Necrotising otitis externa:A single centre experience

Introduction:Necrotising otitis externa(NOE)is a rare infection of the ear canal with frequent bone erosion.This study’s objective is to describe the different features of NOE as well as its management in an ear-nose-throat department.We also tried to identify the particularities of the fungal infection.Patients and methods:It is an observational cohort that included all the patients hospitalised for the management of NOE.The study was carried out in the ear-nose-throat Department of Mahdia University Hospital in Tunisia between January 2006 and december 2019.Results:A total of 40 patients were included.The mean age was 65±12.9 years and the sex ratio was 0.9.Ninety percent of the patients included were diabetics.The most common signs found were oedema of the external canal(97.5%)and auricular discharge(92.5%).The main pathogen isolated was Pseudomonas aeruginosa(61.7%).Fungi were isolated in 9 cases(26.47%).Computed tomography was performed for 32 patients(80%).Bone erosion was seen in 26 cases(81.3%).The main complications were cerebral venous thrombosis,retropharyngeal abscess and cerebral empyema.Thirty one patients received only antibiotics,2 received only antifungal treatment,and 7 received both antibiotics and antifungal treatment.All patients had a favorable outcome.Univariate analysis showed a higher median erythrocyte sedimentation rate was associated with fungal infections.No other differences were noted.Conclusion:Our management protocol seems to be efficient since all patients had initial favorable outcome.A higher median erythrocyte sedimentation rate was associated with fungal infections.

Malignant otitis externa with subsequent internal jugular vein thrombosis and hypoglossal palsy:a report and review of literature

Inflammation of a part or whole of the temporal bone and surrounding soft tissue is termed as malignant otitis externa,which typically spreads to skull base to involve cranial nerves VII.Rarely can it also effect one or more of cranial nerves IX,X,XI,and XII.We present a case of malignant otitis externa which presented with symptomatic palsy of IX and XII nerves sparing the VII cranial nerve.The patient though later on had internal jugular vein thrombosis,which we presume is due to the involvement of the parapharyngeal space that prompted us to reconsider the diagnosis,and later on,to aggravate the therapy.With proper blood sugar control and appropriate long term antibiotics,not only that the patient is disease free at one year follow up,but the cranial nerve deficits also recovered.Apart from sharing the clinical and management details of this patient,we have reviewed the relevant literature in the discussion,which has shed some light onto some of the interesting facts about this condition and its prognosis.

Double Blinded,Randomized and Controlled Comparative Study Evaluating the Cleaning Activity of Two Ear Cleaners in Client-Owned Dogs with Spontaneous Otitis Externa

Ear cleaning is a therapeutic component in the management of otitis externa in dogs. The objectives of this study were to evaluate the in vivo efficacy and safety of a new ear cleanser, Sonotix? against EpiOtic? Advanced for the management of canine otitis externa. Eighteen clients owned dogs with a diagnosis of erythemato-ceruminous or purulent otitis externa were prospectively included and randomized to two treatment group: EpiOtic? Advanced and Sonotix?. Cytology and video-otoscopic examination (erythema, amount of cerumen and thickness and surface of ear canal covered by cerumen) of all affected ears were done at D0, both before (T0) and 30 minutes (T0 + 30 min) after ear cleaning. Then an ear medication was applied (Aurizon?, Vetoquinol). Owners were instructed to clean affected ears daily and apply the ear medication 30 minutes later for 5 days (D1-D5). Dogs were seen again at D6 for cytology and video-otoscopic examination. At T0, no significant differences were found between both ear cleansers groups regarding macroscopic and microscopic scorings. At T0 + 30 min and D6 cytological and video-otoscopic scores were significantly decreased (Wilcoxon test;p < 0.01) compared to baseline in both groups. However, the cleaning activity of Sonotix? was statistically superior to Epiotic? as evidenced by the median global scores of video-otoscopic examination at T0 + 30 min (Mann Whitney Test, p < 0.01). Effective ear cleaning is an essential part of any treatment scheme because it favours the contact between the ointment and the lining ear epidermis and speeds resolution by the removal of cerumen, microbial organisms and cellular debris. In our study, the important reductions in yeast, cocci, and rod-shaped organism counts were demonstrated in smears at T0 + 30 min and D6 in both groups. Video-otoscopic examination performed 30 minutes after ear cleaning suggests that Sonotix? seems to be more effective in removing cerumen than EpiOtic? Advanced.

The diagnostic conundrum in necrotizing otitis externa

Necrotizing otitis externa(NOE)is an aggressive and fast‐evolving infection of the external auditory canal.Late diagnoses and untreated cases can lead to severe,even fatal consequences and so early diagnosis and treatment are paramount.NOE is a notoriously challenging diagnosis to make.It is therefore important to understand what diagnostic modalities are available and how otolaryngologists can use them to accurately treat such an aggressive disease.This review aims to evaluate the different diagnostic options available in NOE and discuss their advantages and limitations,thus,providing an up‐to‐date picture of the multimodal approach required in the diagnosis of this disease.

Hyperbaric oxygen therapy in malignant otitis externa:A systematic review of the literature

Objective:To review the role of adjuvant hyperbaric oxygen therapy(HBOT)in the treatment of malignant otitis externa(MOE).Data sources:PubMed,Scopus,Web of Science,Science Direct,and Cochrane Library were searched for the following concepts:“hyperbaric oxygen”and“malignant or necrotizing otitis externa.”Methods:Studies were included if they contained(1)patients with reported evidence of MOE,(2)employment of adjuvant HBOT,(3)details on patients’medical condition,and(4)documented survival outcomes.Extracted information included patient demographics,underlying medical conditions,infectious etiology,signs and symptoms,medical and surgical treatments,duration of medical treatment,mean follow up time,HBOT setting,number of HBOT sessions,complications,survival rate,and all-cause mortality.Results:A total of 16 studies comprising 58 patients(mean age 68.0 years)were included.Diabetes was present in 94.7%of cases and Pseudomonas spp(64.3%)was the most common infectious agent.Cranial nerve VII was involved in 55.2%of cases.Overall,the disease cure rate with adjuvant HBOT was 91.4%and all-cause mortality was 8.6%.Among those who had cranial nerve VII involvement,72.0%had return of function and 93.8%of them survived.Conclusion:HBOT may be an effective treatment option for refractory or advanced MOE but its efficacy remains unproven due to lack of strong scientific evidence.However,its therapeutic value should not be underestimated given good results and few adverse events reported in this study.

Methicillin-resistant Staphylococcus aureus in acute otitis externa

Objective:Otologic methicillin-resistant Staphylococcus aureus(MRSA)infection has historically been rare,but given the rise in community-acquired MRSA carriage and infection at other body sites,prevalence rates may be changing.The goal of this study was to determine the prevalence of MRSA in recent otologic cultures from patients with acute otitis externa(AOE).Study design:Retrospective review of an institutional microbiologic database.Methods:A retrospective analysis was performedon serial culture isolates taken fromthe ear at a quaternary care hospital from January 2014 to April 2016.The causative pathogen and antibiotic sensitivity was determined by culture isolation and end point mean inhibitory concentration(MIC)testing.Medical records were reviewed to document patient characteristics,chronicity of infection,symptomatology,and previous treatments.Results:Over the study period,173 patients were diagnosed with AOE and underwent otologic cultures of the ear.Fifty-three(30.6%)of cultures grew S.aureus(SA).Of SA infections,15(28.3%)were identified as MRSA.MRSA patients were typically older than patients with methicillin-sensitive SA(MSSA)(mean age 46.7
17.9 vs 29
19.4,PZ0.003)and had more medical comorbidities(4 vs 1.7,PZ0.001).Compared to patients with MSSA,patients with MRSAwere significantly more likely to have had prior ototopical antibiotic exposure(37%vs 73%,PZ0.019).Conclusion:Contemporary ear culture isolates at quaternary care center show higher rates of MRSA compared to historical reports in the literature.Clinicians should consider ear cultures to identify MRSA AOE.Level of Evidence:IV.

Antimicrobial potential of Terminalia chebula Retz. fruit extracts against ear pathogens

AIM： To evaluate the antimicrobial potential of Terminalia chebula （ T. chebula） extracts against pathogens causing otitis externa and compare it with ear drops.METHODS： Four different extracts, methanol, ethanol, acetone and aqueous （hot and cold） extracts, from the T. chebula were tested for their antimicrobial activity through the agar well diffusion method and minimum inhibitory concentration （MIC）/minimum bactericidal concentration （MBC） values were determined through the macrodilution broth method against six different microorganism, five bacterial （one gram positive and four gram negative） and one yeast.RESULTS： Organic and aqueous fruit extracts displayed activity against all fve tested bacterial ear pathogens with a maximum zone of inhibition of 31.6 mm against Staphylococcus aureus , followed by Acinetobacter sp. （24.6 mm）, Pseudomonas aeruginosa （23.6 mm）, Proteus mirabilis （21 mm） and Escherichia coli （19.3mm）. Of the four solvents evaluated, acetonic fruit extract of T. chebula was found to be best. The MIC values ranged between 0.78 mg/mL and 50 mg/mL for the different bacterial ear pathogens and MBC values ranged between 1.56 mg/mL and 50 mg/mL. The acetonic fruit extract showed larger inhibition zones compared to the herbal ear drops, Kan pip with lowest MIC of 0.78 mg/mL and MBC of 1.56 mg/mL.CONCLUSION： Acetonic extract of T. chebula fruit may be used to treat otitis externa. However, more detailed studies, such as in vivo testing and pharmacokinetics properties, are needed to determine its therapeutic potential.

Skull Base Osteomyelitis: A Rare Cause of Multiple Cranial Nerve Palsies—A Case Report from Ghana

Introduction: Skull Base Osteomyelitis (SBO) is an infectious inflammation of the skull bones that is often caused by malignant otitis externa (MOE) and affects the temporal bone. This condition commonly affects immunocompromised individuals and the elderly, particularly those with a history of diabetes mellitus. Diagnosis is challenging because of non-specific symptoms that lead to late detection and complications. This report discusses a case of SBO with multiple bilateral cranial nerve abnormalities and highlights the diagnostic and management challenges in high-risk individuals with subtle clinical signs. Case presentation: This report describes a 63-year-old patient with hypertension and diabetes who underwent surgical debridement of the left ear due to malignant otitis externa 4 months prior to presentation. The patient presented with significant dysarthria, dysphagia, ptosis of the left eye with double vision, and hearing impairment in the left ear. Examination revealed bilateral CN VI palsy, right CN VII palsy, left CN VIII palsy, and a right CN XII deficit. Initial tests were unremarkable, but a high Fungitell assay and a second review of the CT scan and MRI revealed a pathological process in the base of the skull involving bony structures and cranial nerves bilaterally, which helped diagnose SBO. The patient was subsequently discharged with oral voriconazole and continued his usual medications. The patient requested further management abroad, because he did not notice resolution of his symptoms. Surgical treatment was employed abroad to relieve his symptoms, as he recovered slowly. Conclusion: This case report underscores the importance of a multidisciplinary approach to address SBO. Collaboration between specialists in infectious diseases, otolaryngology, radiology, and neurology plays a pivotal role in achieving an accurate diagnosis and developing a tailored treatment plan. Although SBO may be infrequent, this case report highlights the need to maintain heightened clinical suspicion in high-risk individuals.