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Fungal necrotizing otitis externa; challenges in diagnosis and therapy
Gaelle Vofo1, Ofir Zavdy2,3, Rona Bourla2,3
1Department of Otolaryngology- Head and Neck Surgery, Hadassah Medical Center, Jerusalem, 91120, Israel.
Purpose:
Necrotizing otitis externa (NOE) is a severe infection with potential skull base involvement. The role of fungal pathogens and the need for antifungal treatment remain controversial. We aimed to evaluate clinical characteristics, diagnostic challenges, and microbiology results in fungal NOE and assess considerations for antifungal therapy.
Methods:
This retrospective cohort study was conducted at two tertiary centers. NOE patients, based on clinical and radiological findings, were retrospectively reviewed. Clinical characteristics, microbiological findings, and disease persistence were compared between patients categorized by antifungal treatment status: Combined antifungal-antibiotic therapy versus antibiotic therapy alone.
Results:
Of 125 patients, 25 received combined treatment (13 as initial treatment and 12 after persistent disease) and 100 received antibiotics alone. Combined treatment patients were younger, had prolonged symptoms, and more cranial nerve palsy, requiring longer treatment for persistent and aggressive disease. Fungi were found in 72% of combined-treatment cultures, but most were deemed unreliable by infectious diseases specialists, inconsistently leading to antifungal therapy.
Conclusion:
Antifungal therapy decisions in NOE lack standardization. We propose a protocol incorporating clinical and microbiological data to guide antifungal therapy. Prospective studies are needed to validate this protocol and establish standardized guidelines for fungal NOE treatment.
Insights
Necrotizing otitis externa (NOE) treatment decisions for fungal infections lack standardization. A proposed protocol aims to guide antifungal therapy based on clinical and microbiological data for better outcomes.
Area of Science:
- Infectious Diseases
- Otolaryngology
- Mycology
Background:
- Necrotizing otitis externa (NOE) is a severe infection potentially involving the skull base.
- The role of fungal pathogens and the necessity of antifungal treatment in NOE are debated.
Purpose of the Study:
- To evaluate clinical characteristics, diagnostic challenges, and microbiology in fungal NOE.
- To assess considerations for antifungal therapy in NOE patients.
Main Methods:
- Retrospective cohort study at two tertiary centers.
- Comparison of clinical characteristics, microbiology, and disease persistence between patients receiving combined antifungal-antibiotic therapy versus antibiotics alone.
Main Results:
- Fungi identified in 72% of cultures from combined-treatment group, though reliability was often questioned.
- Combined therapy patients were younger, had prolonged symptoms, and more cranial nerve palsy.
- Antifungal therapy decisions were inconsistently made, lacking standardization.
Conclusions:
- Current antifungal therapy decisions for NOE are not standardized.
- A protocol integrating clinical and microbiological data is proposed to guide antifungal therapy.
- Prospective studies are required to validate the proposed protocol and establish treatment guidelines.
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