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Necrotising otitis externa (NOE) remains a challenging condition for ENT departments, particularly with the increased prevalence of diabetes mellitus (DM) in the general population. There is no international consensus on treatment, although many institutions now have local guidelines drawn up by ENT and Infectious Disease specialists. This review is a meta-analysis of literature published from 2000 to 2018, looking at the changes in presentation, causative microbes, treatment modalities and outcomes in the periods pre and post 2009. The research group identified 10 studies incorporating 284 patients treated for NOE. The overall level of evidence of these studies was low, as nine were level 4, and only one was level 2b. DM comprised 82.1% of underlying conditions in the patients overall in these studies. There was a significant increase in the percentage with DM in the post-2009 group, whereas there was not the same increase in other causes of immunocompromise. Otalgia remains a consistent initial presenting complaint (present in 99.3%) of patients with NOE, and 97.3% had oedema of the ear canal. Overall, 65.2% of cases had a positive culture for pseudomonas, but in the post-2009 group there was a significant increase in culture-negative results. Comparison of antibiotic treatment over the study period revealed a statistically significant increase in ceftazidime and a decrease in ciprofloxacin use in the post-2009 group. Comparison of surgical treatment in the last decade revealed no difference in the rates of EAC debridement but a significant decrease in extensive surgery (e.g. mastoidectomy, facial nerve decompression). The most interesting finding of the study was that in the post-2009 group there was a statistically significant decrease in the rate of patients that are cured of NOE, reduced to 76% from 94.1 % (p<0.01). There was no improvement in mortality, persistence, or recurrence rate, which have remained consistent throughout the last two decades. The disease-specific mortality rates were similar and stable between included studies despite the heterogeneity between treatment protocols. Although there are limitations to a meta-analysis of heterogenous data from low level evidence studies, this review has highlighted that perhaps due to the continued rise of DM in our communities, we have yet to find successful regimens to improve outcomes of NOE.

Necrotizing Otitis Externa: A Systematic Review and Analysis of Changing Trends.
Byun YJ, Patel J, Nguyen SA, Lambert PR.
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Aileen Lambert

Great Ormond Street Hospital, London, UK.

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