Candace E. Hobson

Malignant Otitis Externa: Evolving Pathogens and Implications for Diagnosis and Treatment

Objective Malignant otitis externa (MOE) is an invasive infection of the temporal bone that is classically caused by Pseudomonas aeruginosa. Increasingly, however, nonpseudomonal cases are being reported. The goal of this study was to evaluate and compare the clinical presentation and outcomes of cases of MOE caused by Pseudomonas versus non-Pseudomonas organisms. Study Design Retrospective case series with chart review. Setting Tertiary care institution. Subjects and Methods Adult patients with diagnoses of MOE between 1995 and 2012 were identified. Charts were reviewed for history, clinical presentation, laboratory data, treatment, and outcomes. Results Twenty patients diagnosed with and treated for MOE at the University of Pittsburgh Medical Center between 1995 and 2012 were identified. Nine patients (45%) had cultures that grew P aeruginosa. Three patients (15%) had cultures that grew methicillin-resistant Staphylococcus aureus (MRSA). Signs and symptoms at presentation were similar across groups. However, all of the patients with Pseudomonas had diabetes, compared with 33% of MRSA-infected patients (P = .046) and 55% of all non-Pseudomonas-infected patients (P = .04). Patients infected with MRSA were treated for an average total of 4.7 more weeks of antibiotic therapy than Pseudomonas-infected patients (P = .10). Overall, patients with non-Pseudomonas infections were treated for a total of 2.4 more weeks than Pseudomonas-infected patients (P = .25). Conclusions A high index of suspicion for nonpseudomonal organisms should be maintained in patients with signs and symptoms of MOE, especially in those without diabetes. MRSA is an increasingly implicated organism in MOE.

Clinical effects of middle turbinate resection after endoscopic sinus surgery: a systematic review.

Background The middle turbinate (MT) is a structure that is often carefully preserved during endoscopic sinus surgery (ESS) in an effort to preserve nasal physiology and serve as an anatomic landmark. However, resection is performed in select cases because of involvement of the MT in the inflammatory process, obstruction, or instability. Therefore, significant controversy exists among surgeons regarding the indications for proceeding with MT resection in ESS. This study evaluates clinical outcomes of MT resection after ESS. Methods An English language search of the PubMed and Ovid databases was conducted for publications examining clinical outcomes of MT resection after ESS performed for chronic rhinosinusitis. Two authors independently examined the articles to identify those meeting inclusion criteria. Any differences over which studies to include were resolved by discussion and consensus. Bias assessment was conducted using the Cochrane Collaboration bias tool for randomized controlled trials and the Newcastle–Ottawa bias tool for cohort and case–control studies. Results After initial screening, search results revealed 71 articles that warranted detailed evaluation. After applying inclusion criteria, 9 studies were selected. A total of 2123 patients were included among the studies. All studies were controlled. Within the limited available data, olfaction scores may be improved in the MT resection patients compared with MT preservation patients. No difference between the groups was noted for quality of life outcomes, nasal airway resistance, or rates of postoperative frontal sinusitis. In regard to postoperative endoscopic examinations, some studies note greater improvement in the MT resection group compared with the MT preservation group, while others were equivalent. Conclusion Although some studies show outcome benefit in MT resection patients compared with MT preservation patients, several others show no difference. When MT resection was appropriately indicated, no studies showed detrimental effects compared with MT preservation in their designated outcomes. Additional more stringent studies are warranted.

Vestibular nucleus neurons respond to hindlimb movement in the decerebrate cat

The vestibular nuclei integrate information from vestibular and proprioceptive afferents, which presumably facilitates the maintenance of stable balance and posture. However, little is currently known about the processing of sensory signals from the limbs by vestibular nucleus neurons. This study tested the hypothesis that limb movement is encoded by vestibular nucleus neurons and described the changes in activity of these neurons elicited by limb extension and flexion. In decerebrate cats, we recorded the activity of 70 vestibular nucleus neurons whose activity was modulated by limb movements. Most of these neurons (57/70, 81.4%) encoded information about the direction of hindlimb movement, while the remaining neurons (13/70, 18.6%) encoded the presence of hindlimb movement without signaling the direction of movement. The activity of many vestibular nucleus neurons that responded to limb movement was also modulated by rotating the animals body in vertical planes, suggesting that the neurons integrated hindlimb and labyrinthine inputs. Neurons whose firing rate increased during ipsilateral ear-down roll rotations tended to be excited by hindlimb flexion, whereas neurons whose firing rate increased during contralateral ear-down tilts were excited by hindlimb extension. These observations suggest that there is a purposeful mapping of hindlimb inputs onto vestibular nucleus neurons, such that integration of hindlimb and labyrinthine inputs to the neurons is functionally relevant.

Clinical outcome of patients with carcinoma ex pleomorphic adenoma of the parotid gland: A comparative study from a single tertiary center

Carcinoma ex pleomorphic adenoma (CXPA) of the parotid gland is a high‐grade cancer and the prognosis of this cancer has not been compared with non‐CXPA high‐grade primary parotid cancer.

Systematic review and metaanalysis of middle meatal packing after endoscopic sinus surgery.

Objective The objective of this systematic review was to evaluate synechiae formation in patients who underwent packing in the middle meatus at the completion of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis. Data Sources PubMed and Ovid. Review Methods Prospective randomized controlled studies of ESS with the placement of middle meatal packing were reviewed and included for analysis. Metaanalysis of the pooled data was performed. Results Eighteen prospective, randomized, controlled trials met inclusion criteria, resulting in a total of 925 subjects. Although there was a trend toward decreased risk of synechiae formation in the patients who underwent placement of middle meatal packing postoperatively (RR = 0.544), this did not achieve statistical significance on metaanalysis (p = 0.052). Conclusions This systematic review and metaanalysis suggests that use of middle meatal packing does not significantly reduce the risk of synechiae formation after ESS. There was, however, significant heterogeneity of the data analyzed, and the difference between groups was just short of statistical significance in our metaanalysis. Additional prospective randomized studies on this topic will further elucidate the utility of middle meatal packing.

Primary treatment of idiopathic sudden sensorineural hearing loss with intratympanic dexamethasone.

Purpose of reviewSystemic corticosteroids have been the mainstay of treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) for over 30 years. Recently, intratympanic steroids have risen in popularity; however, there is no consensus regarding the details of their application. The purpose of this article is to review the current literature and share our opinion that intratympanic dexamethasone (alone or with systemic steroids) should be offered as primary treatment of ISSNHL. Recent findingsIntratympanic steroids have been shown to result in higher inner ear concentrations than systemic steroids in animal and human studies. Primary treatment of ISSNHL with intratympanic steroids in combination with systemic steroids has been demonstrated to result in better hearing outcomes than systemic steroids alone. Recent evidence has revealed these hearing outcomes to be dependent on the dose of intratympanic steroid. Dexamethasone may be better absorbed than methylprednisolone, and potentially offer a greater benefit. Furthermore, intratympanic steroids provide an effective alternative for patients who cannot tolerate systemic steroids. SummaryIntratympanic dexamethasone alone, or in combination with systemic steroids, provides effective treatment of ISSNHL and should be utilized as primary treatment. Further investigation is required to determine the optimal choice, concentration, and administration schedule of intratympanic steroids.

Response to “Management and Outcomes in Patients Affected by Malignant Otitis Externa”

We read with great interest the recent article from Hobson et al, who studied a retrospective case series of patients diagnosed with the rare manifestations of malignant otitis externa (MOE). We commend the authors for their efforts in trying to identify a sample as homogeneously as possible. However, we highlight some important methodological issues that unfortunately may undermine the scientific rigor of the study, and therefore the clinical evidence provided, more so in light of the very limited sample size (only 15 eyes at final follow-up). While a strict adherence to the Cohen criteria may be no longer fundamental to the diagnosis of MOE, given the use of computed tomography (CT) that documents the presence of bone erosion (osteomyelitis), we feel that it is nowadays mandatory to avoid CT for assessing the progression and documenting the resolution as bone changes persist after treatment of the disease. We would have expected that the authors had provided information regarding their changed practice during the study period if it really occurred, or at least suggested that readers adopt Ga-67 scintigraphy, whether or not combined with single-photon emission computed tomography (SPECT)/CT, for the follow-up of these patients. We also point out that some of the patients included were not treated for at least 6 weeks, as per current recommendations of best practice guidelines. Lastly, perhaps it would have been more appropriate to exclude the 3 patients who underwent combined medical and surgical treatment.

Malignant Otitis Externa: An Evolving Disease

Objectives: 1) Compare the clinical presentations and outcomes of patients with MOE caused by Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). 2) Recognize the evolving trend of atypical and drug-resistant organisms causing malignant otitis externa (MOE). Methods: A retrospective review of disease course and outcome was performed of patients diagnosed with MOE at a tertiary referral center between 1995 and 2012. Results: Forty-four patients with a diagnosis of MOE were identified. Eighteen patients were excluded due to insufficient or inconsistent clinical data, leaving 26 patients for analysis. Forty-six percent of patient cultures grew Pseudomonas and 12% grew MRSA. All patients infected with Pseudomonas had diabetes mellitus, compared to 33% of MRSA-infected patients (P < 0.05). Twenty-five percent of Pseudomonas-infected patients presented with at least one cranial nerve palsy, as compared to none of the MRSA-infected patients (ns). Duration of therapy for Pseudomonas-infected patients lasted an average of 7.2 weeks, while MRSA-infected patients lasted 10 weeks (ns). Excluding failed initial treatment courses, the average treatment durations were 5.0 and 7.7 weeks for Pseudomonas and MRSA infections, respectively. Other atypical pathogenic organisms isolated in culture include Candida, Aspergillus, and Enterococcus species. Conclusions: Increasingly, MOE is being caused by organisms other than Pseudomonas, including MRSA. Empiric treatment, without culture, can lead to delays in definitive therapy. A high index of suspicion for atypical or drug resistant organisms should be maintained in MOE patients who are not diabetic. Culture directed therapy for treatment of MOE is paramount.