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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.

Auricular chondritis of unknown cause was suspected in a 10-year-old male Bolognese dog with a five-month history of painful bilateral nodular and ulcerative pyogranulomatous dermatitis of the pinnae with putative auricular cartilage destruction. Pain and lesions resolved with immunosuppressive doses of prednisolone, yet the condition resulted in deformity of both pinnae and external canals., (© 2024 ESVD and ACVD.)

Purpose: While extensive research with accurate classification has been done in mycoses of the paranasal sinuses and anterior skull base, a similar understanding of lateral skull base fungal pathologies is lacking due to relative rarity and diagnostic difficulties. We introduce a series of eleven cases and two different invasive entities of Aspergillus temporal bone diseases-fungal skull base osteomyelitis (SBO)/malignant otitis externa (MOE) and chronic invasive granulomatous fungal disease (CIGFD)., Methodology: A retrospective observational study was conducted at the neuro-otology unit of a tertiary care referral center between July 2017 and November 2022. Diagnosed cases of lateral skull base osteomyelitis with atypical symptoms and lack of response to culture-directed antibiotics were evaluated for fungal origin. Patient data, including history, laboratory findings, serum galactomannan assay, CT and MRI imaging findings, clinical examination findings, and co-morbidities, were analyzed. The treatment course and response were assessed., Results: A total of 11 cases were included in the study. Of these, 9 were cases of Aspergillus-induced skull base osteomyelitis (SBO) and 2 of Aspergillus-induced chronic invasive granulomatous fungal disease (CIGFD). CIGFD presented with persistent ear discharge and slowly progressive post-aural swelling, while all patients of fungal SBO had lower cranial nerve palsies. CIGFD responded to excision and antifungals, while SBO responded well to conservative anti-fungal treatment., Conclusion: In cases of lateral SBO not responding to antibiotic therapy, the possibility of fungal etiology should be considered. Aspergillus spp. seems to be the major fungal pathogen., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Primary EAC neoplasms include benign and malignant lesions of bony, glandular or cutaneous origin. Small, benign slow growing bony neoplasms are often asymptomatic, diagnosed incidentally and might not require intervention. Both malignant and benign neoplasms of cutaneous and glandular origin can present with symptoms of chronic otitis externa, leading to delays in diagnosis. Prompt biopsy of soft tissue lesions associated with non-resolving otitis externa are warranted. Local and regional imaging is helpful to understand disease extent and origin, but even early-stage malignant neoplasms require aggressive surgical treatment., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Clival osteomyelitis is a potentially life-threatening skull base infection. It is rare and generally challenging to diagnose and treat. Clival osteomyelitis is typically seen in the pediatric population and is very rare in the adult population. It occurs as a complication of recurring paranasal infections and malignant otitis externa. The exact pathophysiology of osteomyelitis of the clivus is relatively uncertain. Here, we describe a case of a 36-year-old man with medical history significant for hypertension and poorly controlled type 1 diabetes mellitus who experienced recurrent paranasal sinus infection for 2 years. He received multiple antibiotic treatments and underwent adenoidectomy without substantial improvement of symptoms. Ultimately, a diagnosis of the clival osteomyelitis through the help of a computed tomography (CT) scan of the paranasal sinus and neck was made. This diagnosis allowed for adequate intervention and treatment of our patient with subsequent resolution of his presenting symptoms. This case highlights the importance of high suspicion for clival osteomyelitis in patients with recurring sinus infections.

Objective: Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE., Study Design: COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition., Setting: Stakeholders from the United Kingdom., Subjects and Methods: Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition., Results: Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'., Conclusion: The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Necrotising otitis externa (NOE) is a severe infection of the temporal bone. The traditional severity based staging system does not fully prognosticate all patients with NOE. We hypothesise that a patient response staging system would more accurately capture the disease process and guide prognosis., Methods: We carried out a retrospective notes review of patients diagnosed with NOE from January 2017 to December 2018 in a regional tertiary referral centre. Patient outcomes from our proposed patient response staging system were compared to a modified previously published severity based Gleeson staging system with patients requiring prolonged treatment classified as having a poor outcome., Results: A total of 34 patients were treated for NOE. The majority were male ( n =24) and had diabetes ( n =25). Patients with the most severe Gleeson staging did not have the worst outcome. Daily delay in resolution of otorrhoea was associated with an increased need for more than six weeks of treatment. Rapid responders are patients who had resolution of otalgia, otorrhoea and C-reactive protein normalisation within 14 days, and all were cured following standard 6 weeks of treatment., Conclusions: The Gleeson staging system was valuable in assessing the extent of disease and all early Gleeson staged patients had good outcomes. However, patients with higher severity staging on the Gleeson system did not necessarily require prolonged treatment. There is a role for a joint approach in staging patients based on both modified Gleeson and treatment response, which would subsequently guide prognosis, duration of treatment and early diagnosis of potential fungal NOE.

Malignant otitis externa is an inflammation of the external auditory canal with preceding osteomyelitis of the temporal bone and the adjacent structures that could be potentially lethal. Malignant otitis externa may present with cranial nerve involvements and massive spread of disease mimicking nasopharyngeal carcinoma or any other malignancies on imaging. Two elderly patients who presented with severe otalgia and significant facial nerve palsy and lower cranial nerve palsies showing extensive spread of disease are reported in this case series. They both had resolution of disease after a prolonged course of antibiotics and cortical mastoidectomy for disease clearance in one of them.

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., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline., Objective: This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management., Methods: A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review., Results: Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately., Conclusion: This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

Introduction: Aspergillus necrotizing otitis externa (NOE) is a rare disease, often associated with delayed diagnosis, the management of which is poorly defined., Summary: The authors report a case of Aspergillus flavus necrotizing otitis externa with temporomandibular arthritis and temporozygomatic osteomyelitis with Staphylococcal coinfection in a diabetic patient. The diagnosis and discontinuation of treatment were guided by PET-CT scan. A favourable course without sequelae was observed after repeated surgical curettage and 3 months of antifungal therapy., Discussion: Aspergillus flavus is the agent most commonly incriminated in NOE. Indirect diagnostic tests (serology) may be negative. The diagnosis is based on imaging-guided surgical biopsy with histological examination and standard and fungal microbiological culture. Treatment requires a combination of surgery and antifungal therapy. The duration of antifungal therapy is poorly defined and discontinuation of therapy can be guided by PET-CT scan., (Copyright © 2019. Published by Elsevier Masson SAS.)

Introduction: Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well., Materials and Methods: Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention., Results: Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression., Conclusion: Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.

Background and Purpose: Necrotizing external otitis is a serious complication of external otitis with different spreading patterns. A persistent foramen of Huschke is a dehiscence located antero-inferior in the osseous external ear canal and posterior-medial to the temporomandibular joint. This dehiscence can facilitate extension of infection in an anterior pattern next to classic spread along the fissures of Santorini. The aim of this study was to define the prevalence and size of a persistent foramen of Huschke in patients with necrotizing external otitis., Materials and Methods: We retrospectively examined 78 CT temporal bone studies (39 patients with necrotizing external otitis, 39 control subjects). The side and presence of the foramen were noted, and its prevalence was calculated. The maximal width of the foramen of Huschke was measured in the axial plane and classified as subtle, mild, moderate, or extensive., Results: A persistent foramen of Huschke was present in 21 patients (26 ears) and 7 control subjects (9 ears). Prevalence was 50% (20/40) and 11.5% (9/78) in affected ears of patients with necrotizing external otitis and control subjects, respectively. Almost all affected ears showed an anterior distribution pattern of necrotizing external otitis. The extensive dehiscence was most common in affected ears., Conclusions: An anterior necrotizing external otitis spreading pattern is associated with the presence and increased size of a persistent foramen of Huschke. These findings facilitate the theory that a persistent foramen of Huschke is an additional risk factor the development of necrotizing external otitis., (© 2019 by American Journal of Neuroradiology.)

Introduction: Malignant otitis externa (MOE) is a potentially life-threatening infection of the soft tissues of the external ear, quickly spreading to involve the periosteum and bone of the skull base. Treatment includes antibiotics and eventually surgery. Hyperbaric oxygen treatment (HBOT) has been proposed as an adjunctive therapy. However, in the tenth consensus conference, this disease was considered as a non-indication for HBOT. The aim of this study was to evaluate the effectiveness of HBOT in MOE treatment., Methods: Retrospective and observational study was conducted of patients with MOE treated in our centre. Staging of the disease was made according to the clinicopathological classification system., Results: From March 1998 to November 2016, 16 patients were referred. 6% patients were on stage 1 of the disease at the time they were referred, 20% in stage 2, 7% in stage 3a, 13% in stage 3b and 53% in stage 4. Seven (43.75%) patients had VII nerve palsy and three (18.75%) patients had multiple nerve palsy. Average length of symptoms of disease was 5 months (maximum 11 months). Average number of sessions was 33 and the length of hospitalization prior to HBOT (median 90 days) was significantly longer than the time between beginning HBOT and cure (p = 0.028, Wilcoxon signed rank test). There were no fatalities due to MOE and all patients were considered free of disease after HBOT., Conclusion: HBOT was well tolerated and revealed to be a helpful adjuvant treatment in MOE. According to our data, HBOT should be considered for patients who failed conventional treatments and in severe cases.

BACKGROUND Pseudomonal infection is the most common cause of malignant otitis externa (MOE), which typically affects elderly diabetic patients. Fungi are a rare cause of MOE. MOE can be life-threatening if not recognized and treated promptly. It can result in a wide spectrum of complications, including skull-base osteomyelitis, cranial nerve palsy, cerebral venous thrombosis, and brain abscess. Pseudoaneurysm formation of the intracranial vessels is a life-threatening complication of MOE that is seldom reported in the literature. CASE REPORT We report the case of a 66-year-old diabetic man with MOE who was initially treated with antipseudomonal antibiotics after negative initial culture results. His MOE resulted in a cascade of complications, including facial nerve palsy, skull base osteomyelitis, and sigmoid sinus thrombosis, and culminated in left maxillary artery pseudoaneurysm formation resulting in massive epistaxis and hemodynamic instability. Endovascular embolization resulted in a successful obliteration of the pseudoaneurysm. A subsequent functional endoscopic sinus surgical (FESS) tissue biopsy confirmed Candida glabrata as the etiological agent. The patient was successfully treated with antibiotics and antifungal and anticoagulation therapy, and was discharged home in good condition. CONCLUSIONS A high index of suspicion for the diagnosis of fungal MOE, particularly in intractable cases of MOE with negative initial cultures, should be maintained. Pseudoaneurysm formation is a life-threatening complication of MOE that is seldom reported in the literature and should be suspected in any patient with MOE who presents with epistaxis or intracranial bleeding.

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.)

Necrotising otitis externa (NOE) is an infection originating in the soft tissues of the external auditory canal (EAC) spreading to the surrounding bone and rarely causing intracranial complications. It is usually caused by Pseudomonas aeruginosa and has historically occurred in elderly patients with diabetes or immunodeficiency. EAC foreign body is a risk factor for otitis externa but has not been described in NOE. A healthy 31-year-old man presented with new-onset seizures and worsening left-sided otalgia and otorrhoea. Brain imaging revealed left temporal subdural abscesses superior to the petrous bone. A retained cotton bud was identified in the left EAC, along with osseocartilaginous junction and mastoid granulation tissue. The foreign body was removed; a cortical mastoidectomy performed and intravenous antibiotic administered. At 10 weeks, the patient remained well, with no neurological deficit and no residual ear symptoms, and CT demonstrated complete resolution of the intracranial abscesses., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Evaluate the relationship between clinical findings and course of disease among patients with necrotizing otitis externa (NOE)., Study Design: Retrospective case series review., Setting: Tertiary referral center., Patients: Adult patients with no previous history of chronic ear disease, hospitalized due to NOE between the years 1990 to 2015., Main Outcome Measures: 1) Duration of hospitalization and 2) necessity for surgery., Results: Eighty-one patients were included in the study, corresponding to 83 effected ears. Thirty-two patients (38.5%) were hospitalized longer than 20 days and 20 patients (24.0%) underwent surgery. Otalgia was the most common complaint (n = 71, 85.5%). Pseudomonas Aeruginosa (PA) was the most common isolated bacteria (n = 40, 48.1%). Shifting incidence of culture results was noted, as rates of PA NOE decreased and rates of sterile culture and fungal NOE increased. Duration of complaints and presence of aural discharge at admission were associated with prolonged hospitalization (p = 0.010, p = 0.011, respectively). Advanced age, duration of hospitalization, and rates of readmission were associated with surgery (p = 0.037, p < 0.001, p < 0.001 respectively)., Conclusions: Duration of complaints and presence of aural discharge may indicate advanced NOE and require longer in-hospital treatment. Elderly patients are at increased risk for conservative treatment failure and are more likely to require surgery. With shifting incidence of pathogens, a wider empirical treatment covering nontraditional pathogens should be considered.

Background: Otitis externa is a common multifactorial disease with a prevalence in dogs as high as 10-20%. In humans, the diversity of the cutaneous mycobiota appears to increase in diseased states, whereas one canine study identified a decrease in diversity of the cutaneous mycobiota in atopic dogs compared to healthy individuals., Hypothesis/objectives: To describe the otic mycobiota in dogs with otitis externa compared to healthy dogs., Animals: Samples were collected from six dogs with clinical and cytological evidence of otitis externa and five clinically normal dogs., Methods and Materials: Swabs were collected from the ears of six dogs with fungal otitis externa. DNA from each sample was isolated and Illumina sequencing was performed targeting the internal transcribed spacer region. Sequences were processed using the bioinformatics software MOTHUR., Results: Fungi from ten different phyla were identified. The mycobiota of all affected ears was dominated by the genera Malassezia, which accounted for 55.7-98.4% of sequences (median 96.8%). Affected ears had significantly decreased observed richness, estimated richness and inverse Simpson's diversity index compared to controls (P = 0.008). Linear discriminant analysis effect size (LEfSe) analysis identified 42 operational taxonomic units (OTUs) that were differentially abundant (P < 0.05). Three OTUs were over-represented in the affected ears, including M. pachydermatis, whereas 39 OTUs were over-represented in healthy ears., Conclusions: Reduced fungal richness and diversity was present in affected ears, with markedly higher relative abundances of Malassezia. The otic fungal mycobiota is much more complex than has been identified with culture-based studies., (© 2018 ESVD and ACVD.)

Background: Canine otitis externa is a common disease. Cytological evaluation of otic exudate is a useful diagnostic test to direct and monitor treatment for otitis externa. One method of collecting ear cytological specimens utilizes a cotton-tipped swab inserted into the vertical ear canal. A proposed alternative method is to aspirate exudate from the deep horizontal canal using a rubber tube., Hypothesis/objectives: To compare cytological findings between two different collection techniques by evaluating the numbers of bacteria, Malassezia yeast and inflammatory cells., Animals: Thirty client-owned dogs with otitis externa., Methods and Materials: A prospective, randomized, blinded comparison study. Ear canals from each dog were sampled using cotton swab and rubber tube. Ear cytological preparations were evaluated independently by two investigators for polymorphonuclear leucocytes (PMN), monocytes/lymphocytes, macrophages, yeast, intracellular (IC) cocci, extracellular (EC) cocci, IC bacilli and EC bacilli., Results: A paired Student's t-test was used to compare the two techniques. The inter-investigator reliability for PMN, EC bacilli and yeast was good, and for EC cocci was moderate. There were significantly higher numbers of PMNs obtained by the tube method (P = 0.0024) than by the cotton swab method. There were no statistically significant differences between cotton swab and rubber tube methods for monocytes/lymphocytes (P = 0.7780), macrophages (P = 0.1751), EC cocci (P = 0.1262), EC bacilli (P = 0.1162), yeast (P = 0.5371), IC cocci (P = 0.6606) or IC bacilli (P = 0.6761). The technique was well tolerated., Conclusion: An alternative ear cytological collection technique was identified which enables sampling of the deep horizontal canal., (© 2018 ESVD and ACVD.)

Objective: The aim of this experimental study was to compare the dose-related effect of topical thymoquinone (TQ) with other topical agents used in the management of acute otitis externa (AOE) in a rat model., Materials and Methods: Forty-eight male Wistar albino rats were divided into six groups each with eight rats per group. Group I was the control group with no external otitis, whereas external otitis were created in the other five groups (study groups). Dexamethasone, 0.1% TQ, 0.4% TQ, ciprofloxacin, and 0.9% saline (NaCl) drops was applied once daily in Groups II-VI, respectively. The treatment was administered regularly for 10 days. Pathologic and microbiologic evaluation were performed. Pathologically, the thicknesses of the stroma and the epithelium in the external auditory canal (EAC) were measured using an occulometer. Edema in the stroma, density of inflammatory cells and blood vessels, presence of fibroblasts, and changes in collagen fibers in the EAC were evaluated in five different areas to obtain the area of highest concentration and classified into four grades (0=no change, 1=mild, 2=moderate, 3=severe)., Results: The higher concentration of TQ (0.4%) was more effective than dexamethasone and 0.1% TQ with respect to antibacterial and the anti-inflammatory properties., Conclusion: TQ, particularly at a concentration of 0.4%, may be considered for topical application alone in the treatment of AOE, without any requirement for a combined treatment.

The emerging pathogen Candida auris is isolated mostly from hospitalized patients and often shows multidrug resistance. We report on the isolation of this yeast in Austria from an outpatient's auditory canal. The isolate showed good susceptibility against antifungals except for echinocandins; the patient was treated successfully with topical administration of nystatin.

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.

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.

An 80-year-old Caucasian man presented with an incidental and asymptomatic lesion in his right ear thought to be secondary to his use of hearing aids for presbycusis. He used Lyric hearing aids, designed for 24 hours-a-day use for 4 months at a time and had no other previous otological problems. He underwent a bony meatoplasty and vascular flap reconstruction via a retroauricular approach to remove the lesion for histological analysis and regrafting of the area. The lesion was confirmed on histopathology as an ear canal cholesteatoma., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Otitis externa caused by fungi (otomycosis) occurs more commonly in tropical areas with high moisture than in temperate regions. Bilateral otomycosis is, however, rarely reported. In a case of bilateral otitis externa in a 56-year-old male patient in Taiwan, direct microscopic examination of the cerumen as well as isolation of strains indicated the presence of two Aspergillus species being different in each of both ears. The species were identified by DNA sequence comparisons and additional morphological confirmation of diagnostic characteristics as Aspergillus flavus and Aspergillus terreus. The rarely reported occurrence of two Aspergillus species in otitis of the same patient deserves attention in other cases of otomycosis, particularly with respect to potentially different resistances of different species against antifungals. Treatment with nystatin/neomycin was not successful, but with clotrimazole was effective., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Purpose: Skull base osteomyelitis (SBOM) is an inflammatory process which often arises from malignant otitis externa (MOE); the diffuse skull base and adjacent soft tissue involvement may be mistaken at initial imaging for advanced nasopharyngeal carcinoma (NPC), especially if there is no prior knowledge of MOE, direct spread from the sphenoid sinus or in atypical presentations of MOE. This study aims to evaluate imaging features on MR that may differentiate SBOM from NPC., Materials and Methods: The MR examinations of 26 patients diagnosed with SBOM between January 1996 and January 2013 were retrospectively reviewed. Comparison was also made with the MR images of 22 consecutive patients with newly diagnosed advanced T3 and T4 NPC between July 2011 and August 2012. Imaging features in both conditions were compared, including the presence of a nasopharyngeal bulge, nasopharyngeal mucosal irregularity, lateral extension, architectural distortion (or lack thereof), increased T2 signal and enhancement patterns., Results: The most prevalent findings in SBOM were lateral extension, increased T2 signal in adjacent soft tissues, lack of architectural distortion and enhancement greater than or equal to mucosa. The combination of these 4 findings was found to best differentiate SBOM from advanced NPC, and found to be statistically significant (p<0.001)., Conclusion: We suggest that the combination of lateral extension, increased T2 signal, lack of architectural distortion and enhancement greater than or equal to mucosa is helpful in differentiating SBOM from advanced NPC., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Few studies report outcomes of surgical management of postinflammatory medial canal fibrosis (PIMCF). The objectives were to compare short- and long-term outcomes after surgical repair of PIMCF at our institution and systematically aggregate published data for meta-analysis., Data Sources: Medical records for the case series; PubMed, Scopus, and OVID/Medline for the systematic review/meta-analysis., Methods: Patients undergoing surgical treatment of PIMCF were identified. Short-term (<2 years) and long-term (>2 years) postoperative outcomes were evaluated for the case series and aggregated for the meta-analysis., Results: At our institution, 16 patients (21 ears) were identified. Compared to the preoperative air-bone gap (ABG) (27.7 ± 7.5 dB), mean postoperative short-term ABG (8.2 ± 7.5 dB) and long-term ABG (15.3 ± 11.3 dB) were significantly improved (P < 0.001 for both). Although short-term restenosis rate was low (0%) among long-term follow-up patients, 64% (9 of 14) experienced some degree of recurrent canal narrowing, including one case of complete restenosis (7%). Similarly, meta-analysis pooled preoperative ABG (29.3 ± 9.7 dB, 95% confidence interval [CI] 27.0-31.6) improved significantly during short-term (11.4 ± 8.0 dB, 95% CI 8.3-4.5, P < 0.0001) and long-term (14.3 ± 9.6 dB, 95% CI 11.6-16.9, P = 0.0004) follow-ups, with partial deterioration in hearing over time. Long-term complete restenosis rate (13.8%) was worse than short-term (8.0%), with no significant difference over time (P = 0.85)., Conclusion: Postinflammatory medial canal fibrosis is a rare condition that can successfully be treated with surgery to restore patency of the external auditory canal. Patients who experience improved hearing early on, however, are at significant risk of restenosis and recurrence of their conductive hearing loss with time., Level of Evidence: N/A. Laryngoscope, 2016 127:488-495, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Proliferative and necrotising otitis externa (PNOE) is a very rare disease affecting the ear canals and concave pinnae of kittens. This report describes a 5-month-old cat with PNOE. Histopathological examination confirmed the diagnosis. Treatment was initiated with local injection of methylprednisolone acetate into the lesions. The cat was subsequently treated with clobetasol propionate cream, a potent topical glucocorticoid ointment. The cat showed marked improvement. While topical treatment with tacrolimus, an immunosuppressive agent, is reported to be an effective therapy, to the best of our knowledge, this is the first report to treat PNOE with local corticosteroid therapy.

The objective of the present study was to elucidate the specific features of the clinical course of malignant externa otitis in the context of the present-day concepts. A total of 5 patients presenting with the confirmed diagnosis of malignant external otitis were available for the examination. The analysis of the clinical observations provided the basis for the characteristic of pathogenesis of this condition, diagnostic principles, and treatment modalities for the management of the pathology in question. It is concluded that the patients suffering from malignant externa otitis must remain under medical care and observation during a long period and the strategy for the treatment of each concrete patient should be chosen on an individual basis taking into consideration the presence of concomitant pathologies and their adequate therapy.

Introduction: Necrotizing otitis externa remains a severe and sometimes life-threatening disease in diabetic patient. Many therapeutic approaches have been described but what about the real benefit of hyperbaric oxygenotherapy in the management of this disease?, Methods: The authors reported a retrospective study about 42 patients treated for necrotizing external otitis over a period of 9 years (2006 to 2014). The patients were treated either by only antibiotherapy (23 cases) or with both antibiotherapy and hyperbaric oxygenotherapy (19 cases). The evolution under treatment was appreciated in the two groups through clinical, biological and radiological parameters., Results: The study included 42 diabetic patients with a mean age of 67 years (50 to 84 years). The sex-ratio M/F was 0.82. The diagnosis of necrotizing otitis externa was assessed through clinical and bacteriologic criteria in diabetic patients. A temporal bone CT-scan and a technetium scintigraphy were performed in order to precise the topography of the disease and the level of bone lysis. Antibiotherapy was prescribed intravenously and then orally for a mean period of 8 weeks (5 to 15 weeks). Hyperbaric oxygenotherapy was given for 19 patients (average: 20 sessions). The recovery was affirmed on clinical, biological and radiological features. Otalgia disappeared at the 11th day of treatment without HOT and at the 5th day with HOT. Otorrhea disappeared at the 6th day of treatment by HOT and at the 13th day without HOT. The recovery or the regression of facial palsy occurred in 75% of the cases when HOT was given. The total recovery from the disease was diagnosed in 36 patients (86%). The rate of recovery was 100% in the group treated by HOT and 74% in the group treated by only antibiotics. The recurrence of the disease was noted in 6 patients that haven't benefited from HOT. The end of the oral therapy was guided by the results of the Gallium bone scintigraphy., Conclusion: Hyperbaric oxygenotherapy must be associated in the treatment of necrotizing otitis externa. The results of our study suggest a real benefit of this therapy regarding clinical, biological and radiological parameters of this severe affection.

The objective of this study is to investigate the effect of topical and systemic enoxaparin sodium on the healing pattern of experimentally induced tympanic membrane perforation and formation of myringosclerosis. A total of 24 Wistar-Albino strain rats were included in the study. Standard myringotomies were performed on each rat. In the first group, isotonic serum physiologic was dropped on external ear canal (control group). Topical enoxaparin was dropped on external ear canal and daily topical doses of enoxaparin were dropped on external ear canal of the rats for 14 days (topical treatment group). Third group received subcutaneous injections of enoxaparin for 14 days (systemic treatment group). Five micrometer thick sections of the bullae of the rats were stained with H&E. Inflammation, edema and sclerotic lesions and neovascularization observed in the lamina propria layer of the tympanic membrane, and total thickness of the tympanic membrane were evaluated. In intergroup comparisons, significant difference in the distribution pattern of severity of inflammation in all three groups was not observed (p = 0.784, p > 0.05). Total TM thickness differed among all three groups (p = 0.028, p < 0.05). A statistically significant difference was observed between the systemic enoxaparin and the control groups (p = 0.022, p < 0.05). A statistically significant difference was observed between the topical enoxaparin and the control groups (p = 0.037, p < 0.05). However, comparison between the topical and systemic treatment groups could not reveal any statistically significant intergroup difference (p = 0.682, p > 0.05). A significant difference was not observed among three groups as for the distribution of myringosclerotic plaques, severity of edema and neovascularization in the lamina propria (p = 0.539, p > 0.05), (p = 0.063, p > 0.05), (p = 0.152, p > 0.05). Topical and systemic enoxaparin treatment did not prevent formation of sclerotic plaques; however, it decreased TM thickness significantly in comparison with the control group.

Purpose: Proton minibeam radiation therapy is a novel approach to minimize normal tissue damage in the entrance channel by spatial fractionation while keeping tumor control through a homogeneous tumor dose using beam widening with an increasing track length. In the present study, the dose distributions for homogeneous broad beam and minibeam irradiation sessions were simulated. Also, in an animal study, acute normal tissue side effects of proton minibeam irradiation were compared with homogeneous irradiation in a tumor-free mouse ear model to account for the complex effects on the immune system and vasculature in an in vivo normal tissue model., Methods and Materials: At the ion microprobe SNAKE, 20-MeV protons were administered to the central part (7.2 × 7.2 mm(2)) of the ear of BALB/c mice, using either a homogeneous field with a dose of 60 Gy or 16 minibeams with a nominal 6000 Gy (4 × 4 minibeams, size 0.18 × 0.18 mm(2), with a distance of 1.8 mm). The same average dose was used over the irradiated area., Results: No ear swelling or other skin reactions were observed at any point after minibeam irradiation. In contrast, significant ear swelling (up to fourfold), erythema, and desquamation developed in homogeneously irradiated ears 3 to 4 weeks after irradiation. Hair loss and the disappearance of sebaceous glands were only detected in the homogeneously irradiated fields., Conclusions: These results show that proton minibeam radiation therapy results in reduced adverse effects compared with conventional homogeneous broad-beam irradiation and, therefore, might have the potential to decrease the incidence of side effects resulting from clinical proton and/or heavy ion therapy., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Aspergillus spp. invasive external otitis (IEO) is a rare infection. We performed a seven-year, single-centre retrospective study from 2007 to 2014 including all patients with proven Aspergillus spp. IEO. Twelve patients were identified. All patients had a poorly controlled diabetes mellitus and one underwent solid organ transplant. The most frequently isolated species was Aspergillus flavus (n = 10) and voriconazole was the first-line therapy in all cases, with a median length of treatment of 338.5 days (158-804 days). None of the patients underwent extensive surgery. The clinical outcome was excellent. However, otological sequelae were reported, including hearing impairment (n = 7) and facial palsy (n = 3)., (Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

ES-62 is the major secreted protein of the rodent filarial nematode Acanthocheilonema viteae. The molecule contains covalently attached phosphorylcholine (PC) residues, which confer anti-inflammatory properties on ES-62, underpinning the idea that drugs based on this active moiety may have therapeutic potential in human diseases associated with aberrant inflammation. Here we demonstrate that two synthetic small molecule analogues (SMAs) of ES-62 termed SMA 11a and SMA 12b are protective in the oxazolone-induced acute allergic contact dermatitis mouse model of skin inflammation, as measured by a significant reduction in ear inflammation following their administration before oxazolone sensitisation and before oxazolone challenge. Furthermore, it was found that when tested, 12b was effective at reducing ear swelling even when first administered before challenge. Histological analysis of the ears showed elevated cellular infiltration and collagen deposition in oxazolone-treated mice both of which were reduced by treatment with the two SMAs. Likewise, the oxazolone-induced increase in IFNγ mRNA in the ears was reduced but no effect on other cytokines investigated was observed. Finally, no influence on the mast cell populations in the ear was observed., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Morphological studies comparing normal and diseased ear canals use primarily subjective scoring. The aim of this study was to compare normal and severely affected ears in dogs with objective measurements using ImageJ software. Ear canals were harvested from cadavers with normal ears and from dogs that underwent total ear canal ablation for unresolved otitis. Histopathology samples from ear canals were evaluated by semi-quantitative scoring and also by using ImageJ-software for histomorphometric measurements. The normal ears were compared to the severely affected ears using the 2 methods. The 2 methods were significantly (P < 0.0001) correlated for epidermal hyperplasia, ceruminous gland dilation, and hyperplasia and tissue inflammation, which were significantly greater in the severely affected ears (P < 0.0001). This study demonstrated that there is a very high correlation between the 2 methods for the most markedly affected components of otitis externa and that ImageJ software can be efficiently used to measure and evaluate ear canal histomorphometry.

A 10-year-old female spayed German Shepherd dog, with a year-long history of recurrent left ear infections, was presented for progressive ataxia, head tilt, and pain on opening of the mouth. On physical examination, a large amount of ceruminous debris was present in the left ear and multiple neurologic defects localizing to the cerebellum and vestibular system were identified. Magnetic resonance imaging (MRI) demonstrated a minimally contrast-enhancing mass within the left bulla, an intracranial space-occupying, heterogeneously contrast-enhancing lesion at the level of the left cerebello-medullary junction, and contrast enhancement of the ipsilateral meninges. Cerebrospinal fluid analysis revealed a marked mixed cell pleocytosis (nucleated cell count 655 cells/μL). The mass was visualized within the horizontal ear canal by otoscopic examination and a biopsy was taken. Impression smears of the biopsy contained many anucleate keratinized squamous epithelial cells, mild mixed inflammation, and few presumptive fibroblasts. With the provided clinical history and MRI findings, a cytologic diagnosis of cholesteatoma was made. A ventral bulla osteotomy was performed, and histopathologic examination of resected tissue confirmed the cytologic diagnosis of cholesteatoma. The dog's clinical symptoms improved postoperatively, but the dog died of unrelated causes, 3.5 months later. To our knowledge, this is the first description of the cytologic features of a cholesteatoma, which is a nonneoplastic, but locally invasive epidermoid cyst, in the middle ear of dogs., (© 2014 American Society for Veterinary Clinical Pathology.)

Background: Lemierre's syndrome, which affects previously healthy, young adults, is a rare complication secondary to infections in the head and neck that result in septic thrombophlebitis of the internal jugular vein., Method: This paper reports a case of a young, healthy female with malignant otitis externa, which resulted in the development of Lemierre's syndrome. A review of the relevant literature was also carried out. This involved a search of the Medline database using multiple search terms including 'Lemierre', 'septic thrombophlebitis', 'otitis externa', 'internal jugular vein thrombosis' and 'management'., Results: The patient presented with fever, left-sided otalgia, otorrhoea, neck swelling and pain. She was subsequently diagnosed with Lemierre's syndrome and managed accordingly., Conclusion: Lemierre's syndrome is a potentially fatal complication associated with significant morbidity. A high index of suspicion is required for prompt recognition and the early institution of treatment.

To investigate the pharmacodynamic effects of Binghuang ear drop on acute suppurative otitis externa in guinea pig model. Thirty guinea pigs were randomly divided into three groups, with ten animals in each group. Group A animals had normal ear canal and Binghuang ear drops (two drops, B.I.D) were applied in both ears for 7 days; Group B animals had induced otitis externa and received identical prescription as group A; Group C had normal ear canal and were treated with normal saline (two drops, B.I.D) for 7 days. After the treatments, the external morphology of ear canals was observed and the paraffin sections of external auditory canal were prepared and examined under the microscope. The inflammatory manifestation and cell infiltration into the skin of group B was significantly attenuated after the Binghuang ear drops treatment. In contrast, no allergy or side effects were produced by Binghuang ear drops application in the animals with normal ear canals. Binghuang ear drops could be used to treat acute otitis externa by eliciting anti-bacterial effects.