ryngology–Head and Neck SurgeryLetters to the Editor 2014© The Author(s) 2010


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Letters to the Editor Otolaryngology– Head and Neck Surgery 2014, V   ol. 151(5)  890­–892 © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav http://otojournal.org

Letters to the Editor

Management and Outcomes in Patients Affected by Malignant Otitis Externa


DOI: 10.1177/0194599814551533

Funding source: None.

No sponsorships or competing interests have been disclosed for this article.

We read with great interest the recent article from Hobson et al,1 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 criteria2 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.3,4 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.4,5 Lastly, perhaps it would have been more appropriate to exclude the 3 patients who underwent combined medical and surgical treatment. Marco Carifi, MD Domenico Napolitano, MD Morando Morandi, MD Department of Otolaryngology, A.O.R.N. “A.Cardarelli”Naples, Italy Email: [email protected]

Competing interests: None. Sponsorships: None.

References 1. Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and implications for diagnosis and treatment. Otolaryngol Head Neck Surg. 2014;151:112-116. 2. Cohen D, Friedman P. The diagnostic criteria of malignant external otitis. J Laryngol Otol. 1987;101:216-221. 3. Jacobsen LM, Antonelli PJ. Errors in the diagnosis and management of necrotizing otitis externa. Otolaryngol Head Neck Surg. 2010;143:506-509. 4. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41:537-549. 5. Courson AM, Vikram HR, Barrs DM. What are the criteria for terminating treatment for necrotizing (malignant) otitis externa? Laryngoscope. 2014;124:361-362.

Response to “Management and Outcomes in Patients Affected by Malignant Otitis Externa” DOI: 10.1177/0194599814551534

No sponsorships or competing interests have been disclosed for this article.

We thank Drs Carifi, Napolitano, and Morandi for their interest in our paper and for their inquiries. Computed tomography (CT) imaging has been used by some to evaluate for disease resolution (by documenting the resolution of soft tissue changes) in malignant otitis externa (MOE).1 While we commonly use CT imaging to help establish the diagnosis, we generally now limit the use of follow-up CT imaging to cases of suspected disease progression.2 As pointed out, some authors advocate for nuclear imaging methodologies (such as gallium scanning) for establishing disease resolution.3 Regarding treatment duration, we posit that, like many other bacterial disease processes, the optimal duration of antibiotic therapy for MOE is not clearly established.4 The treatment

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Management and outcomes in patients affected by malignant otitis externa.

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