year 16, Issue 4 (July - August 2022)                   Iran J Med Microbiol 2022, 16(4): 296-304 | Back to browse issues page

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Hammami F, Koubaa M, Rekik K, Feki W, Sallemi M, Smaoui F, et al . Malignant Otitis Externa: An Experience of A 27-Year Period. Iran J Med Microbiol 2022; 16 (4) :296-304
1- Infectious Diseases Department, Hedi Chaker University Hospital, University of Sfax, Tunisia ,
2- Infectious Diseases Department, Hedi Chaker University Hospital, University of Sfax, Tunisia
3- Radiology Department, Hedi Chaker University Hospital, University of Sfax, Tunisia
4- Department of Otorhinolaryngology, Head and Neck Surgery, Habib Bourguiba University Hospital, University of Sfax, Tunisia
Abstract:   (1043 Views)

Background and Objective: Malignant otitis externa is a rare but potentially fatal infection. It tends to affect the elderly as well as patients with diabetes and immunocompromised status. We aimed to identify the epidemiological, clinical, therapeutic, and evolutionary features of malignant otitis externa.
Methods: We conducted a retrospective study including patients hospitalized in the infectious diseases department in Sfax (South of Tunisia) for malignant otitis externa between 1994 and 2020. Non-documented cases were excluded from the study at enrolment.
Results: We encountered 82 patients, among whom 45 were male (54.9%). The mean age was 62 ±14 years. Seventy-four patients had diabetes mellitus (90.2%). The most common clinical symptoms were otalgia (86.5%) and otorrhea (69.5%). Pseudomonas aeruginosa was the most common organism (56%). The first-line antimicrobial used on admission was a combination of ciprofloxacin (65.8%) and ceftazidime (51.2%). The median duration of treatment was 6 weeks [4-32 weeks]. The disease evolution was favorable in 67 cases (81.8%). According to the length of hospital stay, patients hospitalized for ≥ 21 days consulted after significantly longer duration of complaints (49 days vs. 36 days; P=0.01) and had significantly more frequent complications (35.3% vs. 10.4%; P<0.001), while the recovery was significantly more frequent in patients hospitalized less than 21 days (89.6% vs. 70.6%; P=0.02).
Conclusion: Despite advancements in treatment and the variability of imaging modalities, malignant otitis externa remains a fatal disease. The diagnostic delay may worsen the disease outcome, requiring a longer duration of treatment and referral to surgery.

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Type of Study: Original Research Article | Subject: Medical Bacteriology
Received: 2021/08/14 | Accepted: 2022/02/5 | ePublished: 2022/05/25

1. Amaro CE, Espiney R, Radu L, Guerreiro F. Malignant (necrotizing) externa otitis: the experience of a single hyperbaric centre. Eur Arch Otorhinolaryngol. 2019 Jul;276(7):1881-7. [DOI:10.1007/s00405-019-05396-7] [PMID]
2. Carlton DA, Perez EE, Smouha EE. Malignant external otitis: The shifting treatment paradigm. Am J Otolaryngol. 2018;39(1):41-5. [DOI:10.1016/j.amjoto.2017.05.010] [PMID]
3. Mahdyoun P, Pulcini C, Gahide I, Raffaelli C, Savoldelli C, Castillo L, et al. Necrotizing otitis externa: A systematic review. Otol Neurotol. 2013;34(4):620-9. [DOI:10.1097/MAO.0b013e3182804aee] [PMID]
4. Marina S, Goutham MK, Rajeshwary A, Vadisha B, Devika T. A retrospective review of 14 cases of malignant otitis externa. J Otol. 2019;14(2):63-6. [DOI:10.1016/j.joto.2019.01.003] [PMID] [PMCID]
5. Lee SK, Lee SA, Seon SW, Jae Hyun Jung, Jong Dae Lee, Jae Young Choi, et al. Analysis of prognostic factors in malignant external otitis. Clin Exp Otorhinolaryngol. 2017;10(3):228-35. [DOI:10.21053/ceo.2016.00612] [PMID] [PMCID]
6. Van Kroonenburgh AMJL, van der Meer WL, Bothof RJP, van Tilburg M, van Tongeren J, Postma AA. Advanced Imaging Techniques in Skull Base Osteomyelitis Due to Malignant Otitis Externa. Curr Radiol Rep. 2018;6(1):3. [DOI:10.1007/s40134-018-0263-y] [PMID] [PMCID]
7. Cooper T, Hildrew D, McAfee JS, McCall AA, Branstetter BF, Hirsch BE. Imaging in the Diagnosis and Management of Necrotizing Otitis Externa: A Survey of Practice Patterns. Otol Neurotol. 2018;39(5):597-601. [DOI:10.1097/MAO.0000000000001812] [PMID]
8. Schwam ZG, Ferrandino R, Kaul VZ, Wanna GB, Cosetti MK. Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa. Laryngoscope. 2020;130(9):2220-2228. [DOI:10.1002/lary.28409] [PMID]
9. Peled C, Kraus M, Kaplan D. Diagnosis and treatment of necrotising otitis externa and diabetic foot osteomyelitis - similarities and differences. J Laryngol Otol. 2018;132(9):775-9. [DOI:10.1017/S002221511800138X] [PMID]
10. Bhasker D, Hartley A, Agada F. Is malignant otitis externa on the increase? A retrospective review of cases. Ear Nose Throat J. 2017;96(2):E1-5. [DOI:10.1177/014556131709600211] [PMID]
11. Hutson KH, Watson GJ. Malignant otitis externa, an increasing burden in the twenty-first century: review of cases in a UK teaching hospital, with a proposed algorithm for diagnosis and management. J Laryngol Otol. 2019;133(5):356-62. [DOI:10.1017/S0022215119000604] [PMID]
12. Hollis S, Evans K. Management of malignant (necrotising) otitis externa. J Laryngol Otol. 2011;125(12):1212-7. [DOI:10.1017/S0022215110002550] [PMID]
13. Sokołowski J, Lachowska M, Karchier E, Bartoszewicz R, Niemczyk K. Skull base osteomyelitis: factors implicating clinical outcome. Acta Neurol Belg. 2019;119(3):431-7. [DOI:10.1007/s13760-019-01110-w] [PMID] [PMCID]
14. Sylvester MJ, Sanghvi S, Patel VM, Eloy JA, Ying Y-LM. Malignant otitis externa hospitalizations: Analysis of patient characteristics. Laryngoscope. 2017;127(10):2328-36. [DOI:10.1002/lary.26401] [PMID]
15. Hatch JL, Bauschard MJ, Nguyen SA, Lambert PR, Meyer TA, McRackan TR. Malignant Otitis Externa Outcomes: A Study of the University Health System Consortium Database. Ann Otol Rhinol Laryngol. 2018;127(8):514-20. [DOI:10.1177/0003489418778056] [PMID] [PMCID]
16. Hasibi M, Ashtiani MK, Motassadi Zarandi M, Yazdani N, Borghei P, Kuhi A, et al. A Treatment Protocol for Management of Bacterial and Fungal Malignant External Otitis: A Large Cohort in Tehran, Iran. Ann Otol Rhinol Laryngol. 2017;126(7):561-7. [DOI:10.1177/0003489417710473] [PMID]
17. Selvamalar V, Othman NAN, Daud MKM. A Case Series of Malignant Otitis Externa Mimicking Malignancy. Acta medica (Hradec Kral). 2021;64(1):36-41. [DOI:10.14712/18059694.2021.6] [PMID]
18. Ferlito S, Maniaci A, Luca MD, Grillo C, Mannelli L , Salvatore M, et al. From Uncommon Infection to Multi-Cranial Palsy: Malignant External Otitis Insights. Dose Response. 2020;18(4). [DOI:10.1177/1559325820963910] [PMID] [PMCID]
19. Mehrotra P, Elbadawey MR, Zammit-Maempel I. Spectrum of radiological appearances of necrotising external otitis: a pictorial review. J Laryngol Otol. 2011;125(11):1109-15. [DOI:10.1017/S0022215111001691] [PMID]
20. Courson AM, Vikram HR, Barrs DM. What are the criteria for terminating treatment for necrotizing (malignant) otitis externa? Laryngoscope. 2014;124(2):361-2. [DOI:10.1002/lary.24093] [PMID]
21. Ciorba A, Cultrera R, Di Laora A, Grilli A, Bianchini C, Aimoni C. Malignant otitis externa in the antibiotic resistance era: Key to successful treatment. B-ENT 2018;14:119-23.
22. Chaudhary HA, Ibrahim WH, Yousaf Z, Abubeker IY, Kartha A. Fungal malignant otitis externa involves a cascade of complications culminating in pseudoaneurysm of internal maxillary artery: A case report. Am J Case Rep. 2019;20:562-6. [DOI:10.12659/AJCR.913469] [PMID] [PMCID]
23. Vennewald I, Klemm E. Otomycosis: Diagnosis and treatment. Clin Dermatol. 2010;28(2):202-11. [DOI:10.1016/j.clindermatol.2009.12.003] [PMID]
24. Frost J, Samson AD. Standardised treatment protocol for necrotizing otitis externa: retrospective case series and systematic literature review. J Glob Antimicrob Resist. 2021;26:266-71. [DOI:10.1016/j.jgar.2021.06.015] [PMID]
25. Lullo AMD, Russo C, Piroli P, Petti A , Capriglione P, Cantone E, et al. Malignant Otitis External: Our Experience and Literature Review. Am J Case Rep. 2020;21:1-9. [DOI:10.12659/AJCR.925060] [PMID] [PMCID]
26. Peled C, Parra A, El-Saied S, Kraus M, Kaplan DM. Surgery for necrotizing otitis externa-indications and surgical findings. Eur Arch Otorhinolaryngol. 2020;277(5):1327-34. [DOI:10.1007/s00405-020-05842-x] [PMID]
27. Khan MA, Quadri SAQ, Kazmi AS, Kwatra V, Ramachandran A, Gustin A, et al. A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges among Various Presentations. Asian J Neurosurg. 2018;13(4):959-70. [DOI:10.4103/ajns.AJNS_90_17] [PMID] [PMCID]
28. Yigider AP , Ovunc O, Arslan E, Sunter AV, Cermik TF , Yigit O. Malignant Otitis Externa: How to Monitor the Disease in Outcome Estimation? Medeni Med J. 2021;36(1):23-9. [DOI:10.5222/MMJ.2021.36528] [PMID] [PMCID]
29. Al Aaraj MS, Kelley C. Malignant Otitis Externa. StatPearls 2021 Aug 11.
30. Arsovic N, Radivojevic N, Jesic S, Babac S, Cvorovic L, Dudvarski Z. Malignant Otitis Externa: Causes for Various Treatment Responses. J Int Adv Otol. 2020;16(1):98-103. [DOI:10.5152/iao.2020.7709] [PMID] [PMCID]

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