Pseudomonas aeruginosa remains the dominant pathogen in osteomyelitis of the temporal bone

Abstract

Objective

Osteomyelitis of the temporal bone (OTB) is a rare inflammatory disease that can spread from the ear canal to adjacent soft tissue and bone structures. This expansion is challenging to treat and thus can become life-threatening. The detection of the causative pathogen is crucial for successful therapy. Current studies have revealed a diverse spectrum of pathogenic microorganisms in OTB. The aim of our study was to compare the microbiological background of our OTB-patients with data in recent literature.

Material and Methods

In this retrospective, single-center study patients diagnosed with OTB over a 10-year period were included (n=39). We analyzed the microbiological spectrum, clinical symptoms, radiological findings and course of the disease.

Results

Most common symptoms were otalgia (n=29, 74.4%) and otorrhea (n=24, 61.5%). Microbiological assessment showed most frequently P. aeruginosa (n=21, 53.8%) and the detection of this pathogen was associated with increased CRP levels (p<0.05). Computed tomography showed a washed-out bone texture of the petrous bone in 38 patients (97.4%). During the follow-up period 10 patients (25.6%) reported an improvement of symptoms, whereas 23 patients (59.0%) described their persistence. Four patients (10.3%) died.

Conclusions

In contrast to recently published data, in our patient cohort P. aeruginosa remains the most common and challenging causative pathogen of OTB. Therefore, when selecting an empirical therapy attention should always be given to its efficacy against this pathogen.

Keywords

Otitis externa - Osteomyelitis - Temporal bone - Pseudomonas aeruginosa - Skull base

• Literatur

• 1 Johnson AK, Batra PS. Central skull base osteomyelitis: an emerging clinical entity. The Laryngoscope 2014; 124: 1083-1087
• 2 Lucente FE, Parisier SC. James R. Chandler: “Malignant external otitis”. (Laryngoscope. 1968; 78: 1257–1294). The Laryngoscope 1996; 106: 805-807
• 3 Long DA, Koyfman A, Long B. An emergency medicine-focused review of malignant otitis externa. Am J Emerg Med 2020; 38: 1671-1678
• 4 Hobson CE, Moy JD, Byers KE. et al. Malignant Otitis Externa: Evolving Pathogens and Implications for Diagnosis and Treatment. Otolaryngology-head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2014; 151: 112-116
• 5 Lee SK, Lee SA, Seon SW. et al. Analysis of Prognostic Factors in Malignant External Otitis. Clin Exp Otorhinolaryngol 2017; 10: 228-235
• 6 Auinger AB, Arnoldner C. Current management of skull base osteomyelitis. Current opinion in otolaryngology & head and neck surgery 2021; 29: 342-348
• 7 Brenner A, Cavel O, Shendler G. et al. CT findings in temporal bone sites in skull base osteomyelitis from malignant otitis externa. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology – Head and Neck Surgery 2023; 280: 2687-2694
• 8 Reñé R, Mas A, Villabona CM. et al. Otitis externa maligna and cranial neuropathy. Neurologia 1990; 5: 222-227
• 9 Rubin Grandis J, Barton F, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. The Lancet. Infectious diseases 2004; 4: 34-39
• 10 Bhandary S, Karki P, Sinha BK. Malignant otitis externa: a review. Pacific health dialog 2002; 9: 64-67
• 11 Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngologic clinics of North America 2008; 41: 537-49
• 12 Tisch M, Maier H. Malignant external otitis. Laryngo- rhino- otologie 2006; 85: 763-769
• 13 Hutson KH, Watson GJ. Malignant otitis externa, an increasing burden in the twenty-first century: review of cases in a UK teaching hospital, with a proposed algorithm for diagnosis and management. The Journal of laryngology and otology 2019; 133: 356-362
• 14 Glikson E, Sagiv D, Wolf M. et al. Necrotizing otitis externa: diagnosis, treatment, and outcome in a case series. Diagn Microbiol Infect Dis 2017; 87: 74-78
• 15 Soudry E, Hamzany Y, Preis M. et al. Malignant external otitis: analysis of severe cases. Otolaryngology-head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2011; 144: 758-762
• 16 Slattery 3rd WH, Brackmann DE. Skull base osteomyelitis. Malignant external otitis. Otolaryngologic clinics of North America 1996; 29: 795-806
• 17 Ali T, Meade K, Anari S. et al. Malignant otitis externa: case series. The Journal of laryngology and otology 2010; 124: 846-851
• 18 Bhat V, Aziz A, Bhandary SK. et al. Malignant Otitis Externa – A Retrospective Study of 15 Patients Treated in a Tertiary Healthcare Center. The journal of international advanced otology 2015; 11: 72-76
• 19 Devaraja K, Nayak DR. Malignant otitis externa with subsequent internal jugular vein thrombosis and hypoglossal palsy: a report and review of literature. Journal of otology 2020; 15: 112-116
• 20 Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. S2k Leitlinie Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen. 2019 Zugriff am 22. Februar 2025 unter: https://register.awmf.org/assets/guidelines/082–006l_S2k_Parenterale_Antibiotika_2019–08-abgelaufen.pdf
• 21 Koch U. Malignant otitis externa. Laryngol Rhinol Otol 1983; 62: 276-279
• 22 Mortazavi MM, Khan MA, Quadri SA. et al. Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies. World neurosurgery 2018; 111: 142-153
• 23 Cohen D, Friedman P. The diagnostic criteria of malignant external otitis. The Journal of laryngology and otology 1987; 101: 216-221
• 24 Franco-Vidal V, Blanchet H, Bebear C. et al. Necrotizing external otitis: a report of 46 cases. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2007; 28: 771-773
• 25 Mani N, Sudhoff H, Rajagopal S. et al. Cranial nerve involvement in malignant external otitis: implications for clinical outcome. The Laryngoscope 2007; 117: 907-910
• 26 Thio D, Reece P, Herdman R. Necrotizing otitis externa: a painless reminder. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology – Head and Neck Surgery 2008; 265: 907-910
• 27 Chen J-C, Yeh C-F, Shiao A-S. et al. Temporal bone osteomyelitis: the relationship with malignant otitis externa, the diagnostic dilemma, and changing trends. TheScientificWorldJournal 2014; 2014: 591714
• 28 Rajasekaran V, Mohanraj L, Prabhu ND. Silent otitis media with multiple intracranial complications. BMJ Case Rep 2024; 17
• 29 Faizal B, Nair L, Pavithran J. et al. Role of surgery along with antimicrobials in refractory skull base osteomyelitis – A prospective observational study. Clin Otolaryngol 2024; 49: 640-651
• 30 Chapman PR, Choudhary G, Singhal A. Skull Base Osteomyelitis: A Comprehensive Imaging Review. AJNR. American journal of neuroradiology 2021; 42: 404-413
• 31 Krishnakumar L, Vinayakumar V, Suchit Roy BR. et al. Skull Base Osteomyelitis- Marauders of the Skull. Indian J Otolaryngol Head Neck Surg 2024; 76: 1770-1774
• 32 Wu M, Tong X, Liu S. et al. Prevalence of methicillin-resistant Staphylococcus aureus in healthy Chinese population: A system review and meta-analysis. PloS one 2019; 14: e0223599
• 33 Robert Koch Institut. Aktuelle Daten und Informationen zu Infektionskrankheiten und Public Health Epidemiologisches Bulletin. Zugriff am 22. Februar 2025 unter: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2021/Ausgaben/40_21.pdf?__blob=publicationFile
• 34 Pang Z, Raudonis R, Glick BR. et al. Antibiotic resistance in Pseudomonas aeruginosa: mechanisms and alternative therapeutic strategies. Biotechnology advances 2019; 37: 177-192
• 35 Laborda P, Hernando-Amado S, Martínez JL. et al. Antibiotic Resistance in Pseudomonas. Advances in experimental medicine and biology 2022; 1386: 117-143
• 36 Kloth C, Beck A, Sollmann N. et al. Imaging of Pathologies of the Temporal Bone and Middle Ear: Inflammatory Diseases, Their Mimics and Potential Complications-Pictorial Review. Tomography 2023; 9: 2190-2210