Otomycosis in Nigeria: treatment with mercurochrome

A Comparison of Antifungal Drugs and Traditional Antiseptic Medication for Otomycosis Treatment: A Systematic Review and Meta-Analysis

Objectives/Hypothesis: To perform a systematic review and meta-analysis to compare the efficacy of and complications associated with antifungal drugs and traditional antiseptic medication for the treatment of otomycosis.

Data Sources: The PubMed, EMBASE, GeenMedical, Cochrane Library, CBM, CNKI, VIP and other databases were searched from January 1991 to January 2021.

Methods: The systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and non-randomized studies (case-control, cohort, and case series) were included to assess the topical use of antifungal drugs and traditional antiseptic medication in patients with otomycosis. The research subjects were patients who were clinically diagnosed with otomycosis and whose external auditory canal secretions were positive for fungi. Funnel plots were used to detect bias, and the Q test was used to assess heterogeneity. The random-effects model was used for meta-analysis. The t-test was used to assess significance.

Results: Of the 324 non-duplicate studies screened, 16 studies met the criteria for full-text review, and 7 were included in the meta-analysis. Four studies reported recovery conditions (P = 0.01). Six common complications after medication use were compared, and there were no significant differences. The authors further conducted subgroup analysis according to complications. The differences in the rates of ear distension (P = 0.007), earache (P = 0.03) and tinnitus (P = 0.003) were statistically significant.

Conclusion: The results of this meta-analysis and literature review showed that antifungal drugs and traditional antiseptic medication were effective in relieving symptoms in patients with otomycosis, and the two treatments were associated with different complications. Otolaryngologists have the option to use one medication or a combination of two drugs on the basis of the condition. Future research in this area should include RCTs with long-term follow-up to guide the development of otomycosis guidelines to overcome some of the weaknesses found in the literature.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/#myprospero.

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.

Efficacy of topical clotrimazole vs. topical tolnaftate in the treatment of otomycosis. A randomized controlled clinical trial

Introduction

Otomycosis, an infection of the ear canal by fungi, is prevalent in hot and humid weather. Nevertheless, there is not sufficient evidence for the effectiveness of different topical antifungal treatments. Tolnaftate, is a topical antifungal agent described to be effective in the treatment of otomycosis. Currently there are not sufficient studies that prove its efficacy.

Objectives

To compare the efficacy of clotrimazole and tolnaftate administration in the treatment of otomycosis.

Material and methods

A controlled, randomized and open clinical trial included patients diagnosed with fungal external otitis who were treated with topical antifungals, randomized into two treatment groups: (1) clotrimazole cream; (2) tolnaftate solution. They were microscopically evaluated at one and two weeks of treatment to determine resolution of disease. Recurrence and complications were recorded. Demographic and clinical variables were collected and analyzed. Follow-up and final outcomes (absence of infection) were compared between groups.

Results

Forty eight patients were included, 28 in the clotrimazole group and 20 in the tolnaftate group. Spring was the weather most commonly associated with otomycosis, while otic manipulation was the risk factor more common in both groups. Predominant symptoms were itching and otic fullness. Aspergillus niger organism was isolated most frequently. Treatment with clotrimazole resulted in 75% resolution vs 45% resolution with treatment with tolnaftate at one week of treatment (p = 0.007). The Tolnaftate treatment group demonstrated higher recurrence rates and treatment failures, 20% and 15% respectively.

Conclusions

Clotrimazole cream treatment is more effective than tolnaftate for uncomplicated otomycosis. More studies are needed to corroborate our results.

Bayesian analysis of two methods MALDI-TOF-MS system and culture test in otomycosis infection

Objective

Identification of otomycotic fungi using matrix-assisted laser desorption ionization (MALDI) time of flight (TOF) mass spectroscopy (MS) and to quantify pervasive errors with Bayes rule; values of sensitivity and specificity of culture test and MALDI-TOF-MS method are quantified.

Method

Fungi cultured ear discharge samples were identified with culture test and MALDI-TOF-MS system. Minimum inhibitory concentration (MIC) or MEC (minimum effective concentration) for 6 antifungals were determined by antifungal susceptibility testing in vitro. With Bayes rule, sensitivity and specificity of both MALDI-TOF MS and culture test methods were computed.

Results

Cultures yielded 42 fungal isolates which were confirmed as species (specified against each species) belonging to 8 genera, A. niger 22, Candida sp. 7, A. fumigatus 3, A. flavus 3, mixed Aspergillus sp. 3, Mucor sp. 2, Rhizopus sp. 1, and Scopulariopsis sp.1; and MALDI-TOF-MS system also confirmed those isolates. In vitro antifungal susceptibility testing with terms of MIC 50 and MIC 90, isolates fungi were highly susceptible to 6 antifungals; and caspofungin was the most active antifungal. The high value of specificity 84.6%, suggested a limited loss of confidence on the culture test at the absence of an infection, in comparison to MALDI-TOF-MS. Sensitivity of the culture test was 87.5%; this high figure strongly approves the culture test to be the dependable method for the otomycosis diagnosis, when the infection is stable.

Conclusion

Based on sensitivity and specificity together the culture test could be done in face of the gold-standard MALDI-TOF-MS system the estimating both methods.

Auditory and Histopathological Effects of Topical Mercurochrome Treatment in Rats with Tympanic Membrane Perforation

OBJECTIVES

Topical treatment is first choice in the treatment of uncomplicated chronic otitis media. It was intended to assess auditory and histopathological safety of ototopical use of mercurochrome solution in rats with induced tympanic membrane perforation.

MATERIALS AND METHODS

The study was conducted on 21 female Wistar-Albino rats which were randomly assigned into 3 groups. In all rats, perforation was performed at right tympanic membrane. Distortion product otoacoustic emissions (DPOAEs) measurements were performed at frequencies of 2000, 3000 and 4000 Hz (with L1/L2: 70 /70 dB at 2f1-f2 frequency; f2/f1 ratio: 1:22) before recovery from anesthesia and signal-to-noise ratio (SNR) were recorded. Normal saline, 2% mercurochrome and gentamicin were given to group 1, 2 and 3 twice daily over a week, respectively. Rats were sacrificed after DPOAE measurements on day 14. Right temporal bone specimens were examined under light microscope after processing.

RESULTS

Based on DPOAE results, there was no significant difference among groups before treatment. On day 14, significant differences were found in DPOAE measurements at 3000 and 4000 Hz, and in mean SNR values in 2% mercurochrome and gentamicin groups when compared to normal saline group while no significant difference was detected at 2000 Hz among groups. In addition, significant degeneration was detected in Corti organs, spiral ganglions and stria vascularis in groups 2 and 3.

CONCLUSION

In this study, it was observed that mercurochrome use in external otitis and otitis media with tympanic membrane perforation could cause ototoxicity and concluded that the solution should be used cautiously.

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.

Locacorten Vioform Ototoxicity Upon Guinea Pig Middle Ear Application

Background and Objectives

Locacorten Vioform (Novartis UK) is frequently prescribed for otomycosis. Its component, Clioquinol, also has anti-bacterial properties. Up to this point, its ototoxic potential has not been evaluated. Our objective aims to evaluate Locacorten Vioform’s potential ototoxicity when applied directly to the middle ear cavity.

Materials and Methods

We performed an experimental prospective animal study in our animal research center with 20 Hartley guinea pigs divided into 2 groups. The first group (experimental) was treated with Locacorten Vioform in one ear and with a physiologic saline solution in the other. The second group (positive control) was treated with concentrated gentamycin in one ear and physiologic saline in the other. Auditory brainstem response measurements were obtained before and after three sets of injections. Statistics were analyzed using a variance analysis with repeated measures. The histological state of cochlear outer hair cells was compared between the two groups using scanning electron microscopy.

Results

Average hearing loss in ears treated with Locacorten Vioform was 32.1 dB, compared with a 2.5 dB average loss in the saline-treated ears. Ears treated with gentamycin lost an average of 33.0 dB. There were clinically and statistically significant differences between the two ears of the guinea pigs in both groups (p<0.001). Scanning electron microscopy revealed severe pericochlear and cochlear inflammation and ossification in the Locacorten Vioform-treated ears. Gentamycin caused significant destruction of outer hair cell architecture.

Conclusions

Locacorten Vioform induces a hearing loss similar to that caused by gentamycin when applied directly to the middle ear of a guinea pig model. Electron microscopy indicates a pericochlear and cochlear inflammatory reaction with ossification.

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.

Otomycosis in a Rural Community Attending a Tertiary Care Hospital: Assessment of Risk Factors and Identification of Fungal and Bacterial Agents

INTRODUCTION

Otomycosis is one of the frequently encountered fungal infections of external auditory canal, commonly seen in tropical and subtropical regions of the world. Various host (local, systemic) and environmental factors can predispose a person to otomycosis. Although clinical presentations along with otoscopic findings of the patients are well suggestive of fungal infection, proper identification of causative agents is mandatory in order to prevent recurrences and complications.

AIM

To define the aetiology of clinically diagnosed otomycosis in rural population, to derive association of risk factors with otomycosis, to isolate and identify fungal and bacterial agents and to analyze the association between them.

MATERIALS AND METHODS

A prospective study was conducted in the Department of Microbiology and Department of Ear, Nose and Throat (ENT), SGT hospital over eight months period. A total of 350 consecutive patients of more than five years of age with clinical diagnosis of otomycosis were included in the study. Demographic profile, predisposing factors, presenting complaints and clinical findings of clinically diagnosed patients were evaluated and analyzed. Samples were collected, transported and evaluated by both direct examination and culture method for bacteriological and mycological examination.

RESULTS

Male to female ratio in study participants was 1.3:1. Mycological examination yielded 346 fungal isolates in 310 samples from a total of 350 clinically diagnosed cases of otomycosis. Self cleaning, instillation of mustard oil and use of ear drops appeared to be common predisposing factors in otomycosis. Significant association was observed between these practices and otomycosis. Aspergillus species was the predominant fungi followed by Candida spp., Penicillium, Mucor and Trichophyton mentagrophyte. 11% of the cases were found to have mixed fungal and bacterial infections.

CONCLUSION

The present study highlights the highest isolation of Aspergillus complex in cases of clinically diagnosed otomycosis in a rural community with higher practice of self cleaning and using home remedies and eardrops to get relief from sensation of blocked ear and itching.

Effectiveness of 3 per cent boric acid in 70 per cent alcohol versus 1 per cent clotrimazole solution in otomycosis patients: a randomised, controlled trial

OBJECTIVES

To compare the clinical effectiveness and adverse events for 3 per cent boric acid in 70 per cent alcohol versus 1 per cent clotrimazole solution in the treatment of otomycosis.

METHODS

A total of 120 otomycosis patients were randomly assigned to receive either 1 per cent clotrimazole solution (intervention group) or 3 per cent boric acid in 70 per cent alcohol (control group) at the Khon Kaen Hospital ENT out-patient department. Treatment effectiveness was determined based on the otomicroscopic absence of fungus one week after therapy, following a single application of treatment.

RESULTS

After 1 week of treatment, there were data for 109 participants, 54 in the clotrimazole group and 55 in the boric acid group. The absolute difference in cure rates between 1 per cent clotrimazole solution and 3 per cent boric acid in 70 per cent alcohol was 17.9 per cent (95 per cent confidence interval, 2.3 to 33.5; p = 0.028) and the number needed to treat was 6 (95 per cent confidence interval, 3.0 to 43.4). Adverse events for the two agents were comparable.

CONCLUSION

One per cent clotrimazole solution is more effective than 3 per cent boric acid in 70 per cent alcohol for otomycosis treatment.

A comparison of Locacorten-Vioform and clotrimazole in otomycosis: A systematic review and one-way meta-analysis

OBJECTIVES/HYPOTHESIS

The goal of this systematic review was to compare the efficacy and ototoxicity of Locacorten-Vioform (Paladin Labs Inc., Montreal, Quebec, Canada) and clotrimazole in the treatment of patients with otomycosis.

DATA SOURCES

Embase, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov.

METHODS

We included any randomized controlled trials or nonrandomized studies (case-control, cohort, and case series) assessing the topical use of Locacorten-Vioform (Paladin Labs Inc.) and/or clotrimazole in adult and/or pediatric immunocompetent patient population with otomycosis. DerSimonian and Laird's random effects approach was used for meta-analysis, followed by an assessment of heterogeneity and subgroup analysis.

RESULTS

Of 226 reviewed articles, 14 were retained. Clotrimazole efficacy rate was 85% (95% confidence interval [CI]: 79.7-89.0%), whereas Locacorten-Vioform (Paladin Labs Inc.) was 73% (95% CI: 56.0-84.5%). Overall, study quality was low. There was high heterogeneity in both groups (I(2) of 47 and 49). There were only three studies assessing Locacorten-Vioform (Paladin Labs Inc.); therefore, comparative assessment was not possible. A one-way meta-analysis involving 13 clotrimazole studies was performed. Heterogeneity across studies was high; however, studies using objective analysis assessing treatment efficacy, randomized controlled trials, studies using drops, studies performed in Asia, and studies where Candida was the major fungus at diagnosis demonstrated low heterogeneity.

CONCLUSION

Although both are safe and effective, there is insufficient evidence supporting increased efficacy of either clotrimazole or Locacorten-Vioform (Paladin Labs Inc.) for the treatment of otomycosis. High-quality comparative studies are required.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 126:1411-1419, 2016.

Otomycosis in the north of Iran: common pathogens and resistance to antifungal agents

Otomycosis as a kind of external otitis can be caused by various species of fungi. To use the appropriate treatment, it is necessary to identify the causal agent of otomycosis. The aim of this study was to determine the pathogens that caused otomycosis and also the efficacy of different antifungal agents. 100 patients with diagnosis of otomycosis/otitis extern were entered in this study. Bacterial culture was performed by eosin methylene blue agar, blood agar; and Sabouraud dextrose agar was used to culture the fungal agents. Minimum inhibitory concentration test also was performed to determine the efficacy of Clotrimazole, Fluconazole, Ketoconazole and Nystatin on the fungal pathogens. Otomycosis was confirmed in 43% of patients by positive culture. The most prevalent fungal pathogen was Aspergillus niger which was sensitive to Clotrimazole, Fluconazole, Ketoconazole. Candida albicans was sensitive to all drugs, in which, the most sensitivity was due to fluconazole. The most frequent fungal pathogen in our otomycosis cases is A. niger, and most of fungi that caused otomycosis are sensitive to clotrimazole.

Otomycosis: a retrospective study

Otomycosis is a fungal infection of the external ear canal with only a few studies about its real frequence in Brazil.

Aim

to evaluate otomycosis frequence and characteristics in patients with clinical suspicion of external otitis.

Study design

Retrospective study with transversal cohort (2000-2006).

Materials and methods

103 patients were assigned to mycological diagnosis (direct microscopic examination and culture).

Results

Otomycosis was diagnosed in 19.4% of the patients. Patient age varied from 2 to 66 years (an average of 23.5 years of age), and 60% of otomycosis cases were seen in women between 2 to 20 years of age. Chronic otitis, previous antibiotic therapy and the lack of cerumen were predisposing factors; itching, otalgia, otorrhea and hypoacusis were the symptoms reported by the patients. The most frequently isolated species were C. albicans (30%), C. parapsilosis (20%), A. niger (20%), A. flavus (10%), A. fumigatus (5%), C. tropicalis (5%), Trichosporon asahii (5%) and Scedosporium apiospermum (5%).

Conclusions

Otomycosis is endemic in JoÆo Pessoa-PB. Clinical exam and mycological studies are important for diagnostic purposes because otomycosis symptoms are not specific.

Protease activities of Candida spp. isolated from otitis externa: preliminary result

Otomycosis is a fungal infection of the ear predominantly caused by Candida and Aspergillus spp. The possible virulence factors of Candida spp. are enzymes, such as proteases, phospholipases, phosphatases and esterase. According to our knowledge, protease production in Candida strains isolated from patients with otomycosis has not been investigated. The present study was aimed at determining in vitro protease activity in 8 strains of Candida spp. (C. parapsilosis, C. famata, C. guilliermondii and C. albicans) isolated from children with otomycosis. A majority of isolated strains 7/8 (87.5%) were protease positive. The protease activity ranged from Pz 0.61 to 0.78. Further investigation is necessary to clarify the contribution of protease production to Candida virulence associated with otomycosis.

Ototopical antifungals and otomycosis: a review

There has been an increase in the prevalence of otomycosis in recent years. This has been linked to the extensive use of antibiotic eardrops. Treatment of otomycosis is challenging, and requires a close follow-up. We present a review of the literature on otomycosis, the topical antifungals most commonly used, and discuss their ototoxic potential. Candida albicans and Aspergillus are the most commonly identified organisms. Antifungals from the Azole class seem to be the most effective, followed by Nystatin and Tolnaftate.

Otomycosis in western Nigeria

Otomycosis is a recognized clinical entity in the tropical regions of the world. However, there is scanty information on this disease in some parts of Sub-Saharan Africa. The aim of this study was to determine the prevalence and pattern of etiological agents of otomycosis in western Nigeria. Medical records of patients with otomycosis seen in the Otorhinolaryngology Department of the University College Hospital, Ibadan from 1996-2005 were reviewed for all essential clinical data. Of the 5784 patients with ear diseases, 378 (6.54%) had otomycosis which consisted of 145 (38.36%) males and 233 (61.64%) females. Seventeen patients (4.50%) had recurrence within six months of treatment, 4 (1.06%) had poorly controlled plasma glucose. A significant number of our patients, 52 (13.76%), had prior topical aural antibiotic treatment following misdiagnosis. The predominant etiological agents in our series were Aspergillus niger (48.35%) and Aspergillus fumigatus (33.96%).