Current diagnosis and treatment of skull base osteomyelitis / 临床耳鼻咽喉头颈外科杂志

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

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida! / Aneurisma micótico da aorta em paciente debilitado com imunidade comprometida - um alerta para Cândida

Abstract Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

Resumo A cândida é uma causa rara de aneurismas da aorta infecciosos. Relatamos o caso de um paciente diabético com doença renal terminal, que foi submetido a reparo de aneurisma da aorta abdominal com vazamento. Ele estava em tratamento de longo prazo com antibióticos para otite externa maligna. A Candida albicans foi isolada da cultura da parede do aneurisma que sofreu a excisão. Não há relatos prévios de aneurisma da aorta infeccioso causado por cândida em pacientes com otite externa maligna. Este relato de caso visa reforçar que a cândida deve ser uma das suspeitas de causa de aneurisma da aorta infeccioso em pacientes debilitados e com imunossupressão crônica. O manejo desses casos pode ser extremamente desafiador, principalmente em contextos em que os recursos são escassos, e mencionaremos as vantagens e desvantagens das diversas opções de tratamento.

Facial nerve palsy in otitis externa: A red flag?

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

Otitis externa maligna con ectima gangrenoso en un paciente con infección por VIH / Malignant otitis externa with ecthyma gangrenosum in an hiv-positive patient

La otitis externa maligna es considerada una infección invasiva del conducto auditivo externo, infrecuente y sumamente agresiva, que llega, en ocasiones, a comprometer la base del cráneo. Se presenta habitualmente en inmunocomprometidos, incluidos aquellos con infección por VIH. El ectima gangrenoso es una infección cutánea localizada, inusual, causada, en la mayoría de los casos por Pseudomonas aeruginosa, con compromiso multisistémico y evolución tórpida. La asociación entre ambas entidades es aún más rara. A continuación, presentamos el caso de una mujer de 37 años, con el antecedente principal de infección por VIH desde hace 10 años, adherente al tratamiento antirretroviral y, a pesar de mantener una adecuada respuesta inmunológica y virológica, se presenta a la urgencia de nuestro hospital en shock séptico por otitis externa maligna, con ectima gangrenoso y posible síndrome hemofagocítico como complicación, aislándose Pseudomonas aeruginosa como agente causal.

Malignant otitis externa is an aggressive, infrequent and invasive infection of the external auditory canal. In some cases it leads to skull base compromise, particularly in immunocompromised individuals, including HIV-positive patients. Ecthyma gangrenosum is an unusual, localized cutaneous infection, caused mostly by Pseudomonas aeruginosa, with systemic compromise and a torpid evolution. An association between these 2 entities is even more rare. We present the case of a 37-year old woman with a history of 10 years’ HIV infection and good adherence to antiretroviral therapy. Although she had an adequate immunological and virological response, she presented at our emergency department in septic shock due to malignant otitis externa with ecthyma gangrenosum and possible haemophagocytic syndrome as a complication, with Pseudomonas aeruginosa determined to be the causative agent.

Central Skull Base Osteomyelitis: 10-Case Series in a Single Center / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Skull base osteomyelitis (SBO) typically evolves as a complication of malignant otitis externa (MOE) in diabetic patients and involves the temporal bone. Central SBO (CSBO), which mainly involves the sphenoid or occipital bones, has clinicaland radiological characteristics similar to those of SBO but without coexisting MOE. We investigated a group of patients with CSBO and studied the clinical course of CSBO. SUBJECTS AND METHOD: Medical records of patients who were diagnosed with CSBO were retrospectively analyzed from 1999 to 2014. RESULTS: Ten patients (mean age; 60.5 years) were identified. There were five males and five females. All patients suffered from headache, and six patients had cranial nerve palsy including oculomotor (20%), abducens (10%), vestibulocochlear (10%), glossopharyngeal (20%), vagus (30%) and hypoglossal (10%) nerve. Patients had underlying diseases including diabetes mellitus (40%), immunosuppression status after liver transplantation (10%) and cardiovascular disease (40%). Four patients received endoscopic biopsy and debridement for diagnostic and curative intent. Patients were treated with intravenous antibiotics for 5.1 weeks in average and oral antibiotics for 17 weeks. Mean follow-up period was 12.4 months and the mortality rate was zero. 40% of patients had residual neurologic deficit. The earliest sign of improving CSBO was headache (mean; 3.1 weeks) and the erythrocyte sedimentation rate was the latest improving sign (mean; 4 months). CONCLUSION: CSBO was diagnostic and therapeutic challenge to the clinicians. The timely diagnosis and long-term antibiotics therapy could avoid a mortality case and minimize the permanent neurologic deficit.