Abstract
Objectives
This study aims to assess the clinical trends of malignant otitis externa (MOE) and classify MOE based on the findings related to high-resolution computed tomography (HRCT) of the temporal bone and 99−Tech3-Phase Bone Scintigraphy (TPBS). We also reconstruct a treatment algorithm for MOE in our institution.
Methodology
A 10-year retrospective review was carried out on MOE in a single otology institution from January 2011 to December 2020. The MOE was classified based on proposed Tengku’s radiological stratification according to HRCT and TBPS findings. Phase I is defined as inflammation limited to the soft tissue in the external auditory canal, without involvement of the bone. Phase II is the inflammation beyond the soft tissue, involving bone, but limited to the mastoid. Phase III is when the inflammation extends medially, involving the petrous temporal bone or temporomandibular joint, with or without parapharyngeal soft tissue involvement. Phase IV refers to inflammation extending medially to involve the nasopharynx, with or without abscess formation. Finally, Phase V is inflammation that further extends to the contralateral base of the skull.
Results
A sample of 49 patients was involved in this study. Majority of the patients were having Phase III (36.7%) of the disease, followed by Phase V (24.5%), Phase II (18.4%), Phase IV (16.3%), and Phase I (4.1%). A comprehensive treatment algorithm was drafted based on our institution’s experience in managing MOE. The mortality rate was low (8.2%), mainly involving patients in advanced phase of the disease (Phases IV and V).
Conclusion
This study has revealed the evidence of progression of MOE based on the proposed radiological stratification. This stratification is simple and practically applicable in clinical settings. We suggest the use of our proposed treatment algorithm as a standard diagnostic and treatment protocol for MOE.
Similar content being viewed by others
References
Grandis JR, Branstetter BF, Yu VL (2004) The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis 4:34–39
Chandler JR (1968) Malignant external otitis. Laryngoscope 78:1257–1294
Cohen D, Friedman P (1987) The diagnostic criteria of malignant external otitis. J Laryngol Otol 101(3):216–221. https://doi.org/10.1017/s0022215100101562
Levenson JL (1985) Neuroleptic malignant syndrome. Am J Psychiatry 142(10):1137–1145. https://doi.org/10.1176/ajp.142.10.1137
Peleg U, Perez R, Raveh D, Berelowitz D, Cohen D (2007) Stratification for malignant external otitis. Otolaryngol Head Neck Surg 137:301–305. https://doi.org/10.1016/j.otohns.2007.02.029
Sudhoff H, Rajagopal S, Mani N, Moumoulidis I, Axon PR, Moffat D (2008) Usefulness of CT scans in malignant external otitis: effective tool for the diagnosis, but limited value in predicting outcome. Eur Arch Otorhinolaryngol 265:53–56. https://doi.org/10.1007/s00405-007-0416-8
Okpala NCE, Siraj QH (2005) Radiological and radionuclide investigation of malignant otitis externa. Otolaryngol Head Neck Surg 119:71–75. https://doi.org/10.1016/j.otohns.2004.06.517
Chakraborty D, Battacharya A, Gupta AK, Panda NK, Das A, Mittal BR (2013) Skull base osteomyelitis in otitis externa: the utility of triphasic and single photon emission computed tomography/ computed tomography bone scintigraphy. Indian J Nucl Med 28(2):65–69. https://doi.org/10.4103/0972-3919.118222
Mejzlik J, Cerny M, Zeinerova L, Dedkova J, Kopriva J, Zadrobilek K et al (2019) The routes of infection spread in central skull-base osteomyelitis and the diagnostic role of CT and MRI scans. BMC Med Imaging 19:60. https://doi.org/10.1186/s12880-019-0331-7
Mani N, Sudhoff H, Rajagopal S, Moffat D, Axon PR (2007) Cranial nerve involvement in malignant external otitis: implications for clinical outcomes. Laryngoscope 117:907–910. https://doi.org/10.1097/MLG.0b013e3318039b30f
Chen CN, Chen YS, Yeh TH, Hsu CJ, Tseng FY (2010) Outcomes of malignant external otitis: survival vs mortality. Acta Otolaryngol 130:89–94. https://doi.org/10.3109/00016480902971247
Loh S, Loh WS (2013) Malignant otitis externa: an Asian perspective on treatment outcomes and prognostic factors. Otolaryngol Head Neck Surg 148(6):991–996. https://doi.org/10.1177/0194599813482107
Marina S, Goutham MK, Rajeshwary A, Vadisha B, Devika T (2019) A retrospective review of 14 cases of malignant otitis externa. J Otol 14:63–66. https://doi.org/10.1016/j.joto.2019.01.003
Orji FT, Akpeh JO, Ukaegbe OC (2017) Malignant otitis externa: an assessment of emerging pathogens and the prognostic factors. Int J Med Med Sci 9(7):86–91. https://doi.org/10.5897/IJMMS2017.1305
Kielhofner M, Atmar RL, Hamill RJ, Musher DM (1992) Life-threatening Pseudomonal aeruginosa infection in patients with human immunodeficiency virus infection. Clin Infect Dis 14(2):403–411. https://doi.org/10.1093/clinids/14.2.403
Stevens SM, Lambert P, Baker AB, Meyer TA (2015) Malignant otitis externa: a novel stratification protocol for predicting treatment outcomes. Otol Neurotol 36:1492–1498. https://doi.org/10.1097/MAO.0000000000000839
Soudry E, Hamzany Y, Preis M, Joshua B, Hadar T, Nageris BI (2011) Malignant external otitis: analysis of severe cases. Otolaryngol Head Neck Surg 144(5):758–762. https://doi.org/10.1177/01945998106132
Acknowledgements
The authors would like to thank the Director General of Health Malaysia for the permission to publish this paper. We thank Dr Lim Sin Wee for his assistance in data collection.
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors would like to declare that there is no conflict of interest.
Ethical approval
The study had been approved by Medical Research and Ethics Committee, Ministry of Health Malaysia (NMRR-21-97-58150).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Kamalden, T.M.I.T., Misron, K. A 10-year review of malignant otitis externa: a new insight. Eur Arch Otorhinolaryngol 279, 2837–2844 (2022). https://doi.org/10.1007/s00405-021-06980-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00405-021-06980-6