Otomycosis with Perforated Tympanic Membrane: Self medication with Topical Antifungal Solution versus Medicated Ear Wick

Approach to otitis externa

OBJECTIVE

To provide family physicians with a practical evidence-based approach to management of otitis externa.

SOURCES OF INFORMATION

The approach described is based on MEDLINE and PubMed literature published between 1993 and 2023.

MAIN MESSAGE

Otitis externa is diffuse inflammation of the external auditory canal and typically occurs from moisture exposure and trauma. Management focuses on eliminating infection, pain management, education, and preventing recurrence. The primary treatment of uncomplicated otitis externa is topical. Complicated presentations may require additional systemic therapy.

CONCLUSION

History taking and physical examination can help differentiate among acute, chronic, and necrotizing otitis externa. At-risk populations, typically those who are immunosuppressed, are more likely to develop necrotizing otitis externa and should be carefully monitored.

Approche pour les cas d’otite externe

Objectif

Présenter aux médecins de famille une approche pratique fondée sur des données probantes pour la prise en charge de l’otite externe.

Sources de l’information

L’approche décrite se base sur une recherche documentaire effectuée dans MEDLINE et PubMed pour trouver des ouvrages publiés entre 1993 et 2023.

Message principal

L’otite externe est une inflammation diffuse du conduit auditif externe qui se produit habituellement à la suite d’une exposition à l’humidité ou à un traumatisme. La prise en charge vise l’élimination de l’infection, le contrôle de la douleur, l’éducation et la prévention de la récurrence. Le principal traitement d’une otite externe sans complications est sous forme topique. Les présentations plus complexes peuvent nécessiter une thérapie systémique supplémentaire.

Conclusion

L’anamnèse et l’examen physique peuvent aider à faire la distinction entre une otite externe aiguë, chronique ou nécrosante. Les populations à risque, habituellement celles qui sont immunodéprimées, sont plus susceptibles de développer une otite externe nécrosante et devraient faire l’objet d’une surveillance étroite.

Nanocrystalline Silver for the Treatment of Otomycosis: A Retrospective Study

Introduction

Otomycosis is a common fungal ear infection usually found in tropical and subtropical countries where infections arise due to hot and humid conditions. Also, these infections have a high recurrence rate with limited therapeutic options, which makes their management difficult. There is a long history of applying various antiseptic agents consisting of silver specifically for these broad-spectrum infections. Silver nanoparticles (AgNPs) are futuristic nano-size products for controlling the microbial infection. The study aimed to determine the antifungal properties of nanocrystalline silver in patients with otomycosis.

Materials and Methods

The study was conducted in Pune (India) in the department of Ear Nose Throat & Head at the Dr. D.Y. Patil Medical College, Hospital and research center, Pune (India) for a period of one year (2019 -2020). Our study included 100 patients (58 male and 42 female) with clinically diagnosed otomycosis, which was treated by applying nanocrystalline silver gel-soaked Gelfoam.

Results

Our study had patients of 18 to 60 years, with the highest prevalence in males (58%) aged 30 to 45 years. A large number of infection cases were reported at the hospital, i.e., 62 cases during the wet season as compared to 38 cases during the dry season. Commonly found fungi belonging to the genus Aspergillus (55%), followed by Candida (45%). Improvements in symptoms were observed in 89% of the patients (70% within 5 to 6 days and 19% from 7 to 14 days).

Conclusion

Applying nanocrystalline silver cured most of the patients (89%) within 14 days. Treating otomycosis patients with nanocrystalline silver demonstrated beneficial results. Further studies with larger samples should be conducted to validate the benefits of nanocrystalline silver.

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.

Otomycosis in the South of Iran with a High Prevalence of Tympanic Membrane Perforation: A Hospital-Based Study

INTRODUCTION

Otomycosis is a superficial infection of the external ear caused by fungal pathogens. The genera Aspergillus and Candida are considered the main fungal causative agents, with the predominance of Aspergillus section Nigri. The present study aimed to evaluate the clinical symptoms of patients with otomycosis and predisposing factors and to identify fungal etiological agents using molecular approaches. We also present an overview of published papers on tympanic membrane perforation (TMP) secondary to otomycosis.

MATERIALS AND METHODS

An otorhinolaryngologist collected specimens from external ear canals of patients with suspected otomycosis based on the patient's history and clinical examinations. The specimens were collected using sterile swabs. Fungal isolates were confirmed in clinical specimens by direct microscopy and culture methods. Fungal isolates were identified based on molecular approaches.

RESULTS

In total, specimens from 211 patients with suspected otomycosis were examined. The presence of fungi was confirmed in about 51% of patients based on fungal elements in direct microscopy and culture-positive fungi. Aspergillus tubingensis was the most commonly isolated species (52.77%), followed by Aspergillus niger (25.92%). Otomycosis due to infection with Candida species was observed in 16% of cases. Of note, in 36.11% of cases, otomycosis was associated with TMP.

CONCLUSION

A mycological examination is indispensable for a correct diagnosis in patients with otitis extern. TMP should be considered in patients with otomycosis, as it appears to be relatively common in this population.

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.

Role of Clotrimazole in Prevention of Recurrent Otomycosis

Otomycosis is one of the relatively common diseases in the world which is caused by different fungi especially saprophytes. Concerning the relapse of this disease in a number of individuals, the present study was performed to evaluate the inhibitory effect of clotrimazole drop in the relapse of otomycosis. Clinical samples were taken by an ENT specialist from patients suspicious of having otomycosis. A part of these samples were stained, and others were cultured. The diagnosis of otomycosis was made on the basis of the recognizable and characteristic appearance of fungal hyphae or mycelium and fruiting bodies and/or conidiophores under microscopic examination. Patients with suspected otomycosis are not at risk of recurrence after treatment with clotrimazole drops. Out of the 161 individuals in whom definite diagnosis of otomycosis was made, the most affected individuals were, in the age range of 40–49 years, women, urban citizens, and housewives. Pruritus and diminished hearing were the main complaints of the patients. Aspergillus niger and A. flavus as well as Candida albicans were the main causes of the disease. The relapse of disease was observed in only five patients (3.1%), where A. niger was the main fungus. Most relapses were observed in women and in those with diminished hearing, manipulating the ears, ulcers in the canal, and tympanum. Our results suggested that usage of clotrimazole can be effective in reducing the relapse of otomycosis, and concerning the high cost of treating otomycosis while the low cost of using clotrimazole, usage of this drop is recommended to reduce the relapse of otomycosis.

Otomycosis With Tympanic Membrane Perforation: A Review of the Literature

OBJECTIVE

The purpose of the present study was to assess the rate of tympanic membrane perforation in patients with otomycosis and to discuss the literature regarding the difficulties in managing this condition.

DATA SOURCES

Literature review from 1999 to 2019, Web of Science, PubMed, and Medline.

STUDY SELECTION

We searched for eligible articles concerning the clinical entity of tympanic membrane perforation secondary to otomycosis. Case series and clinical trials were the types of articles included for this review.

DATA EXTRACTION

All the articles described in the study selection were used for this review.

DATA SYNTHESIS

Statistical techniques were not used.

CONCLUSION

Based on the available literature, it seems that tympanic membrane perforation secondary to otomycosis is not uncommon. The presence of this complication is associated with 2 problems: Antimycotic solutions are irritant to middle ear and may be ototoxic to the cochlea. Although most cases of fungus caused tympanic membrane (TM) perforation resolve with proper medical treatment, in a few patients a tympanoplasty may be required.

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.

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.

Assessment of Response to Treatment in Patients with Otomycosis

INTRODUCTION

Due to the prevalence of otomycosis in the north of Iran, which has a humid climate, this study aimed to examine the recurrence rate of otomycosis in Iranian patients.

MATERIALS AND METHODS

This cross-sectional study was performed in all patients suspected of otomycosis referred to the Otorhinolaryngology Clinic of Ayatollah Rouhani Hospital of Babol. Demographic and clinical data of patients as well as their symptoms were collected in a checklist at referral time and also 14 days after referral.

RESULTS

The results showed that 11 (7.3%) cases had a recurrence of otomycosis. There was no significant relationship between the incidence of otomycosis and age or sex (P=0.86 and 0.88, respectively). Septate mycelium was the most observed element on direct examination. Aspergillus flavus was the most common pathogenic agent in culture media, followed by Aspergillus niger and Candida albicans.

CONCLUSION

Based on the results of this research in Babol, the recurrence of otomycosis was 7.3% and was related to swelling and erythema in ear canal.

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.

Primary otomycosis in the Indian subcontinent: predisposing factors, microbiology, and classification

Objective. To define otomycosis and determine the predisposing factors and microbiology in primary otomycosis. Study Design. Prospective study of two years and review of the literature. Setting. Academic Department of Otolaryngology in a coastal city in India. Patients. 150 immunocompetent individuals of whom 100 consecutive patients with a clinical diagnosis of otomycosis are considered as the study group and 50 consecutive patients with no otomycosis are considered as the control group. Results and Observations. Instillation of coconut oil (42%), use of topical antibiotic eardrops (20%), and compulsive cleaning of external ear with hard objects (32%) appeared to be the main predisposing factors in otomycosis. Aspergilli were the most common isolates (80%) followed by Penicillium (8%), Candida albicans (4%), Rhizopus (1%), and Chrysosporium (1%), the last being reported for the first time in otomycosis. Among aspergilli, A. niger complex (38%) was the most common followed by A. fumigatus complex (27%) and A. flavus complex (15%). Bacterial isolates associated with fungi in otomycosis were S. aureus, P. aeruginosa, and Proteus spp. In 42% of healthy external ears fungi were isolated. Conclusion. Aspergillus spp. were the most common fungi isolated, followed by Penicillium. Otomycotic ears are often associated with bacterial isolates when compared to normal ears. Fungi are also present in a significant number of healthy external auditory canals and their profiles match those in cases of otomycosis. The use of terms "primary" and "secondary" otomycosis is important to standardize reporting.