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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., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: 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 ( 18 F-FDG PET) and labeled leukocyte scintigraphy (LS) to monitor treatment responses in NOE., Methods: Consecutive patients with NOE who underwent 18 F-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., Results: 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 (SUV max )-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 SUV max -lesion-to-background ratio was the only predictive factor of recovery when associated with all clinical parameters ( P  < .001)., Conclusion: 18 F-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., Trial Registration: 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)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To identify the earliest sites and spread patterns of bony erosions on high-resolution temporal bone computerized tomographic (HRTBCT) scans and conjugate the radiological findings with clinical/laboratory data for guiding the interpretation of CT images of skull base osteomyelitis (SBOM) from malignant otitis externa (MOE)., Study Design: Retrospective and prospective medical records analysis., Methods: The medical records of all patients who presented to a referral medical center during 2015-2022 and initially diagnosed with SBOM. Radiological assessment of each sub-site was performed by 2 qualified neuro-radiologist, who were blind to the clinical data., Results: 33 patients were enrolled. All patients suffered edema and exudates of the external auditory canal (EAC). The most common osseous markers for SBOM were dehiscence or irregularity of the anterior EAC wall and temporomandibular joint (TMJ) medial wall (21/33, 64% patients, each), followed by a fistula from the TMJ to the EAC (20/33, 61% patients). Eustachian tube bony walls and condylar irregularity and/or dehiscence were as prevalent as 16/33, 48% of patients, each. EAC inferior and posterior walls of the EACs were irregular or dehiscent in patients with more advanced disease., Conclusions: The high symptomatologic overlap between SBOM and other aural pathologies might cause diagnostic (and subsequent treatment) delay and result in dire complications. EAC edema and irregularity or dehiscence of the anterior EAC wall are the most common early CT findings associated with SBOM caused by MOE., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To determine the diagnostic accuracy of Necrotizing Otitis Externa (NOE) based on radiologic studies., Methods: The PubMed, Cochrane, Embase, Web of Science, SCOPUS, and Google Scholar databases were searched. True-positive and false-negative results were extracted for each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool., Results: The included studies contained data on 37 studies diagnosed with NOE. The sensitivity of gallium-67, technetium-99m, and Magnetic Resonance Imaging (MRI) was 0.9378 (0.7688-0.9856), 0.9699 (0.8839-0.9927), and 0.9417 (0.6968-0.9913), respectively. For Computed Tomography (CT), the positive criteria consisted of bony erosion alone and bony erosion plus any soft tissue abnormality. The sensitivity of CT based only on bony erosion was 0.7062 (0.5954-0.7971); it was higher 0.9572 (0.9000-0.9823) when based on bony erosion plus any soft tissue abnormality., Conclusion: The diagnostic sensitivity of technetium-99m, gallium-67, and MRI was favorable. On CT, the presence of bony erosion may be a useful diagnostic marker of NOE, but the diagnostic sensitivity will be even higher if the criterion of any soft tissue abnormality is also included; however, care should be taken when interpreting the results. Our study demonstrates the potential utility of radiology studies for diagnosing NOE, but their lack of specificity must be considered, and standardized anatomic criteria are still needed., Level of Evidence: 2A., (Copyright © 2021 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

Necrotising Otitis Externa (NOE) has often posed some challenges in view of diagnosis and management by clinicians. One such challenge is the appropriate and timely use of imaging techniques, since its use is critical not only in diagnosis but also determining the extent and resolution of the disease. Hence, doctors in both primary and secondary health care need to be familiar with presenting symptoms, while specialists need to be appraised of advances in imagining techniques in management of NOE. Whilst there is a general consensus amongst clinicians on some aspects of management of NOE, there is very limited consensus on the use of imaging modalities. There is no single modality of imaging that can provide a complete picture of diagnosis, disease progression and resolution. There are some advantages and limitation of each methodology, which indicate that a multi-modal imaging technique at particular stages of the disease may provide better management outcomes. However, further research in this area is required, as there is not yet an established 'gold standard' for imaging in NOE.

Background and Purpose: Necrotizing external otitis (NEO) is a serious complication of external otitis. NEO can be classified according to-anterior, medial, posterior, intracranial, and contralateral-extension patterns. Currently there is no consensus on the optimal imaging modality for the identification of disease extension. This study compares NEO extension patterns on MR and CT to evaluate diagnostic comparability., Methods: Patients who received a CT and MR within a 3-month interval were retrospectively examined. Involvement of subsites and subsequent spreading patterns were assessed on both modalities by a radiologist in training and by a senior head and neck radiologist. The prevalence of extension patterns on CT and MR were calculated and compared., Results: All 21 included NEO cases showed an anterior extension pattern on CT and MR. Contrary to MR, medial extension was not recognized on CT in two out of six patients, and intracranial extension in five out of eight patients. The posterior extension pattern was not recognized on MR. Overall, single anterior extension pattern (62%) is more prevalent than multiple extension patterns (38%)., Conclusion: All anterior NEO extension pattern were identified on CT as well as MR. However, the medial and intracranial spreading patterns as seen on MR could only be identified on CT in a small number of patients. The posterior spreading pattern can be overlooked on MR. Thus, CT and MR are complimentary for the initial diagnosis and work-up of NEO as to correctly delineate disease extent through the skull base., (© 2021. The Author(s).)

Abstract: We reported a 66-year-old woman with malignant external otitis who was referred to our department for evaluation of disease extension. Both 99mTc-MDP bone SPECT/CT and 68Ga-citrate PET/CT were done for the patient. Both studies showed concordant areas of increased uptake in the petrous bone. In addition, 68Ga-citrate PET/CT showed soft tissue infection in the nasopharyngeal wall. Our case showed the potential of 68Ga-citrate PET/CT for evaluation of malignant external otitis., Competing Interests: Conflicts of interest and sources of funding: none declare., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: High-resolution temporal bone computer tomography (HRTBCT) is the most common initial radiological modality used for the assessment of necrotizing otitis externa (NOE)., Objectives: (1) To compare the extension of disease, as seen on HRTBCT, in patients with NOE caused by different pathogens and (2) assess whether radiological findings may suggest the offending pathogen in cases of sterile-NOE., Methods: All NOE patients were hospitalized between 1990 and 2018. All patients underwent HRTBCT at admission. Three groups (fungus-NOE, PA-NOE and sterile-NOE) comprising of ten patients each were randomly selected. HRTBCT was reevaluated by a senior radiologist. Thirteen radiological subsites were selected for reevaluation., Results: All patients in the fungal-NOE group complained of otalgia, compared to nine in the sterile-NOE and six in the PA-NOE groups (p value = 0.044). External ear canal edema and granulation tissue were the most common findings in all groups. Surgery was performed in five patients in the fungal-NOE and PA-NOE and three in the sterile-NOE group (p value =  > 0.05). Radiological findings indicating severe bone erosion within the EEC was seen in all patients but 3 (p value =  > 0.05). Severe TMJ erosion was seen in one patient within the fungal-NOE and PA-NOE group (p value =  > 0.05). When mild and severe involvement were combined, TMJ bone erosion was seen in four patients in the fungal-NOE and only in one patient in the PA-NOE (p = 0.04)., Conclusions: TMJ involvement may be more common in fungal disease, suggesting a different spreading pathway, as opposed to PA-NOE. Accordingly, TMJ involvement on HRTBCT may justify antifungal treatment in sterile culture-NOE., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Malignant otitis externa is a progressive infection of the external auditory canal and skull base. Pseudomonas aeruginosa is the most isolated microorganism and it affects mostly to diabetic, elderly, and immunocompromised individuals. Non-resolving otalgia and chronic otorrhea are the clinical manifestations presented. Facial nerve palsy is a common and well recognized complication. (Computed tomography) CT scan is useful for initial assessment, Technetium-99m is highly sensitive and is part of the protocol for diagnosis. Treatment should be individualized, with multidisciplinary cooperation among specialties. Management involves systemic antipseudomonal antibiotics and monitoring with radiologic techniques, it also involves the strict control of diabetes. It is essential to follow up the patients for at least a year post-treatment. In refractory malignant otitis externa and affection of facial nerve, surgical management is recommended. We reviewed the most recent studies on epidemiology, clinical manifestations, diagnosis, and treatment to provide an update on Malignant Otitis Externa that can offer an overview for clinical practice and future research., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Otitis externa and otitis media are common in American Cocker Spaniels, however breed-specific aural CT descriptions are currently lacking. This prospective and retrospective, observational, analytical study aimed to describe quantitative CT characteristics of the horizontal ear canal and the tympanic bulla in American Cocker Spaniels versus similar-sized mesaticephalic dogs. We prospectively performed clinical examinations and aural CT scanning for 38 American Cocker Spaniels. Computed tomographic transverse area of the osseous horizontal ear canal (TA1), transverse area of the widest air-filled part of the cartilaginous horizontal ear canal (TA2), tympanic bulla volume, and tympanic bulla wall thickness were measured. The TA1 and TA2 measurements were compared with those of 23 retrospectively recruited, similar-sized mesaticephalic dogs that had undergone CT-scanning of the head for non-ear-related reasons. The TA1 and TA2 did not differ for healthy American Cocker Spaniels and mesaticephalic dogs. Severely affected American Cocker Spaniels had significantly smaller TA2 (P < .001). The intraclass correlation coefficient for intraobserver and interobserver repeatability was 0.972 and 0.983 for TA1 and 0.994 and 0.998 for TA2, respectively. Variation between individuals was subjectively noted in healthy and affected American Cocker Spaniels, but mean tympanic bulla volume was slightly smaller in relation to body weight, and the tympanic bulla wall was thicker than in previous reports for mesaticephalic dogs. The tympanic bulla wall appeared thicker rostro-ventrally than caudo-ventrally in 44% of the dogs. Our results imply that a relatively thick tympanic bulla wall may be a normal CT variation and should be interpreted cautiously in this breed., (© 2020 American College of Veterinary Radiology.)

Purpose: Malignant external otitis is an aggressive and potentially life-threatening infection. This rare disorder is typically caused by Pseudomonas aeruginosa and affects almost exclusively elderly diabetic patients. However, fungal malignant external otitis have been identified, especially in immunocompromised hosts., Methods: We report a rare case of invasive malignant external otitis caused by Aspergillus flavus in a diabetic patient without other underlying immunosuppression. A review of Aspergillus spp. malignant external otitis since voriconazole became the first line for invasive aspergillosis was performed., Results: A 72-year-old man with diabetes mellitus developed invasive malignant external otitis with a vascular involvement. The patient was treated with empiric courses of antibiotics until a fungal infection was diagnosed. Proven Apsergillus infection was based on histopathological examination and isolation of A. flavus from culture of osteo-meningeal biopsies. Despite optimal antimicrobial therapy with voriconazole, the patient presented with cerebral infarction in the setting of an angioinvasive fungal infection leading to a fatal outcome. From a review of the literature, we found 39 previously published cases of proven Aspergillus spp. malignant external otitis treated with new triazoles., Conclusion: Given our experience and the literature review, a fungal etiology should be considered early in the course of malignant external otitis unresponsive to a conventional broad spectrum antibiotic therapy, with the need for a tissue biopsy to confirm the diagnosis.

Background: Video otoscopy is a valuable tool for the diagnosis and treatment of otitis externa (OE) and otitis media (OM) in dogs. Procedures performed by video otoscopy often are painful and it can be challenging to maintain steady anaesthetic depth and provide smooth anaesthetic recovery. A multimodal approach to analgesia and anaesthesia is ideal to minimize complications associated with high doses of anaesthetic drugs while providing the patient with adequate analgesia., Hypothesis/objective: To describe a technique for regional anaesthesia of the canine ear., Animals: One canine cadaver, obtained as part of a teaching laboratory class for other clinical techniques, with institutional approval, was used for illustration purposes., Results: Clinical technique for regional anaesthesia of the canine ear., Conclusions and Clinical Importance: Nerve blocks for regional anaesthesia are an important aspect of a multimodal anaesthetic approach. A technique for blocking the two major sensory nerves to the canine ear is described., (© 2019 ESVD and ACVD.)

A four-year-old female French bulldog was presented for evaluation of acute, left-sided peripheral vestibular syndrome. Computed tomographic (CT) examination of the head revealed the presence of air within the left cochlea and vestibule, consistent with pneumolabyrinth. This was concurrent with ipsilateral otitis media and externa. Pneumolabyrinth is an uncommon finding in humans and is most frequently due to head trauma and temporal bone fracture. This is the first report describing pneumolabyrinth in a dog, apparently of nontraumatic origin in this case., (© 2017 American College of Veterinary Radiology.)

Objective: The prognosis of patients with malignant external otitis (MEO) depends on the extent of the inflammatory changes in the temporal bone and skull base. The efficacy of high-resolution computed tomography (HRCT) imaging in accurately assessing the extent of disease is compared with that of single-photon emission computed tomography/computed tomography (SPECT/CT) scan., Study Design: A clinical chart review was conducted with medical records and radiologic images., Setting: Tertiary care medical college hospital., Subjects and Methods: This study involved patients with clinically diagnosed MEO who underwent both modalities of imaging of the skull base. Staging of the disease extent was compared between the imaging systems among patients. Symptom control and survival rates were analyzed with respect to the SPECT/CT staging of MEO., Results: Out of 28 patients included in this study, 72% had SPECT/CT scans showing higher staging than the HRCT imaging. Four patients had mild uptake (stage 1), and 15 had disease confined to the mastoid/temporal bone, not reaching midline (stage 2). All patients in stages 1 and 2 were surviving with good symptom control. Five patients with petrous involvement reaching midline (stage 3) had persistent symptoms, and all 4 cases with SPECT/CT showing sphenoid involvement and crossing midline (stage 4) died within a year of diagnosis., Conclusions: SPECT/CT scan is more sensitive than HRCT imaging in detecting the extent of disease and is a better prognosticator for patients with MEO.

A 76-year-old man, who had undergone surgery for esophageal cancer in 2010, presented to our hospital in April 2017 complaining of prolonged slight fever, loss of appetite, and dysphagia. Initial evaluation revealed a paralyzed left vocal cord, slight muscle weakness of the extremities, left facial paralysis, hoarseness, left sternocleidomastoid and trapezius muscle weakness, tongue deviation to the left, and left hypacusia-suggesting a diagnosis of Garcin's syndrome. Laboratory tests revealed increased white blood cells and C-reactive protein. Cerebrospinal fluid (CSF) analysis showed mild pleocytosis (predominantly polymorphonuclear cells), elevated protein, and low CSF/plasma glucose ratio. CT showed mild clival erosion, with no evidence of carcinoma recurrence. Brain contrast-enhanced MRI showed abnormal clival marrow, enhanced soft tissue and dura matter from the clivus to the atlantoaxial joint, enhanced soft tissue around the left ear canal, multiple cerebral infarctions in the left watershed zones, and left internal carotid stenosis. There was excessive ear wax and inflammation of the left external acoustic meatus but no otorrhea or otalgia. On the basis of his overall presentation, he was diagnosed with atypical skull base osteomyelitis due to external otitis. He was treated with antibiotic treatment that included ceftazidime for the Pseudomonas aeruginosa detected on bacterial cultures. He did not respond to treatment and died approximately 4 months later. Skull base osteomyelitis is thus an important differential diagnosis candidate after finding unilateral, multiple cranial neuropathy, underscoring the importance of prompt treatment when suspected.

Objective: Imaging is important for the diagnosis and follow-up of necrotizing external otitis (NEO). The best imaging modality is controversy. To suggest 2-deoxy-2-[fluorine-18] fluoro-D-glucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) as an alternative to technetium-99m and gallium-67 scans for diagnosis and assessment of response to treatment for patients with NEO., Study Design: Case series., Methods: Tertiary referral center. From 2013 through 2017, 12 patients were diagnosed with NEO based on clinical features and positive FDG uptake within the temporal bone on PET/CT. Mean age was 74 ± 11.5; 83% of the patients were male; and 83% had diabetes., Results: PET/CT scans were reviewed independently by two nuclear medicine specialists. Imaging located osteomyelitis in external ear canal, mastoid, temporomandibular joint, and nasopharyngeal region (100%, 50%, 16%, 8%, respectively). Mean follow-up was 16 months. Eight patients (67%) underwent a second PET/CT scan after active otitis resolved and after at least 6 weeks of antibiotic treatment. The scan demonstrated no or substantially reduced FDG uptake and treatment was stopped. The patients had no NEO symptoms at the end of follow-up. One patient had significant uptake, and antibiotic treatment was continued until a third scan demonstrated no FDG uptake. Two patients died before the second PET/CT, and two were lost to follow-up., Conclusion: 18F-FDG-PET/CT is a reliable imaging modality for diagnosis, disease localization, and decision making regarding treatment cessation. 18F-FDG-PET/CT should be considered as the imaging modality of choice for initial diagnosis and follow-up in NEO patients. Larger, controlled studies are warranted., Level of Evidence: 4 Laryngoscope, 129:961-966, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To survey neurotologists and head and neck radiologists regarding use of imaging in the diagnosis and management of necrotizing otitis externa (NOE)., Study Design: Cross-sectional survey study., Setting: Online survey distributed through email to specialty society membership lists., Participants: Neurotologists and head and neck radiologists with membership in either the American Neurotology Society or The American Society of Head and Neck Radiology., Main Outcome Measures: Responses to survey consisting of two demographic and seven clinically oriented questions related to the use of imaging in the diagnosis and management of NOE., Results: One hundred thirty-six participants responded to the survey. The imaging modality of choice in establishing the diagnosis of NOE selected by the respondents was computed tomography (CT) (37.5%) followed by technetium scintigraphy (21.3%). Magnetic resonance imaging (MRI) was the preferred investigation by 41.9% of participants for determining extent of disease. Gallium scanning was the imaging modality preferred by 32.4% of respondents for determining when to cease medical therapy. Ninety-five percent of participants responded that CT scans were always or frequently used in the diagnosis and management of NOE compared with 72.8% for MRI, 34.5% for gallium scans, and 34.2% for technetium scans., Conclusions: There is considerable heterogeneity in the preferred imaging modalities used in the diagnosis and management of NOE. CT and MRI are the preferred contemporary modalities used by many physicians, demonstrating a shift away from the historic use of nuclear medicine scans.

Importance: Malignant external otitis (MEO) is an aggressive infection occurring in immunocompromised hosts. Increasing antimicrobial resistance is making the disease more difficult to treat., Objective: Determine if there has been a shift in the microbiology and outcomes of MEO., Design: A retrospective case series at a tertiary care institution., Setting: Inpatient and outpatient tertiary care hospital., Participants: 12 cases of recent MEO were reviewed., Main Outcomes and Measures: The primary outcome was progression of disease. Secondary outcomes were drug resistance and complications of MEO., Results: Only 4 patients were cured of MEO. Four patients expired during the study period and at least one of these deaths was a direct result of the MEO. 7 patients developed Cranial nerve palsies, and 3 patients developed abscesses., Conclusions: Select cases of MEO now require multi-drug and long-term parenteral antibiotic therapy with extended hospital stays., (Copyright © 2017. Published by Elsevier Inc.)

Background We report a case of bilateral malignant otitis externa complicated with bilateral petrous internal carotid artery pseudoaneurysms and their successful treatment with a flow diverter. Case report A 68-year-old woman with serious complications of type II diabetes mellitus had malignant otitis externa on the right side. She was treated with combined antibiotic therapy and underwent mastoidectomy for mastoiditis. She presented at our hospital with acute hemorrhage from the right external auditory canal. The emergency computed tomography (CT) angiography revealed a multiobulated pseudoaneurysm at the petrous segment of the right internal carotid artery. The pseudoaneurysm was treated with a 5 × 40-mm Surpass flow diverter. Three months later, she developed a malignant external otitis on the left side. As the infection progressed, a left-sided mastoiditis, a brain abscess, and a pseudoaneurysm at the petrous segment of the left internal carotid artery developed. The pseudoaneurysm caused bleeding from the left ear, and was treated with a 5 × 50-mm Surpass flow diverter. No recurrent bleeding was observed. Four months later, a follow-up angiography showed complete occlusion of the pseudoaneurysm on the left side, but a residual aneurysm could be detected on the right side. One year after the first intervention, the follow-up CT and magnetic resonance angiography revealed the complete occlusion of the aneurysms bilaterally. Conclusion The use of a flow diverter appears to be an efficient and safe method to occlude carotid pseudoaneurysms even in an inflammatory milieu.

Objective: To report our initial experience of diffusion-weighted magnetic resonance imaging (DW-MRI) as a novel imaging tool for assessing and monitoring treatment response in necrotizing otitis externa (NOE)., Patients: Seven adults with a diagnosis of NOE on both clinical and computed tomography (CT) criteria who were subsequently monitored with at least two echoplanar DW-MRI investigations were included in this retrospective longitudinal observational study., Intervention: Patients underwent magnetic resonance imaging (MRI), including echoplanar diffusion-weighted sequences, within 2 weeks of diagnosis of NOE to determine the extent of infection and to provide a baseline scan for monitoring response to treatment. Repeated imaging was undertaken after the agreed initial course of antimicrobial therapy was completed., Main Outcome Measure: The primary outcome measure for complete treatment response was complete resolution of high inflammatory signal on the DW-MRI apparent diffusion coefficient (ADC) map. This was correlated to clinical, biochemical, and other MRI measures of disease resolution., Results: Baseline DW-MRI was carried out in all but one patient within 2 weeks of the initial diagnostic CT scan. Patients had between one and three further DW-MRI scans, at a mean interval of 4.4 months from the initial scan (range, 2-8 months). The decision to terminate or continue therapy correlated with ADC signal findings on DW-MRI in all cases. In comparison, conventional MRI sequences performed less well, as there was some degree of persistent residual soft tissue changes in all cases.

Objective: Necrotising otitis externa is associated with high morbidity and mortality rates. This study investigated whether temporomandibular joint involvement had any prognostic effect on the course of necrotising otitis externa in patients who had undergone hyperbaric oxygen therapy after failed medical and sometimes surgical therapy., Methods: A retrospective case series was conducted of patients in whom antibiotic treatment and surgery had failed, who had been hospitalised for further treatment and hyperbaric oxygen therapy., Results: Twenty-three patients with necrotising otitis externa were identified. The temporomandibular joint was involved in four patients (17 per cent); these patients showed a constant gradual improvement in C-reactive protein and were eventually discharged free of disease, except one patient who was lost to follow up. Four patients (16 per cent) without temporomandibular joint involvement died within 90 days of discharge, while all patients with temporomandibular joint involvement were alive. Three patients (13 per cent) without temporomandibular joint involvement needed recurrent hospitalisation including further hyperbaric oxygen therapy; no patients with temporomandibular joint involvement required such treatment., Conclusion: Patients with temporomandibular joint involvement had lower rates of recurrent disease and no mortality. Therefore, we suggest considering temporomandibular joint involvement as a positive prognostic factor in necrotising otitis externa management.

Objectives/hypothesis: On the basis of clinical observations, the shape of the osseous external auditory canal (OEAC) has often been seen as an etiological factor in troublesome cavities after modified radical mastoidectomy., Study Design: Retrospective analysis of CT scans., Methods: To assess the role of the shape of the OEAC in troublesome modified radical cavities using computed tomographic scans of three groups of patients (without pathology and with or without draining cavities), we determined the depth of the pretympanic recess (DPTR) and its anterior curvature (ACPTR). In addition to looking at the shape of the OEAC, we also studied the role of any remaining mastoid air cells in relation to troublesome radical cavities, as well as the consultation frequency., Results: The DPTR was significantly deeper in draining cavities than in ears without pathology and dry cavities. No difference in the ACPTR was observed. The presence of remaining mastoid air cells is significantly associated with the presence of a troublesome radical cavity., Conclusions: The shape of the OEAC (i.e., the DPTR) is a contributory factor to the drainage of modified radical cavities., Level of Evidence: 4. Laryngoscope, 126:693-698, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: 1) Stratify malignant otitis externa into severe and nonsevere disease categories. 2) Predict treatment courses and outcomes based on this stratification., Setting: Tertiary center., Patients: Retrospective review 2004 to 2014; 28 patients. Inclusion criteria are a diagnosis by senior authors, radiographic evidence of disease, admission for intravenous antibiotics/debridement, minimum 1 year of follow-up., Interventions: Severe group stratification if two or more of the following: cranial nerve VII palsy, fungal positive culture, relapse, surgery performed, major radiographic findings. All other patients stratified to nonsevere group., Main Outcome Measures: Cure, alive/refractory disease, death by disease, death by other cause. Secondary measures are antibiotic duration and number of disease-related admissions., Results: Forty-three percent (12 of 28) and 57% (16 of 28) of patients stratified into the severe and nonsevere groups. The severe group had significantly more adverse disease-specific outcomes than the nonsevere group (7 of 12 versus 0 of 16; p = 0.002). Disease-specific mortality was 42% and 0% in the severe and nonsevere groups, respectively. The severe group had longer antibiotic courses (12.8 versus 6.9 wk; p = 0.01) and more disease-related admissions/relapses (1.6 versus 1, p < 0.001). Only four of 12 severe group patients achieved cure. All but two nonsevere patients achieved cure, with those two dying of other causes., Conclusion: A subgroup of malignant otitis externa may exist that is not as susceptible to parenteral antibiotics and local debridement. A combination of clinical and radiographic findings may be useful for stratifying patients into severe/nonsevere categories. Patients with severe disease may be more likely to die of their disease and have worse treatment courses such that additional surgical intervention may be indicated.

Background: Ipsilateral hypoglossal nerve (XII) paresis has never been reported as the first and only complication of malignant otitis external (MOE)., Case Report: A 73-year-old diabetic male with persistent left temporomandibular joint ache and ear fullness was admitted with the diagnosis of MOE. He received intravenous ciprofloxacin for 14 days and then continued with oral administration (per os). After two months, he returned with otalgia, swallowing difficulty, and ipsilateral XII paresis. He was re-admitted, received intravenous ciprofloxacin for 6 weeks, and continued with per os ciprofloxacin for 6 months. A Ga67-scan 6 months after the first admission revealed no active infection. Two years after his last admission, the patient still has XII paresis. There is no other cranial nerve involvement and inflammatory markers continue to be normal., Conclusion: Doctors should consider MOE in the differential diagnosis when there is XII paresis, especially in diabetic and immunocompromised patients.

Necrotizing (malignant) otitis externa (NOE) is a rare and invasive infection originating in the external acoustic meatus seen most commonly in diabetes and other immunocompromised states. After a protracted course, disease can smolder and extend into the mastoid, skull base, dural sinuses, and intracranially. We present a case of NOE complicated by mastoiditis, dural sinus thrombosis, and Bezold's abscess in an uncontrolled diabetic presenting with a prolonged course of facial nerve palsy. We stress the importance of maintaining a high index of clinical suspicion for NOE in diabetic patients and offering timely, aggressive treatment to mitigate its complications., (© 2013 Elsevier Inc. All rights reserved.)

Malignant otitis externa is a severe and rare infection of the external acoustic meatus. Triphasic bone and (67)Ga scintigraphies are used to initial detect and follow-up the response of therapy. With single photon emission computed tomography/computed tomography images, the diagnostic sensitivity is higher. We presented a case with malignant otitis externa with initial negative planar scintigraphic finding. The lesion was detected by photon emission computed tomography/computed tomography images. We concluded that the photon emission computed tomography/computed tomography should be performed routinely for patients with suspected malignant otitis externa, even without evidence of lesion on planar images., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To establish a clinicopathological profile of malignant otitis externa (MOE) in an Australian tertiary referral institution., Study Design: Retrospective cohort outcomes study., Methods: 24 patients were identified with MOE between January 1998 and July 2007. Patients were classified into Radiological Grades I-IV. Laboratory investigations Including C-reactive protein (CRP), white cell count (WCC), glycosylated haemoglobin (HBA1c) and average glucose level over admission were recorded., Results: Radiological Grade was significantly associated with duration of therapy (rank correlation 0.57, p = 0.004). CRP was a useful indicator confirming disease resolution. Diabetics with MOE had elevated average blood sugar levels during their Hospital admission (p < 0.001) and had poor overall glycaemic control represented by Elevated HBA1c scores (p < 0.001)., Conclusions: Malignant otitis externa is a rare disease, which is best managed in a multidisciplinary team setting. This practical grading system can be used to predict the duration of therapy at time of diagnosis, which enables the efficient utilisation of Hospital resources. Poorly controlled diabetics are more susceptible to developing. MOE than diabetics with satisfactory glycaemic control and may represent a subgroup of more brittle diabetics. CRP combined with appropriate clinical and radiological investigations is useful in assessing disease resolution., (Copyright © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. All rights reserved.)

Objectives/hypothesis: Presence of fluid in the middle ear (ME) or mastoid air cells in acute otitis externa (OE) has not been reported. We hypothesize that in patients with OE there is often otitis media (occult middle ear and mastoid fluid) and secondary fluid in the mastoid air cell system, which is not seen during a clinical examination because of edema in the external canal skin., Study Design: Retrospective chart review., Methods: We reviewed the medical records of 209 patients who presented to our ear, nose, and throat (ENT) clinic with acute OE that was resolved with oral and/or topical antibiotics., Results: Twenty-seven of the 209 patients presented with unilateral or bilateral acute OE (29 ears) and received a computed tomography (CT) scan of their temporal bones, which was ordered by the Emergency Department or ENT services. Twenty-three of 29 ears (79%) showed fluid in the ME, mastoid, or both. Nine of the 10 patients (82%), who obtained their CT scan within 1 week of symptom onset, were found to have fluid., Conclusions: These findings support our hypothesis and serve to inform the medical community (both ENT and primary care) that fluid is often present in the ME or mastoid in patients with acute OE whose symptoms will resolve with oral and/or topical antibiotics., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

We report the case of an immunocompromised female patient with external otitis, who developed a picture of external otitis with poor response to conventional treatment and subsequent isolation of Pseudomona Aeruginosa in the ear secretion culture. The final diagnosis was malignant external otitis. Our objective is to describe the scintigraphic findings as well as to analyze their correlation with the clinical pattern and to evaluate the possible causes of the discordance found., (Copyright © 2011 Elsevier España, S.L. y SEMNIM. All rights reserved.)

Malignant otitis externa is a severe, rare infective condition of the external auditory canal and skull base. The diagnosis is generally made from a range of clinical, laboratory, and imaging findings. Technetium 99m methylene diphosphonate bone scintigraphy is known to detect osteomyelitis earlier than computed tomography. The authors present a patient with bilateral malignant otitis externa where the extent of skull base involvement was determined on 3-phase bone scintigraphy with single photon emission computed tomography/computed tomography., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Inflammatory and infectious diseases of the temporal bone are a major indication to perform high-resolution CT and MR imaging studies. Such studies allow one to evaluate the extent of the disease in the soft tissues and in the bony structures of the temporal bone. On these same imaging studies the possible extension of the infection to surrounding regions is visualized. In this article a segmental approach is used, focusing on four structures in the temporal bone: the external ear, the otomastoid and petrous apex, the inner ear, and the facial nerve. For each of the four sections imaging findings are described and illustrated, and if relevant a differential diagnostic approach is highlighted.

Invasive otitis externa (IOE) due to Aspergillus is a rare, potentially life-threatening, invasive fungal infection affecting immunocompromised patients. The invasive process may lead to skull base osteomyelitis with progressive cranial nerve palsies and can result in irreversible hearing and neurological impairment. We report two cases of Aspergillus IOE treated with voriconazole alone and a literature review of antifungal therapy of Aspergillus IOE. Twenty-five patients, including the two described in the present report, were analyzed. Eighteen patients were treated with amphotericin B, and nine of them received itraconazole as an additional agent. Three patients received initial therapy with itraconazole, and one patient was treated with both voriconazole and caspofungin therapy. The two patients in the present report received voriconazole therapy alone with good clinical and biological tolerance despite prolonged treatment. The last patient did not receive antifungal therapy, as the diagnosis was made postmortem. Eighteen patients underwent an initial extensive surgical debridement. The majority of the patients had a favorable outcome, 17 patients experienced a complete recovery, and 6 showed a partial improvement. Both of the patients reported on here had favorable outcomes, and no aggressive surgical debridement was required. Although voriconazole has been shown to be effective for the treatment of invasive aspergillosis, its precise role in the management of Aspergillus IOE had not been documented. These observations demonstrate that voriconazole could be an effective and well-tolerated therapeutic option for the management of Aspergillus IOE.

Objective: This study was undertaken to assess the scope of sonography for the diagnosis of diseases of the external ear., Methods: We developed a description of the sonographic anatomy of the normal ear pinna, including the thickness of the normal cartilage and lobule, through systematic scanning of the external ears of 11 healthy volunteers (2 male and 9 female), and reviewed clinical cases with pathologic entities., Results: Reproducible and recognizable images were collected from normal as well as pathologic cases of the external ear. Images are presented for reference., Conclusions: Sonography permits good visualization of the internal structure, including the cartilage, and it is possible to use sonography as a method of study to differentiate between inflammation, vascular lesions, and tumors.

Objective: Fungal necrotizing otitis externa is rare, although its frequency has increased over the last few years. We report four cases, which to our knowledge make up the largest series published and discuss the main diagnostic problems and the management of this infection., Observations: Our study investigated two men and two women, all diabetics, aged between 69 and 74 years. All four patients were first treated for bacterial necrotizing otitis externa. Diagnosis was reviewed after a lack of response to antibiotic therapy. Aspergillus flavus and Candida parapsilosis were the fungal agents isolated in each of the two patients. Diagnosis was established based on the pathological specimen for one patient. The last patient was treated without identifying the causal fungus. Two patients developed facial paralysis during disease progression. Treatment was based on intravenous amphotericin B and oral itraconazole. Three patients are now free of disease after a three- to six-month course of antifungal therapy; one patient was not followed up., Conclusion: Fungal necrotizing otitis externa should be suspected in cases where there is no response to antipseudomonal antibiotic therapy. Deep biopsies from the external auditory canal or the mastoid are usually needed to confirm the diagnosis.

Computerized tomography (CT) scanning is a well recognised tool for the diagnosis of malignant external otitis. To investigate the degree of correlation between CT findings scan and the patients clinical status focusing on a subgroup of patients with cranial nerve palsies. Diagnosis of malignant external otitis was confirmed in 23 patients (average age 71 years, age range 39-87) based on criteria of severe pain, otitis externa refractory to conventional treatments and possibly diabetes mellitus and pseudomonas detection. CT was performed on 23 of these patients. Results from these scans were analysed and correlated with patient clinical status. Retrospective analysis of CT images and medical notes were used for data analysis.The CT scans of all 23 patients showed evidence of involvement of disease outside the external auditory canal, confirming the diagnosis. Sixteen out of 23 patients (70%) demonstrated evidence of bone erosion. Four of the 16 showed involvement of the petrous apex. From our subset of ten patients with cranial nerve involvement, eight demonstrated evidence of bone erosion and two showed mastoid and middle ear involvement without bone erosion. All four patients with petrous apical involvement presented with cranial nerve palsies (two lower cranial nerve palsies, one seventh nerve palsy and one combined lower and seventh nerve palsy). CT scanning was found to be a fast and economical tool in the initial assessment of patients with malignant external otitis. Petrous apex involvement was constantly associated with cranial nerve palsies, usually the lower cranial nerves. CT findings of temporal bone in itself however, were not closely correlated to the clinical outcome of the patients.

Objective: To propose a CT-based method for early identification of severe cases of malignant external otitis (MEO) by correlating between initial CT findings and clinical course., Study Design and Setting: Eighteen MEO patients who underwent CT on admission were included in this retrospective study conducted at a tertiary center. The number and extent of anatomical areas involved according to CT were compared to clinical course severity., Results: The patients were categorized into two groups according to clinical course. There were 13 patients in the "nonsevere" group and 5 in the "severe." In six out of eight CT anatomical areas the "severe" group had significantly higher scores (P < 0.05 to P < 0.0005). The average number of areas involved in the "nonsevere" group was 2.9 and in the "severe" 5.4 (P < 0.0005)., Conclusion: We found a clear correlation between clinical course and initial CT findings in MEO patients. Based on these findings it may be possible to predict clinical course severity according to initial CT.

A 74-y-old male receiving haemodialysis presented with right-sided otalgia, otorrhoea and diffuse swelling on the right external auditory canal. Following an initial successful treatment with prolonged intravenous antibiotics, the patient relapsed with a secondary infection in the same site due to Candida glabrata. We report an unusual case of malignant otitis externa caused by the fungus C. glabrata.

This study looks at case series of malignant otitis externa, outlines detailed structural (radiological) and functional (radionuclide) investigations, and discusses their utility in the initial diagnosis, patient management and follow up of this condition. Patients were investigated by computerized tomography (CT), magnetic resonance imaging (MRI), two-phase planar and single-photon emission tomography (SPECT), technetium-99m methylenediphosphonate bone scans, gallium-67 planar and SPECT scans, and indium-111 or technetium-99m labelled WBC planar and SPECT scintigraphy. We discuss example case reports with the various radiological and scintigraphic findings and outline a protocol for rational investigation. It is concluded that CT and/or MRI should be supported by routine SPECT bone imaging for initial diagnosis of malignant otitis externa. Routine SPECT bone imaging further supplemented by gallium scintigraphy should be the investigation of choice in the follow up of these cases for assessing response to treatment and disease recurrence.

Malignant (invasive) otitis externa (MOE) is an infection involving the external auditory meatus (EAM), most often found in elderly diabetics, which carries a high morbidity and mortality. In advanced cases it may give rise to osteomyelitis and cranial neuropathies. This is a case ofMOE, which invaded the posterior wall of the right temporomandibular joint (TMJ), resulting in severe trismus and pain. Subsequently, this required treatment by replacement of the glenoid fossa with a Silastic prosthesis.