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A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa

Published online by Cambridge University Press:  05 June 2020

M E Hopkins*
Department of ENT, NHS Lothian, Edinburgh, Scotland, UK
A Bennett
Department of ENT, NHS Lothian, Edinburgh, Scotland, UK
N Henderson
Department of Microbiology, NHS Lothian, Edinburgh, Scotland, UK
K F MacSween
Department of Microbiology, NHS Lothian, Edinburgh, Scotland, UK
D Baring
Department of ENT, NHS Lothian, Edinburgh, Scotland, UK
R Sutherland
Department of Infectious Diseases, NHS Lothian, Edinburgh, Scotland, UK
Author for correspondence: Mr Michael E Hopkins, ENT Department, NHS Lothian, Lauriston Buildings, Lauriston Place, EdinburghEH3 9DE, Scotland, UK E-mail:



Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline.


This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management.


A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review.


Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately.


This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

Main Articles
Copyright © The Author(s), 2020. Published by Cambridge University Press

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Mr M Hopkins takes responsibility for the integrity of the content of the paper

Presented as a poster (and awarded the accolade of ‘Best Poster’) at the ENT-UK Annual Meeting, 13 September 2019, London, UK.


Sylvester, MJ, Sanghvi, S, Patel, VM, Eloy, JA, Ying, YM. Malignant otitis externa hospitalizations: analysis of patient characteristics. Laryngoscope 2017;127:2328–3610.1002/lary.26401CrossRefGoogle ScholarPubMed
Nadol, JB Jr. Histopathology of pseudomonas osteomyelitis of the temporal bone starting as malignant external otitis. Am J Otolaryngol 1980;1:359–71CrossRefGoogle ScholarPubMed
Lambor, DV, Das, CP, Goel, HC, Tiwari, M, Lambor, SD, Fegade, MV. Necrotising otitis externa: clinical profile and management protocol. J Laryngol Otol 2013;127:1071–710.1017/S0022215113002259CrossRefGoogle ScholarPubMed
Guerrero-Espejo, A, Valenciano-Moreno, I, Ramírez-Llorens, R, Pérez-Monteagudo, P. Malignant external otitis in Spain. Acta Otorrinolaringol Esp 2017;68:23–8CrossRefGoogle ScholarPubMed
Soundry, E, Joshua, BZ, Sulkes, J, Nageris, BI. Characteristics of malignant external otitis with facial paralysis. Arch Otolaryngol Head Neck Surg 2007;133:1002–4CrossRefGoogle Scholar
Zainuddin, N, Abdullah, O. Squamous cell carcinoma of the external auditory canal in a patient with non-resolving ear discharge. Malays Fam Physician 2015;10:52–4Google Scholar
Hopkins, ME, Harris, AS, Cuddihy, P. Malignant otitis externa: patient demographics and outcomes. B-ENT 2018;14:53–8Google Scholar
Lee, SK, Lee, SA, Seon, SW, Jung, JH, Lee, JD, Choi, JY et al. Analysis of prognostic factors in malignant external otitis. Clin Exp Otorhinolaryngol 2017;10:228–35CrossRefGoogle ScholarPubMed
Sudhoff, H, Rajagopal, S, Mani, N, Moumoulidis, I, Axon, PR, Moffat, D. Usefulness of CT scans in malignant external otitis: effective tool for the diagnosis, but of limited value in predicting outcome. Eur Arch Otorhinolaryngol 2008;265:53–6CrossRefGoogle ScholarPubMed
Rubin Grandis, J, Branstetter, BF, Yu, VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis 2004;4:34–9CrossRefGoogle ScholarPubMed
Li, HK, Rombach, I, Zambellas, R, Walker, SA, McNally, MA, Atkins, BL et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med 2019;380:425–36CrossRefGoogle ScholarPubMed
Carfrae, MJ. Malignant otitis externa. Otolaryngol Clin North Am 2008;41:537–49CrossRefGoogle ScholarPubMed
Gruber, M, Sela, E, Doweck, I, Roitman, A, Uri, N, Srouji, S et al. The role of surgery in necrotizing otitis externa. Ear Nose Throat J 2017;96:1621Google ScholarPubMed
Mion, M, Bovo, R, Marchese-Ragona, R, Martini, A. Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital 2015;35:307–13Google ScholarPubMed
Pasternak, B, Inghammar, M, Svanstrom, H. Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ 2018;360:k678CrossRefGoogle ScholarPubMed Drug Safety Update: Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. In: [15 March 2019]Google Scholar
Mouas, H, Lutsar, I, Dupont, B, Fain, O, Herbrecht, R, Lescure, FX et al. Voriconazole for invasive bone aspergillosis: a worldwide experience of 20 cases. Clin Infect Dis 2005;40:1141–7CrossRefGoogle ScholarPubMed
Parize, P, Chandesris, MO, Lanternier, F, Poiree, S, Viard, JP, Bienvenu, B et al. Antifungal therapy of aspergillus invasive otitis externa: efficacy of voriconazole and review. Antimicrob Agents Chemother 2009;53:1048–53CrossRefGoogle ScholarPubMed
Patterson, TF, Thompson, GR 3rd, Denning, DW, Fishman, JA, Hadley, S, Herbrecht, R et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63:e16010.1093/cid/ciw326CrossRefGoogle ScholarPubMed
Phillips, JS, Jones, SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev 2013;(5):CD00461710.1002/14651858.CD004617.pub3CrossRefGoogle ScholarPubMed
Singh, J, Bhardwaj, B. The role of surgical debridement in cases of refractory malignant otitis externa. Indian J Otolaryngol Head Neck Surg 2018;70:549–54CrossRefGoogle ScholarPubMed
Chawdhary, G, Pankhania, M, Douglas, S, Bottrill, I. Current management of necrotising otitis externa in the UK: survey of 221 UK otolaryngologists. Acta Otolaryngol 2017;137:818–22CrossRefGoogle ScholarPubMed
Chawdhary, G, Liow, N, Democratis, J, Whiteside, O. Necrotising otitis externa in the UK: a growing problem. Review of five cases and analysis of national Hospital Episode Statistics trends. J Laryngol Otol 2015;129:600–310.1017/S002221511500105XCrossRefGoogle ScholarPubMed