Otomycosis: A Retrospective Study: Brazilian Journal of Otorhinolaryngology June 2009

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Otomycosis: A retrospective study

Article in Brazilian Journal of Otorhinolaryngology · June 2009


DOI: 10.1590/S1808-86942009000300010 · Source: PubMed

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Braz J Otorhinolaryngol.
2009;75(3):367-70. ORIGINAL ARTICLE

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Zélia Braz Vieira da Silva Lima3, Márcio de


Pontes1, Anna Débora Holanda Guerra4,
Ferreira Silva2, Neuza Maria
Edeltrudes
BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 75 de Oliveira
(3) MAY/JUNE 2009
Cavalcanti Oliveira5,
http://www.rborl.org.br / e-mail:
[email protected]
367
M r study with transversal cohort
a o Keywords: (2000-
r g aspergillus, 2006). Materials and methods:
i a candida, otitis 103 patients were assigned to
externa. mycological diagnosis (direct
a
G microscopic examination and
d u culture). Results: Otomycosis
was diagnosed in 19.4% of the
e e
patients. Patient age varied from
r
2 to 66 years (an average of
F r S 23.5 years of age), and 60% of
á a
t 7 u otomycosis cases were seen in
women between 2 to 20 years of
i m age. Chronic otitis, previous
m
a
m antibiotic therapy and the lack of
cerumen were predisposing
a factors; itching, otalgia, otorrhea
F r and hypoacusis were the
a symptoms reported by the
r y patients. The most frequently
i isolated species were C.
a albicans (30%), C. parapsilosis

O
s (20%), A. niger (20%), A. flavus
tomycosis is a fungal (10%), A. fumigatus (5%), C.
P tropicalis (5%), Trichosporon
infection of the external ear canal asahii (5%) and Scedosporium
e with only a few studies about its apiospermum (5%).
i real frequence in Brazil. Aim: to
Conclusions: Otomycosis is
x evaluate otomycosis frequence
and characteristics endemic in JoÆo Pessoa-PB.
o Clinical exam and mycological
t in patients with clinical
suspicion of external otitis. studies are important for
o diagnostic purposes because
Study design: Retrospective
otomycosis symptoms are not
C specific.
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BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 75 (3) MAY/JUNE 2009
http://www.rborl.org.br / e-mail:
[email protected]
368
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Pharmacist, Brazilian Journal of Otorhinolaryngology) on December 29,
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BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 75 (3) MAY/JUNE 2009


http://www.rborl.org.br / e-mail:
[email protected]
369
INTRODUCTION ber of 2006, based on the records from the Department
of Pharmaceutics Mycology Lab, and was approved by
the ethics committee (0019/08) of the Health Sciences
It is estimated that otitis externa make up 5 to 20%
Center Bioethics Committee of a Federal Higher Education
of ear-related visits to ENTs, most of them caused by
Institution. During this period, 103 patients with clinical
bacteria, and from the latter 9 to 25% are caused by
suspicion of external otitis coming from the ENT outpatient
fungi, called fungal otitis or otomycosis1,2. It is an infection ward of a University Hospital in the city of João Pessoa
that involves the external ear canal squamous epithelium, - PB were seen.
characterized by pruritus and occasional otalgia and
The biological material collection procedure was
hypoacusis3,4. innocuous, bringing the patients no risk. Considering that
Predisposing factors such as a failure in the ear’s the inner and middle ears are sterile, the external ear bears
defense mechanisms (changes in the coating epithelium, a skin commensal microbiota, before material collection
changes in pH, quantitative and qualitative changes in we cleaned the external ear canal with a moist swab. In
ear wax), bacterial infection, hearing aid or a hearing case there was secretion in the canal, we used a sterile
prosthesis, self-inflicted trauma (use of q-tips to clean the swab for the collection and the skin scales were collected
ear), swimming, broad spectrum antibiotic agents, steroids with the help of a sterile loop.
and cytostatic medication, neoplasia and immune disor- The samples were processed through a direct mi-
ders, all of which can render the host susceptible to the croscopic exam (KOH 20% + Quink Parker 51 permanent
development of otomycosis2,5,6. (2:1)14 and culture in agar Sabouraud dextrose with chlo-
After clinical exam (otoscopy and biomicroscopy) ramphenicol (0.05 mg/mL). The cultures were cultivated
it is possible to confirm diagnosis through mycological at 25-37°C with weekly observation during 30 days.
exams. Species from genera Aspergillus and Candida are The morphological characteristics of yeasts were
the ones most often involved. These fungi are opportunistic identified according to Lodder’s criteria (1971)15 by the
and usually bear varied pathogenicity, being part of the production of germinative tube, hydrolysis and urea,
normal microbiota from different body parts7,8. pseudofilaments and clamidoconides, and carbohydrate
Treatment recommendations go from germ termi- assimilation and fermentation. The isolates with characte-
nation or controlling predisposing factors, to local debri- ristics of filamentous fungi were identified based criteria
dement (microaspiration) and/or the use of antimicrobial from Hoog and Guarro (1999)16 by microcultivation.
agents (topic/systemic)9,10.
Although otomycosis is a disease spread throughout RESULTS
the world, there are only a handful of studies regarding its
true frequency in Brazil4,11-13, especially in João Pessoa-PB. A total of 103 patients were referred to mycological
The present paper aims at assessing otomycosis symptoms diagnosis of otomycosis, with an average of 12.7 requests
and frequency in patients referred to the Mycology Lab
for mycological diagnosis.
per year. In 19.4% of the patients the clinical diagnosis of
MATERIALS AND METHODS otomycosis was confirmed by direct microscopic exami-
nation and repetitive positive cultures.
A retrospective, descriptive study, with quantitative The age of the 20 patients varied from 2 to 66 years
analysis was carried out from January of 2000 to Decem-

Table 1. Otomycosis etiological agents according to gender, age and ear affected of 20 patients with clinical suspicion of otitis externa

Otomycosis Gender Affected ear


Fungal species Age
n (%) FM Left ear
C. albicans* 6 (30) 51 2, 4, 7, 15, 19, 59 44
C. parapsilosis* 4 (20) 31 2, 14, 15, 45 32
C. tropicalis 1 (5) -1 33 1-
T. asahii 1 (5) 1- 13 -1
A. niger* 4 (20) 31 22, 23, 43, 66 41
A. flavus 2 (10) -2 18, 51 11
A. fumigatus 1 (5) -1 13 1-
S. apiospermum 1 (5) -1 5 -1
TOTAL n (%) 20 (100) 12 (60) 8 (40) 14 (58) 10 (42)

*Bilateral otomycosis case


(mean age: 23.5 years) and 60% of them were between 2 Species of Aspergillus and Candida are the most
and 20 years, and were females (Table I). commonly identified germs causing otomycosis. Studies
We observed 40% of bilateral infections and 57% found a greater prevalence of Aspergillus (A. niger, A. fu-
infections in the right ear. Chronic otitis (30%), prior migatus, A. flavus and/or Aspergillus spp.) as otomycosis
antibiotic treatment (30%), no cerumen (20%) external agents7,17,18,22-25. Jaiswal et al. (1990)26 and Navarrete et
auditory canal manipulation (15%) were the most relevant al. (2000)21 found 46% and 35% of Candida spp.,
predisposing factors; and the most reported clinical signs respectively. In São Paulo, there were 75% of Aspergillus
were: pruritus (60%), otalgia (45%), otorhrea (30%) and and 20% of Candida4 species identified. The data found
hypacusis (30%) (multiple responses). in the present study were of 55% of isolates of Candida
As germs responsible for these otomycosis cases, (C. albicans, C. parapsilosis and C. tropicalis) and 35% of
Candida genus was the most frequent (55%), followed by Aspergillus (A. niger, A. flavus and A. fumigatus).
Aspergillus (35%), Trichosporon (5%) and Scedosporium T. asahii and S. apiospermum were also identified
(5%). Of the species identified, 30% were C. albicans, as causing agents in these cases of otomycosis. Reiersöl
20% C. parapsilosis, 20% A. niger, 10% A. flavus, 5% A. (1955)27 reported a case of otomycosis by T.cutaneum. The
fumigatus, 5% C. tropicalis, 5% T. asahii and 5% S. apios- Scedosporium genus encompasses a group of filamentous
permum (Table I). fungi isolated from water, soil, stalled or polluted water
all over the world. Two species cause human infection: S.
DISCUSSION apiospermum (asexual anamorphous of Pseudoallescheria
boydii) and S. prolificans (S. inflatum). Considered infre-
Otomycoses are frequent infections in tropical quent, more important as human pathogens, especially in
countries, because of humidity and heat2,17-19. In São Paulo immunocompromised patients28,29.
- SP, Brazil of 736 cases of otitis, 2.7% were otomycosis20. A five-year review in Northern England included
Notwithstanding, there are very few otomycosis studies in 3 patients with otitis who had polymicrobial culture, in-
Brazil4,11-13. In João Pessoa - PB, Brazil, of 103 patients cluding P. boydii28. Yao and Messer (2001)30 diagnosed
with clinical suspicion of otitis externa, 19.4% were malignant otitis externa caused by Scedosporium apiosper-
diagnosed with otomycosis. mum in AIDS patients. In immunocompetent patients the
Usually, otomycosis can be diagnosed by means fungi affects the tissues, bones or joints after trauma. Otitis
of a clinical exam; nonetheless, a high rate of assumption media and externa by S. apiospermum was diagnosed
is required, and the most frequent symptom is pruritus; in an immunocompetent woman (62 years of age) who
and otalgia in the most advanced stages, otorrhea and/or had symptoms of chronic otomastoiditis and otorhea32. In
hypocusis7,10,21. However, in this study, the diagnose was the present study, S. apiospermum was found in the left
based on symptoms and laboratory workup; and pruritus, external auditory meatus of a five-year old immunocom-
otalgia, otorrhea and/or hypacusis were the symptoms petent boy.
more frequently reported by the patients. These symp-
toms can be attributed to factors such as humidity and CONCLUSION
heat recorded in João Pessoa, as well as lack of cerumen
by washing the external auditory canal and/or its mani- Otomycosis is, effectively, an endemic disease of
pulation reported by the patients, without losing sight João Pessoa-PB, a tropical climate city. Clinical follow
of the fact that most of the patients were of low socio- up and mycological diagnosis are important since symp-
economical status. toms (pruritus, otalgia, otorrhea and hypacusis) are not
The occurrence of bilateral otomycosis is very specific.
4,7,17
low . Ho et al. (2006)10 observed a bilateral involve-
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