Hyperbaric Oxygen Therapy For Malignant Otitis

The addition of HBOT to medical treatment is highly effective and has facilitated considerable improvement in patients.

Introduction

Malignant external otitis is an infection that affects the external auditory canal and temporal bone. The causative organism is usually Pseudomonas aeruginosa, and the disease commonly manifests in elderly patients (pts) with diabetes. The infection begins as external otitis that progresses to osteomyelitis of the temporal bone. 

The spread of the disease outside the external auditory canal occurs through the fissures of Santorini and the osseocartilaginous junction. Malignant external otitis is a rapidly spreading bacterial infection that accounts for a relatively small proportion of infections, but arises aggressively and may be fatal if left untreated. Hyperbaric oxygen therapy (HBOT) is a medical treatment in which the entire body is placed in an airtight chamber at increased atmospheric pressure. In this chamber, the patient is surrounded by and breathes 100% pure oxygen. 

This treatment has been proven effective for several different medical and surgical conditions either as a primary or as an adjunctive treatment. The pressure can be increased to as much as three times the normal atmospheric pressure (although the usual treatment pressure is 1.5–2.0 atmospheric depending on the diagnosis). Pure, 100% oxygen is continuously maintained and circulated throughout the chamber during the treatment. HBOT is an effective treatment for acute and chronic damaged tissue of all types – any cause, any duration, any location. The underlying causes can be trauma, infection, autoimmunity, ischemia, hypoxia, toxins, or something similar.

These infections may be single aerobic or anaerobic but are more often mixed infections. They are often observed in compromised hosts who have diabetes or a vasculopathy of another type. These infections are named based on their clinical presentation and include malignant external otitis. Irrespective of the depth of the tissue invasion, these infections have similar pathophysiology that includes local tissue hypoxia, which is exacerbated by a secondary occlusive endarteritis. Multiple clinical studies suggest that HBOT is efficacious in the treatment of necrotizing soft tissue infections. These include case series, retrospective and prospective studies, and nonrandomized clinical trials. 

They suggest significant reductions in mortality and morbidity. It is also used to treat many other medical conditions that are still considered experimental by the mainstream medical establishment – despite decades of reported benefits. This article aims to assess the value of hyperbaric oxygen (HBO) as an adjunctive treatment of malignant external otitis along with antimicrobial agents.

What are the effects of oxygen therapy on the body?

• Decreases inflammation
• Increases the body's oxygen saturation by 20-30%
• Increases the body's immunity
• Increases blood circulation and stimulates the formation of new capillaries
• Decreases toxins in the body
• Stimulates the production of new blood cells
• Increases healing rate

Patients and methods 

Patients’ selection criteria 

This is a retrospective study. It was carried out at the O.R.L Department, Ain Shams University Hospitals in the period between January 2011 and December 2014 with Institutional Review Board approval. Informed written consent was obtained from all participants. Forty-three patients (pts) were examined and treated for malignant otitis externa; they all had diabetes mellitus and were undergoing treatment to control diabetes mellitus. They were divided into two groups: group A (28 pts) only received the antibiotic ciprofloxacin and group B (15 pts) was treated with ciprofloxacin and HBO as an adjunctive treatment. The minimum follow-up duration in both groups was 2 months. Their ages ranged from 56 to 72 years. Both groups were similar in age, ear discharge bacteriology, and antimicrobial therapy. 

Treatment strategy 

Control of diabetes: All patients were treated with insulin injections and diabetes mellitus was strictly controlled. Ear discharge culture and sensitivity were assessed for all patients, which indicated growth of pseudomonas. Computed tomography (CT) scan of the temporal bone was performed before and 2 months after treatment. All patients were administered an antibiotic (ciprofloxacin). HBOT was administered at 2.0–2.5 ATA for 90 min per session. HBOT was administered for one session every other day for 2 months. HBOT was administered in the Naser National Institute in Sechrist hyperbaric oxygen chamber (Sechrist Monoplace Hyperbaric Chambers H-Series).

Comparison criteria

• Clinical microscopic examination (ear secretion, external canal edema, and granulation) was performed in all patients. 
• Pain severity (the pain was noted for assessment of pain severity and degree of improvement and healing) - a pain score of 3 indicated severe pain, a pain score of 2 indicates moderate pain (sometimes controlled with strong painkillers), a pain score of 1 indicates mild pain (bearable without painkillers) and a score of 0 was specific to patients without pain
• Post-treatment CT scan: temporal bone was evaluated 2 months after initiation of therapy.

Results

A total of 43 patients had malignant otitis externa; these patients were divided into two groups: group A (n = 28) received only antibiotics (18 men, 10 women; mean age 64 years) and group B (n = 15) received HBO (90 min at 2, 5 ATA) in addition to antibiotics (10 men, five women; average age 62 years).

A total of 43 patients were identified, including 15 patients who received HBOT with antibiotics. The degree of improvement in patients' condition after treatment with adjuvant HBOT with antibiotics was elevated both symptomatically and clinically, as well as on CT scan of the temporal bone.

Discussion

Necrotizing invasive pseudomonas infection of the external auditory canal (malignant otitis externa) is an unusual but major condition in the elderly. The high morbidity, and even mortality, of this disorder, has been reduced by the early and intense use of combined antipseudomonal antibiotics. However, in patients with severe immunocompromise or infections involving the base of the skull, multiple cranial nerves, or meninges, conventional therapy is prolonged, intense, and relatively ineffective.

Infections for which HBOT has been studied and recommended by the Undersea & Hyperbaric Society of Medicine include necrotizing fasciitis, gas gangrene, chronic refractory osteomyelitis (including malignant otitis externa), mucormycosis, intracranial abscesses, and diabetic foot ulcers that have infections. In all of these processes, HBOT is used as an adjunct with antimicrobial agents and aggressive surgical debridement.

Radiologically, CT scans of the temporal bone indicated a considerable improvement with HBOT treatment, with less infection, opacity, fluid in the mastoid, and osteomyelitis changes. Overall, all cases treated with antibiotics and HBOT showed considerable subjective and objective improvement through examination and radiology, with more than 93% of cases cured and discharged early from the hospital. In contrast, those treated with antibiotics showed a slow improvement, a low percentage of complete healing (below 30%), persistent secretion and a certain degree of pain, and a longer duration of hospitalization. No complications have been reported with this treatment.

Davis and colleagues reported that all 16 patients responded promptly when 30-day HBO treatment was added to the antibiotic regimen, and all patients were retained for 1 to 4 years of follow-up. No complications were observed. Pilgramm and co-workers also showed that hyperbaric oxygenation had a positive influence on the reduction of P. aeruginosa in the external auditory canal and on pain symptoms.

Tisch and colleagues found, over more than 5 years, that 16 out of 22 patients treated on a multimodal concept did not relapse. Narozny and colleagues confirmed the role of HBO as a valuable, beneficial, and supportive classic treatment method in the treatment of malignant otitis externa caused by bacteria. Shupak and colleagues treated two patients with necrotizing otitis externa by hyperbaric oxygenation, followed by complete resolution without recurrence.

In the study by Saxby and colleagues, 70% of patients were considered cured and the condition did not recur on monitoring. HBOT confers minimal morbidity, but its role in malignant otitis externa (MOE) remains uncertain. The high mortality of MOE despite a maximum therapeutic intervention highlights the need for more effective treatment protocols.

Conclusion 

The addition of HBOT to medical treatment is highly effective and has led to marked improvements in patient's conditions and the time required to achieve control of infection in these patients.

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Centrokinetic clinic offers all services necessary for a complete rehabilitation process, from the first consultation to the medical specialist to establish the correct diagnosis, to treatment and recovery.

Centrokinetic is the place where you will find clear answers and solutions for your motricity problems. The clinic is dedicated to osteoarticular conditions and is divided into the following departments:

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