Imaging to monitor treatment response
Uitgangsvraag
Which imaging modality (if any) is preferable for the evaluation of treatment response in necrotizing otitis externa?
Aanbeveling
Clinical findings (physical examination, symptoms) are the most important in treatment evaluation in patients with necrotizing otitis externa. If remission is clearly present, no imaging is necessary.
Use imaging for treatment response when clinical symptoms are equivocal and in case of extensive disease (complex NOE). A baseline scan is then indicated. In case of partial response on imaging, clinical signs may be decisive.
Possible imaging modalities:
1. FDG-PET/CT (or MRI) is the preferred imaging modality for assessing treatment response. Preferably a baseline scan is available.
- If FDG uptake is normal or significantly decreased compared to the baseline scan, therapy can be discontinued.
- If FDG uptake is unchanged / increased, the (microbiological) diagnosis shoud be reconsidered or therapy should be prolonged.
2. MRI
- Contrast-enhanced MRI may demonstrate reduced lesion extent and decreased intensity of enhancement during treatment. Other sequences (e.g., T1, diffusion-weighted imaging) may also suggest an adequate response.
- Most patients exhibit persistent MRI abnormalities post-treatment.
Overwegingen
Balance between desired and undesired effects
After reviewing the literature, we found that none of the studies directly compared MRI with FDG-PET/CT as imaging modality for the follow-up of NOE. Only a few studies evaluated the diagnostic benefits of imaging modalities for treatment follow-up in patients with necrotizing otitis externa. Additionally, no studies were identified regarding the role of imaging in determining treatment duration or predicting disease recurrence. Furthermore, no studies have systematically compared the added value of follow-up imaging versus no imaging at all.
No imaging during follow-up
Clinical follow-up is always the most critical parameter. In patients with limited disease severity/extent who are asymptomatic at the end of treatment, remission is likely. In such cases, follow-up imaging may offer little added value. According to the UK criteria this applies to probable and definite NOE (Hodgson, 2023).
Pragmatically, imaging for therapy evaluation may be warranted if there is a higher likelihood of post-treatment findings requiring therapy extension—particularly when such findings cannot be adequately monitored based on clinical symptoms alone. These patients typically fall into the category of NOE with complications or complex NOE (using the same definition).
The committee acknowledges significant practice variations across countries and settings regarding this approach.
Regarding treatment response, we describe the findings and considerations for each imaging modality below:
FDG-PET/CT:
From the systematic literature search, four studies were identified that evaluated FDG-PET/CT as a potential diagnostic tool to guide treatment in patients with necrotizing otitis externa (NOE). High remission rates were observed in patients showing no increased FDG activity or a significant decrease in FDG uptake on follow-up scans. However, these studies were limited by small sample sizes (Shavit 2018, Vosbeek 2023, Thannaru 2024).
In patients with progressive disease (evidenced by increased FDG uptake), FDG-PET/CT results may justify treatment extension. For example, Kulkarni (2020) reported disease progression in 14 patients and regression in 9 based on FDG-PET/CT findings, all of which were later confirmed by clinical follow-up.
Due to the scarcity of high-quality studies, the added value of FDG-PET/CT in assessing treatment response remains uncertain. Nevertheless, its use for this purpose is increasing in NOE, as it remains the optimal modality for visualizing hypermetabolic foci characteristic of infection.
FDG-PET/CT can be reasonably used for treatment response evaluation in NOE, provided:
- Preferably, a baseline FDG-PET/CT is available for comparison.
- Recognition that no validated quantitative thresholds currently exist.
While SUVmax may support therapy monitoring (van der Meer 2023), and preliminary data suggest SUVpeak <3.1 as a potential cutoff for treatment cessation (Jansen 2025), robust evidence is still required before quantitative criteria can be standardized.
MRI:
No studies could be included that evaluated the role of MRI in treatment response. However, the literature does suggest that disease extension and progression in follow-up could be monitored by MRI (Lee, 2011). In contrast, other MRI case series describe the persistent absence of normalization in previously affected tissues at 6- and 12-month scans, even after clinically successful treatment (Al-Noury 2011, Chhabria 2023).
Contrast-enhanced MRI is useful for evaluating the anatomic location of NOE / skull base osteomyelitis. During treatment, MRI may show a decrease in the extent or intensity of enhancement. Other sequences – such as T1-weighted imaging (for both bone and soft tissue abnormalities) or diffusion-weighted imaging (DWI) – may also suggest an adequate response. However, most patients show persistent MRI abnormalities after treatment.
For evaluating complex NOE (e.g., cases involving venous thrombosis, abscess, or empyema), MRI is superior to CT for soft tissue evaluation. If MRI is not feasible (due to the patient’s clinical condition or contraindications), a contrast-enhanced CT scan or FDG-PET/CT could be considered.
CT:
For completeness, no studies were found that evaluated the role of CT in therapy follow-up. However, the literature suggests that bony erosion may persist even after successful treatment (Kroonenburgh, 2018). Follow-up CT scans can continue to show signs of disease, despite successful treatment (Chabria, 2023; Kroonenburgh, 2018).
In the past, bone scintigraphy (99mTc-labelled diphosphonates) or galliumscans (67Ga-citrate) were used for infection imaging. However, these techniques are not preferred anymore. Bone scintigraphy is aspecific, depics abnormalities of the bone, and involvement of or extension to the soft tissue cannot be visualized. The uptake of 67Ga-citrate is aspecific. Besides, PET/CT imaging offers better spatial resolution, better sensitivity, and possibilities for quantification.
Quality of the evidence
For MRI, no evidence could be found regarding the role of MRI in therapy evaluation.
The overall quality of evidence for the use of FDG-PET/CT in therapy evaluation is very low. This means we are very uncertain about the estimated effect of the crucial outcomes found.
There is downgrading due to very serious:
- Risk of bias: patient selection; index test.
- Imprecision: inaccuracy, due to a very small number of events in a small sample size.
Based on the literature, and despite the very low quality of evidence, when imaging techniques are needed since other diagnostic tests are equivocal, FDG-PET/CT is the first imaging technique of choice to evaluate effect of therapy in patients treated for NOE. No evidence could be found when this FDG-PET/CT should be performed. However, based on other studies in infectious diseases, FDG-PET/CT could show therapy effect after six weeks of antibiotic treatment.
No evidence was found for the use of MRI in therapy evaluation. However, it is known that contrast enhanced MRI can be used to evaluate the extent of infection in the adjacent soft tissues or the adjacent bone marrow in the diagnostic phase. Together with FDG-PET/CT this could help in determining the exact location of remaining FDG activity in the therapy phase. Therefore, FDG-PET/MRI could be used for this indication, when available.
Values and preferences of patients (and possibly their relatives/caregivers)
Imaging techniques can be used to evaluate treatment response. FDG-PET/CT involves radiation exposure, so patients should be informed of this risk. The ALARA principle (As Low As Reasonably Achievable) must always be followed when using ionizing radiation. Recent advances in camera technology have significantly reduced radiation doses. For younger children, MRI may be challenging due to long scan times, loud noises, and potential difficulties with cooperation.
Cost considerations
FDG-PET/CT is an expensive imaging technique. However, when used to determine whether treatment should be stopped, modified, or prolonged, cost considerations should not be the primary factor. In fact, performing an FDG-PET/CT scan may prove cost-effective if it prevents unnecessary treatment prolongation.
Acceptability, feasibility, and implementation.
Regarding acceptability, feasibility, and implementation, no significant challenges are anticipated since CT, MRI, and FDG-PET/CT are widely available. In situations with limited capacity for one or two modalities, the remaining technique serves as a viable alternative. If local expertise in image interpretation is lacking, referral to a specialized center remains an option.
Rationale of the recommendation: weighing arguments for and against the interventions
Clinical evaluation is the most critical factor in therapy evaluation.
Based on the literature—and despite the very low quality of evidence—if imaging is required due to inconclusive results from other diagnostic tests, FDG-PET/CT is the preferred imaging technique for evaluating therapy response in patients treated for NOE.
In some centers a PET/MRI camera system is available. This could be synergistic, since the metabolic activity of the PET scan can be combined with the soft-tissue characterization of the MRI which is superior over CT. In those center where PET/MRI is available: FDG-PET/MRI is preferred over FDG-PET/CT for this indication.
Be aware that follow-up imaging often reveals residual abnormalities that are impossible to distinguish from persistent disease. In such cases, clinical remission may be decisive.
Final judgment:
Weak recommendaton against imaging for follow-up of Definite NOE. Weak recommendation for imaging in case of complex NOE.
Weak recommendation for FDG-PET as imaging modality to evaluate treatment response.
Weak recommendation for MRI as imaging modality to evaluate complications of NOE (vascular, intracranial).
Onderbouwing
Achtergrond
Currently, there is no consensus on how to measure therapy response in necrotizing otitis externa (NOE). Many clinics follow a standard treatment duration or continue therapy until symptoms (otorrhea and otalgia) resolve over a minimum period. Treatment is considered successful if the patient becomes asymptomatic and no abnormalities are found on physical examination. If symptoms recur after discontinuation, therapy is resumed. This represents a purely clinical approach.
However, in some patients, clinical signs are equivocal, necessitating further diagnostic tests. With the availability of MRI and/or [¹⁸F]-FDG-PET/CT, there is growing interest in using these imaging modalities to assess treatment success and guide discontinuation. However, their use has not yet been validated, and they have certain limitations.
Evaluating treatment response in NOE through imaging can be challenging due to persistent abnormalities. Both CT and MRI may show ongoing changes (e.g., bone erosions, soft tissue enhancement, or bone marrow signal alterations) even during effective treatment. In such cases, accurately interpreting treatment response remains difficult.
Conclusies / Summary of Findings
Treatment response FDG PET-CT
|
Very low GRADE |
The evidence is very uncertain about the evaluation of treatment response on FDG-PET/CT in patients with suspected skull base osteomyelitis.
Sources: Vosbeek, 2023; Kulkarni, 2020; Shavit, 2018 |
Treatment response MRI
|
Very low GRADE |
No evidence was found about the evaluation of treatment response on MRI in patients with suspected skull base osteomyelitis.
Source: - |
Treatment response MRI vs FDG PET-CT
|
Very low GRADE |
No evidence was found about the evaluation of treatment response on MRI versus FDG-PET-CT in patients with suspected skull base osteomyelitis.
Source: - |
Length of treatment
|
No GRADE |
No evidence was found for using FDG-PET/CT or MRI for determining the length of treatment.
Sources: - |
Samenvatting literatuur
Description of studies
A total of 4 studies were included in the analysis of the literature. None of these studies directly compared MRI with FDG-PET/CT. Important study characteristics and results are summarized in table 1. The assessment of the risk of bias is summarized in the risk of bias tables (under the tab ‘Evidence tables’).
Table 1. Characteristics of included studies
*For further details, see risk of bias table in the appendix
Results
Treatment response
Shavit (2018) evaluated a small group of 8 patients with a follow-up FDG-PET/CT scan after 6 weeks of treatment with intravenous antibiotics in patients with necrotizing otitis externa. Seven patients showed no FDG uptake or reduced uptake (the method for evaluation of reduction was not specified). One patient showed an increase in FDG uptake, and antibiotic treatment was prolonged for another six weeks. After this second round of antibiotic treatment, this patient showed a decrease in FDG uptake. In all patients showing a decrease in or no FDG uptake after treatment, antibiotics were discontinued. None of these patients showed signs of recurrence of refractory disease after clinical follow-up (mean follow-up time of 16 ± 15 months).
Kulkarni (2020) evaluated a follow-up FDG-PET/CT scan in 23 of the original 77 patients with necrotizing otitis externa. Of the 23 patients with a follow-up FDG-PET/CT scan, 14 showed progression of disease and 9 regression. In all patients, the FDG-PET/CT findings were in accordance with later clinical findings in follow up, making the decision to (dis)continue treatment based on FDG-PET correct.
Vosbeek (2023) assessed treatment (dis)continuation using follow-up FDG-PET/CT or Gallium SPECT/CT in 20 patients divided into 3 groups: complete imaging resolution (no signs of active inflammation/infection) (n=9), near-resolution (n=3), or cessation for other reasons despite residual imaging findings (n=8). FDG-PET/CT (n=8) showed 100% remission in groups 1 (5/5) and 2 (1/1), and 50% (1/2) in group 3.
Thanneru (2024) evaluated FDG-PET/CT scans in 20 patients in clinical remission and 8 patients with clinically active disease. All patients underwent an FDG-PET/CT scan. Among the 20 patients in remission, 17 (85%) showed no increased FDG uptake, while 3 (15%) exhibited residual increased uptake. Of this group, no relapses were mentioned (100% remission rate). In contrast, all eight patients with active disease showed signs of active disease on the follow-up FDG-PET scan. The study did not specify the timing of the scans or the criteria used for evaluation.
Length of treatment
No studies evaluated if imaging modalities could help in determining the length of treatment.
Zoeken en selecteren
A systematic review of the literature was performed to answer the following question(s):
What are the advantages and/or disadvantages of MRI compared to FDG-PET scans in the evaluation of treatment response in necrotizing otitis externa [prognostic/impact question].
| Patients | Patients treated/under treatment for necrotizing otitis externa |
| Intervention | (Dis)Continuation of therapy on basis of MRI |
| Control | (Dis)Continuation of therapy on basis of FDG-PET/CT scans |
| Referral | Clinical remission of disease (after stopping treatment) |
| Outcomes | Remission, duration of treatment |
| Other selection criteria | Study design: systematic reviews and randomized controlled trials, observational studies |
Relevant outcome measures
The guideline panel considered treatment response and recurrence of disease as a critical outcome measure for decision making; and duration of treatment as an important outcome measure for decision making.
The guideline panel defined the outcome measures as:
- Remission: curation rate, defined as the absence of disease > 3 months.
- Duration of treatment: the length of treatment, preferably in weeks.
The guideline development group defined the following as a minimal clinically (patient) important difference:
- Remission: GRADE standard limits.
- Duration of treatment: Absolute difference > 5%.
* Default thresholds proposed by the international GRADE working group were used: a 25% difference in relative risk (RR) for dichotomous outcomes (RR <0.80 or RR >1.25), or 0.5 standard deviations (SD) for continuous outcomes
Search and select (Methods)
The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms until 10-11-2023. An additional search was performed on 12-02-2025 by a medical information specialist using the following bibliographic databases: Embase.com and Ovid/Medline. Both databases were searched from inception till 12-2-2025 for systematic reviews, clinical trials and observational studies. Systematic searches were completed using a combination of controlled vocabulary/subject headings (e.g., Emtree-terms, MeSH) wherever they were available and natural language keywords. The overall search strategy was derived from 3 primary search concepts: (1) Osteomyelitis skull base AND ((2) MRI OR (3) PET-CT). Duplicates were removed using EndNote software. After deduplication a total of 233 records were imported for title/abstract screening. The detailed search strategy is listed under the tab ‘Literature search strategy’. Initially, 223 studies were selected based on title and abstract screening. After reading the full text, 24 studies were excluded (see the exclusion table under the tab ‘Evidence tabellen’), and 4 studies were included.
Referenties
- Al-Noury K, Lotfy A. Computed tomography and magnetic resonance imaging findings before and after treatment of patients with malignant external otitis. Eur Arch Otorhinolaryngol. 2011 Dec;268(12):1727-34. doi: 10.1007/s00405-011-1552-8. Epub 2011 Mar 15. PMID: 21400256.
- Chabria S, Vishnurag A. Observational Study on Clinical Features and Management of Skull Base Osteomyelitis in Hospitalised Patients at a Tertiary Care Hospital. Indian J Otolaryngol Head Neck Surg. 2023 Apr;75(Suppl 1):635-643. doi: 10.1007/s12070-023-03675-8. Epub 2023 Mar 18. PMID: 37206859; PMCID: PMC10188806.
- Jansen RW, Kemp P, Wiegers SE, de Graaf P, van Schie A, Martens RM, Boellaard R, Zwezerijnen GJC, Goderie T. Treatment Response Evaluation in Necrotizing Otitis Externa Using 18 F-FDG-PET Imaging. Otol Neurotol. 2025 Mar 1;46(3):295-302. doi: 10.1097/MAO.0000000000004402. Epub 2025 Jan 9. PMID: 39794893.
- Hodgson SH, Khan MM, Patrick-Smith M, Martinez-Devesa P, Stapleton E, Williams OM, Pretorius P, McNally M, Andersson MI. UK consensus definition for necrotising otitis externa: a Delphi study. BMJ Open. 2023 Feb 20;13(2):e061349. doi: 10.1136/bmjopen-2022-061349.
- van Kroonenburgh AMJL, van der Meer WL, Bothof RJP, van Tilburg M, van Tongeren J, Postma AA. Advanced Imaging Techniques in Skull Base Osteomyelitis Due to Malignant Otitis Externa. Curr Radiol Rep. 2018;6(1):3. doi: 10.1007/s40134-018-0263-y. Epub 2018 Jan 22. PMID: 29416952; PMCID: PMC5778178.
- Kulkarni SC, Padma S, Shanmuga Sundaram P. In the evaluation of patients with skull base osteomyelitis, does 18F-FDG PET CT have a role? Nucl Med Commun. 2020 Jun;41(6):550-559. doi: 10.1097/MNM.0000000000001187. PMID: 32282638.
- Lee JE, Song JJ, Oh SH, Chang SO, Kim CH, Lee JH. Prognostic value of extension patterns on follow-up magnetic resonance imaging in patients with necrotizing otitis externa. Arch Otolaryngol Head Neck Surg. 2011 Jul;137(7):688-93. doi: 10.1001/archoto.2011.98. PMID: 21768413.
- van der Meer WL, Mitea C, Waterval JJ, Kunst HPM, Mottaghy FM, Postma AA. The Role of F18-FDG PET-MRI in Necrotising External Otitis Follow-Up: A Single Centre Experience. Ann Otolaryngol Rhinol 2023; 10(2): 1313.
- Stern Shavit S, Bernstine H, Sopov V, Nageris B, Hilly O. FDG-PET/CT for diagnosis and follow-up of necrotizing (malignant) external otitis. Laryngoscope. 2019 Apr;129(4):961-966. doi: 10.1002/lary.27526. Epub 2018 Dec 14. PMID: 30549258.
- Thanneru S, Sikka K, Bhalla AS, Tripathi M, Thakar A, Singh A, Singh CA, Verma H. Deciding treatment end point in necrotizing otitis externa: validation of a standardized clinical response assessment strategy with positron emission tomography findings. Eur Arch Otorhinolaryngol. 2025 Mar;282(3):1171-1177. doi: 10.1007/s00405-024-09006-z. Epub 2024 Oct 11. PMID: 39394331.
- Vosbeek EGM, Straatman LV, Braat AJAT, de Keizer B, Thomeer HGXM, Smit AL. Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center. Otol Neurotol Open. 2023 Nov 22;3(4):e042. doi: 10.1097/ONO.0000000000000042. PMID: 38516544; PMCID: PMC10950167.
Evidence tabellen
Risk of Bias tables
Risk of bias assessment diagnostic accuracy studies (QUADAS II, 2011)
|
Study reference
(first author, publication year) |
Patient selection
|
Index test
|
Reference standard
|
Flow and timing
|
Comments wioth respect to applicability |
|
|
Kulkarni, 2020 |
yes |
Were the index test results interpreted without knowledge of the results of the reference standard? yes
If a threshold was used, was it pre-specified? No threshold was used |
Is the reference standard likely to correctly classify the target condition? Probably
Were the reference standard results interpreted without knowledge of the results of the index test? no |
Was there an appropriate interval between index test(s) and reference standard? yes
Did all patients receive a reference standard? Because of the reference standard being multifactorial all patient recieved one or multiple factors
Did patients receive the same reference standard? no Were all patients included in the analysis? yes |
Are there concerns that the included patients do not match the review question? no
Are there concerns that the index test, its conduct, or interpretation differ from the review question? no
Are there concerns that the target condition as defined by the reference standard does not match the review question? no |
|
|
Shavit, 2018 |
yes |
Were the index test results interpreted without knowledge of the results of the reference standard? yes
If a threshold was used, was it pre-specified? No threshold was used |
Is the reference standard likely to correctly classify the target condition? Probably
Were the reference standard results interpreted without knowledge of the results of the index test? no |
Was there an appropriate interval between index test(s) and reference standard? yes
Did all patients receive a reference standard? Because of the reference standard being multifactorial all patient recieved one or multiple factors
Did patients receive the same reference standard? no Were all patients included in the analysis? yes |
Are there concerns that the included patients do not match the review question? no
Are there concerns that the index test, its conduct, or interpretation differ from the review question? no
Are there concerns that the target condition as defined by the reference standard does not match the review question? no |
|
|
Vosbeek, 2023 |
no |
Were the index test results interpreted without knowledge of the results of the reference standard? yes
If a threshold was used, was it pre-specified? No threshold was used |
Is the reference standard likely to correctly classify the target condition? yes
Were the reference standard results interpreted without knowledge of the results of the index test? no |
Was there an appropriate interval between index test(s) and reference standard? yes
Did all patients receive a reference standard? Because of the reference standard being multifactorial all patient recieved one or multiple factors
Did patients receive the same reference standard? no Were all patients included in the analysis? yes |
Are there concerns that the included patients do not match the review question? no
Are there concerns that the index test, its conduct, or interpretation differ from the review question? no
Are there concerns that the target condition as defined by the reference standard does not match the review question? no |
|
|
Thanneru, 2024 |
no |
Were the index test results interpreted without knowledge of the results of the reference standard? yes
If a threshold was used, was it pre-specified? No threshold was used |
Is the reference standard likely to correctly classify the target condition? yes
Were the reference standard results interpreted without knowledge of the results of the index test? no |
Was there an appropriate interval between index test(s) and reference standard? yes
Did all patients receive a reference standard? Because of the reference standard being multifactorial all patient recieved one or multiple factors
Did patients receive the same reference standard? no Were all patients included in the analysis? yes |
Are there concerns that the included patients do not match the review question? no
Are there concerns that the index test, its conduct, or interpretation differ from the review question? no
Are there concerns that the target condition as defined by the reference standard does not match the review question? no |
Randomization: generation of allocation sequences have to be unpredictable, for example computer generated random-numbers or drawing lots or envelopes. Examples of inadequate procedures are generation of allocation sequences by alternation, according to case record number, date of birth or date of admission.
Allocation concealment: refers to the protection (blinding) of the randomization process. Concealment of allocation sequences is adequate if patients and enrolling investigators cannot foresee assignment, for example central randomization (performed at a site remote from trial location). Inadequate procedures are all procedures based on inadequate randomization procedures or open allocation schedules.
Blinding: neither the patient nor the care provider (attending physician) knows which patient is getting the special treatment. Blinding is sometimes impossible, for example when comparing surgical with non-surgical treatments, but this should not affect the risk of bias judgement. Blinding of those assessing and collecting outcomes prevents that the knowledge of patient assignment influences the process of outcome assessment or data collection (detection or information bias). If a study has hard (objective) outcome measures, like death, blinding of outcome assessment is usually not necessary. If a study has “soft” (subjective) outcome measures, like the assessment of an X-ray, blinding of outcome assessment is necessary. Finally, data analysts should be blinded to patient assignment to prevents that knowledge of patient assignment influences data analysis.
Lost to follow-up: If the percentage of patients lost to follow-up or the percentage of missing outcome data is large, or differs between treatment groups, or the reasons for loss to follow-up or missing outcome data differ between treatment groups, bias is likely unless the proportion of missing outcomes compared with observed event risk is not enough to have an important impact on the intervention effect estimate or appropriate imputation methods have been used.
Selective outcome reporting: Results of all predefined outcome measures should be reported; if the protocol is available (in publication or trial registry), then outcomes in the protocol and published report can be compared; if not, outcomes listed in the methods section of an article can be compared with those whose results are reported.
Other biases: Problems may include: a potential source of bias related to the specific study design used (e.g., lead-time bias or survivor bias); trial stopped early due to some data-dependent process (including formal stopping rules); relevant baseline imbalance between intervention groups; claims of fraudulent behavior; deviations from intention-to-treat (ITT) analysis; (the role of the) funding body (see also downgrading due to industry funding https://kennisinstituut.viadesk.com/do/document?id=1607796-646f63756d656e74). Note: The principles of an ITT analysis implies that (a) participants are kept in the intervention groups to which they were randomized, regardless of the intervention they actually received, (b) outcome data are measured on all participants, and (c) all randomized participants are included in the analysis.
Overall judgement of risk of bias per study and per outcome measure, including predicted direction of bias (e.g., favors experimental, or favors comparator). Note: the decision to downgrade the certainty of the evidence for a particular outcome measure is taken based on the body of evidence, i.e., considering potential bias and its impact on the certainty of the evidence in all included studies reporting on the outcome.
Table of excluded studies
|
Reference |
Reason for exclusion |
|
Auinger AB, Dahm V, Stanisz I, Schwarz-Nemec U, Arnoldner C. The challenging diagnosis and follow-up of skull base osteomyelitis in clinical practice. Eur Arch Otorhinolaryngol. 2021 Dec;278(12):4681-4688. doi: 10.1007/s00405-020-06576-6. Epub 2021 Jan 28. PMID: 33511482; PMCID: PMC8553694. |
Wrong outcome |
|
Maramattom BV, Ram SA, Viswam V, Nair S. Central Skull Base Osteomyelitis: Multimodality Imaging and Clinical Findings from a Large Indian Cohort. Neurol India. 2022 Sep-Oct;70(5):1911-1919. doi: 10.4103/0028-3886.359218. PMID: 36352587. |
Wrong outcome |
|
Takata J, Hopkins M, Alexander V, Bannister O, Dalton L, Harrison L, Groves E, Kanona H, Jones GL, Mohammed H, Andersson MI, Hodgson SH. Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research. Clin Otolaryngol. 2023 May;48(3):381-394. doi: 10.1111/coa.14041. Epub 2023 Feb 22. PMID: 36759416. |
Wrong outcome |
|
Chhabria S, Vishnurag A. Observational Study on Clinical Features and Management of Skull Base Osteomyelitis in Hospitalised Patients at a Tertiary Care Hospital. Indian J Otolaryngol Head Neck Surg. 2023 Apr;75(Suppl 1):635-643. doi: 10.1007/s12070-023-03675-8. Epub 2023 Mar 18. PMID: 37206859; PMCID: PMC10188806. |
Case report |
|
Ismail H, Hellier WP, Batty V. Use of magnetic resonance imaging as the primary imaging modality in the diagnosis and follow-up of malignant external otitis. J Laryngol Otol. 2004 Jul;118(7):576-9. doi: 10.1258/0022215041615100. PMID: 15318971. |
Wrong outcome |
|
Lee JE, Song JJ, Oh SH, Chang SO, Kim CH, Lee JH. Prognostic value of extension patterns on follow-up magnetic resonance imaging in patients with necrotizing otitis externa. Arch Otolaryngol Head Neck Surg. 2011 Jul;137(7):688-93. doi: 10.1001/archoto.2011.98. PMID: 21768413. |
Small case series |
Verantwoording
Beoordelingsdatum en geldigheid
Laatst beoordeeld : 25-09-2025
Algemene gegevens
For more details on the guideline methodology used, we refer you to the Werkwijze. Relevant information for the development of this guideline is presented below.
The revision of this guideline module was supported by the Knowledge Institute of the Federation of Medical Specialists (www.demedischspecialist.nl/kennisinstituut) and was funded by the Quality Funds for Medical Specialists (SKMS).
Samenstelling werkgroep
For the development of the guideline, a multidisciplinary guideline development group was established in 2022, consisting of representatives from all relevant specialties (see Composition of the working group) involved in the care of patients with necrotizing otitis externa.
Werkgroep
- Dr. J.J. (Jérôme) Waterval (chairman), Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied, otorhinolaryngologist, Maastricht University Medical Center, Maastricht; Academic Alliance Skull Base Pathology Maaastricht University Medical Center – Radboud University Medical Center
- Dr. M.J. (Mark) van Tilburg, Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied, otorhinolaryngologist, Elistabeth-TweeSteden Ziekenhuis, Tilburg
- Drs. S.A.H. (Sjoert) Pegge, Nederlandse Vereniging voor Radiologie, radiologist, Radboud University Medical Center, Nijmegen; Academic Alliance Skull Base Pathology Maaastricht University Medical Center – Radboud University Medical Center
- Prof. Dr. A.W.J.M. (Andor) Glaudemans, Nederlandse Vereniging voor Nucleaire Geneeskunde, nuclear physicist UMCG, Groningen
- Dr. M. (Moniek) Heusinkveld, Nederlandse Vereniging voor Medische Microbiologie, medical microbiologist, Gelderse Vallei Hospital, Ede
- Dr. E.J.G. (Edgar) Peters, Nederlandse Internisten Vereniging, infectious disease specialist, Amsterdam University Medical Center (tot oktober 2022)
- Dr. J.J. (Jonne) Sikkens, Nederlandse Internisten Vereniging, infectious disease specialist, Amsterdam University Medical Center (vanaf october 2022)
- Dr. I.R. (Raluca) Mihailescu, Nederlandse Internisten Vereniging, infectious disease specialist, Onze Lieve Vrouwe Gasthuis, Amsterdam (vanaf juli 2024)
- Dr. S.H. (Selwyn) Lowe, Nederlandse Internisten Vereniging, infectious disease specialist, Maastricht University Medical Center, Maastricht (vanaf juli 2024)
Klankbordgroep
- Dr. N.G.L. (Nynke) Jager, NVZA, hospital pharmacist Radboud University Medical Center, Nijmegen
- Drs. F.S. (Fleur) Sinkeler, NVZA, hospital pharmacist Radboudumc Nijmegen
Ondersteuning
- Drs. J.M.H. (Jasper) Janssen, NVKNO, otorhinolaryngologist in training, Maastricht University Medical Center, Maastricht
- Dr. A. (Anja) van der Hout, advisor Knowledge Institute of the Dutch Association of Medical Specialists
Belangenverklaringen
An overview of the conflicts of interests of the guideline development group members and the assessment of how potential conflicts of interest were addressed can be found in the table below. The signed declarations of interest are available upon request from the Secretariat of the Knowledge Institute of the Dutch Federation of Medical Specialists at secretariaat@kennisinstituut.nl.
|
Werkgroeplid |
Functie |
Nevenfuncties |
Gemelde belangen |
Ondernomen actie |
|
Waterval (voorzitter) |
KNO-arts MUMC |
Accreditatiecommissie Stichting Audiciensregister |
Geen |
Geen |
|
Glaudemans |
Nucleair geneeskundige UMCG
|
Voorzitter NVNG (onbetaald) |
We hebben als ziekenhuis en afdeling een samenwerking met Siemens (UMCG-Siemens PUSH collaboration/Partnership of UMCG-Siemens for building the future of Health). Hieruit vloeit uit voort dat de nieuwste camera’s bij ons komen (bv UMCG neemt nieuwe Whole-Body PET/CT-scanner in gebruik) en dat er gezamenlijk onderzoek gedaan wordt. Hierbij heb ik een aantal promovendi die door Siemens betaald worden (niet op het gebied van osteomyelitis schedelbasis) |
Geen restricties. Extern gefinancierd onderzoek valt buiten bestek richtlijn
|
|
Heusinkveld |
Arts-microbioloog in ziekenhuis Gelders Vallei |
Richtlijn otitis externa
Bestuur SKML sectie infectieserologie (onbetaald) |
Geen |
Geen |
|
Peters (tot oktober 2022) |
Internist-infectioloog-acute geneeskundige, Amsterdam UMC |
richtlijnontwikkeling: Covid-19 FMS, diabetische voet NIV, diabetische voet IWGDF, alle onbetaald
|
afdeling krijgt geld van Roche voor biomarker onderzoek bij diabetische voet osteomyelitis Diabetische voet onderzoek (extern gefinancierd)
|
Geen restricties. Extern gefinancierd onderzoek valt buiten bestek richtlijn
|
|
Pegge |
Radioloog (Neuro/Hoofdhals) Radboud UMC Nijmegen |
Geen |
Geen |
Geen |
|
Van Tilburg |
KNO-arts ETZ
|
Geen |
Geen |
Geen |
|
Sikkens |
Internist acute geneeskunde & infectioloog, Amsterdam UMC |
post-doc onderzoeker Amsterdam UMC, onbetaald
|
Ja, via ZonMw (onderzoek naar COVID bij een medewerkerscohort, onderwerp infectiepreventie en vaccin-immunologie)
|
Geen restricties. Extern gefinancierd onderzoek valt buiten bestek richtlijn
|
|
Lowe
|
Internist-infectioloog. Afdeling Medische Microbiologie, Infectieziekten en Infectiepreventie (MMI), Maastricht UMC+
|
Geen |
Geen |
Geen |
|
Mihailescu
|
Internist-infectioloog OLVG Amsterdam |
Geen |
Geen |
Geen |
|
Jasper Janssen
|
KNO-arts in opleiding bij het MUMC+ (0,8 FTE), promovendus (0,2 FTE). |
Geen |
Geen |
Geen |
|
Sinkeler
|
Ziekenhuisapotheker AmsterdamUMC
|
Geen |
Geen |
Geen |
|
Jager |
Ziekenhuisapotheker
|
Geen |
Geen |
Geen |
Inbreng patiëntenperspectief
Attention was paid to the patient perspective by inviting Stichting Hoormij and Patiëntenfederatie Nederland for the invitational conference, and close contact with Stichting Hoormij during the development of the guideline. The report of this [see related products] was discussed in the guideline development group. The input obtained was taken into account when formulating the key questions, selecting the outcome measures, and drafting the considerations. The draft guideline was also submitted for comments to Stichting Hoormij and Patiëntenfederatie Nederland, and any comments received were reviewed and processed.
Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz
Bij de richtlijnmodule voerde de werkgroep conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uit om te beoordelen of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling is de richtlijnmodule op verschillende domeinen getoetst (zie het stroomschema bij Werkwijze).
|
Module |
Uitkomst raming |
Toelichting |
|
Imaging to monitor treatment response |
geen financiële gevolgen |
Uit de toetsing volgt dat de aanbeveling(en) niet breed toepasbaar zijn (<5.000 patiënten) en daarom naar verwachting geen substantiële financiële gevolgen zal hebben voor de collectieve uitgaven. |
Zoekverantwoording
Algemene informatie
|
Cluster/richtlijn: NVKNO Osteomyelitis schedelbasis |
|
|
Uitgangsvraag/modules: Wat zijn de voor- en nadelen van MRI t.o.v. PET-CT voor de evaluatie van het therapie-effect? [prognose/impact vraag] |
|
|
Database(s): Embase.com, Ovid/Medline |
Datum: 10-11-2023,12-2-2025 |
|
Periode: vanaf nvt |
Talen: geen restrictie |
|
Literatuurspecialist:Ingeborg van Dusseldorp |
Rayyan review: https://rayyan.ai/reviews/839938 |
|
BMI-zoekblokken: voor verschillende opdrachten wordt (deels) gebruik gemaakt van de zoekblokken van BMI-Online https://blocks.bmi-online.nl/ Bij gebruikmaking van een volledig zoekblok zal naar de betreffende link op de website worden verwezen. |
|
|
Toelichting: 12-2-2025
Op verzoek is de strategie PET-CT toegevoegd. Daarmee verandert de vraag in: Wat zijn de voor- en nadelen van MRI of PET CT voor de evaluatie van therapie en is gezocht met de volgende 3 concepten:
10-11-2023
Voor deze vraag is gezocht op de concepten:
Osteomyelitis schedelbasis EN MRI
Het sleutelartikel van Kulkarni wordt gevonden. Het artikel van vader Meer wordt niet gevonden omdat het tijdschrift niet in de databases is opgenomen. |
|
|
Te gebruiken voor richtlijntekst: A systematic literature search was performed by a medical information specialist using the following bibliographic databases: Embase.com and Ovid/Medline. Both databases were searched from inception to12-2-2025 for systematic reviews, clinical trials and observational studies. Systematic searches were completed using a combination of controlled vocabulary/subject headings (e.g., Emtree-terms, MeSH) wherever they were available and natural language keywords. The overall search strategy was derived from 3 primary search concepts: (1) Osteomyelitis skull base AND ((2) MRI OR (3) PET-CT). Duplicates were removed using EndNote software. After deduplication a total of 233 records were imported for title/abstract screening. Initially, XXX studies were selected based on title and abstract screening. After reading the full text, XXX studies were excluded (see the exclusion table under the tab ‘Evidence tabellen’), and XXX studies were included. |
|
Zoekopbrengst
|
|
EMBASE |
OVID/MEDLINE |
Ontdubbeld t.o.v. Rayyan |
|
SR |
26 |
15 |
7 |
|
RCT |
16 |
3 |
11 |
|
Observationele studies |
130 |
121 |
55 |
|
Totaal |
172 |
139 |
*233 |
|
|
EMBASE |
OVID/MEDLINE |
Ontdubbeld |
|
SR |
18 |
12 |
23 |
|
RCT |
6 |
2 |
8 |
|
Observationele studies |
82 |
83 |
129 |
|
Totaal |
106 |
97 |
*160 |
*in Rayyan
Zoekstrategie
Embase.com 12-2-2025
|
No. |
Query |
Results |
|
#1 |
'positron emission tomography-computed tomography'/exp OR 'pet-ct scanner'/exp OR (('positron*emission' NEAR/2 ('computed tomography' OR 'computer assisted' OR 'tomography computed' OR 'tomography-computed' OR 'computed tomography')):ti,ab,kw) OR (('pet' NEAR/1 'ct' NEAR/2 ('scan*' OR 'system')):ti,ab,kw) |
99282 |
|
#2 |
'malignant otitis externa'/exp OR (((maligna* OR necroti* OR necrosis) NEAR/3 ('otitis externa' OR 'external otitis')):ti,ab,kw) OR ('otitis externa'/mj AND (maligna*:ti,kw OR necroti*:ti,kw OR necrosis:ti,kw)) OR (('osteomyelitis'/exp/mj OR 'osteomyelit*':ti,ab,kw OR osteitis:ti,ab,kw) AND ('skull'/exp/mj OR 'skull disease'/exp/mj OR skull*:ti,ab,kw OR cranial:ti,ab,kw OR cranium:ti,ab,kw)) OR 'skull base malignant osteomyelitis':ti,ab,kw |
4864 |
|
#3 |
'nuclear magnetic resonance imaging'/exp OR 'mri scanner'/exp OR ('magnetic resonance':ab,ti AND (image:ab,ti OR images:ab,ti OR imaging:ab,ti)) OR mri:ab,ti OR mris:ab,ti OR nmr:ab,ti OR mra:ab,ti OR mras:ab,ti OR zeugmatograph*:ab,ti OR 'mr tomography':ab,ti OR 'mr tomographies':ab,ti OR 'mr tomographic':ab,ti OR 'mr imag*':ti,ab,kw OR 'proton spin':ab,ti OR ((magneti*:ab,ti OR 'chemical shift':ab,ti) AND imaging:ab,ti) OR fmri:ab,ti OR fmris:ab,ti OR rsfmri:ti,ab,kw |
1577837 |
|
#4 |
#2 AND (#1 OR #3) |
697 |
|
#5 |
#4 NOT ('conference abstract'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it) NOT (('animal'/exp OR 'animal experiment'/exp OR 'animal model'/exp OR 'nonhuman'/exp) NOT 'human'/exp) |
549 |
|
#6 |
'meta analysis'/exp OR 'meta analysis (topic)'/exp OR metaanaly*:ti,ab OR 'meta analy*':ti,ab OR metanaly*:ti,ab OR 'systematic review'/de OR 'cochrane database of systematic reviews'/jt OR prisma:ti,ab OR prospero:ti,ab OR (((systemati* OR scoping OR umbrella OR 'structured literature') NEAR/3 (review* OR overview*)):ti,ab) OR ((systemic* NEAR/1 review*):ti,ab) OR (((systemati* OR literature OR database* OR 'data base*') NEAR/10 search*):ti,ab) OR (((structured OR comprehensive* OR systemic*) NEAR/3 search*):ti,ab) OR (((literature NEAR/3 review*):ti,ab) AND (search*:ti,ab OR database*:ti,ab OR 'data base*':ti,ab)) OR (('data extraction':ti,ab OR 'data source*':ti,ab) AND 'study selection':ti,ab) OR ('search strategy':ti,ab AND 'selection criteria':ti,ab) OR ('data source*':ti,ab AND 'data synthesis':ti,ab) OR medline:ab OR pubmed:ab OR embase:ab OR cochrane:ab OR (((critical OR rapid) NEAR/2 (review* OR overview* OR synthes*)):ti) OR ((((critical* OR rapid*) NEAR/3 (review* OR overview* OR synthes*)):ab) AND (search*:ab OR database*:ab OR 'data base*':ab)) OR metasynthes*:ti,ab OR 'meta synthes*':ti,ab |
976433 |
|
#7 |
'clinical trial'/exp OR 'randomization'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp OR 'placebo'/exp OR 'prospective study'/exp OR rct:ab,ti OR random*:ab,ti OR 'single blind':ab,ti OR 'randomised controlled trial':ab,ti OR 'randomized controlled trial'/exp OR placebo*:ab,ti |
3911098 |
|
#8 |
'major clinical study'/de OR 'clinical study'/de OR 'case control study'/de OR 'family study'/de OR 'longitudinal study'/de OR 'retrospective study'/de OR 'prospective study'/de OR 'comparative study'/de OR 'cohort analysis'/de OR ((cohort NEAR/1 (study OR studies)):ab,ti) OR (('case control' NEAR/1 (study OR studies)):ab,ti) OR (('follow up' NEAR/1 (study OR studies)):ab,ti) OR (observational NEAR/1 (study OR studies)) OR ((epidemiologic NEAR/1 (study OR studies)):ab,ti) OR (('cross sectional' NEAR/1 (study OR studies)):ab,ti) |
7922528 |
|
#9 |
'case control study'/de OR 'comparative study'/exp OR 'control group'/de OR 'controlled study'/de OR 'controlled clinical trial'/de OR 'crossover procedure'/de OR 'double blind procedure'/de OR 'phase 2 clinical trial'/de OR 'phase 3 clinical trial'/de OR 'phase 4 clinical trial'/de OR 'pretest posttest design'/de OR 'pretest posttest control group design'/de OR 'quasi experimental study'/de OR 'single blind procedure'/de OR 'triple blind procedure'/de OR (((control OR controlled) NEAR/6 trial):ti,ab,kw) OR (((control OR controlled) NEAR/6 (study OR studies)):ti,ab,kw) OR (((control OR controlled) NEAR/1 active):ti,ab,kw) OR 'open label*':ti,ab,kw OR (((double OR two OR three OR multi OR trial) NEAR/1 (arm OR arms)):ti,ab,kw) OR ((allocat* NEAR/10 (arm OR arms)):ti,ab,kw) OR placebo*:ti,ab,kw OR 'sham-control*':ti,ab,kw OR (((single OR double OR triple OR assessor) NEAR/1 (blind* OR masked)):ti,ab,kw) OR nonrandom*:ti,ab,kw OR 'non-random*':ti,ab,kw OR 'quasi-experiment*':ti,ab,kw OR crossover:ti,ab,kw OR 'cross over':ti,ab,kw OR 'parallel group*':ti,ab,kw OR 'factorial trial':ti,ab,kw OR ((phase NEAR/5 (study OR trial)):ti,ab,kw) OR ((case* NEAR/6 (matched OR control*)):ti,ab,kw) OR ((match* NEAR/6 (pair OR pairs OR cohort* OR control* OR group* OR healthy OR age OR sex OR gender OR patient* OR subject* OR participant*)):ti,ab,kw) OR ((propensity NEAR/6 (scor* OR match*)):ti,ab,kw) OR versus:ti OR vs:ti OR compar*:ti OR ((compar* NEAR/1 study):ti,ab,kw) OR (('major clinical study'/de OR 'clinical study'/de OR 'cohort analysis'/de OR 'observational study'/de OR 'cross-sectional study'/de OR 'multicenter study'/de OR 'correlational study'/de OR 'follow up'/de OR cohort*:ti,ab,kw OR 'follow up':ti,ab,kw OR followup:ti,ab,kw OR longitudinal*:ti,ab,kw OR prospective*:ti,ab,kw OR retrospective*:ti,ab,kw OR observational*:ti,ab,kw OR 'cross sectional*':ti,ab,kw OR cross?ectional*:ti,ab,kw OR multicent*:ti,ab,kw OR 'multi-cent*':ti,ab,kw OR consecutive*:ti,ab,kw) AND (group:ti,ab,kw OR groups:ti,ab,kw OR subgroup*:ti,ab,kw OR versus:ti,ab,kw OR vs:ti,ab,kw OR compar*:ti,ab,kw OR 'odds ratio*':ab OR 'relative odds':ab OR 'risk ratio*':ab OR 'relative risk*':ab OR 'rate ratio':ab OR aor:ab OR arr:ab OR rrr:ab OR ((('or' OR 'rr') NEAR/6 ci):ab))) |
14563337 |
|
#10 |
#5 AND #6 |
26 |
|
#11 |
#5 AND #7 NOT #10 |
16 |
|
#12 |
#5 AND (#8 OR #9) NOT #10 NOT #11 |
130 |
|
#13 |
#10 OR #11 OR #12 |
172 |
|
#14 |
'in the evaluation of patients with skull base osteomyelitis, does':ti |
1 |
|
#15 |
#13 AND #14 |
1 |
10-11-2023
|
No. |
Query |
Results |
|
|
#2 |
'malignant otitis externa'/exp/mj OR (((maligna* OR necroti* OR necrosis) NEAR/3 ('otitis externa' OR 'external otitis')):ti,kw) OR ('otitis externa'/mj AND (maligna*:ti,kw OR necroti*:ti,kw OR necrosis:ti,kw)) OR (('osteomyelitis'/exp/mj OR 'osteomyelitis':ti,kw OR osteitis:ti,kw) AND ('skull'/exp/mj OR 'skull disease'/exp/mj OR skull*:ti,ab,kw OR cranial:ti,ab,kw OR cranium:ti,ab,kw)) |
3456 |
|
|
#3 |
'nuclear magnetic resonance imaging'/exp OR 'mri scanner'/exp OR ('magnetic resonance':ab,ti AND (image:ab,ti OR images:ab,ti OR imaging:ab,ti)) OR mri:ab,ti OR mris:ab,ti OR nmr:ab,ti OR mra:ab,ti OR mras:ab,ti OR zeugmatograph*:ab,ti OR 'mr tomography':ab,ti OR 'mr tomographies':ab,ti OR 'mr tomographic':ab,ti OR 'mr imag*':ti,ab,kw OR 'proton spin':ab,ti OR ((magneti*:ab,ti OR 'chemical shift':ab,ti) AND imaging:ab,ti) OR fmri:ab,ti OR fmris:ab,ti OR rsfmri:ti,ab,kw |
1577837 |
|
|
#4 |
#2 AND #3 |
605 |
|
|
#5 |
#4 NOT ('conference abstract'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it) NOT (('animal'/exp OR 'animal experiment'/exp OR 'animal model'/exp OR 'nonhuman'/exp) NOT 'human'/exp) |
484 |
|
|
#6 |
'meta analysis'/exp OR 'meta analysis (topic)'/exp OR metaanaly*:ti,ab OR 'meta analy*':ti,ab OR metanaly*:ti,ab OR 'systematic review'/de OR 'cochrane database of systematic reviews'/jt OR prisma:ti,ab OR prospero:ti,ab OR (((systemati* OR scoping OR umbrella OR 'structured literature') NEAR/3 (review* OR overview*)):ti,ab) OR ((systemic* NEAR/1 review*):ti,ab) OR (((systemati* OR literature OR database* OR 'data base*') NEAR/10 search*):ti,ab) OR (((structured OR comprehensive* OR systemic*) NEAR/3 search*):ti,ab) OR (((literature NEAR/3 review*):ti,ab) AND (search*:ti,ab OR database*:ti,ab OR 'data base*':ti,ab)) OR (('data extraction':ti,ab OR 'data source*':ti,ab) AND 'study selection':ti,ab) OR ('search strategy':ti,ab AND 'selection criteria':ti,ab) OR ('data source*':ti,ab AND 'data synthesis':ti,ab) OR medline:ab OR pubmed:ab OR embase:ab OR cochrane:ab OR (((critical OR rapid) NEAR/2 (review* OR overview* OR synthes*)):ti) OR ((((critical* OR rapid*) NEAR/3 (review* OR overview* OR synthes*)):ab) AND (search*:ab OR database*:ab OR 'data base*':ab)) OR metasynthes*:ti,ab OR 'meta synthes*':ti,ab |
976433 |
|
|
#7 |
'clinical trial'/exp OR 'randomization'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp OR 'placebo'/exp OR 'prospective study'/exp OR rct:ab,ti OR random*:ab,ti OR 'single blind':ab,ti OR 'randomised controlled trial':ab,ti OR 'randomized controlled trial'/exp OR placebo*:ab,ti |
3911098 |
|
|
#8 |
'major clinical study'/de OR 'clinical study'/de OR 'case control study'/de OR 'family study'/de OR 'longitudinal study'/de OR 'retrospective study'/de OR 'prospective study'/de OR 'comparative study'/de OR 'cohort analysis'/de OR ((cohort NEAR/1 (study OR studies)):ab,ti) OR (('case control' NEAR/1 (study OR studies)):ab,ti) OR (('follow up' NEAR/1 (study OR studies)):ab,ti) OR (observational NEAR/1 (study OR studies)) OR ((epidemiologic NEAR/1 (study OR studies)):ab,ti) OR (('cross sectional' NEAR/1 (study OR studies)):ab,ti) |
7922528 |
|
|
#9 |
'case control study'/de OR 'comparative study'/exp OR 'control group'/de OR 'controlled study'/de OR 'controlled clinical trial'/de OR 'crossover procedure'/de OR 'double blind procedure'/de OR 'phase 2 clinical trial'/de OR 'phase 3 clinical trial'/de OR 'phase 4 clinical trial'/de OR 'pretest posttest design'/de OR 'pretest posttest control group design'/de OR 'quasi experimental study'/de OR 'single blind procedure'/de OR 'triple blind procedure'/de OR (((control OR controlled) NEAR/6 trial):ti,ab,kw) OR (((control OR controlled) NEAR/6 (study OR studies)):ti,ab,kw) OR (((control OR controlled) NEAR/1 active):ti,ab,kw) OR 'open label*':ti,ab,kw OR (((double OR two OR three OR multi OR trial) NEAR/1 (arm OR arms)):ti,ab,kw) OR ((allocat* NEAR/10 (arm OR arms)):ti,ab,kw) OR placebo*:ti,ab,kw OR 'sham-control*':ti,ab,kw OR (((single OR double OR triple OR assessor) NEAR/1 (blind* OR masked)):ti,ab,kw) OR nonrandom*:ti,ab,kw OR 'non-random*':ti,ab,kw OR 'quasi-experiment*':ti,ab,kw OR crossover:ti,ab,kw OR 'cross over':ti,ab,kw OR 'parallel group*':ti,ab,kw OR 'factorial trial':ti,ab,kw OR ((phase NEAR/5 (study OR trial)):ti,ab,kw) OR ((case* NEAR/6 (matched OR control*)):ti,ab,kw) OR ((match* NEAR/6 (pair OR pairs OR cohort* OR control* OR group* OR healthy OR age OR sex OR gender OR patient* OR subject* OR participant*)):ti,ab,kw) OR ((propensity NEAR/6 (scor* OR match*)):ti,ab,kw) OR versus:ti OR vs:ti OR compar*:ti OR ((compar* NEAR/1 study):ti,ab,kw) OR (('major clinical study'/de OR 'clinical study'/de OR 'cohort analysis'/de OR 'observational study'/de OR 'cross-sectional study'/de OR 'multicenter study'/de OR 'correlational study'/de OR 'follow up'/de OR cohort*:ti,ab,kw OR 'follow up':ti,ab,kw OR followup:ti,ab,kw OR longitudinal*:ti,ab,kw OR prospective*:ti,ab,kw OR retrospective*:ti,ab,kw OR observational*:ti,ab,kw OR 'cross sectional*':ti,ab,kw OR cross?ectional*:ti,ab,kw OR multicent*:ti,ab,kw OR 'multi-cent*':ti,ab,kw OR consecutive*:ti,ab,kw) AND (group:ti,ab,kw OR groups:ti,ab,kw OR subgroup*:ti,ab,kw OR versus:ti,ab,kw OR vs:ti,ab,kw OR compar*:ti,ab,kw OR 'odds ratio*':ab OR 'relative odds':ab OR 'risk ratio*':ab OR 'relative risk*':ab OR 'rate ratio':ab OR aor:ab OR arr:ab OR rrr:ab OR ((('or' OR 'rr') NEAR/6 ci):ab))) |
14563337 |
|
|
#10 |
#5 AND #6 SR |
18 |
|
|
#11 |
#5 AND #7 NOT #10 Clinical trials |
6 |
|
|
#12 |
#5 AND (#8 OR #9) NOT #10 NOT #11 OBS |
82 |
|
|
#13 |
#10 OR #11 OR #12 |
106 |
|
|
#14 |
'in the evaluation of patients with skull base osteomyelitis, does'sleutelartikel |
1 |
|
|
#15 |
#13 AND #14 sleutelartikel gevonden |
1 |
|
|
#16 |
'annals of otolaryngology and rhinology' Tijdschrift niet in Embase |
0 |
|
Ovid/Medline 12-2-2025
|
# |
Searches |
Results |
|
1 |
((maligna* or necroti* or necrosis) adj3 (otitis externa or external otitis)).ti,ab,kf. or (exp Otitis Externa/ and (maligna* or necroti* or necrosis).ti,ab,kf.) or ((exp Osteomyelitis/ or osteomyelitis.ti,ab,kf. or osteitis.ti,ab,kf.) and (exp Skull/ or skull*.ti,ab,kf. or cranial.ti,ab,kf. or cranium.ti,ab,kf.)) |
4480 |
|
2 |
exp *magnetic resonance imaging/ or ("magnetic resonance" and (image or images or imaging)).ti,ab,kf. or mri.ti,ab,kf. or mris.ti,ab,kf. or nmr.ti,ab,kf. or mra.ti,ab,kf. or mras.ti,ab,kf. or zeugmatograph*.ti,ab,kf. or "mr tomography".ti,ab,kf. or "mr tomographies".ti,ab,kf. or "mr tomographic".ti,ab,kf. or "proton spin".ti,ab,kf. or ((magneti* or "chemical shift") and imaging).ti,ab,kf. or fmri.ti,ab,kf. or fmris.ti,ab,kf. or (imag* adj3 modalit*).ti,ab,kf. |
914939 |
|
3 |
Positron Emission Tomography Computed Tomography/ or (positron* emission adj2 (computed tomography or computer assisted or tomography computed or computed tomography)).ti,ab,kf. or (pet adj1 ct).ti,ab,kf. |
54746 |
|
4 |
1 and (2 or 3) |
373 |
|
5 |
4 not ((exp animals/ or exp models, animal/) not humans/) not (letter/ or comment/ or editorial/) |
365 |
|
6 |
meta-analysis/ or meta-analysis as topic/ or (metaanaly* or meta-analy* or metanaly*).ti,ab,kf. or systematic review/ or cochrane.jw. or (prisma or prospero).ti,ab,kf. or ((systemati* or scoping or umbrella or "structured literature") adj3 (review* or overview*)).ti,ab,kf. or (systemic* adj1 review*).ti,ab,kf. or ((systemati* or literature or database* or data-base*) adj10 search*).ti,ab,kf. or ((structured or comprehensive* or systemic*) adj3 search*).ti,ab,kf. or ((literature adj3 review*) and (search* or database* or data-base*)).ti,ab,kf. or (("data extraction" or "data source*") and "study selection").ti,ab,kf. or ("search strategy" and "selection criteria").ti,ab,kf. or ("data source*" and "data synthesis").ti,ab,kf. or (medline or pubmed or embase or cochrane).ab. or ((critical or rapid) adj2 (review* or overview* or synthes*)).ti. or (((critical* or rapid*) adj3 (review* or overview* or synthes*)) and (search* or database* or data-base*)).ab. or (metasynthes* or meta-synthes*).ti,ab,kf. |
808514 |
|
7 |
exp clinical trial/ or randomized controlled trial/ or exp clinical trials as topic/ or randomized controlled trials as topic/ or Random Allocation/ or Double-Blind Method/ or Single-Blind Method/ or (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or randomized controlled trial or multicenter study or clinical trial).pt. or random*.ti,ab. or (clinic* adj trial*).tw. or ((singl* or doubl* or treb* or tripl*) adj (blind$3 or mask$3)).tw. or Placebos/ or placebo*.tw. |
2845064 |
|
8 |
Epidemiologic studies/ or case control studies/ or exp cohort studies/ or Controlled Before-After Studies/ or Case control.tw. or cohort.tw. or Cohort analy$.tw. or (Follow up adj (study or studies)).tw. or (observational adj (study or studies)).tw. or Longitudinal.tw. or Retrospective*.tw. or prospective*.tw. or consecutive*.tw. or Cross sectional.tw. or Cross-sectional studies/ or historically controlled study/ or interrupted time series analysis/ [Onder exp cohort studies vallen ook longitudinale, prospectieve en retrospectieve studies] |
4959968 |
|
9 |
Case-control Studies/ or clinical trial, phase ii/ or clinical trial, phase iii/ or clinical trial, phase iv/ or comparative study/ or control groups/ or controlled before-after studies/ or controlled clinical trial/ or double-blind method/ or historically controlled study/ or matched-pair analysis/ or single-blind method/ or (((control or controlled) adj6 (study or studies or trial)) or (compar* adj (study or studies)) or ((control or controlled) adj1 active) or "open label*" or ((double or two or three or multi or trial) adj (arm or arms)) or (allocat* adj10 (arm or arms)) or placebo* or "sham-control*" or ((single or double or triple or assessor) adj1 (blind* or masked)) or nonrandom* or "non-random*" or "quasi-experiment*" or "parallel group*" or "factorial trial" or "pretest posttest" or (phase adj5 (study or trial)) or (case* adj6 (matched or control*)) or (match* adj6 (pair or pairs or cohort* or control* or group* or healthy or age or sex or gender or patient* or subject* or participant*)) or (propensity adj6 (scor* or match*))).ti,ab,kf. or (confounding adj6 adjust*).ti,ab. or (versus or vs or compar*).ti. or ((exp cohort studies/ or epidemiologic studies/ or multicenter study/ or observational study/ or seroepidemiologic studies/ or (cohort* or 'follow up' or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multi-cent*' or consecutive*).ti,ab,kf.) and ((group or groups or subgroup* or versus or vs or compar*).ti,ab,kf. or ('odds ratio*' or 'relative odds' or 'risk ratio*' or 'relative risk*' or aor or arr or rrr).ab. or (("OR" or "RR") adj6 CI).ab.)) |
5907260 |
|
10 |
4 and 6 |
15 |
|
11 |
(4 and 7) not 10 |
3 |
|
12 |
(4 and (8 or 9)) not 10 not 11 |
121 |
|
13 |
10 or 11 or 12 |
139 |
10-11-2023
|
# |
Searches |
Results |
|
1 |
((maligna* or necroti* or necrosis) adj3 ('otitis externa' or 'external otitis')).ti,kf. or (exp *Otitis Externa/ and (maligna* or necroti* or necrosis).ti,kf.) or ((exp *Osteomyelitis/ or 'osteomyelitis'.ti,kf. or osteitis.ti,kf.) and (exp Skull/ or skull*.ti,ab,kf. or cranial.ti,ab,kf. or cranium.ti,ab,kf.)) |
3139 |
|
2 |
exp *magnetic resonance imaging/ or ("magnetic resonance" and (image or images or imaging)).ti,ab,kf. or mri.ti,ab,kf. or mris.ti,ab,kf. or nmr.ti,ab,kf. or mra.ti,ab,kf. or mras.ti,ab,kf. or zeugmatograph*.ti,ab,kf. or "mr tomography".ti,ab,kf. or "mr tomographies".ti,ab,kf. or "mr tomographic".ti,ab,kf. or "proton spin".ti,ab,kf. or ((magneti* or "chemical shift") and imaging).ti,ab,kf. or fmri.ti,ab,kf. or fmris.ti,ab,kf. or (imag* adj3 modalit*).ti,ab,kf. |
849591 |
|
3 |
1 and 2 |
251 |
|
4 |
3 not ((exp animals/ or exp models, animal/) not humans/) not (letter/ or comment/ or editorial/) |
247 |
|
5 |
meta-analysis/ or meta-analysis as topic/ or (metaanaly* or meta-analy* or metanaly*).ti,ab,kf. or systematic review/ or cochrane.jw. or (prisma or prospero).ti,ab,kf. or ((systemati* or scoping or umbrella or "structured literature") adj3 (review* or overview*)).ti,ab,kf. or (systemic* adj1 review*).ti,ab,kf. or ((systemati* or literature or database* or data-base*) adj10 search*).ti,ab,kf. or ((structured or comprehensive* or systemic*) adj3 search*).ti,ab,kf. or ((literature adj3 review*) and (search* or database* or data-base*)).ti,ab,kf. or (("data extraction" or "data source*") and "study selection").ti,ab,kf. or ("search strategy" and "selection criteria").ti,ab,kf. or ("data source*" and "data synthesis").ti,ab,kf. or (medline or pubmed or embase or cochrane).ab. or ((critical or rapid) adj2 (review* or overview* or synthes*)).ti. or (((critical* or rapid*) adj3 (review* or overview* or synthes*)) and (search* or database* or data-base*)).ab. or (metasynthes* or meta-synthes*).ti,ab,kf. |
705919 |
|
6 |
exp clinical trial/ or randomized controlled trial/ or exp clinical trials as topic/ or randomized controlled trials as topic/ or Random Allocation/ or Double-Blind Method/ or Single-Blind Method/ or (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or randomized controlled trial or multicenter study or clinical trial).pt. or random*.ti,ab. or (clinic* adj trial*).tw. or ((singl* or doubl* or treb* or tripl*) adj (blind$3 or mask$3)).tw. or Placebos/ or placebo*.tw. |
2654379 |
|
7 |
Epidemiologic studies/ or case control studies/ or exp cohort studies/ or Controlled Before-After Studies/ or Case control.tw. or cohort.tw. or Cohort analy$.tw. or (Follow up adj (study or studies)).tw. or (observational adj (study or studies)).tw. or Longitudinal.tw. or Retrospective*.tw. or prospective*.tw. or consecutive*.tw. or Cross sectional.tw. or Cross-sectional studies/ or historically controlled study/ or interrupted time series analysis/ [Onder exp cohort studies vallen ook longitudinale, prospectieve en retrospectieve studies] |
4576875 |
|
8 |
Case-control Studies/ or clinical trial, phase ii/ or clinical trial, phase iii/ or clinical trial, phase iv/ or comparative study/ or control groups/ or controlled before-after studies/ or controlled clinical trial/ or double-blind method/ or historically controlled study/ or matched-pair analysis/ or single-blind method/ or (((control or controlled) adj6 (study or studies or trial)) or (compar* adj (study or studies)) or ((control or controlled) adj1 active) or "open label*" or ((double or two or three or multi or trial) adj (arm or arms)) or (allocat* adj10 (arm or arms)) or placebo* or "sham-control*" or ((single or double or triple or assessor) adj1 (blind* or masked)) or nonrandom* or "non-random*" or "quasi-experiment*" or "parallel group*" or "factorial trial" or "pretest posttest" or (phase adj5 (study or trial)) or (case* adj6 (matched or control*)) or (match* adj6 (pair or pairs or cohort* or control* or group* or healthy or age or sex or gender or patient* or subject* or participant*)) or (propensity adj6 (scor* or match*))).ti,ab,kf. or (confounding adj6 adjust*).ti,ab. or (versus or vs or compar*).ti. or ((exp cohort studies/ or epidemiologic studies/ or multicenter study/ or observational study/ or seroepidemiologic studies/ or (cohort* or 'follow up' or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multi-cent*' or consecutive*).ti,ab,kf.) and ((group or groups or subgroup* or versus or vs or compar*).ti,ab,kf. or ('odds ratio*' or 'relative odds' or 'risk ratio*' or 'relative risk*' or aor or arr or rrr).ab. or (("OR" or "RR") adj6 CI).ab.)) |
5552579 |
|
9 |
3 and 5SR |
12 |
|
10 |
(3 and 6) not 9 Clinical trials |
2 |
|
11 |
(3 and (7 or 8)) not 9 not 10 OBS |
83 |
|
12 |
9 or 10 or 11 |
97 |
|
13 |
"The role of F18-FDG PET-MRI in necrotizing external otitis follow-up" [Article Title] |
0 |
|
14 |
"Annals of Otolaryngology and Rhinology$" [Journal Name] |
0 |