Pakistan Journal of Otolaryngology Otorrhea

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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.

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

     80                                                                       Otomycosis: Clinical Presentation and

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 :
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