Long-term follow-up of otomycosis and its treatment with bifonazole

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Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials.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.

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.

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.

Randomized prospective comparative study: short-term treatment with ciclopiroxolamine (cream and solution) versus boric acid in the treatment of otomycosis

Sixty-four patients with symptomatic otomycosis (80 infected ears) confirmed by direct microscopy and culture were randomly treated for I week with ciclopiroxolamine cream 11% (group A, 20 infected ears, 17 patients), ciclopiroxolamine solution 1% (group B, 20 infected ears, 17 patients) and boric acid (group C, 40 infected ears, 30 patients) and daily mechanical suction aspiration of the debris. An attempt was made to match 11 clinical parameters with both the mycological and bacteriological findings. There was no significant association between the fungal species cultured and the clinical parameters did not vary with the presence or absence of different bacteria; pus was never present in fungal otitis externa (Fisher's test, P < 0.001). Before therapy, a significant number of ears had completely sterile bacterial cultures (p < 0.01, chi2 test); saprophytic Gram-positive bacteria increased after treatment, whilst Gram-negative bacteria, Pseudomonas aeruginosa and Proteus species, decreased after treatment. Clinical total cure rates 3 days after the end of therapy ranged from 50% in group A, 25% in group B to 22.5% in group C. Mycological cure rates were 80% (group A), 95% (group B) and 72.5% (group C). Two weeks after the end of therapy the clinical cure rates were 60% (group A), 65% (group B) and 80% (group C) and the mycological cure rates was 65% for group A and 75% for both group B and C. Eleven patients relapsed with otitis externa: four (20%) in groups A and C and three (15%) in group B. In four cases the infection was due to bacteria and the remaining seven were due to fungi. Six sites relapsed with the same fungal species as that isolated at the start of the study. In this short-term assessment the relapse rate was not significantly associated with predisposing conditions. The tolerance was excellent in group A. Four patients (20%) in group B had mild (two patients) or moderate (two patients) burning and itching with each application. Twelve patients (30%) in group C had severe stinging and five of these patients who had perforated tympanic membranes also experienced pain. In terms of clinical and mycological effectiveness, there were no significant differences between the three treatment groups, although group A (ciclopiroxolamine cream 1%) and B (ciclopiroxolamine solution 1%) both showed significantly better tolerance (Fisher's test, P < 0.05) when compared with boric acid (group C).

Otomycosis--a clinico-mycological study and efficacy of mercurochrome in its treatment

A total of 110 patients of symptomatic otomycosis was investigated, prospectively. Aural swabs were collected on 1st, 7th and 14th day and examined by direct microscopy and culture for fungi. Of these, 80 patients found to be having pure fungal infection, were taken up for mycological and therapeutic study. Fungi belonging to genus Aspergillus were isolated in 76 (95.0%) patients of which Aspergillus niger was the commonest isolate in 46 (57.5%), followed by A. flavus in 27 (33.7%), A. fumigatus in 3 (3.7%), Candida species in 3 (3.7%) and Mucor in 1 (1.2%). The patients were of all age groups but majority were between 21 and 30 years and the male-female ratio was equal. Of the total of 40 male patients, twenty-one were Sikhs using turban. Before developing the symptoms, forty five patients used oil, mixture of oil and garlic juice, antibiotics, steroids, antiseptics or wax solvent as ear drops. Only two patients were diabetic. No patient had fungal infection elsewhere in the body. The patients were called for regular follow-up for three weeks. In forty cases mercurochrome was applied as the antifungal agent after cleaning the external auditory canal, in twenty-three clotrimazole and in rest of the seventeen patients miconazole was used. On 7th day, only 11 (13.7%) patients grew different fungi in culture. They became symptom-free on 14th day and no fungal material could be seen on otoscopy, direct microscopy or culture. Mercurochrome was found to be most effective in these patients.