{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,11]],"date-time":"2026-05-11T18:09:25Z","timestamp":1778522965519,"version":"3.51.4"},"reference-count":26,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,10,3]],"date-time":"2025-10-03T00:00:00Z","timestamp":1759449600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,10,3]],"date-time":"2025-10-03T00:00:00Z","timestamp":1759449600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100003483","name":"Hebrew University of Jerusalem","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100003483","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur Arch Otorhinolaryngol"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Necrotizing otitis externa (NOE) is a severe infection with potential skull base involvement. The role of fungal pathogens and the need for antifungal treatment remain controversial. We aimed to evaluate clinical characteristics, diagnostic challenges, and microbiology results in fungal NOE and assess considerations for antifungal therapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective cohort study was conducted at two tertiary centers. NOE patients, based on clinical and radiological findings, were retrospectively reviewed. Clinical characteristics, microbiological findings, and disease persistence were compared between patients categorized by antifungal treatment status: Combined antifungal-antibiotic therapy versus antibiotic therapy alone.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 125 patients, 25 received combined treatment (13 as initial treatment and 12 after persistent disease) and 100 received antibiotics alone. Combined treatment patients were younger, had prolonged symptoms, and more cranial nerve palsy, requiring longer treatment for persistent and aggressive disease. Fungi were found in 72% of combined-treatment cultures, but most were deemed unreliable by infectious diseases specialists, inconsistently leading to antifungal therapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Antifungal therapy decisions in NOE lack standardization. We propose a protocol incorporating clinical and microbiological data to guide antifungal therapy. Prospective studies are needed to validate this protocol and establish standardized guidelines for fungal NOE treatment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00405-025-09685-2","type":"journal-article","created":{"date-parts":[[2025,10,3]],"date-time":"2025-10-03T19:28:26Z","timestamp":1759519706000},"page":"235-242","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Fungal necrotizing otitis externa; challenges in diagnosis and therapy"],"prefix":"10.1007","volume":"283","author":[{"given":"Gaelle","family":"Vofo","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ofir","family":"Zavdy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rona","family":"Bourla","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hila","family":"Elinav","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maya","family":"Korem","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Israel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reut","family":"Book","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fatima Azhraa","family":"Haddad","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dvir","family":"Bar-On","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomer","family":"Menzely","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ohad","family":"Hilly","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1675-8644","authenticated-orcid":false,"given":"Sagit","family":"Stern Shavit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,10,3]]},"reference":[{"key":"9685_CR1","doi-asserted-by":"publisher","first-page":"775","DOI":"10.1017\/S002221511800138X","volume":"132","author":"C Peled","year":"2018","unstructured":"Peled C, Kraus M, Kaplan D (2018) Diagnosis and treatment of necrotising otitis externa and diabetic foot osteomyelitis - similarities and differences. J Laryngol Otol 132:775\u2013779","journal-title":"J Laryngol Otol"},{"key":"9685_CR2","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1016\/j.amjoto.2016.04.005","volume":"37","author":"S Stern Shavit","year":"2016","unstructured":"Stern Shavit S, Soudry E, Hamzany Y et al (2016) Malignant external otitis: factors predicting patient outcomes. Am J Otolaryngol 37:425\u2013430","journal-title":"Am J Otolaryngol"},{"key":"9685_CR3","doi-asserted-by":"publisher","first-page":"316","DOI":"10.1097\/00020840-200310000-00002","volume":"11","author":"GS Sreepada","year":"2003","unstructured":"Sreepada GS, Kwartler JA (2003) Skull base osteomyelitis secondary to malignant otitis externa. Curr Opin Otolaryngol Head Neck Surg 11:316\u2013323","journal-title":"Curr Opin Otolaryngol Head Neck Surg"},{"key":"9685_CR4","doi-asserted-by":"crossref","unstructured":"Slattery WH 3rd, Brackmann DE (1996) Skull base osteomyelitis. Malignant external otitis. Otolaryngol Clin North Am 29:795\u2013806","DOI":"10.1016\/S0030-6665(20)30316-9"},{"key":"9685_CR5","doi-asserted-by":"publisher","first-page":"620","DOI":"10.1097\/MAO.0b013e3182804aee","volume":"34","author":"P Mahdyoun","year":"2013","unstructured":"Mahdyoun P, Pulcini C, Gahide I et al (2013) Necrotizing otitis externa: a systematic review. Otol Neurotol 34:620\u2013629","journal-title":"Otol Neurotol"},{"key":"9685_CR6","doi-asserted-by":"publisher","first-page":"216","DOI":"10.1017\/S0022215100101562","volume":"101","author":"D Cohen","year":"1987","unstructured":"Cohen D, Friedman P (1987) The diagnostic criteria of malignant external otitis. J Laryngol Otol 101:216\u2013221","journal-title":"J Laryngol Otol"},{"key":"9685_CR7","doi-asserted-by":"publisher","unstructured":"Petrak RM, Pottage JC Jr, Levin S (1985) Invasive external otitis caused by aspergillus fumigatus in an immunocom- promised patient. J Infect Dis 151:196. https:\/\/doi.org\/10.1093\/infdis\/151.1.196","DOI":"10.1093\/infdis\/151.1.196"},{"key":"9685_CR8","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1016\/j.amjoto.2017.05.010","volume":"39","author":"DA Carlton","year":"2018","unstructured":"Carlton DA, Perez EE, Smouha EE (2018) Malignant external otitis: the shifting treatment paradigm. Am J Otolaryngol 39:41\u201345","journal-title":"Am J Otolaryngol"},{"key":"9685_CR9","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1016\/S1473-3099(03)00858-2","volume":"4","author":"JR Grandis","year":"2004","unstructured":"Grandis JR, Branstetter BF, Victor LY (2004) The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis 4:34\u201339","journal-title":"Lancet Infect Dis"},{"key":"9685_CR10","doi-asserted-by":"publisher","first-page":"226","DOI":"10.1016\/j.jinf.2011.01.001","volume":"62","author":"Y Hamzany","year":"2011","unstructured":"Hamzany Y, Soudry E, Preis M et al (2011) Fungal malignant external otitis. J Infect 62:226\u2013231","journal-title":"J Infect"},{"key":"9685_CR11","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1177\/0003489418778056","volume":"127","author":"JL Hatch","year":"2018","unstructured":"Hatch JL, Bauschard MJ, Nguyen SA et al (2018) Malignant otitis externa outcomes: a study of the university healthsystem consortium database. Ann Otol Rhinol Laryngol 127:514\u2013520","journal-title":"Ann Otol Rhinol Laryngol"},{"key":"9685_CR12","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1007\/s15010-020-01394-8","volume":"48","author":"M Pichon","year":"2020","unstructured":"Pichon M, Joly V, Argy N et al (2020) Aspergillus flavus malignant external otitis in a diabetic patient: case report and literature review. Infection 48:193\u2013203","journal-title":"Infection"},{"key":"9685_CR13","first-page":"e71345","volume":"16","author":"G Sideris","year":"2024","unstructured":"Sideris G, Petsiou D-P, Kourklidou M et al (2024) Fungal Malignant Otitis Externa: Syst Rev Cureus 16:e71345","journal-title":"Fungal Malignant Otitis Externa: Syst Rev Cureus"},{"key":"9685_CR14","doi-asserted-by":"publisher","first-page":"1070","DOI":"10.1007\/s00405-006-0118-7","volume":"263","author":"D Stodulski","year":"2006","unstructured":"Stodulski D, Kowalska B, Stankiewicz C (2006) Otogenic skull base osteomyelitis caused by invasive fungal infection: case report and literature review. Eur Archives Oto-Rhino-Laryngology Head Neck 263:1070\u20131076","journal-title":"Eur Archives Oto-Rhino-Laryngology Head Neck"},{"key":"9685_CR15","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1016\/0002-9343(89)90475-0","volume":"86","author":"DW Denning","year":"1989","unstructured":"Denning DW, Tucker RM, Hansen LH et al (1989) Treatment of invasive aspergillosis with itraconazole. Am J Med 86:791\u2013800","journal-title":"Am J Med"},{"key":"9685_CR16","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1007\/s10096-005-0080-0","volume":"25","author":"S Girois","year":"2006","unstructured":"Girois S, Chapuis F, Decullier E et al (2006) Adverse effects of antifungal therapies in invasive fungal infections: review and meta-analysis. Eur J Clin Microbiol Infect Dis 25:138\u2013149","journal-title":"Eur J Clin Microbiol Infect Dis"},{"key":"9685_CR17","doi-asserted-by":"publisher","DOI":"10.3389\/fphar.2021.697330","volume":"12","author":"Y-L Yang","year":"2021","unstructured":"Yang Y-L, Xiang Z-J, Yang J-H et al (2021) Adverse effects associated with currently commonly used antifungal agents: a network meta-analysis and systematic review. Front Pharmacol 12:697330","journal-title":"Front Pharmacol"},{"key":"9685_CR18","doi-asserted-by":"crossref","unstructured":"Halwani C, Mtibaa L, El Hamdi M et al (2022) A retrospective study of 43 cases of fungal malignant external otitis. Pan Afr Med J 41(1). https:\/\/doi.org\/10.11604\/pamj.2022.41.1.28587","DOI":"10.11604\/pamj.2022.41.287.29585"},{"key":"9685_CR19","doi-asserted-by":"publisher","first-page":"907","DOI":"10.1097\/MLG.0b013e318039b30f","volume":"117","author":"N Mani","year":"2007","unstructured":"Mani N, Sudhoff H, Rajagopal S et al (2007) Cranial nerve involvement in malignant external otitis: implications for clinical outcome. Laryngoscope 117:907\u2013910","journal-title":"Laryngoscope"},{"key":"9685_CR20","doi-asserted-by":"publisher","first-page":"538","DOI":"10.1002\/lio2.1035","volume":"8","author":"A Zonnour","year":"2023","unstructured":"Zonnour A, Shahnazar R, Jamshidi A et al (2023) Cranial nerve palsy prevalence and associated factors in patients with malignant otitis externa. Laryngoscope Investig Otolaryngol 8:538\u2013545","journal-title":"Laryngoscope Investig Otolaryngol"},{"issue":"5","key":"9685_CR21","doi-asserted-by":"publisher","first-page":"3766","DOI":"10.1007\/s12070-024-04852-z","volume":"76","author":"M Pereira","year":"2024","unstructured":"Pereira M, Rao K, Sharin F et al (2024) Topical antibiotic-induced otomycosis-a systematic review of aetiology and risk factors. Indian J Otolaryngol Head Neck Surg 76(5):3766\u20133776. https:\/\/doi.org\/10.1007\/s12070-024-04852-z","journal-title":"Indian J Otolaryngol Head Neck Surg"},{"key":"9685_CR22","doi-asserted-by":"publisher","first-page":"2941","DOI":"10.1007\/s00405-018-5151-9","volume":"275","author":"R Abu Eta","year":"2018","unstructured":"Abu Eta R, Gavriel H, Stephen K et al (2018) The significance of tissue biopsy for fungi in necrotizing otitis externa. Eur Arch Otorhinolaryngol 275:2941\u20132945","journal-title":"Eur Arch Otorhinolaryngol"},{"key":"9685_CR23","first-page":"616","volume":"108","author":"JE Monheit","year":"1984","unstructured":"Monheit JE, Cowan DF, Moore DG (1984) Rapid detection of fungi in tissues using calcofluor white and fluorescence microscopy. Arch Pathol Lab Med 108:616\u2013618","journal-title":"Arch Pathol Lab Med"},{"key":"9685_CR24","doi-asserted-by":"publisher","first-page":"S89","DOI":"10.1093\/clinids\/22.Supplement_2.S89","volume":"22","author":"MA Pfaller","year":"1996","unstructured":"Pfaller MA (1996) Nosocomial candidiasis: emerging species, reservoirs, and modes of transmission. Clin Infect Dis 22:S89\u2013S94","journal-title":"Clin Infect Dis"},{"key":"9685_CR25","doi-asserted-by":"crossref","unstructured":"Lodhi S, Timms S, Stapleton E (2024) A systematic review of antimicrobial treatment regimens and their outcomes in necrotising otitis externa. J Laryngology Otology 1\u201344","DOI":"10.1017\/S0022215123001664"},{"key":"9685_CR26","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1086\/596757","volume":"48","author":"GP Peter","year":"2009","unstructured":"Peter GP (2009) Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 48:503\u2013535","journal-title":"Clin Infect Dis"}],"container-title":["European Archives of Oto-Rhino-Laryngology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00405-025-09685-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00405-025-09685-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00405-025-09685-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T07:15:53Z","timestamp":1770966953000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00405-025-09685-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,3]]},"references-count":26,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1]]}},"alternative-id":["9685"],"URL":"https:\/\/doi.org\/10.1007\/s00405-025-09685-2","relation":{},"ISSN":["0937-4477","1434-4726"],"issn-type":[{"value":"0937-4477","type":"print"},{"value":"1434-4726","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,3]]},"assertion":[{"value":"1 July 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 August 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 October 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the respective hospitals\u2019 ethical committees (2021\/0590-21-HMO and 2017\/0019-17-RMC).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"Given the retrospective aspect of the study, consent was not sought.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate\u00a0and consent to publish"}},{"value":"The authors have no relevant financial or non-financial interests to disclose.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}