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Diagnostic Test Accuracy and Semi-Quantitative Metrics of 18F-FDG PET in Assessing Treatment Response in Skull Base Osteomyelitis and Necrotising Otitis Externa: A Systematic Review and Meta-Analysis
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DOI：10.3390/tomography12030032.png)
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Abstract
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Background/Objectives: Skull base osteomyelitis and necrotising otitis externa require prolonged antibiotic therapy, yet determining optimal treatment cessation timing remains challenging. Conventional imaging modalities demonstrate persistent abnormalities beyond infection resolution, confounding treatment decisions. This systematic review evaluated the diagnostic test accuracy of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) for treatment response monitoring in skull base osteomyelitis and necrotising otitis externa. Methods: We conducted a systematic review following PRISMA-DTA guidelines, searching MEDLINE, Embase, CENTRAL, CINAHL, Scopus, and Web of Science from inception to November 2025. Studies evaluating 18F-FDG PET diagnostic accuracy for treatment response assessment in confirmed skull base osteomyelitis or necrotising otitis externa were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias using QUADAS-2. Bivariate random-effects meta-analysis was performed using MetaBayesDTA to obtain pooled sensitivity and specificity. Results: Eight studies comprising 154 lesions contributed to the primary analysis. Pooled sensitivity was 95.2% (95% credible interval 85.6-99.0%) and pooled specificity was 89.1% (95% credible interval 70.7-96.7%). The positive likelihood ratio was 8.7 (95% credible interval 3.2-28.4) and negative likelihood ratio was 0.05 (95% credible interval 0.01-0.17), with a diagnostic odds ratio of 172.0. Seven studies evaluating detection rate at initial presentation yielded a pooled rate of 96.1% (95% confidence interval 91.3-98.3%). SUVmax was the most frequently used metabolic parameter. Conclusions: 18F-FDG PET, specifically using SUVmax, demonstrates high sensitivity and good specificity for treatment response monitoring, with excellent capacity to rule out persistent infection. However, evidence quality is limited by retrospective designs and substantial heterogeneity. Prospective studies with standardised thresholds are needed to validate clinical utility.
Keywords:
fluorodeoxyglucose F18
positron emission tomography
skull base osteomyelitis
necrotising otitis externa
malignant otitis externa
treatment monitoring
diagnostic test accuracy
systematic review
meta-analysis
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