severe complications.

Methods:

We conducted a retrospective study of 13 cases of basal cranial osteomyelitis (SBO) due to malignant external otitis, by the ENT Department of the University of Catania. Through a standardized approach and following the latest guidelines, we have evaluated all patients performing a standardized and personalized radiological protocol according to the stage of the patient’s pathology and modulating the treatment consequently.

Results:

Clinical signs have been observed such as otorrhea (100%), otalgia in 13/13 patients (100%), granulations in external auditory canal (100%), preauricular cellulitis in 9/13 patients (69%) headache 6/13 cases (46%), dysphonia 4/13 cases (31%). HRCT of the temporal bone proved useful in identifying even minimal bone lesions in 13/13 (100%) while improving MRI in vascular and nervous involvement, although in 1/13 patient with nerve palsy clinical symptomatology preceded radiological evidence. The 99mTc 3-phase planar bone scintigraphy was positive for SBO in 9/13 cases (69%) during the initial phase and, in 100% of the cases in images delayed to 2-3 hours. Subsequent checks up to 1 year, using the Ga 67 scintigraphy, excluded the presence of recurrences in 100% of patients.

Conclusion:

The osteomyelitis of the base of the skull is a severe complication of malignant external otitis, often not always easily diagnosed. Recurrence can occur up to 1 year after stopping therapy. Imaging techniques such as Tc and MRI are relevant for the initial diagnostic approach and the staging of the pathology and its complications. Nuclear medicine imaging plays a fundamental role in the evaluation of related osteoblastic activity, especially in the remission phase of the disease.

Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa

OBJECTIVES

To determine independent risk factors for 30-day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.

METHODS

Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013-2014). Overall and disease-specific complication and mortality data were analyzed using chi-squared and multivariate analysis.

RESULTS

There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio [OR] 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65-79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.

CONCLUSIONS

Thirty-day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2220-2228, 2020.

Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database

OBJECTIVE

To characterize factors that affect outcomes for patients with malignant otitis externa (MOE).

METHODS

Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed.

RESULTS

A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41).

CONCLUSIONS

This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.

Malignant external otitis following radiotherapy for oral cancer: A case report

RATIONALE

Although an ototoxicity is well-known as adverse event of the radiotherapy, it is not widely known that immunosuppressed patients who underwent radiotherapy in head and neck region have risk of malignant external otitis.

PATIENT CONCERNS

A 68-year-old man with diabetes, who had been diagnosed as intraosseous squamous cell carcinoma of the right mandible, underwent surgical resection. He received a total of 60 Gy/30Fr postoperative radiation. Four months after the course of radiation, he suffered from right aural fullness, otalgia and otorrhea.

DIAGNOSES

Clinical examination revealed granulation and existence of Pseudomonas aeruginosa in the external auditory canal. Computed tomography showed expansive inflammation and erosion in the temporal bone. The patient is elderly and diabetes. These findings led to the diagnosis of malignant external otitis.

INTERVENTIONS

The ear irrigation and administration of quinolones were started. Afterwards, fistula was formed in the oral cavity, and connected to the right external auditory canal. Therefore, irrigations were performed not only from ear but also from the oral fistula.

OUTCOMES

Eight weeks after starting treatment, the malignant external otitis was completely healed.

LESSONS

Physicians should raise awareness of malignant external otitis in immunosuppressed patients with oral cancer after radiotherapy.

Infections and foreign bodies in the ear, nose and throat

Infections of the ear, nose and throat are common and may threaten life. Intracranial complications may arise from infections of the ear and paranasal sinuses. Orbital complications (loss of vision) may arise from infection of the paranasal sinus. Respiratory embarrassment may result from infections of the upper aerodiogestive tract. The clinical presentation, implications and management of foreign bodies in the ear, nose and throat depend on the nature of the foreign body and the site at which it becomes lodged.