Otology & Neurotology 36:1121Y1125 Ó 2014, Otology & Neurotology, Inc.


Domenico Napolitano, M.D. Department of Otolaryngology Azienda Ospedaliera di Rilievo Nazionale BA.Cardarelli[ Naples, Italy [email protected]

To the Editor: We read with interest the recent article by Verim et al. who attempted to investigate whether early hospital admission might have a positive effect on treatment duration and outcomes (1). The study included only 14 patients that might have undergone different treatments as specified in the methods section of the manuscript, although information relating to who underwent what is actually missing. In addition, we also note that there is missing information regarding the length of antibiotic treatment undergone by the 14 patients, and we think that this should be made available to the readers as it is the main purpose of the study to correlate treatment duration to whether the hospital admission had occurred early. It is largely accepted that CT and Tc-99mMDP SPET/CT are useful to assess the extent of tissue inflammation and offer a good spatial resolution of the affected area (2); however, both seem to be poorly reliable for follow-up. This contrasts to the statement of Verim and associates who consider ‘‘nuclear imaging with Tc-99mMDP the principal diagnostic imaging modality for NEO.’’ The limitations inherent CT and SPECT/CT in studying the evolution of the process reside in the persistence of detectable skull base demineralization and osteoblastic activity despite resolution of the disease. Instead, ‘‘gallium imaging’’ (gallium citrate Ga67 SPECT/CT) may be a better option for this specific purpose (3). Many studies pointed out the importance of this radiologic procedure (4), observing that a Ga 67scan should be performed every 4 to 6 weeks to obtain indication on whether to prolong antimicrobial therapy, regardless of whether symptoms might have improved. More recently, the indium In111Ylabeled leukocyte nuclear imaging has appeared to be as sensitive as Ga 67 SPECT/CT to monitor therapy and even more specific to detect an inflammatory process (5), and it might well become the gold standard in patients affected by NEO. Lastly, we agree that treatment is based on effective management of diabetes, biopsy, and culture-guided antibiotherapy, and we query whether all patients included in the study had a biopsy, given the report of granulation tissues in the external auditory canal in only 42% of cases.

The authors disclose no conflicts of interest. REFERENCES 1. Verim A, Naibo?lu B, Karaca Ç, et al. Clinical outcome parameters for necrotizing otitis externa. Otol Neurotol 2014;35:371Y6. 2. Grandis JR, Curtin HD, Yu VL. Necrotizing (malignant) external otitis: prospective comparison of CT and MR imaging in diagnosis and follow-up. Radiology 1995;196:499Y504. 3. Carfrae MJ1, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am 2008;41:537Y49. 4. Franco-Vidal V, Blanchet H, Bebear C, et al. Necrotizing external otitis: a report of 46 cases. Otol Neurotol 2007;28:771Y3. 5. Okpala NC, Siraj QH, Nilssen E, et al. Radiological and radionuclide investigation of malignant otitis externa. J Laryngol Otol 2005; 119:71Y5.

RESPONSE TO LETTER TO THE EDITOR RE: CLINICAL OUTCOME PARAMETERS FOR NECROTIZING OTITIS EXTERNA In Reply: We appreciate the authors’ interest in our recent study on the clinical outcome parameters for necrotizing otitis externa (NEO), and we would like to address some of their concerns. The main purpose of this retrospective study was to increase awareness of the effect of time from symptom onset to admission on the clinical, laboratory, and radiologic outcomes in NEO. The results were all collected after observing the positive correlation between the time to admission and outcomes data and, therefore, patient groups were formed with regard to the median time to hospitalization. As has been detailed previously, patients whose admission time was earlier than 30 days from symptom onset responded to a single antibiotic (750 mg of intravenous ciprofloxacin every 12 hr) within 1 week and went on to receive the same treatment until complete cure (61.60 T 4.33 d). Those who were hospitalized later than 30 days after symptom onset did not respond to ciprofloxacin and were administered ceftazidime or piperacillin according to culture results together with hyperbaric oxygen therapy for a total of 20 sessions. Combined therapy was modified to ciprofloxacin after 41.78 T 11.84 days and treatment

Marco Carifi, M.D. Morando Morandi, M.D. Teresa Ruocco, M.D. 1121

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Assessing Treatment Efficacy and Progression of Necrotizing Otitis Externa.

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