HSC Section 8_April 2017

normalization of inflammatory markers and without relapse

within 12 weeks.

Those in whom disease resolved after a 6-week course of

intravenous antibiotics were deemed as having a good out-

come. Those who had persistent symptoms despite 6 weeks

of therapy were considered to have a poor outcome.

The clinical characteristics and laboratory and imaging

findings between the 2 groups were compared to identify

possible prognostic factors. Data analysis was performed

with SPSS 16.0 software (SPSS, Inc, an IBM Company,

Chicago, Illinois). Statistically significant differences in

categorical variables were cross-tabulated and analyzed with

the Fisher exact test. The Mann-Whitney

test and

test

were used to analyze continuous variables as appropriate.

values .05 were considered statistically significant.

Results

Demographics and Outcome

Twenty-two cases of MOE were identified. Three were

excluded from analysis: 2 foreign patients chose to continue

treatment in their own country, and 1 died of pneumonia

shortly after initiating treatment. The remaining 19 patients

consisted of 16 men and 3 women. Mean age was 69.1

years (range, 51-86 years).

Disease resolved in 63.2% (n = 12) after 6 weeks of antibio-

tics. In 36.8% (n = 7), disease was persistent after 6 weeks, and

additional antibiotics were required. Four in this group ultimately

died. The overall mortality rate in our series was 21.1% (n = 4).

Three patients died from MOE-associated intracranial complica-

tions. The remaining patient died from intracranial hemorrhage

secondary to ceftazidime-induced thrombocytopenia.

There was a tendency for those 65 years and older to

have disease that persisted after 6 weeks of antibiotics

(45.0% of those 65 years and older vs 25.0% of those

younger than 65 years), but this did not reach statistical sig-

nificance (

= .633).

Comorbidities

All patients were immunocompromised. Diabetes was present

in 94.7% (n = 18). The only patient (n = 1) without diabetes

was on long-term steroids for rheumatoid arthritis. The

macrovascular and microangiopathic effects of diabetes were

present in a significant proportion: 63.2% (n = 12) had

ischemic heart disease, 15.8% (n = 3) had peripheral vascular

disease, and 26.3% (n = 5) had end-stage renal failure.

Diabetes severity was assessed based on glycated hemoglobin

(HbA1c) levels at diagnosis. Of those with diabetes, 55.6%

(n = 10) had HbA1c in excess of 7.0%, reflecting poor glu-

cose control prior to diagnosis of MOE. There was no associ-

ation between HbA1c levels and outcome (

= 1.00).

Clinical Presentation

The most common complaint, present in 73.7% (n = 14),

was concomitant otalgia and otorrhea; 10.5% (n = 2) had

parotid swelling. Facial nerve palsy was the main symptom

in 21.0% (n = 4). The mean duration of symptoms before

MOE was diagnosed was 6.79 weeks (range, 1-12 weeks).

There was no statistically significant difference in the dura-

tion of symptoms prior to diagnosis between the group in

which disease resolved after 6 weeks of intravenous treat-

ment and the group in which disease persisted. Mean dura-

tion of symptoms was 6.67 weeks in the former group

compared with 7.0 weeks in the latter group (

= .859).

Although patients with cranial nerve involvement tended to

have more persistent disease, this did not reach statistical

significance (50.0% of patients with cranial nerve palsy had

poor outcome vs 33.3% of those without;

= .603).

Inflammatory Markers

Inflammatory markers were evaluated at diagnosis and seri-

ally as treatment progressed. Total white cell count (TWC;

normal range, 3.40-9.60

/L), C-reactive protein (CRP;

normal range, 0-10 mg/L), and erythrocyte sedimentation rate

(ESR; normal range, 5-15 mm/h) levels were measured.

Leukocytosis was less prominent compared with derange-

ments in CRP and ESR levels. At diagnosis, only 26.3% (n =

5) had abnormal TWC levels compared with 72.2% (n = 13)

with raised CRP and 84.2% (n = 16) with raised ESR. The

mean (SD) values of these inflammatory markers were as fol-

lows: TWC, 9.98 (4.12)

/L; CRP, 42.56 (51.89) mg/L;

and ESR, 66.82 (34.73) mm/h.

Inflammatory marker levels were compared between the

2 outcome groups at the time of diagnosis and at the 2- and

6-week point after initiating antibiotics. The results are pre-

sented in

Table 1

. No significant difference in mean CRP

and ESR levels was detected between the 2 outcome groups

at these 3 intervals. The group in which disease progressed

had a statistically significant higher TWC after 6 weeks of

antibiotics compared with the group in which disease

resolved, but overall, leukocytosis was not prominent and

remained at the upper limit of normal. Although the abso-

lute levels of the inflammatory markers appeared to be of

limited usefulness in predicting outcome, a more prominent

downward trend of levels was seen as treatment progressed

in the group in which disease resolved, as compared with

the group in which it persisted (

Figure 1

Imaging

Computed tomography (CT) was the imaging modality of

choice at our institution and was performed in 89.5% (n =

17) at diagnosis. Computed tomography findings were

divided into minor and major findings based on a study by

Soudry et al

that showed a correlation between major CT

findings and persistent disease. Minor findings were defined

as EAC tissue swelling, EAC bony erosion, and mastoid

involvement. Major findings were defined as infratemporal

fossa involvement, temporomandibular joint involvement,

parapharyngeal involvement, and nasopharyngeal involve-

ment. The CT findings are presented in

Table 2

The presence of major findings on initial CT scans was

not seen to be predictive of outcome (33.3% in the poor out-

come group and 36.4% in the good outcome group had

major findings;

= 1.00).

Otolaryngology–Head and Neck Surgery 148(6)