Necrotizing Otitis Externa: A Proposal for Diagnostic and Therapeutic Approach

Abstract Introduction Necrotizing otitis externa has a high impact on the quality of life of patients and has shown a significant increase in its incidence in recent years. There has been a change in the profile of affected patients and a lack of consensus on the management of these patients. Objective To develop a practical and effective care protocol to standardize the diagnostic and therapeutic management of necrotizing otitis externa. Methods A retrospective cohort study of necrotizing otitis externa patients between January 2015 and December 2020. Results There were 34 patients with two bilateral cases, totaling 36 ears. The mean age was 68.5, with a higher prevalence of males (76%). Diabetes was present in 97% of the samples. The involvement of cranial pairs was identified in 35% of the sample. Pseudomonas aeruginosa was the most frequent pathogen isolated, found in 50% of the cases. Among the cultures with bacterial agents isolated, 35% showed resistance to ciprofloxacin. The most frequent exam was computed tomography (94%). Hospital admission was indicated for 31 patients (91%), and ceftazidime was the most prescribed drug (35.5%). There were 11 recurrences (32%), and 12 patients (35%) had complications during treatment. Among the unfavorable outcomes, 12% persisted with some degree of peripheral facial paralysis, 6% maintained dysphagia, and 9% died of the disease. Conclusions The present study developed a diagnostic and therapeutic protocol for the effective management of necrotizing otitis externa. This protocol is a dynamic tool and should be revised and updated as new demands emerge during its implementation.

Otitis externa difusa: ¿una patología trivial?

Resumen La otitis externa es una patología frecuente en la consulta médica, se estima que 10% de las personas la padecerán al menos una vez en su vida, la presentación aguda cursa con afección del conducto auditivo externo de origen infeccioso en el 90% de los casos, llamada otitis externa difusa (OED). El presente artículo tiene como objetivo exponer la mejor evidencia actual que permita una descripción general de la patología, para ello se realizó una búsqueda de literatura científica en bases de datos reconocidas. Se encontró que la OED es caracterizada microbiológicamente por la presencia de Pseudomonas aeruginosa y Staphylococcus aureus, clínicamente los pacientes refieren otalgia lo que abre la puerta a una variedad de diagnósticos diferenciales y en el tratamiento se debe hacer una clasificación a partir de diversas variables (edad, compromiso auricular y estado inmunológico) a fin de determinar la vía terapéutica adecuada.

Abstract External otitis is a frequent pathology in the medical consultation, it is estimated that 10% of people will suffer it at least once in their life, the acute presentation compromises the external auditory canal of infectious origin in 90% of cases, called diffuse external otitis (DEO). The objective of this article is to present the best current evidence that allows a general description of the pathology, for which a search of scientific literature was carried out in recognized databases, finding that it was characterized microbiologically by the presence of Pseudomonas aeruginosa and Staphylococcus aureus, clinically, patients refer to otalgia generating a variety of differential diagnoses, and for treatment, a classification must be made based on various variables (age, atrial compromise, and immune status) in order to determine the appropriate therapeutic route.

Estudio clínico y micológico de otomicosis en diabéticos: una serie de 17 casos / Clinical and mycological study of otomycosis in diabetics: series of 17 cases

RESUMEN Introducción: La otomicosis en pacientes inmunosuprimidos esta caracterizada por ser bilateral y ser causada por candida. Pocos estudios comparan las características micológicas encontradas en la microscopía directa y el cultivo. Objetivo: Identificar las características clínicas y micológicas de la otomicosis en pacientes diabéticos. Material y método: Estudio transversal en centro hospitalario de segundo nivel. Criterios de inclusión: pacientes diabéticos con diagnóstico clínico de otomicosis. Intervención: la muestra se examinó directamente bajo el microscopio y se cultivó. Resultados: Se incluyeron 17 pacientes, 10 mujeres y 7 hombres con una edad media de 47,5 años. Los síntomas predominantes fueron hipoacusia en 91,4% (n =16), prurito en 82,4% (n =14), otorrea en 76,5% (n=13)y otalgia en 70,6% (n =12). Afección bilateral se encontró en 47,1% (n =8). Estudio directo al microscopio mostró levaduras en 94,1% (n =16) y 5,9% mostró aspergillus (n =1). Cándida fue el género más comúnmente encontrado en los cultivos y en el examen directo microscópico con 94,1% (n =16) y Candida albicans la especie más común con 88,2% (n =15). Conclusión: Candida albicans es el agente etiológico más común en pacientes diabéticos con otomicosis. Su presentación clínica más frecuente es hipoacusia, prurito y otorrea. El examen directo identificó adecuadamente a los géneros fúngicos.

ABSTRACT Introduction: Otomycosis in immunocompromised patients is characterize by its bilateral course and the predominant etiologic agent is Candida. Few studies compare the mycological features between microscopic direct exam and culture. Aim: To identify the clinical and mycological characteristics of otomycosis in diabetic patients. Material and method: Transversal study. Secondary care center. Inclusion criteria: diabetic patients with clinical diagnosis of otomycosis. Intervention: Direct examination under a microscope of the ear sample and culture. Results: We included 17 patients, 10 women, 7 men with a mean age of 47.5 years. Symptoms were hearing loss 94.1% (n = 16), pruritus 82.4% (n =14) otorrhoea 76.5% (n =13) and otalgia 70.6% (n =12). Bilateral involvement was found in 47.1% (n =8). Direct microscopic study found 94.1% of yeast (n =16) and 5.9% of Aspergillus (n =1). Candida was the most common fungal genus in culture and microscopic exam with 94.1% (n =16) of cases and Candida albicans was the most common species in 88.2% (n =15) cases. Conclusion: Candida albicans is the most common etiologic agent in diabetic patients with otomycosis. Main symptoms were hearing loss, itching and otorrhea. Direct exam correctly identified the fungal genus.

Caracterización clínica, epidemiológica y terapéutica de los pacientes con otitis externa maligna / Clinical, epidemiological and therapeutical characterization of patients with malignant external

Se realizó un estudio descriptivo de serie de casos, de 42 pacientes con otitis externa maligna, atendidos en el Servicio de Otorrinolaringología del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora de la provincia de Santiago de Cuba desde enero de 2002 hasta diciembre de 2014 y tratados básicamente con ciprofloxacina, a fin de caracterizarles clínica, epidemiológica y terapéuticamente, así como determinar su evolución clínica con el tratamiento indicado. También se incluyó un segundo grupo de 29 integrantes con la misma afección, quienes durante esos 12 años recibieron otros antibióticos y no la citada quinolona, tratados igualmente en dicho Servicio durante el período señalado. Entre los principales resultados sobresalió el predominio del grupo etario de 55-64 años (30,6 por ciento) en los que se utilizó ciprofloxacino y de 75 y más (74,8 por ciento) en los que se indicaron otros antimicrobianos; del tiempo de evolución de la diabetes mellitus de 0-10 años en 24 (57,1 por ciento) de quienes recibieron ciprofloxacino y en 14 (48,2 por ciento) de aquellos que no la consumieron y de la Pseudomonas aeruginosa como el germen más frecuentemente aislado. La evolución de los pacientes fue favorable, independientemente del tratamiento antimicrobiano prescrito, pero todos los tratados con ciprofloxacina egresaron en menos de 30 días mejorados o curados. Se concluyó que la edad avanzada favorece la aparición de la otitis externa maligna, sin importar el tiempo de evolución de la diabetes mellitus

A descriptive, serial cases study, of 42 patients with malignant external otitis was carried out. They were assisted in the Otolaryngology Service of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba from January, 2002 to December, 2014 and treated basically with ciprofloxacin, in order to characterize them clinical, epidemiological and therapeutically, as well as to determine their clinical course with the suitable treatment. A second group of 29 members with the same disorder was also included who received other antibiotics during those 12 years, treated in this Service during that period. Among the main results there was a prevalence of the 55-64 years age group (30.6 percent) in which ciprofloxacin was used and over 75 years (74.8 percent) in which other antimicrobians were indicated; of the time in the diabetes mellitus course 0-10 years in 24 (57.1 percent) of those who received ciprofloxacin and in 14 (48.2 percent) of those that didn't consume it and of the Pseudomonas aeruginosa as the most frequently isolated germ. The patients had a favorable clinical course, no matter the antimicrobian prescribed treatment, but all the patients treated with ciprofloxacin got better or were cured and were discharged in less than 30 days. It was concluded that the advanced age favors the emergence of the malignant external otitis, no matter the time of the diabetes mellitus course

Phenotypic characterization of canine Malassezia spp., isolates / Caracterización fenotípica de aislamientos de Malassezia spp., de origen canino

ABSTRACT Objective . To characterize and identify yeasts of the genus Malassezia by phenotypic features. Materials and methods. First, the macroscopic and microscopic morphological characteristics were described. In addition we performed biochemical and physiological assays as Tweens and Cremophor, including more. Results. Our results evidenced of 105 isolates obtained from dogs diagnosed with external otitis, it was possible to identify two distinct species from 46 isolates within the Malassezia genus: 36.19% (n=38) were identified as M. pachydermatis and 7.62% (n=8) as M. furfur. According to phenotypic patterns the remaining 56.19% (n=59) were reported as Malassezia spp., possibly corresponding to M. furfur and/or M. pachydermatis. Conclusions. Results emphasize the necessity to characterize according to species. It is not feasible to define Malassezia by species based on morphological, biochemical, and physiological findings. Therefore, molecular genotyping should be performed to identify markers allowing a more precise isolate identification. This would broaden our epidemiological knowledge regarding different species involved in canine otitis pathologies.

RESUMEN Objetivo . Caracterizar e identificar levaduras del género Malassezia, mediante características fenotípicas. Materiales y métodos . Inicialmente se describieron las características morfológicas macroscópicas y microscópicas, adicionalmente se realizaron pruebas bioquímicas y fisiológicas como Tween y Cremophor, entre otras. Resultados . De 105 aislamientos de caninos diagnosticados previamente con otitis, 46 fueron caracterizados hasta especie, así: El 36.19% (n=38) correspondió a M. pachydermatis, el 7.2% (n=8) a M. furfur; y 56.19% (n=59) restante fueron reportados como Malassezia spp., debido a los patrones fenotípicos atípicos que presentaron, y que podrían corresponder a variantes de M. furfur y/o M. pachydermatis. Conclusión. Estos resultados enfatizan la necesidad de hacer una caracterización a nivel de especie y/o genotipos mediante marcadores moleculares que permitan una identificación más precisa de los aislamientos. Con el presente estudio, se contribuye al conocimiento de las diferentes especies involucradas en patologías óticas en caninos.

Diseño y evaluación de las propiedades antibacterianas de un prototipo de molde de audífono que incorpora cobre en su manufactura / Design and evaluation of antibacterial properties of a prototype of earmold with copper incorporated in the manufacture

Introducción: La otitis externa infecciosa es una consulta otorrinolaringológica frecuente en usuarios de audífonos. Las propiedades antibacterianas descritas del cobre, han motivado el desarrollo de aplicaciones clínicas de este metal. Objetivo: Evaluar la capacidad antibacteriana de moldes de audífonos manufacturados con polímeros sensible a luz UV, silicona y acrílico que incorporan cobre metálico, en un sistema experimental in vitro. Material y método: Se diseñaron moldes de audífonos con y sin cobre, que fueron inoculados con distintas concentraciones de microorganismos (S aureus y P aeruginosa), para luego determinar el porcentaje de adherencia bacteriana a distintos tiempos de contacto (4, 8 y12 horas). Resultados: Existió reducción significativa en la adhesión bacteriana a los moldes con cobre respecto a aquellos sin cobre, independiente del material, del tipo de microorganismo y del inóculo bacteriano. Discusión: La disminución en la adherencia bacteriana en los prototipos con cobre, puede atribuirse a su actividad inhibitoria sobre los microorganismos en función de su concentración y el tiempo de contacto, ejerciendo su efecto por difusión a través de los distintos materiales. Conclusión: Con estos resultados, se hace necesario el desarrollo de estudios clínicos enfocados en comprobar si el uso de audífonos con cobre disminuyen las otitis externas de origen infeccioso.

Introduction: External otitis of infectious etiology among hearing aid users is a common motive of otolaryngology consultation. Antibacterial properties described copper, they have motivated the development of clinical applications of this metal. Aim: Evaluate the antibacterial capacity of copper-based ear molds manufactured with different materials such UV sensitive polymers, silicone and acrylic incorporating metallic copper, in an experimental system in vitro. Material and method: Ear molds with and without copper, were inoculated with different concentrations of microorganisms (S aureus and P aeruginosa) and determine the percentage of bacterial adherence to different contact times (4-8 and 12 hours). Results: There was significant reduction in bacterial adhesion to copper molds than those without copper, independent of the material, the type of microorganism and the bacterial inoculum. Discussion: The decrease in bacterial adherence on prototypes with copper, can be attributed to inhibitory activity on microorganisms depending on their concentration and contact time, exerting its effect by diffusion through the various materials. Conclusion: With these results, is necessary the development of clinical studies focused on checking whether the use of hearing aids with copper decreases external otitis of infectious origin.

Perfil clínico e microbiológico de cães com e sem otoacaríase / Clinical and microbiological profile of dogs with and without otoacariasis

Os objetivos do estudo foram identificar a presença de microrganismos nos condutos auditivos dos cães através dos exames citológico e microbiológico, assim como avaliar a associação destes à otoacaríase e seus sinais clínicos. O diagnóstico da infestação por Otodectes cynotis foi realizado através de otoscopia bilateral e pela coleta de material e visualização do parasito sob microscópio esterioscópico, constituindo o exame parasitológico. Outras coletas de secreção otológica de cada orelha foram realizadas para confecção de lâminas para a citologia e para o isolamento microbiológico, sendo este último material coletado através de "swab" estéril. Dos 250 animais examinados, em 15 (6%) foi identificado o ácaro O. cynotis.Observou-se associação entre a presença do parasito e a ocorrência de otite clínica externa caracterizada especialmente por eritema auricular (P<0,001) e a produção excessiva de secreção otológica (P=0,0016), assim como a observação, pelos proprietários, de prurido ótico nos cães (P<0,001). Sugere-se a possibilidade de essas associações serem efeito da infestação. Houve também a associação (P<0,01) entre a otoacaríase e a ocorrência de microrganismos nos dois condutos auditivos de cada animal, detectados através da citologia. No entanto, não houve associação (P=0,04 e p=0,07) entre a presença do ácaro O. cynotis e a ocorrência de microrganismos no exame microbiológico das orelhas direita e esquerda, respectivamente.

The goals of this study were to identify microorganisms in dogs' ear canals through cytological and microbiological examination, and evaluate their association with otoacariasis and its clinical signs. Otodectes cynotis infestation diagnosis was achieved by bilateral otoscopy, and by parasite viewing on cerumem under stereoscopic microscope, representing the parasitological exam. Ear discharge was also collected from each canal to fix cytology slides and for microbiological isolation, but this last sample was collected with sterile swab. Among the 250 studied animals, 15 (6%) had ear mites. There was an association between the parasite and external clinical otitis specially as established by auricular erythema (P<0,001) and excessive production of ear discharge (P=0,0016), as well as ear pruritus observed by the owners (P<0,001). It has been suggested that these associations can be an effect of the infestations. There was also an association (P<0,01) between otoacariasis and microorganisms detected by cytological exam in both ear canals of each dog. However, there was no association (P=0,04 e P=0,07) between the presence of ear mite and microorganisms detected by microbiological exam of right and left ears.

Temporomandibular joint disorder from skull-base osteomyelitis: a case report / 대한악안면성형재건외과학회지

Skull-base osteomyelitis is a rare disease affecting the medulla of the temporal, sphenoid, and occipital bones. In general, it occurs due to external ear canal infections caused by malignant external otitis. Skull-base osteomyelitis usually affects elderly diabetic patients. The patient, a 58-year-old man, was referred for evaluation and management of the left jaw. Clinical examination of the patient revealed pain in the left jaw and mouth-opening deflection to the left. The maximum active mouth opening was measured to about 27 mm. Panoramic, CT, and CBCT revealed bone resorption patterns in the left condyle. Through control of diabetes, continued pharmacological treatment, arthrocentesis, and occlusal stabilization appliance therapy were carried out. The extent of active mouth opening was increased to 45 mm, and pain in the left jaw joint was alleviated. This was a case wherein complications caused by failure to control diabetes induced skull-base osteomyelitis. There is a need for continued discussion about the advantages and disadvantages of arthrocentesis with lavage for patients with skull-base osteomyelitis and other treatment options.

First isolation of the Stephanoascus ciferrii in feline otitis in Brazil

Ear infections in cats are uncommon, especially involving yeasts. This report describes the first isolation of the Stephanoascus ciferrii, teleomorph of the Candida genus, in a case of feline otitis in Brazil. The identification and characterization of Stephanoascus ciferrii were confirmed by the Vitek2 System (BioMerieux ®).

Imaging features of malignant external otitis / 实用放射学杂志

Objective To explore the value of computed tomography (CT)and magnetic resonance imaging (MRI)in the diagno-sis and delineation of the extent of malignant external otitis (MEO).Methods Clinical manifestations and imaging features of 10 pa-tients with definite diagnosis of MEO were collected and analyzed.Plain and contrast-enhanced CT of the ear were performed on all 10 patients,of which 6 patients also received MRI scans.Results Abnormal soft tissue opacity within the external auditory canal and involvement of surrounding structures were found in all 10 patients.Bone erosion of the external auditory canal was showed in 7 pa-tients.Other CT findings included bone erosion of skull base and intracranial involvement.Abnormal soft tissue of the external audi-tory canal,effusion in the mastoid cavity and medullary abnormalities were showed very well on MR images in 6 patients while the cortical bone erosion was not well showed.Conclusion Imaging features of the lesions in the external auditory canal,bone erosion of skull base and intracranial involvement play crucial roles in the diagnosis and delineation of the extent of the lesion in patients with MEO.

Skin Prick Test Reactivity in Patients with Chronic Eczematous External Otitis

OBJECTIVES: To investigate the incidence of skin prick test (SPT) positivity in patients with eczematous external otitis. METHODS: Forty-six patients with eczematous external otitis and forty-four healthy volunteers were included in the study. All the patients were skin-tested by prick test. Reactions were assessed by the degree of redness and swelling and the size of the wheal produced. RESULTS: According to SPT positivity and total immunoglobulin E values, the difference between the study and the control groups was statistically significant (P<0.05). The most common skin reactions were against to mites and grasses in this study. CONCLUSION: Eczematous external otitis is perhaps the most difficult to treat of all forms of external otitis because the provocative agents usually remain undiagnosed. Patients suffering from eczematous external otitis symptoms should be investigated for allergens and be informed for prevention of the causative agents. SPT might be performed in cases of prolonged or treatment-resistant external otitis.

Pericondrite pós-piercing / Post-piercing perichondritis

O uso de piercing tem se tornado uma prática muito freqüente entre os jovens. O procedimento na maioria vezes realizado por profissionais não-qualificados não é isento de riscos. O manuseio de material contaminado ou a higiene imprópria predispõem à pericondrite e à celulite. A pericondrite caracteriza-se pelo eritema do pavilhão auricular, dor intensa e febre. Sem tratamento, desenvolve-se um edema generalizado do pavilhão com formação de abscesso subpericondrial, podendo evoluir para necrose isquêmica da cartilagem e a temível deformidade estética conhecida como "orelha em couve flor". O agente responsável mais encontrado é o Pseudomonas aeruginosa. No estágio inicial da doença o tratamento pode ser feito com antibióticos de amplo espectro. Nos casos em que o abscesso está presente, a incisão e drenagem cirúrgica são obrigatórios acompanhado de antibioticoterapia guiado pela cultura e antibiograma. OBJETIVO: O objetivo deste relato de caso é realizar uma revisão bibliográfica dos últimos 10 anos abordando os aspectos anatômicos do pavilhão auricular, a história do uso de piercing e suas mais conhecidas complicações. MÉTODO: Relato de um caso de pericondrite pós-piercing transcartilaginoso onde houve a necessidade de tratamento cirúrgico com praticamente nenhuma deformidade estética. RESULTADO: Aquisição de experiência teórico-prática através de revisão bibliográfica e relato de um caso de evolução favorável para a paciente. CONCLUSÃO: Incidência crescente das complicações de pericondrites na população jovem deve levar à prevenção primária mais elaborada.

Piercing has become more and more popular among adolescents. The procedure is generally performed by unqualified professionals and carries its risk. Non-sterilized material or inappropiate hygiene increases the possibility of perichondritis and celulitis. The disease is characterized by erythema of the auricula pinna, unbearable pain and fever. Left untreated, the condition progresses with edema along the auricula and abscess formation that may result in ischemic necrosis and a cauliflower anesthetic deformation. The most common bacteria is Pseudomonas aeruginosa. In cases with abscesses, drainage is necessary along with antibiotic therapy guided by cultures and antibiogram. AIM: The aim of this case report was to review the past 10 years of published papers dealing with anatomical aspects of the auricular pinna, the history of piercing and its most common complications. METHODS: A case report of perichondritis after "high" ear piercing that required surgical treatment and that progressed with no esthetic loss. RESULTS: Theoretical and practical experience based on a review and a report of a case that progressed satisfactorily. CONCLUSIONS: The increased incidence of perichondritis in adolescents should require more elaborated primary prevention measures.

Tuberculose de orelha, doença profissional? / Tuberculosis of the ear, a professional disease?

Na literatura, a otite média tuberculosa está como uma causa rara de infecção crônica supurativa da orelha média e mastóide, e os fatores predisponentes foram pouco referidos. Em nosso país há um aumento da incidência de tuberculose, inclusive de formas raras como a otite média tuberculosa. Esses pacientes classicamente têm múltiplas perfurações da membrana timpânica e otorréia, associada à perda auditiva progressiva. O diagnóstico deve ser aventado nos pacientes com otite que não responde a terapia de rotina, seja por fungo da orelha externa ou bacteriana da orelha média. Os autores apresentam, em estudo retrospectivo, quatro pacientes com otite média tuberculosas, sendo duas médicas, uma engenheira química e um menor com casos de tuberculose ativa na família, sendo, portanto, fatores predisponentes o contato familiar com tuberculoso, contato profissional e exposição a agressores de vias aéreas.

Tuberculosis is a rare cause of chronic suppurative otitis media and mastoiditis; the predisposing factors of this association, however, are not commonly described. There has been an alarming increase in the incidence of tuberculosis in Brazil, including tuberculous otitis media. These patients typically present multiple perforations of the tympanic membrane, an ear discharge, and progressive hearing loss. This diagnosis should be taken into account in patients that do not respond to routine therapy for fungal external otitis or bacterial otitis media. In this retrospective study, the authors describe four cases of patients with tuberculous otitis media. This sample consisted of two physicians, a chemical engineer and an underage child in whose family there were cases of active tuberculosis. Predisposing factors for tuberculous otitis were contact with family members that had tuberculosis, professional contact with patients and exposure to pathogenic microorganisms in airways.

A Case of Malignant External Otitis with Pichia ohmeri / 감염

Pichia ohmeri is a rare fungal pathogen for human infection. To date, only 5 cases of P. ohmeri infection have been reported including fungemia, disseminated infection and peritonitis. We report the first case of malignant external otitis and mastoid osteomyelitis caused by P. ohmeri. The patient had a long history of diabetes, hypertension and arrrhythmia. The patient was admitted to the hospital because of otorrhea, otalgia and hearing difficulty for 3 months. Internal auditory canal MRI showed osteomyelitis of left mastoid bone and skull base. Culture of ear discharge and bone biopsy specimen grew P. ohmeri. The patient had been treated with amphotericin-B followed by fluconazole.

Transepidermal Water Loss in Patients of Eczematous External Otitis / 대한이비인후과학회지

The difference of transepidermal water loss(TEWL) between normal persons and patients with eczematous external otitis was identified by statistical analysis. In this study, 20 healthy volunteers without history of atopic dermatitis and 20 patients with eczematous external otitis were participated. Measurements were performed at ear lobes and other various anatomical sites(proximal forearm, mid forearm, distal forearm, palm, upper back, lower back, leg(shin), leg(calf), and sole) by Tewameter TM 210(Courage;Rhazaka, Koln, Germany). Prior to the procedure, subjects stayed still for 30 minutes in the room where the temperature was controlled(18-23degreesC) with a relative humidity of 35-45%. The results are summarized as follows:1) TEWL values at ear lobes were higher in patients with eczematous external otitis than in normal persons(p<0.05). 2) TEWL values at other various anatomical sites except upper back were higher in patients with eczematous external otitis than in normal persons(p<0.05).