Otomycosis: Diagnosis and treatment

Fungal Otitis Externa (Otomycosis) Associated with Aspergillus Flavus: A Case Image

A 48-year-old man presented with a chief complaint of intermittent right ear otorrhea of several-month duration, occasional otalgia and progressive unilateral hearing impairment. He also reported frequent episodes of headache and pressure in the sinuses and maxilla. Previous systemic treatment with antibiotics failed to alleviate the symptoms. A head/neck CT showed completely normal mastoid, middle ear and external auditory canal regions without any evidence of opacification or bone erosion. Otoscopic examination of the right ear disclosed aggregates of dried, brown, fibrillar material and debris occluding the external auditory canal and obstructing the otherwise intact tympanic membrane. Dilation of the external auditory canal or thickening of the tympanic membrane were not appreciated. The canal was debrided and the fibrillar material was placed in formalin. Histopathologic examination revealed numerous branching, septated fungal hyphae organized in densely-packed clusters. In other areas, the fungal hyphae abutted or were attached to lamellated collections of orthokeratin. As highlighted by GMS staining, the fungi were morphologically compatible with Aspergillus species. The clinicopathologic findings supported a diagnosis of fungal otitis externa, while the numerous anucleate squamous cells were compatible with colonization of an underlying, probably developing, cholesteatoma. Culture of material isolated from the external auditory canal confirmed the presence of Aspergillus flavus. In this illustrative case, we present the main clinical and microscopic characteristics of Aspergillus-related otomycosis developing in the setting of a tautochronous cholesteatoma.

Screening Candida auris through a multiplex stepwise PCR algorithm directly from clinical samples of patients suspected of otomycosis in south of Iran; Detection of five cases

BACKGROUND

Otomycosis is an infection of the external auditory canal caused by molds and yeasts with descending frequency. Laboratory diagnosis is usually confirmed by microscopy and culture. However, they are not specific enough to reliably differentiate the causative agents, especially for rare pathogens such as Candida auris. The purpose of the current study was to the molecular screening of C. auris species from direct clinical samples of patients with suspected otomycosis in Southern of Iran.

MATERIALS AND METHODS

A total of 221 ear aspirates collected from 221 patients with suspected otomycosis over a four-year period. All the ear aspirations were examined with pan-fungal primers, then those with a positive result was included in two separate reaction mixtures simultaneously to identify the most clinically relevant Aspergillus and Candida species. The validity of positive samples for C. auris was assessed by sequencing.

RESULTS

Of the 189 pan-fungal positive PCRs, 78 and 39 specimens contained Aspergillus spp. and Candida spp., respectively. Furthermore, 65 specimens showed simultaneous positive bands in both Candida and Aspergillus species-specific multiplex PCR including five samples/patients with positive result for C. auris (5/189; 2.6%). Four out of five cases with C. auris species-specific PCR were reconfirmed by sequencing, while none were positive for C. auris in culture.

CONCLUSION

Unfortunately, due to high treatment failure rates of antifungal classes against C. auris species, rapid and accurate identification of patients colonised with C. auris is critical to overcome the challenge of preventing transmission. This PCR assay can be successfully applied for rapid and accurate detection of C. auris directly in patient samples and is able to differentiate C. auris from closely related Candida species.

Identification of Microbial Community in Otomycosis by Metagenomic Next Generation Sequencing (mNGS): Potential Implication of Treatment with Terbinafine

The present study was designed to identify the microbial community as well as to analyze its diversity by means of metagenomic Next Generation Sequencing (mNGS) in 17 patients with otomycosis treated with terbinafine in the Department of Otolaryngology of Shandong Provincial Hospital from June 2021 to June 2022, so as to evaluate the relationship between microbial community and terbinafine resistance. Those 17 patients were divided into two groups, i.e., Terbinafine Effective Group (TEG, n = 14 cases) and Terbinafine Resistance Group (TRG, n = 3 cases) according to the therapy effect, whose microbial community of secretion of external auditory canal was identified using mNGS. We found that the sequence of bacteria was significantly more than that of fungi and, whereas, the difference between the two groups of bacteria was not significant. There were significant differences in fungal community between the two groups. Aspergillus was the main pathogenic fungus of TEG patients while Malassezia was a dominant fungus in TRG patients. In conclusion, the results from this work indicate that Aspergillus terreusis is the main pathogenic fungus in this cohort of otomycosis patients and MNGS sequencing can offer comprehensive information about the microbial community of otomycosis. The fungus community dominated by Malassezia is more likely to be resistant to terbinafine, which provides certain guidance for clinical treatment of otomycosis with terbinafine.

Case Report: The application of metagenomic next generation sequencing in diagnosing fungal malignant external otitis: a report of two cases

Background

Most of malignant external otitis (MEO) cases reported in the literature are attributed to Pseudomonas aeruginosa. Fungal infections in MEO are also likely but extremely rare. And conventional microbiology tests is difficult to diagnose.

Case description

Two patients were diagnosed with Fungal malignant external otitis (FMEO) due to Aspergillus by metagenomic Next-Generation Sequencing (mNGS) and recovered after comprehensive treatment including operation and voriconazole. The antifungal treatment was delayed due to repeated cultures of secretions being negative and pathological examination showed granulation tissue proliferation with extensive neutrophil infiltration.

Conclusion

mNGS might be helpful for patients suspected with FMEO, especially when conventional microbiology tests were negative.

Etiology, Predisposing Factors, Clinical Features and Diagnostic Procedure of Otomycosis: A Literature Review

Otomycosis (OM) is a superficial fungal infection of the external auditory canal (EAC) with a worldwide prevalence ranging from 9% to 30%. Commonly, otomycoses are caused by Aspergillus (A.) niger complex and Candida spp. Other causative agents are yeasts of the genera Cryptococcus spp., Rhodotorula spp., Geotrichum candidum, dermatophytes (Trichophyton mentagrophytes), and non-dermatophytes molds (Fusarium spp., Penicillium spp., Mucorales fungi). The widest range of different species causing OM are found in the territories of Iran, India, China, Egypt, Mexico, and Brazil. Fungal infection of the EAC varies from mild to severe forms. It can be acute, subacute, or chronic, and is often unilateral, while the bilateral form is more common in immunocompromised patients. From an epidemiological point of view, tropical and subtropical climates are the most significant risk factor for the development of otomycosis. Other predisposing conditions include clothing habits, EAC hygiene practices, long-term antibiotic therapy, diabetes, and immunodeficiency. Since it is often difficult to distinguish otomycosis from an infection of a different origin, laboratory-based evidence, including standard procedures (microscopy and cultivation), is essential for diagnosis. For the treatment of this superficial fungal infection, there are no official therapeutic guidelines and protocols. However, many antifungals for local application, such as polyene, imidazoles, and allylamines, can be applied, as well as systemic antimycotics (triazoles) in severe forms of infection.

Otoendoscopy in the era of narrow-band imaging: a pictorial review

PURPOSE

Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation.

METHODS

Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard.

RESULTS

NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice.

CONCLUSIONS

NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.

Fungal otitis externa and tympanic membrane perforation

Introduction

Otomycosis is a fungus-causing superficial infection of the external auditory canal that is common in otolaryngology practice. Though it is a worldwide infection, but is more prevalent in warm and humid regions. There has been rise in the occurrence of otomycosis in the last few years because of the extensive usage of antibiotic eardrops. Other influencing reasons for the occurrence of otomycosis is swimming, an immunocompromised host (e.g.: DM, AIDs) pregnancy, post-canal wall down mastoidectomy, tympanic membrane perforation, hearing aids and self-inflicted injuries.

Methods

Approval from the institutional ethics committee and penned informed agreement from all patients involved in the examination were obtained. 40 patients were included in the study, starting from 1stAugust to 30th September 2021, which emphasized on otomycosis infection with central tympanic membrane perforation. Physical findings such as whitish ear discharge and the presence of hyphae in the EAC, the ear drum, the middle ear mucosa were used to diagnose otomycosis.

Result

20 patients of patched group and 20 patients of non-patched group did not visit for follow up. Data here is for patients who followed-up for 3 weeks. Any significant observation regarding statistical variation in the age, size of perforation, mycological analysis and pure tone audiometry among the two groups were not seen.

Conclusion

To conclude, we state that treatment with clotrimazole solution in patched group is safe in managing otomycosis with tympanic membrane perforation. Otomycosis is a fungus causing surface infection of the external auditory canal that otolaryngologists routinely diagnose by medical examination. In acute otomycosis, overgrowth of the fungus in the external auditory canal is due to increased humidity.

Single Topical Application of 1% Clotrimazole Cream in Otomycosis

Aim: To assess the clinical improvement after single dose topical application of 1% clotrimazole cream in otomycosis and follow up for recurrence at the end of first and the third month. Materials and Methods: A prospective observational study was carried out at Government Medical college hospital. Patients with KOH diagnosed fungal infection of external auditory canal were included in the study. After obtaining informed written consent from the participating patients, a detail clinical history was taken. Single topical application of 1% clotrimazole cream in otomycosis. The fungal debris was removed with the help of suction aspiration and dry mopping. A single topical application of 1% clotrimazole cream was applied under all aseptic precautions. On the 3rd day the applied cream was cleaned with help of suction under ear microscope. Patients were advised to follow up after one month and three months. During each follow up patients were assessed clinically and examined for residual fungal debris. Result: Otomycosis was seen predominantly in middle aged females, housewives and laborers by occupation. Earache was most common symptom seen in 65.2%. Unilateral involvement was seen in 89.3% cases. The most common organism isolated in otomycosis was Aspergillus niger. At the end of one month of treatment with a single dose of 1% clotrimazole cream, 102 (91.0%) patients were recovered and 10 (9.0%) patients were with persistence or recurrence of the symptoms. At the end of third month, the recovery rate was 84.8% and recurrence rate was 6.3%. Conclusion: Single topical application of 1% clotrimazole cream is effective in treating otomycosis.

Definite therapy of mixed infection alleviates refractory dilemma of adult chronic suppurative otitis media

The characteristics, risk factors, microbial distributions and effective treatment regimens for Chronic suppurative otitis media (CSOM) patients intractable to empirical therapy were analyzed. Adult CSOM patients of China Medical University Hospital from 2018 to 2020 were included. Subjects of refractory and non-refractory groups were investigated for characteristics of age, sex, nation, comorbidities, otomycosis, and associated complications. Risk factors, microbiology distributions, and treatment regimens were analyzed. Twenty-six refractory patients (55.0 ± 17.7 years) and 66 non-refractory patients (54.1 ± 13.7 years) were studied. A significantly higher rate of otomycosis and CSOM complications was observed in refractory group than in non-refractory one (73.1% vs. 36.4%; p = 0.002; 57.7% vs. 10.6%, p < 0.001, respectively). Multivariate analysis revealed atopic diathesis (p = 0.048), otomycosis (p = 0.003) and CSOM complications (p < 0.001) were risk factors of refractory CSOM. Coagulase-negative staphylococci (CoNS) and methicillin-resistant Staphylococcus aureus (MRSA) were the prevailing pathogens. Patients of refractory group tented to have higher rates of mixed infection (42.9%% vs. 23.7%) and significantly more included fungal pathogen (19.0% vs. 2.6%; p = 0.049) than those of non-refractory cohort. Topical treatment of fungus significantly improved outcome of refractory CSOM. Atopic diathesis, otomycosis, and CSOM-associated complications were risk factors of refractory CSOM. Systemic and local treatment to possible drug-resistant pathogens, likely CoNS and fungus, possible improves recalcitrant CSOM. Correspondingly, early identification of CSOM complications, routine culture and susceptibility testing and treatment of resistant bacteria and fungus are key elements to the successful management of adult CSOM.

Isolation, Characterization, and Antifungal Sensitivity Pattern of Fungal Species with Potential Resistance to Antifungal Drugs in Patients with Otomycosis

Background: Otomycosis is defined as a superficial fungal infection, accounting for about 10% of infectious otitis externa cases. Objectives: This study investigated patients with suspicious symptoms through the examination of their demographic information, isolate etiological agents, and in vitro antifungal susceptibility patterns. Methods: The samples of 170 patients with otitis externa symptoms were collected and confirmed for otomycosis by mycological examination (e.g., potassium hydroxide, methylene blue staining, and fungal culture) and molecular sequencing. In vitro antifungal susceptibility tests against miconazole, fluconazole, itraconazole, voriconazole, posaconazole, amphotericin B, and caspofungin were performed according to the Clinical and Laboratory Standards Institute (M27-A3/S4 and M38-A2). Results: Out of 170 patients, 145 subjects (85.29%) showed positive mycological findings. In this study, 55.8% of the patients were male, and the most common age group affected was 50 - 59 years (26.2%). Hearing loss and pruritus were the most common clinical manifestations. The most common occupation was being a housewife (47.5%), and most cases occurred during the winter (40%). Aspergillus niger was the most common species, followed by Aspergillus fumigatus, Candida albicans, and Candida glabrata. Caspofungin showed the highest activity against Aspergillus and Candida isolates; nevertheless, itraconazole demonstrated the lowest activity against Aspergillus isolates. Fluconazole showed the weakest power against Candida species. Conclusions: Due to climatic conditions, humidity, and dust, otomycosis has a high occurrence in Iran. Although otomycosis needs long-term antifungal therapy and recurrence is high in some cases, it is rarely life-threatening, and eardrop antifungals are usually enough to eradicate the infection. Local information about the antifungal pattern is useful for the control, prevention, and treatment of otomycosis.

Prevalence and Antifungal Susceptibility of Clinically Relevant Candida Species, Identification of Candida auris and Kodamaea ohmeri in Bangladesh

Candida species are major fungal pathogens in humans. The aim of this study was to determine the prevalence of individual Candida species and their susceptibility to antifungal drugs among clinical isolates in a tertiary care hospital in Bangladesh. During a 10-month period in 2021, high vaginal swabs (HVSs), blood, and aural swabs were collected from 360 patients. From these specimens, Candida spp. was isolated from cultures on Sabouraud dextrose agar media, and phenotypic and genetic analyses were performed. A total of 109 isolates were recovered, and C. albicans accounted for 37%, being derived mostly from HVSs. Among non-albicans Candida (NAC), C. parapsilosis was the most frequent, followed by C. ciferrii, C. tropicalis, and C. glabrata. Three isolates from blood and two isolates from aural discharge were genetically identified as C. auris and Kodamaea ohmeri, respectively. NAC isolates were more resistant to fluconazole (overall rate, 29%) than C. albicans (10%). Candida isolates from blood showed 95% susceptibility to voriconazole and less susceptibility to fluconazole (67%). Two or three amino acid substitutions were detected in the ERG11 of two fluconazole-resistant C. albicans isolates. The present study is the first to reveal the prevalence of Candida species and their antifungal susceptibility in Bangladesh.

Identification of the Fungal Community in Otomycosis by Internal Transcribed Spacer Sequencing

We used internal transcribed spacer (ITS) sequencing to identify the fungal community in otomycosis patients and to evaluate the treatment effects of bifonazole. Ten patients who visited the Department of Otolaryngology of Jiangsu Provincial Hospital on Integration of Chinese and Western Medicine from May 2020 to April 2021 were recruited. Otomycosis patients were treated with bifonazole solution once a day for 14 days. Samples collected from the external auditory canal before and after treatment (Pre-treatment, n = 14 ears; Post-treatment, n = 14 ears) were used for microscopic examination, fungal culture, and ITS sequencing. Samples collected from 10 volunteers (Control, n = 20 ears) were used as controls. The symptoms, including ear itching, aural fullness, otalgia, hearing loss, and physical signs were recorded before treatment as well as on the 7th and 14th days after treatment. Aspergillus was identified as a main pathogenic fungus by microscopic examination, fungal culture, and ITS sequencing. At the genus level, Aspergillus was more abundant in the pre-treatment group than the control and post-treatment groups, and Malassezia was more abundant in the control and post-treatment groups than the pre-treatment group. The fungal species richness and diversity reduced significantly in the pre-treatment group compared with the control and post-treatment groups. The effective rate of bifonazole was 64.29% and 100% on the 7th and 14th days after treatment, respectively. In conclusion, the results obtained from morphologic studies and ITS sequencing indicate that Aspergillus is the main pathogenic fungus of otomycosis patients in Nanjing, Jiangsu Province, China. Malassezia is the dominant resident fungi in healthy individuals. ITS sequencing provides comprehensive information about fungal community in otomycosis and is helpful in evaluating the efficacy of antifungal agents.

Clinical Presentations, Cluster Analysis and Laboratory-Based Investigation of Aspergillus Otomycosis—A Single Center Experience

Species of Aspergillus (A.) niger complex and A. flavus complex are predominant molds that are causative agents of otomycoses. The goal of this study was to investigate the clinical presentation, diagnostic procedure, and appearance of relapse in patients with Aspergillus-otomycosis, as well as to determine the biofilm production ability of species isolated in relapse. Thirty patients with laboratory evidenced Aspergillus-otomycosis followed by two check-ups (30 and 60 days after initiation of treatment with antimycotics for local application) were included in the study. For isolation and identification of Aspergillus spp. the standard mycological procedure was applied. Results showed very high sensitivity of microscopy, but 16.7% Aspergillus species required the optimal temperature of 27–28 °C for cultivation. Applied statistical cluster analysis showed a defined specific cluster/group of patients with A. niger complex-otomycosis. Sixty days after diagnosis and treatment initiation, six patients had a relapse, with the same species of Aspergillus genus being the cause. To establish the ability of biofilm production, the modified method described by Pierce and Kvasničková was performed, and all six species isolated in the relapse episode had the ability to produce biofilm. Official criteria and recommendations are needed due to the possibility of misdiagnosis, which leads to the prolongation and complication of the disease.

Efficacy of topical isoconazole nitrate in the treatment of otomycosis

PURPOSE

Various agents with various antifungal properties are widely used for otomycosis eradication. However, there is still no consensus on the most effective agent. Therefore, the present study aims to investigate the efficacy of topical 1% isoconazole nitrate cream in the treatment of otomycosis.

METHODS

This prospective study included 43 patients who were applied to our outpatient clinic with complaints of ear pain, itching, aural fullness, and hypoacusis, and were diagnosed with unilateral otomycosis. After aspiration and cleaning, the external ear canal was filled with 1% isoconazole nitrate cream using an iv cannula and insulin syringe. Control examinations were performed on the 5th, 10th, 15th, and 20th days. In the follow-up examinations, patients were asked about how many days after the cream administration the pain and itching completely relief and the answers were recorded.

RESULTS

In the first control examination of 23 (92%) of 25 patients with pain, it was observed that the pain and otoendoscopic examination findings completely recovered. In the second control, it was found that both pain and otoendoscopic examination findings completely recovered in the remaining 2 patients (25 patients, 100%). 35 patients complained of itching and it was observed that itching and otoendoscopic examination findings completely recovered in 26 patients (75%) in the first control, 5 more patients (31 patients, 88.6%) in the second control, and 2 more patients (33 patients, 94.3%) in the third control examination.

CONCLUSION

Isoconazole nitrate cream appears to be an effective and easily applicable agent for the treatment of otomycosis.

Comparing the Therapy of Otomycosis Using Clotrimazole with Iodine Tincture: A Clinical Trial

INTRODUCTION

Otomycosis, as a common superficial fungal infection, is the term to infection of external auditory canal. Despite numerous studies on diverse antifungal agents, there is no common consent on effective agent for treatment of otomycosis. Therefore, the purpose of this study is compared therapy of otomycosis using two therapeutic agents; clotrimazole and iodine tincture.

MATERIALS AND METHODS

This research is a clinical trial study included 160 patients who were presented otomycosis. All patients were randomly assigned into two therapeutic groups of clotrimazole and Iodine Tincture (80 cases in each group). The results of response to thrapy were evaluated on 4, 10, and 20 days. Statistical analyses were performed using Independent-Samples t-test, Chi-Square, and Fishers҆ Exact tests in SPSS software v.18, in 0.05 significant level.

RESULTS

Fungal species were isolated including Aspergillus (72.5%) and Candida albicans (22.5%). After 4thday of treatment, 7.5% of the tincture group and 11.2% of the clotrimazole group revealed a good response to treatment (P=0.30). A good response to treatment was observed in35.0 and 41.2% of the patients on 10th day of treatment (P=0.44); and in 67.5 and 62.5% of the patients on 20th day of treatment (P= 0.20). There was no significant relationship between the two therapeutic arms.

CONCLUSION

In this study, both clotrimazole and tincture showed the identical therapeutic efficacy on otomycosis. Our findings suggested that tincture can be used as a supplementary antifungal option for treatment of otomycosis.

Topical azole treatments for otomycosis

BACKGROUND

Otomycosis is a fungal infection of the outer ear, which may be treated with topical antifungal medications. There are many types, with compounds belonging to the azole group ('azoles') being among the most widely used.

OBJECTIVES

To evaluate the benefits and harms of topical azole treatments for otomycosis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 11 November 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults and children with otomycosis comparing any topical azole antifungal with: placebo, no treatment, another type of topical azole or the same type of azole but applied in different forms. A minimum follow-up of two weeks was required.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: 1) clinical resolution as measured by the proportion of participants with complete resolution at between two and four weeks after treatment (however defined by the authors of the studies) and 2) significant adverse events. Secondary outcomes were 3) mycological resolution and 4) other less serious adverse effects. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included four studies with 559 participants from Spain, Mexico and India. Three studies included children and adults; one included only adults. The duration of symptoms was not always explicitly stated. Mycological resolution results were only reported in one study. The studies assessed two comparisons: one type of topical azole versus another and the same azole but administered in different forms (cream versus solution). A. Topical azoles versus placebo None of the studies assessed this comparison. B. Topical azoles versus no treatment None of the studies assessed this comparison. C. One type of topical azole versus another type of topical azole i) Clotrimazole versus other types of azoles (eberconazole, fluconazole, miconazole) Three studies examined clotrimazole versus other types of azoles. The evidence is very uncertain about the difference between clotrimazole and other types of azole in achieving complete clinical resolution at four weeks (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.07; 3 studies; 439 participants; very low-certainty evidence). The anticipated absolute effects are 668 per 1000 for clotrimazole versus 835 per 1000 for other azoles. One study planned a safety analysis and reported no significant adverse events in either group. The evidence is therefore very uncertain about any differences between clotrimazole and other types of azole (no events in either group; 1 study; 174 participants; very low-certainty evidence). Clotrimazole may result in little or no difference in mycological resolution at two weeks follow-up (RR 1.01, 95% CI 0.96 to 1.06; 1 study; 174 participants; low-certainty evidence) or in other (less serious) adverse events at two weeks follow-up (36 per 1000, compared to 45 per 1000, RR 0.79, 95% CI 0.18 to 3.41; 1 study; 174 participants; very low-certainty evidence). ii) Bifonazole cream versus bifonazole solution One study compared bifonazole 1% cream with solution. Bifonazole cream may have little or no effect on clinical resolution at two weeks follow-up when compared to solution, but the evidence is very uncertain (RR 1.07, 95% CI 0.73 to 1.57; 1 study; 40 ears; very low-certainty evidence). Bifonazole cream may achieve less mycological resolution compared to solution at two weeks after the end of therapy, but the evidence for this is also very uncertain (RR 0.53, 95% CI 0.29 to 0.96; 1 study; 40 ears; very low-certainty evidence). Five out of 35 patients sustained severe itching and burning from the bifonazole solution but none with the bifonazole cream (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We found no studies that evaluated topical azoles compared to placebo or no treatment. The evidence is very uncertain about the effect of clotrimazole on clinical resolution of otomycosis, on significant adverse events or other (non-serious) adverse events when compared with other topical azoles (eberconazole, fluconazole, miconazole). There may be little or no difference between clotrimazole and other azoles in terms of mycological resolution. It may be difficult to generalise these results because the range of ethnic backgrounds of the participants in the studies is limited.

Molecular Identification and Antifungal Susceptibility of Yeasts and Molds Isolated from Patients with Otomycosis

Fungal otitis externa, an infection of the external auditory canal caused by molds and yeasts, accounts for approximately 10-20% of ear canal infections accompanying high recurrence. The purpose of the current study was to assess the pattern of etiological agents of otomycosis and resistance profile as well as the rate of tympanic membrane perforation. A total of 1040 patients with symptoms of fungal otitis externa, in a period of two years, were investigated. The mycological tests revealed the presence of different fungi in 237 ears (22.8%). Fungal otitis was more related to filamentous fungi of the species Aspergillus flavus (54.43%), A. tubingensis (10.97%), and A. niger (8.86%), followed by yeasts, Candida orthopsilosis (7.59%), C. albicans (6.75%), and C. parapsilosis (5.06%). Tympanic membrane perforation rate was found to be 6.75% and was more common with otomycosis caused by A. flavus, A. tubingensis and C. albicans. In antifungal susceptibility tests, all tested drugs showed generally good activity against most isolates of molds and yeasts, while tolnaftate, clotrimazole, nystatin, and terbinafine had lowest effects. We found that among Aspergillus isolates, one A. niger isolate was resistant to voriconazole, and one A. flavus isolate was resistant to amphotericin B. Furthermore, among Candida species, three isolates of C. orthopsilosis showed high MIC values to fluconazole, two C. albicans isolates were considered fluconazole resistant and one isolate of C. parapsilosis was resistant to caspofungin and 3 isolates were resistant to fluconazole. Regarding the existence of the cases with perforated tympanic membrane and emerging species causing fungal otitis in the current report, the importance of the early physical examination, precise molecular identification, and the antifungal susceptibility evaluation is highlighted.

Otomycosis in Africa: Epidemiology, diagnosis and treatment

This review sets out to highlighted knowledge gaps regarding the epidemiological, diagnostic (clinical and laboratory) and therapeutic aspects of otomycosis in Africa. A computerized literature search for otomycosis related articles were performed using MEDLINE. The search encompassed articles published in early January 1980 to May 2019 yielded 220 articles. Electronic search on PubMed was performed with the specific keywords. This review shows the higher prevalence rates of otomycosis in Africa. These prevalences varies from one country to the other and also from one population to another within the same country. The main symptoms are otalgia, otorrhea, hearing loss, aural fullness, pruritus, and tinnitus. Otomycosis is due to several predisposing factors, however, use of topical antibiotic/steroid eardrops, trauma to the external ear canal or instrumentation of the ear, being exposed to hot humid atmospheres, and close contact with water are the common risk factors. Aspergillus species are the most commonly identified organisms compared with Candida species. Worldwide, A. niger and C. albicans are the most commonly described agents of otomycosis in Africa. The Laboratory diagnosis of otomycosis is usually confirmed by mycologic tests relied on a set of evidences. Further conventional methods such as Chromagar Candida System, latex agglutination test, Biochemical tests (Api 20C AuxTM and auxanogram), phenotypical tests (Germ-tube and chlamydosporulation), and rRNA gene sequencing (PCR) are performed to improve diagnosis and the management of the disease. Adequate treatment of otomycosis includes microscopic suction clearance of fungal mass, discontinuation of topical antibiotics and treatment with antifungal eardrops for three weeks.

The changing nature of paediatric otomycosis in the mid-west of Ireland

BACKGROUND

Fungal otitis externa is prevalent in tropical and sub-tropical climates; however, over the past two decades, there has been a reported increase in the prevalence of otomycosis in paediatric patients from more temperate climates. This study aimed to review the children diagnosed with otomycosis at the University Hospital Limerick with reference to frequency, causative organism, predisposing factors and management.

METHODS

A retrospective review was conducted of paediatric patients from 2001 to 2015. Patients with positive fungal ear swabs and a diagnosis of otomycosis were identified.

RESULTS

Ninety-three patients were positive for candida (mean age, 5.8 years), 10 patients were positive for aspergillus (mean age, 9.1 years) and 1 patient had mixed fungal infection containing both fungi. There was a positive correlation between a diagnosis of otomycosis and prior treatment with topical fluoroquinolones (r = 0.8; p < 0.01).

CONCLUSION

The incidence of otomycosis has been increasing since 2001, which correlates with an increase in the use of topical fluoroquinolones. Previous studies identify aspergillus as the commonest causative fungi; however, this study found that candida was the commonest isolated fungi in the paediatric population.

Species distribution patterns and epidemiological characteristics of otomycosis in Southeastern Serbia

INTRODUCTION

Otomycosis, a superficial fungal infection of the external auditory canal (EAC), is a disease with exceptionally high prevalence.

AIM

The aim of this study was to determine the prevalence of otomycosis, the distribution of causative species and to evaluate epidemiological characteristics of these infections.

METHODOLOGY

The patients' data were collected from record book and database of mycological examinations conducted at Public Health Institute Nis, Serbia. In the period from 2014 to 2018 samples of 1287 patients with symptoms and signs of EAC infection were investigated. Standard mycological methods were used for isolation and determination of fungi.

RESULTS

High prevalence of otomycosis was determined in examined patients (22.7%). However, the prevalence rates did not differ significantly in the studied period (p=0.931). The majority of patients were diagnosed with only unilateral EAC infection (82.9%). Considering all patients with otomycosis, mold infections caused by the genus Aspergillus (143/48.9%) were more frequent than Candida spp. ear infections (133/45.6%), with Aspergillus niger and Candida аlbicans being predominant causative agents. Mixed Aspergillus and Candida otomycosis was established in 16 (5.5%) patients. Otomycosis was more common in male subjects (26.8%, p=0.003) who also suffered from Aspergillus otomycosis more frequently (17.5%, p<0.001). The prevalence of these infections increases with age (p=0.005), while they do not show seasonal pattern (p>0.05).

CONCLUSION

Noted high prevalence of otomycosis, with both yeasts and non-dermatophyte molds acting as infectious agents which require different treatment, implies the necessity for further epidemiological monitoring of this form of superficial mycoses.

Aspergillus niger otomycosis in a child with chronic otitis externa

Aspergillus niger is commonly associated with otomycosis. Currently, local guidelines lack appropriate guidance on the definitive treatment and management when the fungus is identified. The repeated use of antibiotics in children with refractory episodes of otitis externa is concerning and may contribute towards otomycosis. This case report highlights the importance of a well-collected pus swab from the ear and suggests a topical antifungal to use in paediatric patients with Aspergillus niger otomycosis.

Occurrence of Trichophyton verrucosum in cattle in the Ningxia Hui autonomous region, China

Background

Ningxia Hui Autonomous Region is an important cattle breeding area in China, and cattle breeding bases are located in this area. In Ningxia, dermatophytes have not been paid attention to, so dermatophytosis is becoming more and more serious. For effective control measures, it is important to determine the disease prevalence and isolate and identify the pathogenic microorganism.

Results

The study showed the prevalence of dermatophytes was 15.35% (74/482). The prevalence in calf was higher than adult cattle (p < 0.05). The morbidity was the highest in winter compared with autumn (p < 0.0001), summer (p < 0.05) and spring (p < 0.0001). The prevalence in Guyuan was the highest compared with Yinchuan (p < 0.05) and Shizuishan (p < 0.05). The incidence of lesions on the face, head, neck, trunk and whole body was 20.43, 38.71, 20.43, 10.75 and 9.68%, respectively. From all samples, the isolation rate of Trichophyton was highest (61.1%). The phylogenetic tree constructed showed that the 11 pathogenic fungi were on the same branch as Trichophyton verrucosum.

Conclusions

This study reports, for the first time, the presence of Trichophyton verrucosum in cattle in Ningxia and showed that the incidence of dermatophytosis is related to different regions, ages and seasons. A better knowledge of the prevalence of dermatophytosis of cattle may allow the adoption of more efficient control measures and prophylaxis.

Antifungal susceptibility profiles of otomycosis etiological agents in Ahvaz, Iran

Background and Purpose

Otomycosis is a secondary ear fungal infection among predisposed individuals in humid conditions. Aspergillus species are the most common etiologic agents of this infection. Several ototopical antifungals are currently used for the treatment of this disease; however, recurrence and treatment failure are usually observed in some cases. Regarding this, the present study was conducted to investigate the antifungal activity of caspofungin, azoles, and terbinafine against the isolated agents of otomycosis.

Materials and Methods

This study was conducted on the specimens collected from 90 patients with otomycosis. The samples were cultured on Sabouraud dextrose agar and identified based on morphological characteristics, physiological tests, and microscopic features. Furthermore, the microdilution method was used for antifungal susceptibility testing according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Finally, the minimum inhibitory concentration (MIC) and minimum effective concentration (MEC) ranges, MIC/MEC₅₀, MIC/MEC₉₀, and geometric mean (GM) MIC/MEC were calculated for the isolates.

Results

According to the results, 77 patients with otomycosis were positive for different Aspergillus (88.3%) and Candida (11.7%) species. Aspergillus niger complex (n=36) was found to be the most common agent, followed by A. flavus, A. terreus, and A. nidulans complexes. Furthermore, epidemiological cutoff values (ECVs) were lower than those presented by the CLSI for itraconazole and caspofungin in 98.5% and 42.6% of Aspergillus species, respectively. Terbinafine exhibited a great activity against Aspergillus species, while fluconazole revealed a low activity against both Aspergillus species. Based on the results, 77.8% of Candida species were resistant to caspofungin; however, miconazole and econazole had low MIC ranges.

Conclusion

Aspergillus niger and A. flavus complexes were identified as the most common agents accounting for 85.7% of the isolates. In addition, terbinafine was identified as the best antifungal for both Aspergillus and Candida species. Moreover, tested azoles had relatively low MICs, whereas most of the isolates had the MIC values beyond the caspofungin ECVs.

Otomycosis Due to the Rare Fungi Talaromyces purpurogenus, Naganishia albida and Filobasidium magnum

Otomycosis is a common finding in otorhinolaryngology clinics and is usually caused by species of Candida and Aspergillus, particularly black aspergilli. Meanwhile, other fungi can give rise to this infection, and the identification of these requires accurate methods. Here, we report three cases of otomycosis due to rare fungal pathogens. All the patients were young females, and manipulation of the ear canal was identified as a common potentially predisposing factor. In direct examination, filamentous fungal elements (in one case) and yeast cells (in two other cases) were seen. Culture was positive in all cases. Based on PCR-sequencing of internal transcribed spacers and β-tubulin (for mold isolate), the isolated fungi were identified as Talaromyces purpurogenus, Naganishia albida and Filobasidium magnum. By susceptibility testing of the isolates to fluconazole, itraconazole, voriconazole and amphotericin B, the lowest minimum inhibitory concentration values were observed for amphotericin B followed by voriconazole. Patients were successfully treated by a combination of antifungals and corticosteroids with no relapse over the next year, except for the case due to F. magnum, in which, despite partial recovery, a course of relapse was reported in the 1-year follow-up call.

Oxymetazoline, Mupirocin, Clotrimazole-Safe, Effective, Off-Label Agents for Tympanostomy Tube Care

OBJECTIVES

Only a few medications have a United States Food and Drug Administration indications for prevention and/or treatment of infections in patients with tympanic perforations or tympanostomy tubes. We examined 3 off-label agents that have become important in tympanostomy tube care hoping to demonstrate the effectiveness and safety of each in experimental assays and human application.

METHODS

Computerized literature review.

RESULTS

(1) Oxymetazoline nasal spray applied at the time of surgery is equivalent to fluoroquinolone ear drops in the prevention of early postsurgical otorrhea and tympanostomy tube occlusion at the first postoperative visit. (2) Topical mupirocin 2% ointment is effective alone or in combination with culture-directed systemic therapy for the treatment of tympanostomy tube otorrhea caused by community-acquired, methicillin-resistant Staphylococcus aureus. (3) Topical clotrimazole 1% cream is highly active against the common yeast and fungi that cause otomycosis. A single application after microscopic debridement will cure fungal tympanostomy tube otorrhea in most cases. None of these 3 agents is ototoxic in animal histological or physiological studies, and each has proved safe in long-term clinical use.

CONCLUSIONS

Oxymetazoline nasal spray, mupirocin ointment, and clotrimazole cream are safe and effective as off-label medications for tympanostomy tube care in children.

Treatment of Otomycosis in Ears with Tympanic Membrane Perforation is Easier with Paper Patch

Objective

To assess the effectiveness of paper patch closure of tympanic membrane perforation in patients with otomycosis and tympanic membrane perforation.

Methods

Fifty-six otomycosis patients with central tympanic membrane perforations were included in the study. Patients were randomized into two groups as patched (PG) and non-patched (NPG) groups. In both groups, Castellani's solution was applied to the external auditory canal. In PG patients, the perforated tympanic membrane was covered with carbon paper patch soaked in Castellani's solution to reduce ear canal humidity and to prevent fungi from passing from the ear canal to the middle ear mucosa. Paper patch was not used in NPG patients.

Results

There were statistically significant differences between the two groups in terms of severity scores in the first, second, third, fourth and sixth weeks of admission (p=0.004, p=0.018, p=0.001, p=0.009, and p<0.001, respectively). Time to complete recovery was statistically shorter in PG patients (p<0.001). Disease recurrence was statistically less among PG patients compared to NPG patients (p=0.025).

Conclusion

Closing of perforation with paper patch and topical application of Castellani's solution was found to be an effective and safe method. The method eliminated otomycosis in a shorter period and reduced recurrence rate in patients with eardrum perforation.

Diagnosis and treatment of otomycosis in southern China

To analyse and discuss the clinical features and pathogenic characteristics, diagnosis and treatment of patients with otomycosis in southern China. Two hundred fifty-six patients from southern China diagnosed with otomycosis were randomly separated into two groups: the drug filling group and drug smearing group. Patients in the drug filling group were first examined and then had the pathogenic secretions in their external auditory canals cleared by otoendoscopy. Then, the local antifungal cream triamcinolone acetonide clotrimazole was injected into the external auditory canal. The same treatment was undertaken 1 week later and repeated once or twice more. Patients in the drug smearing group were also treated by otoendoscopy. Then, they were told to smear their external auditory canals once per day with the antifungal cream. All cases were followed for more than 6 months after the 3- to 4-week treatment. The main symptoms and otoendoscopic examination were used to evaluate the prognosis. Aspergillus was the commonest fungus. The cure rate was 93% in the drug filling group and 81% in the drug smearing group. Otomycosis is very common in southern China, but it lacks characteristic features in its early stages. Once diagnosed, the local lesions in the external auditory canal should be cleared thoroughly using otoendoscopy, and then, the local antifungal cream is injected into external auditory canal. The cure rate can be significantly improved with the foregoing treatment.

[Opportunistic mycoses of ENT organs. Part 1]

The present literature review summarizes information about the diseases of the upper respiratory tract and the ears caused by opportunistic fungi. The factors responsible for the increased frequency of opportunistic infections, among which mycosis is the leading one, are given. The exogenous and endogenous risk factors are described. The main pathogens of opportunistic mycotic infections of the ENT-organs are listed. Special attention is given to the mechanism underlying the development of anti-colonial immunity of the upper respiratory tract and the ears and the formation of the antifungal immunity of the macroorganism as a whole. The data on the pathogenetic factors of mycelial and yeast-like micromycetes are presented. The main variants of the pathogenetic mechanisms, such as adhesion, invasive growth, and penetration, behind the formation of the mycotic lesions are considered. These biological properties of the fungi contribute to their ability to cause a wide range of pathological changes - from the superficial lesions of the skin and mucous membranes of the ENT organs to the deep invasive processes. The protective cellular and humoral immune reactions of a macroorganism that develop in response to the introduction of a pathogenic fungus are described. The review lists the main nosological forms of mycosis known to affect the ENT-organs with special reference to the leading role of the yeast-like fungi belonging to the genus Candida in the development of mycotic lesions of these biotopes (64.65%). The most pathogenic species, Candida albicans, prevails in the structure of the yeast-like fungi biome whereas the leading role in the development of mycosis of the ENT organs by micromycetes of mold belongs to the species Aspergillus niger.

Molecular epidemiology of otomycosis in Isfahan revealed a large diversity in causative agents

PURPOSE

To elucidate the clinical and microbial epidemiology of otomycosis in Isfahan, Iran.

METHODOLOGY

From January 2016 to January 2017 all patients clinically suspected of otomycosis at Al-Zahra Hospital, Isfahan, Iran were recruited. Specimens were taken using sterile swabs by an otorhinolaryngologist and subjected to culture and microscopy using potassium hydroxide and Giemsa stain. Isolated fungi were identified based on morphological and molecular characteristics.

RESULTS

Otomycosis was confirmed in 97/120 patients (80.8 %). Females (72.2 %) and patients aged 30-39 years (33 %) were more commonly affected than others. Manipulation of ear canal (62.9 %) was the most common predisposing factor. Pruritus was observed in 84.54  % of the patients followed by hearing impairment (81.4 %), and most episodes were detected over the summer (50.5 %). Culture was positive for 81 (83.5  %) of confirmed cases and molds were the most prevalent causative agents (n=51, 63 %) followed by yeasts (n=19, 23.4 %) and yeast/mold mixes (n=11, 13.6 %). For the 16 remaining patients, no growth was seen in culture despite a positive result on direct examination. In total, 92 isolates (63 molds and 29 yeasts) were recovered in culture. Application of molecular methods showed 18 fungal species and the vast majority of them belonged to Aspergillus (n=53, 57.6 %) and Candida genus. Among the species involved, Candida parapsilosis (n=22, 22.7 %) and Aspergillus tubingensis (n=15, 15.5 %) were the most encountered species.

CONCLUSION

Outcomes from this study showed a different picture of prevalence, where C. parapsilosis and A. tubingensis but not Aspergillus niger were the most species encountered from patients suffering from otomycosis.

Clinical and microbial epidemiology of otomycosis in the city of Yasuj, southwest Iran, revealing Aspergillus tubingensis as the dominant causative agent

PURPOSE

Otomycosis is a mycotic infection of the external auditory canal and can be caused by a wide range of fungal species. In this study, we aimed to identify fungal isolates from patients suspected of otomycosis.

METHODOLOGY

External ear canal samples were taken from patients referred to the outpatient department of Shahid-Mofatteh Clinic in the city of Yasuj, Iran, and examined by direct microscopy and culture. DNA of the isolated fungi was tested by internal transcribed spacer PCR restriction fragment length polymorphism analysis for identification of yeasts and β-tubulin sequencing for identification of Aspergillus species.

RESULTS

Among 275 patients suspected of otomycosis, 144 cases (83 female and 61 male) were confirmed with otomycosis. For 89% (n=128) of positive cultures, microscopy was also positive, while there were no cases with a microscopy-positive and culture-negative result. The predominant predisposing factor was self-cleaning of the external ear using unhygienic tools, and the main risk occupation was 'housewife'. The most common isolated fungi were typically Aspergillus (n=120), including 73 isolates of Aspergillus section Nigri, 43 of section Flavi, 3 of section Terrei and 1 of section Fumigati. After sequencing, 44 out of 73 strains primarily identified as Aspergillus niger turned out to be Aspergillus tubingensis. Thirty-five isolates were identified as Candida, including Candida parapsilosis (n=22), Candida albicans (n=12) and Candida tropicalis (n=1).

CONCLUSION

Aspergillus tubingensis was the most common species involved in otomycosis. This work corroborates the difficulty of precise identification of species within the black Aspergilli by morphological characteristics.

Single Dose Topical Application of Clotrimazole for the Treatment of Otomycosis: Is This Enough?

Background and Objectives

To determine the efficacy of filling the external auditory meatus with 1% clotrimazole at a single visit for the treatment of otomycosis.

Subjects and Methods

This prospective study included 40 patients who were referred to our clinic with complaints of ear itching, pain, and fullness, and were diagnosed with unilateral otomycosis. After cleaning the mycotic hyphae from the external auditory meatus, the ear canal was filled with 1% clotrimazole, using an intravenous catheter and syringe. The patients received follow-up examinations on post-treatment days 7, 15, and 45.

Results

The follow-up otomicroscopic examinations revealed that 95% of the ear canals were entirely clean and that all symptoms had resolved. The post-treatment scores of pain, aural fullness and itching were significantly lower than the pre-treatment scores (p<0.01).

Conclusions

Filling the external auditory meatus with 1% clotrimazole at a single visit is an easy, efficient, and cost-effective treatment for otomycosis. Additionally, high patient compliance makes this treatment superior to long-term topical therapy.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

Effect of combination therapy with ceftizoxime and clotrimazole in the treatment of otomycosis

Background and Purpose:

There are controversial findings regarding the efficacy of antifungal drugs in the treatment of a ruptured eardrum following fungal infections. Regarding this, the aim of the present study was to evaluate the therapeutic effect of the co-administration of antifungal and antibacterial agents in the treatment of otomycosis with tympanic membrane perforation.

Materials and Methods:

This analytical, clinical trial was conducted on 87 patients with otomycosis showing no bacterial elements in the direct observation and culture. The study population was assigned into two groups of intervention (n=45) and control (n=42). The demographic and clinical data, as well as the data related to the direct observation and culture of the ear samples were recorded in a checklist. All statistical analysis was performed in SPSS (version 24).

Results:

The most prevalent symptoms in both groups were hearing loss and itching, and the most common finding was secretion. Aspergillus and Candida were the most frequent fungi isolated from the samples. After the implementation of combination therapy, the intervention group demonstrated a significant decrease in symptoms and signs, compared to the control group (P=0.005).

Conclusion:

The findings of the present study indicated that the use combination therapy with ceftizoxime powder and clotrimazole ointment was effective the in treatment of the patients with tympanic membrane rupture showing no bacterial effects in direct examination and culture.

Efficacy and safety of eberconazole 1% otic solution compared to clotrimazole 1% solution in patients with otomycosis

PURPOSE

To demonstrate non-inferiority of eberconazole 1% otic solution to clotrimazole 1% solution, and to compare their safety profiles in the treatment of otomycosis.

MATERIALS AND METHODS

Multicenter, randomized, double-blind, active treatment-controlled phase 3 clinical trial. One hundred and ninety patients with diagnosis of otomycosis were randomly assigned to eberconazole 1% otic solution or clotrimazole 1% solution.

RESULTS

Baseline characteristics were comparable between both groups for age, gender, ethnicity, and clinical variables. Both study groups had high complete response rates: 81.8% in the eberconazole group and 83.5% in the clotrimazole group. Although non-inferiority of eberconazole relative to clotrimazole could not be demonstrated, a post-hoc sensitivity analysis demonstrated that eberconazole 1% otic solution was not inferior to clotrimazole 1% solution for the primary efficacy endpoint. Secondary endpoints also demonstrated that eberconazole 1% and clotrimazole 1% solutions were therapeutically similar at the end of the study. The incidence of adverse events was similar in both groups, and none had related AEs and withdrawals due to an AE.

CONCLUSIONS

Eberconazole 1% otic solution is an efficacious and safe option to treat otomycosis-affected patients in the general practice.

Fungal Suppurative Otitis Media (Histopathology) Among Patients in North India

Chronic suppurative otitis media (CSOM) has a substantial worldwide prevalence and is a major cause of hearing impairment. In cases of CSOM unresponsive to local antibiotics, superimposed fungal infection should be suspected. The aim of the present study was to study the spectrum of cases with fungal otitis media. The study was conducted over a period of 12 years (2006-2017). Fifteen cases of CSOM clinically not suspected to be of fungal etiology that underwent surgery with identification of fungal organisms on histopathology were included in the study. Age of the patients ranged from 12 to 75 years (mean age: 37.1 ± 22.7 years). Of 15 cases, 9 (60.0%) were males and 6 (40.0%) were females. It was a unilateral presentation in all. The complaints observed were ear discharge in all followed by itching (86.7%), pain (46.7%), decreased hearing (26.7%) and blocking sensation (13.3%). Histomorphologic typing of fungus was possible in 13/15 patients. Isolated aspergillus was identified in eight patients while mucor alone was seen in three patients. Mixed infection with Aspergillus + Candida and Aspergillus + Mucor was seen in one patient each. Categorization of fungus could not be done in rest of the two patients due to paucity of fungal profiles. Histopathological identification of fungal organisms in otomycosis provides a quick and fairly reliable diagnosis. Culture is considered the gold standard but it may not always be available or fruitful. Less turnaround time and accurate diagnosis facilitates prompt and optimal therapy in fungal otitis media thus preventing adverse outcomes.

Successful treatment of a recurrent Aspergillus niger otomycosis with local application of voriconazole

Fungal otitis (otomycosis) is a common infection encountered by otolaryngologists. Nevertheless, its management can be challenging because of its high recurrence rate and of the limited therapeutic options. A 45-year-old woman suffered from recurrent otomycosis. The ineffectiveness of successive antibiotic cures and repeated topical treatments with nystatin and then with econazole cream led to perform microbiological analyses. Culture of ear swab grew Aspergillus niger. The use of a 1% voriconazole sterile solution previously validated for treatment of eye infections was considered after ensuring the absence of known ototoxic effects of the antifungal and of the excipients. The patient was advised to apply locally this voriconazole solution daily for 14 days (3 drops, 3-4 times a day). Full recovery was obtained at the end of the treatment, and no relevant side effects were noticed. More than one year after completion of therapy, there was no recurrence. Our observation shows that voriconazole 1% solution is an interesting option for treating otomycosis which failed to respond to usual therapeutic options. Further prospective studies are now warranted to confirm these findings.

Species identification and in vitro antifungal susceptibility testing of Aspergillus section Nigri strains isolated from otomycosis patients

INTRODUCTION

Aspergillus niger is the most commonly reported etiology of otomycosis based on morphological characteristics. This fungus is a member of Aspergillus section Nigri, a set of morphologically indistinguishable species that can harbor various antifungal susceptibility patterns. The aim of this study was to accurately identify and determine the susceptibility pattern of a set of black aspergilli isolated from otomycosis patients.

METHODS

Forty-three black Aspergillus isolates from otomycosis patients were identified by using the PCR-sequencing of the β-tubulin gene. Furthermore, the susceptibility of isolates to three antifungal drugs, including fluconazole (FLU), clotrimazole (CLT) and nystatin (NS), were tested according to CLSI M38-A2. The data were analyzed using the SPSS software (version 15).

RESULTS

The majority of isolates were identified as A. tubingensis (32/43, 74.42%) followed by A. niger (11/43, 25.58%). The lowest minimum inhibitory concentration (MIC) values were observed for NS with geometric means (GM) of 4.65μg/mL and 4.83μg/mL against A. tubingensis and A. niger isolates, respectively. CLT showed wide MIC ranges and a statistically significant inter-species difference was observed between A. tubingensis and A. niger isolates (P<0.05). FLU was inactive against both species with GMs>64μg/mL.

CONCLUSION

Species other than A. niger can be more frequent as observed in our study. In addition, considering the low and variable activity of tested antifungal drugs, empirical treatment can result in treatment failure. Accurate identification and antifungal susceptibility testing of isolates is, however, recommended.

[Otomycosis: the modern view of etiology and management]

This article deals with the modern approaches to the diagnostics and treatment of fungal ear infection depending on the localization of the inflammatory process and the species of the causative fungal agent with special reference to the factors underlying the development of otomycosis under the present-day conditions based on the results of the analysis of the studies carried out during the period from 2010 to 2014. The materials of the examination of 2152 patients who applied for the medical care to various clinical departments of the Institute and were found to present with chronic inflammatory ear pathology were available for the analysis. Fungal lesions were diagnosed in 495 (23%) patients with this condition. Fungal lesions of the external ear were the predominant form of pathology; they were documented in 331 (67%) patients. Fungal otitis media was diagnosed in 85 (17%) patients and fungal lesions of the postoperative cavity in 79 (16%) patients suffering from otomycosis. 65% of the patients presenting with external fungal otitis, 20% of those with fungal otitis media, and 95% of the patients with inflammation of the postoperative cavity were infected with mold fungi dominated by the genus Aspergillus spp. 79 (16%) patients suffering from otomycosis. In 35% of the patients presenting with fungal external otitis, 80% of those with fungal otitis media, and 5% of the patients with inflammation of the postoperative cavity of the middle ear, the causative agents of the disease were the fungi Candida spp. The authors describe the modern schemes for the treatment of otomycosis elaborated at the L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology.

Povidone iodine soaked gelfoam for the treatment of recalcitrant otomycosis - Our experiences at a tertiary care teaching hospital of eastern India

INTRODUCTION

Otomycosis is a common clinical condition seen in outpatient department of otorhinolaryngology. The treatment of the otomycosis is also very simple. However, sometime it is difficult to treat otomycosis along with mastoid cavity, chronic suppurative otitis media, immunocompromised patient, etc. with conventional treatment, called recalcitrant otomycosis. Here, we describe a technique of treatment for recalcitrant otomycosis.

MATERIALS AND METHODS

This is a prospective observational study/clinical trial carried out on 44 patients of recalcitrant otomycosis. They are divided into two groups, each of 22. One group treated with routine clotrimazole topical eardrops whereas other group treated with povidone iodine soaked gelfoam, placed in the external auditory canal.

RESULTS

There was no significance difference according to the age (P=0.134), gender (P=0.760) and causative agents (P=0.750) between treatment groups. The resolution of the symptoms showed statistically significant on itching (P=0.0001), otorrhoea (P=0.0033), fullness (P=0.0432) and earache (P=0.0259), whereas no statistical significant on hearing loss (P=0.0683), when treating with povidone iodine soaked gelfoam as compared to routine (clotrimazole) treatment. Resolution of signs like canal wall erythema (P=0.0045), tragal tenderness (P=0.0012) and congestion of tympanic membrane (P=0.0088) is statistically significant when comparing clotrimazole with povidone iodine. Apart from these, we did not reveal any adverse effects from the study populations treated with povidone iodine soaked gelfoam.

CONCLUSION

Use of the povidone iodine soaked gelfoam at the external auditory canal in recalcitrant otomycosis is an effective and well-tolerated treatment.

Diversity of clinical isolates of Aspergillus terreus in antifungal susceptibilities, genotypes and virulence in Galleria mellonella model: Comparison between respiratory and ear isolates

We analyzed the antifungal susceptibility profiles, genotypes, and virulence of clinical Aspergillus terreus isolates from six university hospitals in South Korea. Thirty one isolates of A. terreus, comprising 15 respiratory and 16 ear isolates were assessed. Microsatellite genotyping was performed, and genetic similarity was assessed by calculating the Jaccard index. Virulence was evaluated by Galleria mellonella survival assay. All 31 isolates were susceptible to itraconazole, posaconazole, and voriconazole, while 23 (74.2%) and 6 (19.4%) showed amphotericin B (AMB) minimum inhibitory concentrations (MICs) of ≤ 1 mg/L and > 4 mg/L, respectively. Notably, respiratory isolates showed significantly higher geometric mean MICs than ear isolates to AMB (2.41 vs. 0.48 mg/L), itraconazole (0.40 vs. 0.19 mg/L), posaconazole (0.16 vs. 0.08 mg/L), and voriconazole (0.76 vs. 0.31 mg/L) (all, P <0.05). Microsatellite genotyping separated the 31 isolates into 27 types, but the dendrogram demonstrated a closer genotypic relatedness among isolates from the same body site (ear or respiratory tract); in particular, the majority of ear isolates clustered together. Individual isolates varied markedly in their ability to kill infected G. mellonella after 72 h, but virulence did not show significant differences according to source (ear or respiratory tract), genotype, or antifungal susceptibility. The current study shows the marked diversity of clinical isolates of A. terreus in terms of antifungal susceptibilities, genotypes and virulence in the G. mellonella model, and ear isolates from Korean hospitals may have lower AMB or triazole MICs than respiratory isolates.

Otomycosis in Damascus, Syria: Etiology and clinical features

Background and Purpose:

Otomycosis is a fungal infection that frequently involves the external auditory canal. The epidemiologic data on the etiologic agents of otomycosis in Syria are very limited. In this study, we aimed to determine the fungal agents, gender distribution, and clinical presentation of otomycosis.

Materials and Methods:

Two hundred and ninety nine patients (153 [51.17%] male and 146 [48.83%] female) clinically prediagnosed as otomycosis were studied at Al-mouassat University Hospital and ENT Crescent Syrian Clinic. Clinical samples were collected from the ear discharges and cultured on Sabouraud Agar.

Results:

Otomycosis was diagnosed in 70 (23.4%) cases, with the highest prevalence in males aged 16-75 years (73.6%). The isolation rates of mold and yeast fungi were 75.7% and 24.3%, respectively. The most common presentations were otorrhea (98.66%), otalgia (18.06%), and hearing loss (6.35%). Our results showed that 64.28% of otomycosis agents were Aspergillus species. A.niger was the most common agent (45.7%), and 24.3% of the pathogens were C.albicans.

Conclusion:

Otomycosis agents most commonly belonged to the genus of Aspergillus followed by Candida, which should be seriously considered by physicians for appropriate treatment.

A case of bilateral otomycosis associated with Aspergillus flavus and A. terreus in Taiwan

Otitis externa caused by fungi (otomycosis) occurs more commonly in tropical areas with high moisture than in temperate regions. Bilateral otomycosis is, however, rarely reported. In a case of bilateral otitis externa in a 56-year-old male patient in Taiwan, direct microscopic examination of the cerumen as well as isolation of strains indicated the presence of two Aspergillus species being different in each of both ears. The species were identified by DNA sequence comparisons and additional morphological confirmation of diagnostic characteristics as Aspergillus flavus and Aspergillus terreus. The rarely reported occurrence of two Aspergillus species in otitis of the same patient deserves attention in other cases of otomycosis, particularly with respect to potentially different resistances of different species against antifungals. Treatment with nystatin/neomycin was not successful, but with clotrimazole was effective.

Freshwater Fungal Infections

Fungal infections as a result of freshwater exposure or trauma are fortunately rare. Etiologic agents are varied, but commonly include filamentous fungi and Candida. This narrative review describes various sources of potential freshwater fungal exposure and the diseases that may result, including fungal keratitis, acute otitis externa and tinea pedis, as well as rare deep soft tissue or bone infections and pulmonary or central nervous system infections following traumatic freshwater exposure during natural disasters or near-drowning episodes. Fungal etiology should be suspected in appropriate scenarios when bacterial cultures or molecular tests are normal or when the infection worsens or fails to resolve with appropriate antibacterial therapy.

Antifungal Effect of Malaysian Aloe vera Leaf Extract on Selected Fungal Species of Pathogenic Otomycosis Species in In Vitro Culture Medium

OBJECTIVES

Aloe barbadensis miller or Aloe vera has been used for therapeutic purposes since ancient times with antifungal activity known to be amongst its medicinal properties. We conducted a pilot study to determine the antifungal properties of Malaysian Aloe vera leaf extract on otomycosis species including Aspergillus niger and Candida albicans.

METHODS

This laboratory-controlled prospective study was conducted at the Universiti Sains Malaysia. Extracts of Malaysian Aloe vera leaf was prepared in ethanol and solutions via the Soxhlet extraction method. Sabouraud dextrose agar cultured with the two fungal isolates were inoculated with the five different concentrations of each extract (50 g/mL, 25 g/mL, 12.5 g/mL, 6.25 g/mL, and 3.125 g/mL) using the well-diffusion method. Zone of inhibition was measured followed by minimum inhibitory concentration (MIC).

RESULTS

For A. niger, a zone of inhibition for alcohol and aqueous extract was seen for all concentrations except 3.125 g/mL. There was no zone of inhibition for both alcohol and aqueous extracts of Aloe vera leaf for C. albicans. The MIC values of aqueous and alcohol extracts were 5.1 g/mL and 4.4 g/mL for A. niger and since no zone of inhibition was obtained for C. albicans the MIC was not determined.

CONCLUSIONS

The antifungal effect of alcohol extracts of Malaysian Aloe vera leaf is better than the aqueous extract for A. niger (p < 0.001). Malaysian Aloe vera has a significant antifungal effect towards A. niger.