otomycosis

VISWANATHA, SUMATHA, VIJAYASHREE

114 www.entjournal.com ENT-Ear, Nose & Throat Journal March 2012

Otomycosis in immunocompetent and immunocompromised patients: Comparative study and literature review

ORIGINAL ARTICLE

Borlingegowda Viswanatha, MS, DLO; Dadarao Sumatha, MBBS; Maliyappanahalli Siddappa Vijayashree, MBBS, MS

From the Department of ENT, Victoria Hospital and Bangalore Medical College and Research Institute, Bangalore, India.

Corresponding author: Dr. Borlingegowda Viswanatha, MS, DLO, #716, 10th Cross, 5th Main, M.C. Layout, Vijayangar, Bangalore - 560 040, Karnataka, India. Email: [email protected]

AbstractA comparative clinical study was carried out that included 50 cases of otomycosis in immunocompetent patients and 50 cases of otomycosis in immunocompromised patients. Clinical presentation, predisposing factors, mycologic profile, and treatment outcomes were compared. Asper-gillus spp were the most commonly isolated fungi in the immunocompetent group, and Candida albicans in the immunocompromised group. Bilateral involvement was more common in the immunocompromised group. All the patients were treated with topical clotrimazole ear drops. Four patients in the immunocompromised group did not respond to treatment with clotrimazole but were treated successfully with fluconazole ear drops. Three patients had a small tympanic membrane perforation due to otomycosis.

IntroductionOtomycosis is a superficial, subacute, or chronic infec-tion of the outer ear canal, usually unilateral, that is characterized by inflammation, pruritis, and scaling.1 It occurs because the protective lipid/acid balance of the ear is lost.2

Fungi cause 10% of all cases of otitis externa.2 In re-cent years, opportunistic fungal infections have gained greater importance in human medicine, perhaps because of the huge number of immunocompromised patients. However, such fungi may also produce infection in immunocompetent hosts.1 In immunocompromised patients, treatment of otomycosis should be vigorous to

prevent complications such as hearing loss and invasive temporal bone infection.3

We conducted a comparative clinical study involving 50 immunocompetent and 50 immunocompromised patients with otomycosis. Clinical presentation, pre-disposing factors, mycologic profile, and treatment outcomes were compared.

A review of the literature revealed no reported case series of otomycosis in immunocompromised patients.

Patients and methodsThis prospective study was carried out in 100 patients with otomycosis—50 who were immunocompetent and 50 who were immunocompromised. In the immunocom-promised group, 36 patients were diabetic, 9 patients had AIDS, and 5 patients were undergoing radiation therapy. The patients’ clinical profiles regarding age, sex, laterality, and clinical presentation were documented.

Only cases of otomycosis in patients with positive cultures were included in this study. Patients with oto-mycosis associated with otitis media and those already using antifungal ear drops were excluded.

The outer part of patients’ external auditory canals was cleaned using sterile swabs, taking material from the deeper portion of the ear canal that was sent for fungus culture. After microscopic suction clearance, antifungal ear drops were given for 3 weeks. All patients were followed for a minimum of 6 weeks.

Swabs were also taken from the external auditory canals of 10 immunocompetent and 10 immunocom-promised individuals without otomycosis. No fungi were isolated on fungal culture of these swabs.

Treatment of patients with otomycosis includes microscopic suction clearance of the fungal mass, dis-



continuation of topical antibiotics, and treatment with antifungal ear drops for 3 weeks. Our patients’ initial treatment regimen consisted of clotrimazole ear drops for 3 weeks. Those whose otomycosis did not re-spond to clotrimazole were switched to fluconazole ear drops. Patients were also advised to keep their ears dry for 3 weeks.

ResultsDemographics. In the immunocom-petent group, patients’ ages ranged from 18 to 65 years, and the peak incidence (48%) was seen in the third decade of life. In the immunocom-promised group, ages ranged from 26 to 74 years, and peak incidence (52%) was seen in the fifth decade of life (table 1). In both groups, a higher incidence was seen in male patients; there were more female patients in the immunocompromised group (36%) than the immunocompetent group (24%) (table 1).

Laterality. Right ear involvement was more common in both the groups: in 26 (52%) of the immunocompe-tent patients and in 18 (36%) of the immunocompro-mised patients. The left ear was involved in 16 (32%) and 12 (24%), respectively, of these groups. Bilateral involvement was seen more in 20 (40%) of the immu-nocompromised patients compared with 8 (16%) of the immunocompetent patients.

Predisposing factors. Ear cleaning with sticks and swabs, the use of topical antibiotic or steroid ear drops, and the use of nonsterile oil in the ear were seen in more immunocompetent pa-tients than immunocompromised patients (table 2). No predisposing factors were seen in 8 (16%) of the immunocompetent and 12 (24%) of the immunocompromised patients.

Symptoms and complications. Itching and ear discharge were seen more in the immunocompetent than in the immunocompromised patients, while ear pain was pres-ent in more immunocompromised patients. A blocked sensation, de-creased hearing, and tinnitus were

Table 1. Age and sex distribution of patients participating in the present study

Immunocompetent Immunocompromised group group (n = 50) (n = 50)

Age (yr)

0-10 0 (0%) 0 (0%)

11-20 6 (12%) 0 (0%)

21-30 24 (48%) 2 (4%)

31-40 10 (20%) 18 (36%)

41-50 3 (6%) 26 (52%)

51-60 4 (8%) 2 (4%)

61-70 3 (6%) 1 (2%)

71-80 0 (0%) 1 (2%)

Sex

Male 38 (76%) 32 (64%)

Female 12 (24%) 18 (36%)

Table 2. Predisposing factors for the development of otomycosis in study patients

Immunocompetent Immunocompromised group group (n = 50) (n = 50)Predisposing factorsEar cleaning with 31 (62%) 23 (46%) sticks & swabs

Use of nonsterile oil in ear 15 (30%) 11 (22%)

Use of topical antibiotic or 16 (32%) 9 (18%) steroid ear drops

Swimming habits 4 (8%) 1 (2%)

None 8 (16%) 12 (24%)

seen more in the immunocompromised than in the immunocompetent group (table 3).

Clinical examination revealed canal skin erythema and fungal debris in all cases. Three immunocompromised patients had a small central perforation of the tympanic membrane behind the handle of the malleus. They had not previously experienced ear pain or otitis media.

Fungus isolated. In immunocompetent patients Asper-gillus niger was isolated in 28 (56%) of cases, Aspergillus fumigatus in 9 (18%), Candida albicans in 8 (16%), and Penicillium chrysogenum (previously known as Penicil-lium notatum) in 5 (10%) (figure). In immunocompro-



mised patients, A niger was isolated in 17 (34%) cases, A fumigatus in 5 (10%), C albicans in 26 (52%), and P chrysogenum in 2 (4%) (table 4).

Treatment outcomes. All the patients in our immu-nocompetent group responded well to treatment, and there were no recurrences. In our immunocompromised group, 4 patients did not respond to treatment with clotrimazole ear drops, but they were successfully treated with fluconazole ear drops.

DiscussionOtomycosis is described as a fungal infection of the external ear canal. This infection is worldwide in dis-tribution, but it is more common in tropical and subtropical regions.4

Otomycosis is sporadic and caused by a wide variety of fungi, most of which are saprobes occurring in diverse types of environmental mate-rial.1 In his review of the literature, Wolf stated that no less than 53 different species of fungi had been reported to cause the disease.5 Oto-

mycosis affects 10% of the population in their lifetime.2

Fungi are abundant in soil or sand that contains de-composing vegetable matter. This material is desiccated rapidly in tropical sun and blown in the wind as small dust particles. The airborne fungal spores are carried by water vapors, a fact that correlates the higher rates of infection with the monsoon, during which the relative humidity rises to 80%.6

A fungal mass does not protrude from the external ear canal, even in most chronic cases. This is because the fungus does not find its nutritional requirements outside the external ear canal. In the present study, the Aspergillus growth rate was found to be higher at the temperature of 37°C, a fact that is clinically supported by the predilection of fungi to grow in the inner one-third of the external ear canal.7

An immunocompromised host is more susceptible to otomycosis. Patients with diabetes, lymphoma, or AIDS and patients undergoing or receiving chemotherapy or ra-diation therapy are at increased risk for potential complications from otomycosis.8

Literature review. Incidence by age and sex. In our study, the high-est incidence of otomycosis in the immunocompetent patients was seen in the age group of 21 to 30 years (48%), which agreed with the findings of Chander et al,8 Paulose et al,9 Mohanty et al,10 and Ho et

Table 3. Symptoms seen in study patients


Symptoms

Itching 46 (92%) 40 (80%)

Ear discharge 38 (76%) 32 (64%)

Ear pain 20 (40%) 24 (48%)

Blocked sensation 16 (32%) 22 (44%)

Decreased hearing 9 (18%) 14 (28%)

Tinnitus 5 (10%) 12 (24%)

Figure. Photomicrographs (original magnification ×40) show Aspergillus niger (A), Aspergillus fumigatus (B), Candida albicans with budding cells (C), and Penicillium chrysogenum (D) fungi.

A B

C D



al.11 The higher incidence in these patients may be due to the fact that these people are more exposed to the mycelia (due to occupational exposure, traveling, etc.), whereas older and younger age groups are not as exposed to these pathogens. The highest incidence in our immu-nocompromised patients was found in the age group of 41 to 50 years (52%). This may be due to the fact that immunocompromised states are less common in younger age groups.

In both our immunocompetent and immunocompro-mised patients, the incidence of otomycosis was higher in male patients, which agreed with the findings of Paulose et al,9 Ho et al,11 Yassin et al,12 and Hueso Gutiérrez et al.13

Laterality. Paulose et al,9 Yassin et al,12 and Yehia et al14 found that otomycosis is predominantly a unilateral disease and that the right ear is affected more often than the left, which also was true in both groups of our pa-tients. Bilateral involvement was more common in our immunocompromised than in our immunocompetent patients (2.5:1). This may be due to bilateral ear canal susceptibility to fungal infection in immunocompro-mised patients.

All our patients with bilateral otomycosis had similar findings in both the ears, and the same fungus was iso-lated on culture from each ear. Chander et al also found that the same fungus was responsible in both ears in bilateral otomycosis.8

Predisposing factors. Ear cleaning and the use of topical ear drops or oils were seen more often in our immunocompetent than in our immunocompromised patients. The use of topical antibiotics and nonsterile oil changes the physiochemical environment of the ear and thus favors fungal growth and colonization.

Ear cleaning habits may contribute to pathogenesis because traumatized external ear canal skin can present a favorable condition for fungal growth.12 Mechanical trauma also aids in the colonization of fungus.

Yassin et al stated that airborne fungi are responsible for otomycosis.12 They considered many factors in the external ear canal to contribute to a favorable condition for the establishment of many fungi, including12:

• trauma;• relatively high humidity in the external ear canal;• epithelial debris in various stages of chemical

breakdown;

• high temperature that closely approximates body temperature; and

• general diseases, such as diabetes mellitus.

Mohanty et al,10 Rama Kumar et al,15 and Than et al16 found trauma to be the most common predisposing fac-tor, as it was in both groups in the present study. Joy et al17 conducted an experimental study for the production of otomycosis in human volunteers. The results were more positive when trauma was inflicted, and ear wax was absent in most of the cases. Wax probably has an inhibitory effect on fungal growth.9

Symptoms. The most common symptoms in our pa-tients were itching, ear pain, ear discharge, a blocked sensation, decreased hearing, and tinnitus. These were also the symptoms observed by Paulose et al, Mohanty et al, and Ho et al.9-11 It should be noted that the correct diagnosis of otomycosis requires a high index of suspi-cion, given that the most common presenting symptoms, otalgia and otorrhea, are nonspecific.3

In our study, itching and ear discharge were seen more in immunocompetent patients than in immuno-compromised patients. Pain was present in 24 (48%) immunocompromised patients and in 20 (40%) immu-nocompetent patients. A blocked sensation, decreased hearing, and tinnitus were also seen in more immuno-compromised than immunocompetent patients. The duration of symptoms varied from 5 to 21 days. There was no significant difference in duration of symptoms between immunocompetent and immunocompromised patients.

Fungi isolated. In the studies conducted by Chander et al, Paulose et al, Mohanty et al, and Yassin et al, As-pergillus spp were the most common fungi isolated, and C albicans was the next most common.8-10,12

In our group of immunocompetent patients, A niger was isolated in 28 (56%) cases, A fumigatus in 9 (18%) cases, C albicans in 8 (16%) cases, and P chrysogenum

Table 4. Fungus isolated in samples obtained from study patients


Fungus

Aspergillus niger 28 (56%) 17 (34%)

Aspergillus fumigatus 9 (18%) 5 (10%)

Candida albicans 8 (16%) 26 (52%)

Penicillium chrysogenum 5 (10%) 2 (4%)

Volume 91, Number 3 www.entjournal.com 121

OtOmycOsis in immunOcOmpetent and immunOcOmprOmised patients: cOmparative study and literature review

in 5 (10%) cases. In our immunocompromised patients, A niger was isolated in 17 (34%) cases, A fumigatus in 5 (10%) cases, C albicans in 26 (52%) cases, and P chrys-ogenum in 2 (4%) cases.

In tropical countries, Aspergillus spp are considered the predominant organisms implicated in the etiology of otomycosis.1 In separate clinical studies, Rama Kumar15 and Jaiswal18 found C albicans to be responsible for the majority of cases, and it was isolated in 47 and 46%, respectively, of their cases.

Treatment. Bassiouny et al studied the effects of anti-fungal agents and found that clotrimazole and econazole were effective antifungal agents in the treatment of oto-mycosis.19 According to Stern et al and Jackman et al, clotrimazole is an effective antifungal agent against most yeasts and fungi, and nystatin has the widest spectrum of activity among the antifungals.20,21 In a study by Yadav et al, fluconazole was found to be an effective antifungal agent in the treatment of otomycosis.22

Complications. Tympanic membrane perforation may occur as a complication of otomycosis that starts in an ear with an intact ear drum.3 In the study by Rama Ku-mar, the incidence of tympanic membrane perforation in otomycosis was found to be 11%.15 He also stated that perforations were more common with otomycosis caused by C albicans. Most of the perforations were behind the handle of the malleus. The mechanism of perforation has been attributed to mycotic thrombosis of the tympanic membrane blood vessels, resulting in avascular necrosis of the tympanic membrane.3,23

Three patients in our immunocompromised group experienced tympanic membrane perforation. The perforations were small and situated in the posterior quadrant of the tympanic membrane. They healed spontaneously with medical treatment.

Rarely, fungi can cause invasive otitis externa, especial-ly in immunocompromised patients. Aggressive systemic antifungal therapy is required in these patients, and a high rate of mortality is associated with this condition.2

In conclusion, C albicans and Aspergillus spp were the most commonly isolated fungi seen in immu-nocompromised and immunocompetent patients, respectively. Bilateral involvement was seen more in the immunocompromised group. Clotrimazole is an effective treatment for otomycosis, and fluconazole is a good alternative for patients in whom clotrimazole is not effective. Rarely, tympanic membrane perforations can occur as a complication of otomycosis in immuno-compromised patients.

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5. Wolf FT. Relation of various fungi to otomycosis. Arch Otolaryngol-ogy 1947;46(3):361-4.

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13. Hueso Gutiérrez P, Jiménez Álvarez S, Sañudo E, et al. Presumption diagnosis: Otomycosis. A 451 patients study [in Spanish]. Acta Otorrinolaringol Esp 2005;56(5):181-6.

14. Yehia MM, Al-Habib HM, Shehab NM. Otomycosis: A common problem in north Iraq. J Laryngol Otol 1990;104(5):387-9.

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16. Than KM, Naing KS, Min M. Otomycosis in Burma, and its treat-ment. Am J Trop Med Hyg 1980:29(4):620-3.

17. Joy MJ, Agarwal MK, Samant HC. Mycological and bacteriological studies in otomycosis. Indian Journal of Otolaryngology and Head & Neck Surgery 1980;32:72-5.

18. Jaiswal SK. Fungal infection of ear and its sensitivity pattern. Indian Journal of Otolaryngology and Head & Neck Surgery 1990;42(1): 19-22.

19. Bassiouny A, Kamel T, Moawad MK, Hindawy DS. Broad spectrum antifungal agents in otomycosis. J Laryngol Otol 1986;100(8):867-73.

20. Stern JC, Shah MK, Lucente FE. In vitro effectiveness of 13 agents in otomycosis and review of the literature. Laryngoscope 1988;98 (11):1173-7.

21. Jackman A, Ward R, Apri M, Bent J. Topical antibiotic induced otomycosis. Int J Pediatr Otorhinolaryngol 2005;69(6):857-60.

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23. Stern JC, Lucente FE. Otomycosis. Ear Nose Throat J 1988:67(11):804-5, 809-10.

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