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Otomycosis in relation to csom

Article in Gujarat Journal of Otorhinolaryngology and Head and Neck Surgery · January 2011

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 Main Article

Otomycosis in relation to csom

Santosh UP1, Deepak Janardhan2 -Davangere (Karnataka)
Abstract:
Introduction-Otomycosis, an entity frequently encountered by Otolaryngologists, can usually be diagnosed by clinical
examination. Due to non specific symptoms, accurate diagnosis requires a high index of suspicion, especially in cases of
Chronic Suppurative Otitis Media (CSOM).
Objectives- To study the etiology, causative agents and clinical features of fungal ear
infection with special reference to previously diagnosed CSOM patients and the effectiveness of treatment with Clotrimazole
containing antibiotic ear drops in these patients.
Methodology- Cross sectional study of 100 CSOM patients who attended the outpatient department of ENT of Bapuji Hospital
and Chigateri General Hospital, teaching hospitals attached to J.J.M. Medical College, Davangere, from Nov 2008 to July 2010,
with microbiological confirmation of Otomycosis, were studied.
Results-Otomycosis in CSOM, mostly affected males (54%).The 20-30 year age group,
students and housewives were more often affected. Prior antibiotic ear drops usage (51%)
and manipulations (31%) were common predisposing factors. Cultures revealed
Aspergillus (69%) and Candida (22%) in majority. Treatment with clotrimazole containing antibiotic ear drops was found to be
effective in most patients. Relapses were noted in post mastoidectomy (CWD) patients.
Conclusions- The diagnosis of Otomycosis in CSOM patients due to nonspecific presentations and refractoriness to usual
topical therapy requires clinicians to be vigilant. Treatment with 1% Clotrimazole containing antibiotic topical drops with aural
toileting is generally effective. However, recurrence is not uncommon.
Keywords: Otomycosis, Fungal Otitis externa

Introduction Patients previously diagnosed with CSOM were subjected to

Otomycosis, an entity frequently encountered by
Otolaryngologists, can usually be diagnosed by clinical
examination. Due to non specific symptoms, accurate
diagnosis requires a high index of suspicion, especially in
cases of Chronic Suppurative Otitis Media (CSOM).
Objective
To study the Etiology, Causative agents and Clinical features
of fungal ear
infection with special reference to previously diagnosed
Chronic Suppurative Otitis
Media patients and to study the effectiveness of treatment
with Clotrimazole containing antibiotic ear drops in these
patients.
Methodology
Inclusion Criteria:
· Previously diagnosed cases of CSOM presenting with
discharging ear and Otomycotic super-infection
evidenced clinically or microbiologically, irrespective of
whether patient is on treatment.
Exclusion Criteria:
· Patients not willing for clinical examination and relevant
investigations.
· Patients not adhering to treatment and follow up
schedule.
a detailed history and thorough ENT examination. Swabs
were taken from cases with suspected ear discharge and / or
scrapings of debris, were taken for microscopic examination
with 10% KOH. No transport media was used. Fungal culture
was done with Saboraud's dextrose agar incubated at room
temperature for three to four weeks. Morphology of fungal
spores,
hyphae and conidia were studied using Lacto phenol cotton
blue mount preparation. Patients were treated with topical
Clotrimazole ear drops for 2 weeks and reviewed on the 7th,
14th and 21st day with Otoscopy and swabs from EAC for
microscopy; and thereafter 2 weekly in second month.
Successful treatment: Defined as resolution of fungal
infection on physical
examination on 21st day of follow up.
Residual disease: Defined as a condition that failed to respond
to initial treatment.
Results
Majority of subjects were aged between 21- 30 years, and
predominantly males (54%). They were mainly housewives,
students, manual laborers and farmers.Presenting complaints
were itching (67%), ear discharge (58%) and earache (57%).
2% had only itching of ear while 32% had both itching and
pain. In this study, all had unilateral disease (60% in right ear),

1
Professor,2 Resident, Department of Otolaryngology, JJM Medical College, Davangere(Karnataka)

15 Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 2, August 2011
despite 5% patients having had bilateral CSOM.
The most common predisposing factor was excessive use of
antibiotic ear drops (51%), followed by aural manipulation or
trauma (31 %). 15% of the patients had history of similar
illness in the past. 17% were diabetic, 6% had
dermatophytosis elsewhere for which dermatology opinion
was sought and 3% were retro positive and on antiretroviral
treatment Inspection revealed fungal debris within the canal
in the form of mycelial mat in 46%, and mycological plug in
29%. On Otoscopy, 17% had cotton wooly appearance and
8% had a soft debris picture. While 13% had associated
redness, 10% had edema on examination of the ear canal skin.
Scanty - moderate quantity of mucoid / mucopurulent
discharge was found in 36% while 9% had granulations. 5%
had post operative open mastoid cavity and 3% had post aural
scar following Myringoplasty. 50% of CSOM was associated
with small central perforation, 24% with large perforation and
3% had intact tympanic membrane following prior
Myringoplasty. 64% of the cases were found to have fungal
elements on microscopic examination of aural swabs.
However, 99% yielded positive fungal cultures. Cultures
revealed Aspergillus species in 69% and Candidal growth in
22% and mixed 2%.
Otoscopic appearances of fungal plug in 41 patients were
studied. 32 had a white plug and 9 had a yellow plug. This
correlated with culture reports which showed that whitish
plugs included A. niger, A flavus, Candida or even mixed
growth while yellow plugs included A. fumigatus, or
Candida. All patients were treated with aural toileting, oral
antibiotics, antihistaminics and analgesics (as required) for
five days along with topical Ofloxacin, Beclomethasone
(0.02%) and Clotrimazole (1%) thrice daily for 14 days.
During treatment, 5% of patients were not able to tolerate
antibiotic, antifungal or steroids combination ear drops. They
were treated with Clotrimazole ointment impregnated cotton
wick, every alternate day, for 14 days. Surprisingly, treatment
was successful in all patients, with no residual disease found
on regular follow up till 1 month. Follow up on 21st, 35th and
49th day revealed 100% successful treatment outcome.
Recurrence over a period of 3-6 months was noted in five
patients (5%) who had undergone Canal wall down
procedures.
Discussion
Andrall and Gaverrett were the first to describe fungal
infections in ear 1.Otomycosis is the fungal infection of the
external auditory canal (EAC). It can be acute, sub acute or
chronic. It is characterized by exudative inflammation and
pruritus from which a number of fungi and bacteria can be
16 Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 2, August 2011
isolated. Its prevalence ranges from 9% of cases of Otitis
externa 2, to as high as 30.4% in patients presenting with
symptoms of Otitis or inflammatory conditions of the ear 3.It
is more common in tropical and subtropical countries with
warm humid climates.Certain saprophytic fungi abundant in
nature and present as commensal flora of healthy EAC can
cause Otomycosis. e.g., Aspergillus, Penicillium, Rhizopus,
Candida species and Dermatophytes.
Otomycosis in CSOM patients occurs predominantly in
young adults. The relatively young 21 – 30 year old age group
constituted a majority of the cases in this study (40-70 %),
possibly due to low socioeconomic status and poor personal
hygiene 4, 5 .
Men working in damp, warm conditions as in agricultural
fields are exposed to dust and have a risk of deposition of
fungal spores. Unhygienic practices such as cleaning the EAC
with dirty fingers, twigs of plants or match sticks may result in
deeper deposition of locally prevalent fungi. Also, the moist
environment in the middle ear and EAC, and epithelial debris
favor fungal growth. Housewives with CSOM, who regularly
sweep their houses, are exposed to fungal spores mixed with
dust that predispose to disease initiation. Though studies have
shown equal or slightly higher incidences in either males or
females, it can be understood that gender has no influence on
immunity against Otomycosis, which can therefore affect
either gender group.
Active indulgence by students in sports activities and poor
hygienic practices like cleaning the EAC with folded paper,
pencil or dirty fingers can contribute to the development of
Otomycosis.
The most common symptom was itching, followed by pain
and discharge though other studies found that the sensation of
fullness was most common 4. There has been escalating
concern about the widespread use of Quinolone ear drops
acting as a predisposing factor for the development of
Otomycosis 6 . Recurrent Otomycosis following
mastoidectomy was reported to be 4.6% 4 .Swimming leads to
dampness of EAC skin which results in meatal skin
maceration, an excellent culture medium for fungal growth.
Antibiotic ear drops are bactericidal to most organisms in
EAC causing a consequent fungal proliferation due to
depletion of competing bacteria. Simultaneous management
of co-morbid conditions like diabetes and dermatophytosis
elsewhere is mandatory, in order to prevent recurrences and
refractoriness to treatment.
Otoscopic examination of the EAC revealed redness and
edema with presence of granulations in 10-13% of patients, as
reported earlier 5. Lack of wax or unhealthy cerumen
appearing soft, watery and non-sticky implies defective
 functioning of ceruminous glands and can be due to References
Otomycosis 5. 1. Mugliston T and O'Donoghue G (London). Otomycosis
Microscopic examination with 10% KOH and or Lactophenol – A continuing problem. The
Cotton Blue mount preparation identifies fungal elements Journal of Laryngology & Otology April 1985; 99: 327-
which are confirmed by cultures. Previous studies found 33.
11.5% negative reports on culture and microscopic 2. Ta n g H o , J e f f r e y a n d N e w t o n ( Te x a s ) .
examination, in contrast to 1% in this study. This proves that Otomycosisclinical features and treatment.
mere microscopic examination cannot be taken as evidence Head and Neck Surgery 2006; 135: 787-91.
for fungal presence and has to be authenticated with culture 3. Kurnatowski P, Filipiak A. Otomycosis : Prevalence,
reports. clinical symptoms, therapeutic procedures. Mycoses
The commonly acknowledged fungal etiological agents of 44.(2001): 472-79
Otomycosis include A. niger, A. fumigatus, A. flavus, C. 4. Bibihu Pradhan, Ratna N, Amatya RM. Prevalence of
albicans, other Candida species, Alternaria and Penicillium. Otomycosis in OPD of ENT in Tribhuvan University
Clotrimazole, the most widely used, non ototoxic, topical Teaching Hospital, Kathmandu, Nepal. Ann Otol
azole, is one of the most effective agents for the management Rhinollarygol 2003; 112: 384-87
of Otomycosis. Clotrimazole is helpful in treating mixed 5. Paulose KO, Khalifa S Al, Shenoy P, Sharma RK.
bacterial-fungal infections. None of our patients had residual Mycotic infection of the ear
disease. (Otomycosis) – A prospective study. JLO Jan 1989; 3:
Recurrence in patients with Canal wall down mastoid cavities 30-35.
has been reported to be between 4.6 to 23% 4,2. Factors 6. Jackman A, Ward R, April M, Bent J. Topical antibiotic
implicated in fungal growth are recurrent drainage, induced Otomycosis, Int J
injudicious use of antibiotic ear drops favoring nosocomial Pediatr Otorhinolaryngol 69 (2005) 857—860.
fungal super infection and alteration of anatomy by CWD
procedure, altering cerumen production and relative Address for correspondence
humidity. Frequency of recurrent cases seen in tertiary Dr. Santosh U.P
Otology practice may also be due to the inherent referral bias. ‘Saavan' No 4123,14th cross, Anjaneya layout
Moreover, difficulty in applying topical medications in the Davangere -577004
relatively large surface area of the cavity especially when Cell +91 9845155223
focus of infection is in the superior or posterior aspects of the Email – drsantoshup@gmail.com
cavity also needs special mention.

Conclusion
Otomycosis in CSOM patients is an entity that Otologists
worldwide need to be aware of. This will aid in reducing the
morbidity, need for recurrent clinic visits and the financial
burden imposed on the patient by unnecessary prescriptions
of topical antibiotics for prolonged periods.A 14- day, thrice
daily usage of broad spectrum topical preparation (with
Ofloxacin) is one of the shortest and most effective treatment
regimes studied till date, with no evidence of associated
Ototoxicity. However, this becomes effective only when in
conjunction with thorough aural toileting, which is the most
important aspect of treatment.Fungal culture and drug
sensitivity testing is warranted in patients from Clotrimazole
resistant areas as mere Otoscopy may not suffice in
identification of fungal species. Prior otological procedures
like CWD surgeries can alter the EAC anatomy and hence,
regular follow up is imperative.

17 Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 2, August 2011

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