Otomycosis

Source
1. Current Diagnosis & Treatment – Otolaryngology 4th edition, 2020
2. Cummings Otolaryngology 7th ed, 2020
3. Bailey’s Head and Neck Surgery Otolaryngology, 5th Edition, 2014
4. Ballenger’s Otorhinolaryngology 18th edition, 2016
5. KJ Lee Essentials of Otolaryngology 11th edition, 2016

I. General Considerations
A. Definition
 Otomycosis is an inflammatory process of the EAC due to infection with fungi.[1]
 Otomycosis is a fungal infection of the skin of the external canal.[3]
 Fungal infections are frequently involved in inflammatory processes of the ear canal
(Figure 14-7).[4]


B. Etiology
 A variety of fungal microorganisms are involved.[4]
 In 80% of cases, the etiologic agent is Aspergillus, whereas Candida is the
next most frequently isolated pathogen. Other rare fungal pathogens include
Phycomycetes, Rhizopus, Actinomyces, and Penicillium.[1]
 Although fungi may be the primary pathogens, they are usually superimposed on
chronic bacterial infection of the external canal or middle ear. Secondary otomycosis
tends to recur if the underlying primary infection is not controlled. All fungi have three
basic growth requirements: moisture. warmth, and darlmess. Altering moisture will
discourage fungal growth. Aspergillus species are the most common, usually A. niger;
If aural culture should grow A. fumigatus or A. flavus, one would be concerned about a
more invasive infection.[3]
 Much of the time, fungus found in the ear canal is saprophytic, meaning that it grows
on dead organic matter. This most often occurs in cases of chronic suppurative otitis
media where the pus serves as a food source for the fungus. In such cases, the fungus
involved, usually aspergilllus, is not a true infective pathogen. [4]
  Another common fungal infection found in the external ear is due to Candida species.
[4]
 Some external-ear complaints will be due to infection caused by
dermatophytes.[4]

C. Epidemiology
 and is responsible for roughly 10% of the diagnoses of otitis externa.[1]

D. i

II. Pathogenesis
 Otomycosis has similar predisposing factors to bacterial otitis externa. Patients with
diabetes mellitus or an immunocompromised state are particularly susceptible to
otomycosis. Patients with a mastoid bowl after a canal wall-down procedure are also
predisposed to development of otomycosis.[1]
 All fungi have three basic growth requirements: moisture. warmth, and darkness.
Altering moisture will discourage fungal growth.[3]
 Much of the time, fungus found in the ear canal is saprophytic, meaning that it grows on
dead organic matter. This most often occurs in cases of chronic suppurative otitis media
where the pus serves as a food source for the fungus. In such cases, the fungus involved,
usually aspergilllus, is not a true infective pathogen. The drainage and infection may be
due to a middle-ear infection.[4]
 Sapprophytes, however, can become invasive infectious microorganisms when there is
significant immune suppression or limited circulation of blood. Invasive fungal
infections can be rapidly fatal and requires aggressive treatment. Often their presentation
is identical to that of necrotizing otitis externa. The fungal hyphae often spread in the
endothelial layer of the blood vessels, causing hypoperfusion and necrosis (as seen in
mucormycosis).[4]
 Candidal infections are also more saprophytic in nature. They are characterized by a
large amount of cheesy, white debris in the canal. The underlying canal skin may be
slightly edematous and erythematous but less severe than that seen in AOE. Very often,
these candidal overgrowths are the result of overuse of newer antibiotic otic drops. Otic
quinolone preparations will suppress bacteria and allow overgrowth of the resident
Candida species.[4]
 These microorganisms (dermatophytes), notorious as a cause of athlete's foot and
ringworm, will cause severe ear itching and scaling of the canal skin.[4]

III. Clinical Findings

 Pruritus is the primary clinical complaint. The otoscopic examination commonly reveals
a white, black, or dotted gray membrane.[3]
 Patients with otomycosis most frequently present with pruritus, aural fullness, and
otorrhea, and may also complain of otalgia and hearing loss. The hearing loss associated
with otomycosis usually results from the accumulation of mycotic debris rather than
extensive canal edema.[1]
  Otoscopy often reveals mycelia, establishing the diagnosis. The EAC may be
erythematous and fungal debris may appear white, gray, or black. Patients have typically
been tried on topical antibacterial agents with no significant response. The diagnosis
can be confirmed by identifying fungal elements on a KOH preparation or by a positive
fungal culture.[1]
 For invasive fungal infection : Often their presentation is identical to that of necrotizing
otitis externa.[4]
 For Candida infections : They are characterized by a large amount of cheesy, white
debris in the canal. The underlying canal skin may be slightly edematous and
erythematous but less severe than that seen in AOE.[4]
 One interesting aspect of dermatophytic infection is the risk of the dermatophytid, or “id”
reaction. This phenomenon, not uncommon with dermatophytes, is when a local
inflammatory skin reaction is caused by an infection some distance away.19 This is
sometimes seen in the external ear, where a patient will present with chronic itching and
scaling of the canal that does not respond to any local therapy. Canal scrapings viewed
with a potassium hydroxide (KOH) preparation fail to show any microorganisms. Often,
additional questioning will reveal the presence of a troublesome dermatophytic
infection such as an athlete's foot. Successful treatment of the primary dermatophytic
infection will often cause a clearing of the id reaction as well.[4]

IV. Treatment
A. In General
 The treatment of otomycosis includes cleansing and debriding the EAC, acidifying
the canal, and administering antifungal agents. Non-specific antifungal agents
include thimerosal (eg, Merthiolate) and gentian violet Commonly used specific
antifungals include clotrimazole, nystatin (otic drops or powder), and ketoconazole.
Topical ketoconazole, cresylate otic drops, and aluminum acetate otic drops are all
relativety effective with > 80% resolution rate on initial application. CSP powder
(chloramphenicol, sulfamethaxazole or sulfanilamide, and fungizone/amphotericin
B) is also an acellent option.[1]
 Thorough cleaning under a microscope with the patient supine to remove any fungal
debris is the first and absolutely most important step in therapy.[3]
 Thorough aural toilet is supplemented by the topical application ofan
acidifyingsolution such as aluminum sulfatecalcium acetate (Domeboro) or by a
drying powder such as boric acid.[3]
 Clotrimazole cream or solution (Lotrimin) may also be used.[3]
 In the presence of a TM perforation or a patent ventilation tube, clotrimazole drops
or lotion may be very painful. Thorough cleaning and drying therapies such as
powders are best. Metacresyl acetate (Cresylate) may be painted on the margin of a
perforation or an infected ventilation tube. This is best done under the microscope.
This medication should not enter the middle ear cleft because it is quite irritating.[3]
 In recalcitrant infections, a foreign body such as a ventilation tube acts as the nidus
for infection and should be removed.[3]
 Tympanoplasty is best performed to close a perforation that intermittently drains
with a superimposed fungal infection.[3]
 Gentian violet is usually well tolerated in patients with mastoid cavities, although it
is best left out of the middle ear cleft in the presence of a perforation. Because it will
 permanently stain skin and clothing, small amounts are used with adequate
protection of the surrounding area.[3]
 Treating physicians should realize that all drops are formulated with moisture and
do not persist indefinitely in an homogenized state. Eventually, the water component
will separate from the precipitate of the active medical ingredient. Water is exactly
what fungi need to grow. Adding drops indefinitely to an ear with otomycosis may
prove counterproductive. In these cases, an acidifying powder such as boric acid or
a compounded powder, as described below, will often help dry up a refractory ear.
[3]
 Many patients with refractory otomycotic infections may have had previous mastoid
surgery. Often the canal wall is down. Due to moderate to severe hearing loss, the
patient may need to wear a hearing aid with a closed mold. This is a significant
problem because the patient relies on the aid virtually all day and is reluctant to
leave the instrument out Careful instruction to the patient,. Meticulous debridement
of the ear, and the use a drying agent such as boric acid powder, Chloromycetin-
sulfanilamideFungizone (amphotericin B) powder or Chloromycetinsulfanilamide-
Tinactin (tolnaftate) powder will often help clean up the cavity. Ointments in
cavities with closed hearing aids may promote fungal growth due to the
accumulation of moisture. In refractory cases, gentian violet or
metacresyl acetate (Cresylate) is used topically.[3]

B. Specific
 For Aspergillus infection
o Saprophytic
 Debridement of granulation and necrotic tissue and treatment of the
underlying suppuration will usually resolve the fungal overgrowth.[4]
o Invasive
 Aggressive surgical debridement, correction of immune suppression and
high-dose amphotericin B are appropriate therapy for these frail patients.[4]
 For Candida infection
Complete debridement, acidifying drops, and, occasionally, instillation of antifungal
creams or ointments (eg, nystatin) will frequently be curative.[4]
 For Dermatophyte infection
Patients with dermatophytic infections are usually treated with acidifying drops with a
corticosteroid and on occasion may need more specific antifungal treatment.[4]