Clinical Review of Necrotizing Otitis Externa, a single center experience

Khalid Alshaikh; Adari Alqurashi; Saad Alenzi; Abdulaziz Alqahtani; Abdulmo nemAlshaikh

doi:10.4103/1319-8491.277841

ORIGINAL ARTICLE

Year : 2019 | Volume : 21 | Issue : 1 | Page : 13-18

Clinical Review of Necrotizing Otitis Externa, a single center experience

Khalid Alshaikh¹, Adari Alqurashi², Saad Alenzi³, Abdulaziz Alqahtani⁴, Abdulmo nemAlshaikh⁵
¹ Department of Otolaryngology, King Abdulaziz Medical City, Jeddah, Saudi Arabia (MBBS), Saudi Arabia
² Department of Otolaryngology, East Jeddah Hospital, Jeddah, Saudi Arabia (MBBS), Saudi Arabia
³ Department of Otolaryngology, King Khaled Hospital, Tabouk, Saudi Arabia (MBBS), Saudi Arabia
⁴ Department of Otolaryngology, Ha'il University, Ha'il, Saudi Arabia (MBBS), Saudi Arabia
⁵ ENT Consultant, Otology and Cochlear Implant Surgeon , Formerly Head of Cochlear Implant Program, King Fahad Hospital, Jeddah, Saudi Arabia

Date of Web Publication

6-Feb-2020

Correspondence Address:
Khalid Alshaikh
P.O.Box 10462, Jeddah 21433
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.277841

Abstract

Background: Necrotizing otitis externa defined as an infectious disease affecting external auditory canal and might involve the mastoid space and base of skull as well, and thus a fatal neurological complications if left untreated. Generally; there’s an emergence of antibiotics resistance have been reported as well as a various causative organisms.
Objectives: To investigate the clinical presentation, related co-morbidities, antimicrobial patterns, and associated complications.
Patients and Methods: This is a case series of patients with diagnosis of necrotizing otitis externa who admitted and treated at otolaryngology department, king Fahad hospital, Jeddah from üctober-2007 to üctober-2017. Detailed medical data were reviewed included demographics, clinical presentation, antimicrobial sensitivity, and clinical outcome.
Results: Fourteen patients with NOE were treated at our institution, of these, eleven were male and three were female. All the included patients were diabetic and they had aural polyp. Ear discharge was the most common presenting symptoms. Eight cultures isolated a pseudomonas aeruginosa. All patients received an intravenous antibiotics either monotherapy or combination therapy. The mean hospital stay was 39 days. Zero mortality rate 30 days post discharge.
Conclusion: Necrotizing otitis externa remain an aggressive disease with growing bacterial resistance so the choice of antimicrobial should be chosen with cautious. Nevertheless; severe ear pain, and ear discharge in elderly diabetic patients the diagnosis of NOE should be ruled out. Prevalence of pseudomonas aeruginosa is remain quite high, although non-pseudomonal organisms are increasing over should paid.

Keywords: Necrotizing otitis externa, Malignant otitis externa-bacterial Sensitivity, Osteomyelitis base of the skull

How to cite this article:
Alshaikh K, Alqurashi A, Alenzi S, Alqahtani A, nemAlshaikh A. Clinical Review of Necrotizing Otitis Externa, a single center experience. Saudi J Otorhinolaryngol Head Neck Surg 2019;21:13-8

How to cite this URL:
Alshaikh K, Alqurashi A, Alenzi S, Alqahtani A, nemAlshaikh A. Clinical Review of Necrotizing Otitis Externa, a single center experience. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2023 Jun 4];21:13-8. Available from: https://www.sjohns.org/text.asp?2019/21/1/13/277841

Introduction

Necrotizing otitis externa ( NEO ) is an infectious disease affecting external auditory canal which can involve the mastoid space as well as base of skull and lead to a fatal neurological complications, carries a 20% mortality rate despite antibiotic therapy^[1]. In 1959, Meltzer and Kelemen et al;described this infection as osteomyelitis of the temporal bone with serious complications that is originated from otitis externa in diabetic patient^[2]. Interestingly their patient ear culture reported as Bacillus pyocyanea which is known now as Pseudomonas aeruginosa

A). However term “ malignant otitis externa was proposed by Chandler in 1968^[3]. Decade and half later Bayardelle et al;demonstrated a first case of Non-pseudomonal NOE due to oxacillin-sensitive Staphylococcus aureus^[4]. Consequently multiple reports have been reported the similar result^[5],[6]. Several studies revealed the incidence of Pseudomonas infection ranged from 27% to 54% of the cases^[5],[7]. Local surgical treatment has been suggested and used in patients who have necrotizing otitis externa in 1984; by Strashunto remove the diseased bone^[8].Since then; such of modality has been used in 47% of published cases in the literatures^[9].One of the hypothesized mechanism of development of the disease is vascular insults that devitalize the external auditory canal dermis which gives a route for opportunistic bacteria to invade deeply^[10].Diagnostic criteria has been proposed by Cohen and Fridmanin 1987 which were divided into major criteria including (otalgia, otorrhea, edema of external auditory canal, granulation tissue, micro-abscess “if operated”, positive culture for pseudomonas pathogen, positive technetium 99 scan or failure of 1 week duration of local antibiotics) and minor criteria which enlisted as diabetic patients , cranial nerves palsy, positive radiographic studies, debilitating condition, and old age^[11].The most common causative organism found to be Pseudomonas, but other pathogens can be the cause, either bacterial or fungal[12-14].Simple anti-pseudomonal antibiotics have been used as the first line of treatment recently, later on; an antibiotic resistance to those group have emerged, consequently a broad spectrum antibiotics have been utilized and thus; reduce sensitivity such as a combination therapy of intravenous ceftazidime and oral fluoroquinolone^[15],[16].Bacterial pathogens that are resistant to multiple drugs represent a growing public health threat, because multiple drug-resistant (MDR) infections are challenging and expensive to treat^[17].The aim of this study was to investigate the clinical presentation, related co-morbidities, antimicrobial patterns, and associated complications.

Methodology

This is a chart review of patients diagnosed as necrotizing otitis external at king Fahad general Hospital, Jeddah, Saudi Arabia. Diagnosis was based on Cohen and Fridman criteria^[11]. from October-2007 to December-2017 included (Age, gender, co-morbidities, side of involvement, presenting and associated signs and symptoms, cranial nerves involvement, presence of granulation tissue, tympanic membrane status, culture and sensitivity results, type of antibiotics, biopsy result if performed, duration of hospital stay, clinical outcome). Institutional review board approval was obtained for the study ( Ministry of Health institutional review board approval #PRO H-02-J-002 , medical record database was searched for all patients diagnosed with NOE between October-2007 and december-2017.

Results

Fourteen patients were included in the study after confirmation of the diagnosis of necrotizing otitis externa , at diagnosis the mean age was 64 years for all patients, 78.5% (n=11) were men and 21.5% (n=3) were women,all patients were diabetic.Most of the patients had unilateral disease in 80% (n=11) of the patients, of these;42.85 % (n=6) were the disease ear left sided and 35.71% (n=5) where in the right side, 21.42% (n=3) where the disease is bilateral [Table 1]. The main presenting symptoms were pain in 71.4% (n=10), persistent discharge in 85.7 % (n=12) and 42.8 % (n= 6) of the patients had facial nerve palsy. External auditory canal narrowing and aural polyp were present in all the patients.Laboratory investigations complete blood count showed no leukocytosis in the included patients, and 46% ( n=7 ) of them had elevated C-Reactive protein (CRP) andErythrocyte sedimentation rate (ESR). Temporal Computed tomography ( CT ) scan showed bone erosion in all the patients. Aural discharge culture yielded pseudomonas aeruginosa in 57% (n=8) patients as shown in [Table 2],Tazocin and Ciprofloxacin were sensitive in 7 patients in pseudomonal group while 5 cultures were sensitives to Ceftazidime, Nevertheless Meropenem in 4 cultures. However it’s seem the entire group was resistant ceftriaxone. A combination therapy including a Tazocin and Ciprofloxacin were given in 6 patients, and one patient received Meropenem and Ciprofloxacin, as well as the other patient Cefepime was given. Non-pseudomonas aeruginosa pathogens in 43% ( n= 6) which includeE.coli, Canadia non albicans, kelbiseelapneumonia, mixed growth, staph aureus, Aspergillus flavus except for enterobacterium were isolated from 2 patients. E.coli was resistant to most of antibiotics include Cephalosporin, Gentamicin, and Ciprofloxacin. Unlikely to E.coli we found kelbesslapneumonia and Enterobacteriumwere sensitive to most of antibiotics except 1st,2nd cephalosporin generations. On other hand Staph. Aureus were sentive to ciprofloxacin and vancomycin while in mixed growth culture we failed to determine the sensitivity. The main treatment in non-pesudomsal group were a single or combination of tazocin, ceftazidime.All patients were admitted and treated as in-patient, The mean duration of hospital stay was around 39 days and ranged between 10 days and 60 days. except for single patient who is currently receiving the treatment.CRP, ESR, and gallium scan were used as discharge criteria to ensure the disease is resolved. All patients were clinically improved except for one follow up was lost. 2, 4, 6 and 8 weeks out patients follow up post discharge showed all patients clinically improved except for one patient discharged against medical advice and follow up evaluation was lost. 30 days post discharge mortality rate was zero.

Table 1: Summarize the demographic data.
HTN( Hypertension), DM ( Diabetes Mellitus), IHD ( Ischemic Heart Disease), CVA ( Cerebrovascular Accident), DVT ( Deep Venous Thrombosis).

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Table 2: Summarize the microbiological data, duration of hospital stay, and clinical outcome.

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Discussion

Fourteen patients included in this study. The vast majority were male patients and they suffered from unilateral disease. The mean age was 64 years. Persistent discharge was most persistent symptoms. Nevertheless; aural polyp was presented in all patients. About half of patients had associated facial nerve palsy. Pseudomonas aeruginosa was most prevalent organism in our patients as well as anti-microbial sensitivity tazocin and ciprofloxacin was sensitive among most of the cultures that revealed pseudomonas aeruginosa. In contrast non pseudomonas group were sensitive to most of antibiotics except first and second generation cephalosporin. The mean hospital stay was 39 days. Diabetic patients remain the most vulnerable group to have necrotizing otitis externa. In comparison the incidence of diabetes mellitus among our group was 100% this finding is consistent with reported incidence in such group of patients^{[3],[15],[18],[19],[20]}.Chandler’s et al;suggested an explanation to this phenomena as they had associated endarteritis, crushed small vessels, microangiopathy which is complemented by capability of the pseudomonas aeruginosa to penetrate the blood vessels and lead to vasculitis and thrombus formation which are eventually ended with coagulation necrosis of adjacent structures^[3]. However many studies reported immune-comprised patients at greater risk to develop necrotizing otitis externa in compare to medically free population^[21],[22].In recent systematic review done by Mahdyoun et al;9 The mean age was ranged between 59 to 77 years old and this finding is similar with the mean age reported in our study^[9]. Furthermore; Male predominance was observed as more than half of the included patients in the original studies are male these findings consistent to our result. Anticipated findings were found among most of our patients which are the persistent otorrhea and otalgia and these findings are non-specific to necrotizing otitis externa. Moreover such findings have been reported in many studies^{[11],[23],[24],[25]}. However numerous studies documented failed to local treatment after of duration around 10 days is one of the main criteria to diagnose NOE.Facial nerve palsy has been evident associated with (NOE). However; conflicting results toward facial nerve palsy that can play a role as prognostic factor. Franco and his colleagues suggested that patient with facial nerve palsy might need longer duration of treatment and indicate a poor prognosis^[26]. Contrary; a recent review suggested the observed association between cranial nerve involvement and the prognosis of NOE was not significant^[19]. In compare to our patients who had facial nerve palsy they showed clinical improvement and disease resolving despite the facial nerve recovery was poor with adequate treatment among our group.PA has been recognized as the main causative organism since 1959^[2].Since then the incidence has declined as other organisms have been identified^[12],[14]. Among our patients various bacterial and non-bacterial organisms have been discovered. Furthermore; The majority of our patients were found to have PA 57% (n=8). In accordance with the present results, a recent systematic review have demonstrated that PA was the most frequent organism in the pooled analysis of 1185 cases^[9].Particularly, bacterial sensitivity among this group found to have sort of resistance. Hence; the first three generation of cephalosporins found to be resistant in all cultures that obtained. In other hand; Tazocin and ciprofloxacin were the most sensitive anti-bacterial within the same group. In contrast to earlier findings in several studies that found different PA strains were resistant to ciprofloxacin^{[15],[26],[27],[28]}. However, with a small sample size, and bacterial resistance and this could be owing to inappropriate antibiotics utilization. Thus; this contradictory might be explained by prevalence of organism itself among various population, and previous exposure of the antibiotic, so caution must be applied. Therefor; other pathogens including bacterial and fungal have been found in our patients particularly Escherichia ^{More Details} coli,klebsiella pneumoniae, Staphylococcus aureus, Enterobacterium, Aspergillus flavus, candida non-albicans, and one culture we failed to determine the organism which reported as mixed growth. Regardless of causative organism; different anti-microbial regimens have been reported in the literatures; the most frequent protocol was either monotherapy or combination therapy of ciprofloxacin and ceftazidime^[9].This result contrary to our regimens we used which was mainly composed of combination of tazocin and ciprofloxacin, although a monotherapy such as meropenem, cefepime, Tazocin, and Ceftazidime also was used. Furthermore; there was no clinical outcome or hospital stay significance association found among our patients regardless of regimens except for one patients who labeled as PA positive and improved in 10 days, Furthermore hospital stay was ranged from 4-8 weeks despite the organism. The aims of antimicrobial to eliminate the disease, reduce the hospital stay as well as the risk of devastating and lethal complications thus; the health care cost. A historical inverse correlation to hospital stay which seems to be increasing over the time^[9]. Perhaps; this association be demonstrated by a growing antimicrobial resistance. However;The overall cure rate reported was ranging from 85-100% and this finding comparable to our report^[9].Nevertheless; there was no evidence of recurrence. Accordingly this might to due short follow up among our patients. Previous studies documented a recurrence rate from 0 to 25^ω/0^[26],[29]. In 1984 Strashun;reported a 60% recurrence rate^[8]. Usefulness of local antibiotics is uncertain,In other hand many reports discourage to use such of treatment as it’s assumed these compositions is limited to external auditory canal flora and it might reduce the culture sensitivity as well as increase the antimicrobial resistance^[25],[31].Generally extensive cranial base surgery no longer used since 1980 as medical management would provide a favorable outcome with lower cost effective. However; local surgical treatment has been proposed by different authors to obtain histological and microbiological samples. A validated indications to utilize such treatment doesn’t exist. Therefore; further studies to investigate this approach is crucial to determine effectiveness^[32],[33].

Conclusion

NOE remain an aggressive disease with growing bacterial resistance so the choice of antimicrobial should be chosen with cautious. Nevertheless; severe ear pain, and ear discharge in elderly diabetic patients the diagnosis of NOE should be ruled out. Prevalence of PA is remain quite high, although non-pseudomonal organisms should be consider in treating those patients.

Disclosure:

None.

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