Otomycosis: a clinical entity--clinical and experimental study

Otomycosis: Clinical features and treatment implications

OBJECTIVES: To determine the clinical presentation, predisposing factors, complications, and treatment outcomes of otomycosis.

STUDY DESIGN AND SETTING: Retrospective review of 132 patients with a clinical diagnosis of otomycosis treated from 1998 to 2004 in an academic otology practice.

RESULTS: Otalgia and otorrhea were the most common presenting complaints (48%). Prior otologic procedures increase the risk of developing otomycosis. Residual disease was observed in 13% and recurrence in 15% of the subjects. The presence of a mastoid cavity was associated with higher recurrent and residual disease rates. Topical ketoconazole, cresylate otic drops, and aluminum acetate otic drops were all relatively effective with >80% resolution rate on initial application, although topical ketoconazole had a higher resolution rate and lower rate of disease recurrence.

CONCLUSIONS AND SIGNIFICANCE: Otomycosis can usually be diagnosed by clinical examination and often occurs in the setting of persistent otorrhea. Complications are not uncommon but usually resolve with application of appropriate topical antifungal agents. Eradication of disease is more difficult in the presence of a mastoid cavity.

Otomycosis; clinical features, predisposing factors and treatment implications

Objectives : The aim of this study was to determine the frequency of otomycosis, the clinical presentation, predisposing factors and treatment outcomes.

METHODS

This observational study was conducted at ENT department of Combined Military Hospital Attock, from October, 2010 to September, 2012. Convenient sample comprising 180 patients of both sexes and all age groups were selected from ENT OPD. The frequency, predisposing factors and most common symptoms of otomycosis were recorded. The response to different antifungal agents was also observed. RESULTS were recorded in percentages.

RESULTS

There were 180 patients with documented diagnosis of otomycosis. There were 107 (59%) males and 73 (41%) females. The age of patients ranged from 1½ years to 75 years with a mean age of 38.5 years. Mean follow up time was 2 years. Most common presenting symptom was hearing loss (77.7%) followed by pruritis (68.8%) and otalgia (40%). We prescribed 1% clotrimazole drops or lotion in 58% patients and 2% salicylic acid in 31% cases. Both of these agents are effective. Topical 1% clotrimazole drops yielded highest resolution rate with lowest recurrent rate. Overall 149 (83%) patients were improved with initial treatment and 31 (17%) did not respond to initial treatment. Eight (4.4%) patients had a history of otological procedures. Four (2.2%) patients had canal wall down procedures that resulted in mastoid cavity. To analyse the efficacy of 1% clotrimazole and 2% salicylic acid we applied Z-Test to calculate the difference between 2 proportions of patients before treatment with those patients who remained uncured after treatment.

CONCLUSION

Otomycosisis commonly presented with decreased hearing, pruritis, otalgia & otorrhoea. It usually resolves with local toilet of ear and instillation of antifungal agents. Eradication of disease is difficult in presence of a mastoid cavity and metabolic diseases like diabetes mellitus.

Otomycosis in Shanghai: aetiology, clinical features and therapy

Otomycosis is frequently seen in Shanghai and is a challenging problem due to recurrence and resistance to therapy. The aims of this study were to determine the pattern of fungal agents, sex distribution, clinical presentation, predisposing factors, complications and treatment outcomes of otomycosis. Retrospective review of 108 patients with a clinical diagnosis of otomycosis treated from September 2009 to September 2010 in otolaryngology outpatient department. It has been found to be more prevalent in female patients than male patients with a sex ratio (F : M) of 2 : 1. Aspergillus niger (54.78%) followed by Candida albicans (16.52%) were the dominant fungi. Pruritus and otorrhea were the most common presenting complaints. The predisposing factors included frequent scratching of the external ear canal (79.63%), taking ototopical and/or oral antimicrobials (24.07%), diabetes (11.11%) and otologic procedures (7.41%). Residual disease was observed in 9.26% and recurrence in 8.89% of the subjects. Topical Fluconazole ear drops and mechanical debridement of visible fungal elements in the external auditory canal were all relatively effective with 83.33% resolution rate on initial application. The diagnosis of otomycosis requires vigilance from clinicians given its non-specific symptoms. Sometimes mycological examinations are necessary. Treatment regimens such as topical fluconazole coupled with mechanical debridement are generally effective. However, recurrence is not uncommon and eradication of disease can be particularly difficult in patients with diabetes and a mastoid cavity.

Fungal infections of the head and neck: an update

Despite the vast literature regarding fungal infections of the head and neck, little has changed in diagnosis or management of these infections except in the nose and sinuses. Three main points regarding fungal involvement in the paranasal sinuses are evident now. First, fungi may be important in a significant percentage of patients with chronic rhinosinusitis. Second, the pathophysiologic mechanism responsible for fungal rhinosinusitis remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of the two. Finally, there is certainly a spectrum of disease thus far defined: allergic fungal sinusitis as defined by Bent and Kuhn [35], eosinophilic mucin rhinosinusitis defined by Ferguson [50], and eosinophilic fungal rhinosinusitis as proposed by Ponikau [45]. Fungal infections of the head and neck are panoramic in distribution and pathophysiology. They represent a broad range of disease of which medical science has only recently begun to uncover the surface. As research begins to unravel the complex host defense mechanisms against these pathogens from a cellular and even genetic level, the body of knowledge will continue to increase exponentially and the ability to treat patients suffering from fungal infections will improve.

Prevalence of otomycosis in outpatient department of otolaryngology in Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Otomycosis is a not-uncommon clinical problem encountered in our otolaryngology practice. We report 100 diagnoses (107 ears) of otomycosis, of which, on microbiological examination, 87 specimens (81.3%) showed positive fungal cultures. Of these, a single isolate was found in 85 cases (79.4%), mixed isolates were found in 2 cases, and 20 cases (18.7%) had no growth. The most common fungal pathogen found was Aspergillus, followed by Candida albicans. The causative factors for otomycosis were examined. The results of treatment with clotrimazole were analyzed.

Otomycosis in São Paulo

In view of the lack of researches on otomycosis in Brazil, we have tried to study their incidence, their clinical characteristics and the predispondent factors. During one year, 22 suspected cases were seen, 20 of them corresponded to otomycosis infections. The most frequent species were Aspergillus niger (35%) and Candida albicans (20%). The genus Aspergillus represented 75% of the isolates. Itching and hyperaemia (70%), otalgia (65%), hipoacusia (50%) were the commonest signs. Lack of cerumen (70%) chronic otitis (30%) previous antibiotic therapy and eczema (25%) were the most outstanding predispondent factors.

Etiological agents of otomycosis in Nigeria

A total of 159 suspected cases of otomycosis comprising 101 adults and 58 children, 61 males and 98 females were investigated. Of these, 36 cases were confirmed specifically of mycotic etiology on the basis of microscopic demonstration of fungal structures in epithelial debris/plugs and positive culture. Another 31 cases positive for fungi by culture but negative for direct microscopy were considered of doubtful fungal etiology. The predominant etiological agents in the confirmed cases were Aspergillus niger (13 cases), followed by A. flavus (6), Candida albicans (6) and C. parapsilosis (4). Other species represented were Pseudoallescheria boydii (2), C. guilliermondii (1), Aspergillus sp. (unidentified) (2), and Candida sp. (unidentified) (1). One case was of mixed infection due to A. niger and C. albicans. Fungal cultures from normal healthy ear canals of 46 persons were positive in 17 cases, the predominant fungus being Aspergillus (mainly A. niger).

Mycotic infection of the ear (otomycosis): a prospective study

Otomycosis (fungal infection of the ear) is not uncommon clinical problem encountered in our ENT practice. It makes up to 6 per cent of all patients with symptoms of ear disease seen in the Outpatient Clinic. Of the 193 patients with a clinical diagnosis of otomycosis, 171 cases produced positive fungal isolates. In this study Aspergillus species (niger and fumigatus) have been the most common fungal pathogens. Various aetiopathological factors have been examined in detail, and the available literature reviewed. The results of the treatment by nine antifungal agents currently available in Bahrain have been analysed.

Broad spectrum antifungal agents in otomycosis

The in vitro inhibitory activities of four currently used antimycotic agents (clotrimazole, econazole, miconazole and cyclopirox-olamine) against 304 fungal isolates comprising 51 species from 14 genera of moulds and yeasts, using a serial dilution procedure, were studied. Clotrimazole and econazole were found to have a grossly similar broad-spectrum antifungal activity, inhibiting all the tested yeasts and moulds at a concentration ranging from 0.1-4 micrograms/ml. At this range miconazole inhibited 90 per cent of the strains and cyclopirox-olamine inhibited 57 per cent only and thus they were less effective. Econazole 1 per cent solution was very effective in vivo in the treatment of otomycosis within 1-3 weeks. The drug was well tolerated, with no side-effects. Owing to the high broad-spectrum antifungal activity of clotrimazole and econazole, they should be the treatment of choice in otomycosis and can be used safely as otic drops.

Fungi from otitis media of agricultural field workers

Twenty four fungi were isolated from ear wax or otitis media of agricultural field workers, of which 18 are being reported for the first time from India. Direct observation, revealed the presence of hyphal fragments, spores of Alternaria, Bipolaris, conidial head of Aspergillus, smut teliospores and pollen. Spores of only four fungi, Alternaria humicola, Aspergillus niveus, Bipolaris spicifera and Fusarium moniliforme germinated in otitis media at 37 degrees C, and their germination was affected by relative humidity. Alternaria humicola and Aspergillus niveus appeared to be the causative agents of otomycosis, and otitis media is fungistatic in nature.