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Pakistan Journal of Otolaryngology 2010; 26: 78-80 Original Article Otomycosis: Clinical Presentation and Management Zeba Ahmed, Atif Hafeez, Tariq Zahid, Mehboob A Jawaid Salman Matiullah, Muhammad Saleem Marfani ABSTRACT: OBJECTIVE: To determine the clinical presentation, predisposing factors, complications and treatment outcomes of otomycosis in the ENT department. STUDY DESIGN: A descriptive study. PLACE AND DURATION: Department of Otorhinolarngology – Head and Neck Surgery, Dow Medical College, Civil Hospital Karachi and Dow University of Health Sciences from January 2009 to January 2010. PATIENTS AND METHODS: This study included 70 consecutive cases of otomycosis over a period of 13 months, with minimum follow up of one month. Each patient was studied for gender, age, presenting symptoms, site, comorbidities, fungal species identified, prior treatments, disease complications, outcome after current treatment and duration of follow up. RESULTS: Out of seventy patients, 52 were females and 18 were males. 57% patients were between the ages of 20-50 years. In 62 (89%) patients only one ear was affected. Otalgia (91%), itching (89%) and aural fullness (80%) were the common most presenting complaints. Typical discharge is often a marked feature. Prior otalgic procedures like syringing increase the risk of developing otomycosis. In 52 patients (74%) typical discharge was identified as Aspergillus niger on otoscopic examination.Proper suction clearance of fungal discharge along with topical application of clortimazole(drops/cream) was found to be effective with higher resolution rate.Disease recurrence seen in 11% of the patients. CONCLUSION: In this study we found that otomycosis is more common in females than males. Aspergillus niger is the major etiologic agent. The typical presentation is with inflammation, severe discomfort, itching, scaling. Pruritus is more marked than with other forms of ear infections. Key Words: Otomycosis, Aspergillus niger, Aural symptoms. INTRODUCTION: It is estimated that otitis externa of otomycosis and treatment outcomes in our makes up 5 to 20% of ear related visits to ENT; most of population. them caused by bacteria, and from the latter 9 to 25% PATIENTS AND METHODS: This descriptive study are caused by fungi, termed as fungal otitis or included seventy patients of all age groups of both otomycosis. Otomycosis is an acute, subacute or chronic genders attended the out patient department of fungal infection of the pinna, the external auditory Otolaryngology- Head and Neck surgery Civil Hospital meatus and the ear canal. However the disease may Karachi and DUHS from January 2009 to January occur in the middle ear in case of perforated tympanic 2010. Data collected and analyzed including age, sex, membrane. The infection is usually unilateral and presenting symptoms, site, co morbidities, fungal characterized by inflammation, pruritus, scaling and species identified, prior treatments and disease severe discomfort such as suppuration and pain 1 . complications, outcome after treatments and duration Andrall and Gaverret were the first to describe fungal of follow up. All cases of Otitis externa (black spores infections of the ear2. Infection is caused by some species with pus discharge/ wet tissue paper in external of the saprophytic fungi, such as moulds and yeasts, auditory canal)were included in the study. In majority especially Aspergillus niger3,4. Other etiologic agents of patients 74%, diagnosis of otomycosis was made on include: A. flavus, A. fumigatus, Allescheria boydii, the basis of the recognizable and characteristic Scopulariopsis, Penicillium, Rhizopus, Absidia and appearance of fungal mats on otoscopy so, culture was Candida Spp 1,5,6. Classically, fungal infection is the not routinely obtained. But in 26% of patients, secretion result of prolonged treatment of bacterial otitis externa and pus were collected from the ear (one swab was used that alters the flora of the ear canal. Mixed bacterial for direct microscopy and other for culture examination). and fungal infections are thus common. However, fungus Successful treatment outcome was defined as resolution is occasionally the primary pathogen in otitis externa , of all evidence of fungal infection on physical especially in the presence of excessive moisture or heat7. examination. Duration of follow-up was defined as time Other predisposing factors for otomycosis, including a elapsed from the date of diagnosis to the last date of humid climate, presence of cerumen , instrumentation clinic visit. Recurrent disease was defined as a condition of the ear, immunocompromised host and recently that occurred in patients who had resolution of disease increased use of topical antibiotic / steroid after initial treatment but recurred in the same ear at preparations 8 . Although otomycosis rarely life- a later date. Data was presented as percentages. threatening, but presents as a challenging and RESULTS: Seventy patients attending ENT OPD frustrating entity for both patients and supposed to be suffered from disease were involved in otolaryngologists for its long term treatment and follow the study. It included fifty two females (74%) and 18 up, yet the recurrence rate remains high9. The aim of males (26%). The ages of the patients ranged from 5 this study is to determine the clinical presentation, years to 60 years. 57% patients were between the ages predisposing factors, otoscopic findings, complications of 20-50 years .Most of patients were seen between April Department of ENT-Head & Neck Surgery, Dow University of Health Sciences & Civil Hospital, Karachi. 8 79 Otomycosis: Clinical Presentation and Management to September. All patients had one or more of the aural other parts of the world1,10. But Kaur et al11 and Ho T9 symptoms (itching, otalgia, hearing loss) depicted in observed that otomycosis was more common in young Table 1. In 62 (89%) patients only one ear was men i.e. 60% and 56% respectively. In present study, 57% of the patients were between the ages of 20-50 Symptoms Percentage years, similar to the findings of other researchers10,11,12 Otalgia 91 % while Ho T9 found mean age of 47.6 years in his study Itching 89 % of Aural Fullness 80 % 132 patients. Otomycosis usually occurs most Otorrhea 77 % frequently in adults and less in children3. In this study Hearing Loss 51 % only two children were found below 10 yrs of age. The Tinnitus 43 % occurrence of otomycosis was unilateral and showed no preference for either side1,11. Bilateral ear involvement Table. 1: Otomycosis-Aural Symptoms. seen in 11% of patients was consistent with the finding observed by Ho et al (7%).9 Otalgia, itching, aural affected.Before developing the symptoms, twenty five fullness and otorrhea were the common symptoms patients used oil, mixture of oil and garlic juice, reported by the patients. Although pruritus has been antibiotics, steroids, antiseptics or wax solvent as ear frequently cited as one of the hallmark symptoms of drops. Only seven (10%) patients were diabetic. otomycosis 10 . The pruritus may be quite intense, Seventeen patient had dandruff. Four patient with resulting in scratching and further damage to the chronic allergic skin disease. History of swimming and epidermis.However, other investigators have reported aural syringing found in 36 and 18 patients respectively. that other symptoms were more common in their Physical examination findings suggested that studies:discharge4, itching10 and ear blockage11. These otomycosis include external auditory canal edema with symptoms were by no means specific to fungal infection black spores with pus discharge/ wet tissue paper and and diagnosis was mainly based on symptoms along sometime small well circumscribed areas of granulation with the otoscopic examination as done in other studies tissue within the external canal or on the TM. In 52 7,9 but in few patients, confirmation done by patients (74%) typical discharge was identified as laboratory Aspergillus niger on otoscopic examination, while in 18 workup. In this study Aspergillus species, especially patients culture revealed fungi of the genus Aspergillus A. niger, was the most common isolate (87%) on culture niger (9/18). 4 were positive for Apergillus Fumigatus medium. This finding was consistent with the studies species, two were positive for Aspergillus flavus and conducted by Mahmoudabadi AZ1, Hurst12 and three were positive for Candida species. Disease Ozcan et al13.In present study factors that predispose complications included serous otitis media in 8 (11%) to otitis externa include absence/ presence of patients, TM perforation in 10 (14%) patients, tympanic cerumen, local trauma, usually from use of cotton membrane perforations were considered a complication swabs, by syringing or hearing aids, swimming and of otomycosis if they were present during the initial diabetes appear to increase the risk for developing presentation and healed with the resolution of infection otomycosis consistent with the other studies1,7,8,9,14. or if they were observed to occur during the course of Various antifungal agents have also been used clinically treatment. The therapeutic agents were always used with variable rate success 9 . Both antifungal and in conjunction with thorough removal and cleaning of antibacterial may be used as eardrops with visible fungal elements in the external auditory canal. hydrocortisone drops if there is obvious infection or The most common therapeutic option used in our canal edema seen. practice was clotrimazole either in lotion or (cream in In current study, appropriate topical antifungal agents case of perforation) with or without antibiotic or steroids especially clotrimazole ear solution, sometimes with drops (in presence of pus / granulation tissues); (antibiotic/ steroid), were also prescribed and frequent treatment duration ranged from 1 to 3 weeks with the clearance with suction usually results in the resolution minimum follow up for one month. Overall, 64 (94%) of the symptoms of otomycosis. These results were patients improved with initial treatment. Two (3%) similar to the results of Jackmen’s study15. On the other patients were lost to follow-up after initiation of hand Ho T9 found ketoconazole as a preferred antifungal treatment. Among the 64 subjects that responded to agent for its efficacy against both Aspergillus and initial treatment, 6(11%) patients had recurrent Candida species. Most recently, there has been disease with 83% complete cure rate. Prevention of increasing concern with respect to increasing incidence recurrence included avoidance of the many predisposing of otomycosis from widespread use of antibiotics/ factors that have been discussed, particularly important steroid preparations, yet there was no such proof for patients with a narrowed external auditory canal provided on the incidence of otomycosis9. In this series especially in those who were immunosuppressed. neomycin-polymixin B-hydrocortisone drops were DISCUSSION: Otomycoses are frequent infections in prescribed as ototopical therapy only in six patients tropical countries, because of humidity and heat. before presentation. Although the chronic use of Majority of patients were seen in summer season when ototopical antimicrobial preparations remain a it was hot, humid and dusty environment in Karachi. potential predisposing risk factor, no specific Females were affected more than the males (2.9: 1); preparation appears to convey an increased risk for this finding was consistent with studies conducted in development of otomycosis. Complications such as TM perforation and serous otitis media as a result of 9 80 Otomycosis: Clinical Presentation and Management otomycosis are not uncommon and tend to resolve with treatment. The pathophysiology of the TM perforation may be attributed to avascular necrosis of the TM as a result of mycotic thrombosis in the adjacent blood vessels9. Tympanic Membrane perforation seen in 14% of patients is similar to that observed by Pradhan et al (16%)10 and Filipiak (12%)9. In this series, 83% of the patients had complete resolution of the infection with initial treatment. Limitation of study was that culture and sensitivity could not be done in every patient. Culture and sensitivity test is costly and not justifiable in patient with strongly suggestive clinical disease on otoscopy, there is generally a rapid response to antifungal treatment.Culture was not routinely obtained in every patient only performed in recurrent/resistant cases. CONCLUSION: Otomycosis can usually be diagnosed by clinical examination. Complications are not uncommon but usually resolve with application of appropriate topical antifungal agents. REFERENCES : 1. Mahmoudabadi AZ. Mycological Studies in 15 cases of Otomycosis, Pak J Med Sci October – December 2006 Vol. 22 No.4 486-488. 2. Joy MJ, Agarwal MK, Samant HC, et al. Mycologicaland bacteriological studies in otomycosis. Indian Journal of Otolaryngology 1980;32:72-5 3. Geaney GP. Tropical otomycosis, J Laryngol Otol 1967;8:987- 97. 4. Meirtusova S, Simaljakova M. Yeasts and fungi isolated at the mycology laboratory of the First Dermatovenerology Clinic of the Medical Faculty Hospital of Comenius University in Bratislava (1995-2000). Epidermiol Microbial Imunol 2003; 52:76-80. 5. Roland PS. Chronic external otitis, ENT J 2001; 80:12-6. 6. Pahwa VK, Chamiyal PC, Suri PN. Mycological study in otomycosis, Indian J Med Res 1983; 77:334-8. 7. Sander R.Otitis Externa: A Practical Guide to Treatment and Prevention Am Fam Physician 2001; 63:927-36,941-2. 8. Stern JC, Lucente FE. Otomycosis. Ear Nose Throat J 1988;67: 804-10. 9. Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: clinical features and treatment implications. Otolaryngol Head Neck Surg. 2006 Nov; 135(5):787-91. 10. Pradhan B, Tuladhar NR, Amatya RM. Prevalence of otomycosis in outpatient department of otolaryngology in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Ann Otol Rhino Laryngol 2003; 112:384-7. 11. Kaur, R., N. Mittal, M .Kakkar, A. K. Aggarwal, and M.D.Mathur .Otomycosis: a clinicomycologic study, Ear Nose Throat J.2000; 79:606-9. 12. Hurst WB. Outcome of 22 cases of perforated tympanic membrane caused by otomycosis. J Laryngol Otol 2001; 115:879-80. 13. Ozcan KM, Ozcan M Karaarslan A, Karaarslan F. Otomycosis in Turkey: predisposing factors, etiology, and therapy. J Laryngol Otol 2003; 117:39-42. 14. Mugliston T, O’ Donoghue G. OtomycosisÊ: a continuing problem. J Larygol Otol 1985; 99:327-33. 15. Jackman A, Ward R, April M, et al. Topical antibiotic induced otomycosis, Int J Pediatr Otorhinolaryngol 2005; 69:857- 60.
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