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Otomycosis in immunocompetent and immunocompromised patients: comparative study and literature review.

Abstract

A comparative clinical study was carried out that included 50 cases of otomycosis in immunocompetent im·mu·no·com·pe·tent
adj.
Having the normal bodily capacity to develop an immune response following exposure to an antigen.



im
 patients and 50 cases of otomycosis in immunocompromised immunocompromised /im·mu·no·com·pro·mised/ (-kom´pro-mizd) having the immune response attenuated by administration of immunosuppressive drugs, by irradiation, by malnutrition, or by certain disease processes (e.g., cancer).  patients. Clinical presentation, predisposing factors, mycologic my·col·o·gy  
n. pl. my·col·o·gies
1. The branch of botany that deals with fungi.

2. The fungi native to a region.

3.
 profile, and treatment outcomes were compared. Aspergillus Aspergillus

Any fungus of the genus Aspergillus of the Fungi Imperfecti (form-class Deuteromycetes). Species for which the sexual phase is known are placed in the order Eurotiales. A. niger causes black mold on some foods; A. niger, A. flavus, and A.
 spp were the most commonly isolated fungi in the immunocompetent group, and Candida albicans Candida albicans,
n a pathogenic yeast, which is the causal agent of thrush, vaginal infections, and systemic candidiasis.

Candida albicans 
 in the immunocompromised group. Bilateral involvement was more common in the immunocompromised group. All the patients were treated with topical clotrimazole clotrimazole /clo·trim·a·zole/ (klo-trim´ah-zol) an imidazole derivative used as a broad-spectrum antifungal agent.

clo·trim·a·zole
n.
 ear drops. Four patients in the immunocompromised group did not respond to treatment with clotrimazole but were treated successfully with fluconazole fluconazole /flu·con·a·zole/ (floo-kon´ah-zol) a triazoleantifungal used in the systemic treatment of candidiasis and cryptococcal meningitis.

flu·con·a·zole
n.
 ear drops. Three patients had a small tympanic membrane perforation tympanic membrane perforation Perforated, punctured, ruptured ear drum ENT A disruption of the tympanic membrane due to acoustic trauma, direct injury, barotrauma, introduction of Q-tips or small objects, or infection with fluid buildup in the middle ear. See Tympanoplasty.  due to otomycosis.

Introduction

Otomycosis is a superficial, subacute, or chronic infection of the outer ear canal ear canal
n.
The narrow, tubelike passage through which sound enters the ear. Also called external auditory 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 recent 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, predisposing 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 methods

This prospective study was carried out in 100 patients with otomycosis--50 who were immunocompetent and 50 who were immunocompromised. In the immunocompromised group, 36 patients were diabetic, 9 patients had AIDS, and 5 patients were undergoing radiation therapy. The patients' clinical profiles regarding age, sex, laterality laterality
 or hemispheric asymmetry

Characteristic of the human brain in which certain functions (such as language comprehension) are localized on one side in preference to the other.
, and clinical presentation were documented.

Only cases of otomycosis in patients with positive cultures were included in this study. Patients with otomycosis 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 immunocompromised 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, discontinuation 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 respond to clotrimazole were switched to fluconazole ear drops. Patients were also advised to keep their ears dry for 3 weeks.

Results

Demographics. In the immunocompetent group, patients' ages ranged from 18 to 65 years, and the peak incidence (48%) was seen in the third decade of life. In the immunocompromised 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 immunocompetent patients and in 18 (36%) of the immunocompromised 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 immunocompromised 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 patients 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 present in more immunocompromised patients. A blocked sensation, decreased hearing, and tinnitus Tinnitus Definition

Tinnitus is hearing ringing, buzzing, or other sounds without an external cause. Patients may experience tinnitus in one or both ears or in the head.
 were seen more in the immunocompromised than in the immunocompetent group (table 3).

Clinical examination revealed canal skin erythema erythema (ĕr'əthē`mə), more or less diffuse redness of the skin due to concentration of an abnormally large amount of blood within the small vessels of the skin (hyperemia), as in burns.  and fungal debris in all cases. Three immunocompromised patients had a small central perforation per·fo·ra·tion
n.
1. The act of perforating or the state of being perforated.

2. An abnormal opening in a hollow organ or viscus, as one made by rupture or injury.


Perforation
A hole.
 of the tympanic membrane behind the handle of the malleus malleus /mal·le·us/ (mal´e-us) [L.] the outermost of the auditory ossicles, and the one attached to the tympanic membrane; its club-shaped head articulates with the incus

mal·le·us
n. pl.
. They had not previously experienced ear pain or otitis media.

Fungus isolated. In immunocompetent patients Aspergillus niger was isolated in 28 (56%) of cases, Aspergillus fumigatus in 9 (18%), Candida albicans in 8 (16%), and Penicillium chrysogenum (previously known as Penicillium Penicillium

Any blue or green mold in the genus Penicillium (kingdom Fungi; see fungus). Common on foodstuffs, leather, and fabrics, they are economically important in producing antibiotics (see
 notatum) in 5 (10%) (figure). In immunocompromised 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 immunocompetent 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 theywere successfully treated with fluconazole ear drops.

[FIGURE OMITTED]

Discussion

Otomycosis is described as a fungal infection of the external ear canal. This infection is worldwide in distribution, but it is more common in tropical and subtropical sub·trop·i·cal  
adj.
Of, relating to, or being the geographic areas adjacent to the Tropics.


subtropical
Adjective

of the region lying between the tropics and temperate lands

 regions? Otomycosis is sporadic and caused by a wide variety of fungi, most of which are saprobes occurring in diverse types of environmental material. (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) Otomycosis affects 10% of the population in their lifetime. (2)

Fungi are abundant in soil or sand that contains decomposing 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 pro·trude
v.
1. To push or thrust outward.

2. To jut out; project.
 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[degrees]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 radiation therapy are at increased risk for potential complications from otomycosis. (8)

Literature review. Incidence by age and sex. In our study, the highest 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 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 immunocompromised 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 immunocompromised 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 Gutierrez et al. (13)

Laterality. Paulose et al, (9) Yassin et al, (12) and Yehia et al (14) 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 patients. 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 immunocompromised patients.

All our patients with bilateral otomycosis had similar findings in both the ears, and the same fungus was isolated 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 physiochemical /phys·io·chem·i·cal/ (fiz?e-o-kem´ik-il) pertaining to both physiology and chemistry.

physiochemical

pertaining to both physiology and chemistry.
 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, including (12):

* 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 al (16) found trauma to be the most common predisposing factor, as it was in both groups in the present study. Joy et al (17) 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 patients 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 suspicion index of suspicion Medtalk A phrase broadly used to indicate how seriously a particular disease is being entertained as a diagnosis; as an example, there is a high IOS that rapid and unexplained weight loss in an elderly Pt is due to pancreas CA, and a low IOS that , given that the most common presenting symptoms, otalgia otalgia /otal·gia/ (o-tal´jah) pain in the ear; earache.

o·tal·gia
n.
Pain in the ear; earache.



o·tal
 and otorrhea, are nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.

2. not directed against a particular agent, but rather having a general effect.


nonspecific

1.
. (3)

In our study, itching and ear discharge were seen more in immunocompetent patients than in immunocompromised patients. Pain was present in 24 (48%) immunocompromised patients and in 20 (40%) immunocompetent patients. A blocked sensation, decreased hearing, and tinnitus were also seen in more immunocompromised 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, Aspergillus 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 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 chrysogenum 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 Kumar (15) and Jaiswal (18) 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 antifungal agents and found that dotrimazole and econazole were effective antifungal agents in the treatment of otomycosis. (19) According to Stern et al and Jackman et al, clotrimazole is an effective antifungal agent against most yeasts and fungi, and nystatin nystatin /ny·sta·tin/ (ni-stat´in) an antifungal produced by growth of Streptomyces noursei; used in treatment of infections caused by Candida albicans and other Candida species.  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 Kumar, 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 mycotic /my·cot·ic/ (mi-kot´ik)
1. pertaining to mycosis.

2. caused by a fungus.


my·cot·ic
adj.
1. Relating to mycosis.

2.
 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, especially 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 immunocompromised 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 immunocompromised patients.

References

(1.) Jadhav VJ, Pal M, Mishra GS. Etiological etiological

pertaining to etiology.


etiological diagnosis
the name of a disease which includes the identification of the causative agent, e.g. Streptococcus agalactiae mastitis.
 significance of Candida albicans in otitis externa. Mycopathologia 2003;156(4):313-15.

(2.) Carney AS. Otitis externa and otomycosis. In: Gleeson MJ, Jones NS, Clarke R, et al (eds). Scott-Brown's Otolaryngology, Head and Neck Surgery, Vol. 3.7th ed. London: Hodder Arnold Publishers; 2008:3351-7.

(3.) Rutt AL, Sataloff RT. Aspergillus otomycosis in an immunocompromised patient. Ear Nose Throat J 2008;87(11):622-3.

(4.) Aktas E, Yigit N. Determination of antifungal susceptibility of Aspergillus spp. responsible for otomycosis by E-test method. J Mycol Med 2009;19(2):122-5.

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

(6.) Geaney GP. Tropical otomycosis. J Laryngol Otol 1967;81(9):987-97.

(7.) Mugliston T, O'Donoghue G. Otomycosis--a continuing problem. J Laryngol Otol 1985;99(4):327-33.

(8.) Chander J, Maini S, Subrahmanyan S, Handa A. Otomycosis--a clinico-mycological study and efficacy of mercurochrome in its treatment. Mycopathologia 1996;135(1):9-12.

(9.) Paulose KO, Al Khalifa S, Shenoy P, Sharma RK. Mycoticinfection of the ear (otomycosis): A prospective study. J Laryngol Otol 1989;103 (1):30-5.

(10.) Mohanty JC, Mohanty SK, Sahoo RC, et al. Clinico-microbial profile of otomycosis in Berhampur. Indian Journal of Otology otology /otol·o·gy/ (o-tol´ah-je) the branch of medicine dealing with the ear, its anatomy, physiology, and pathology.otolog´ic

o·tol·o·gy
n.
The branch of medicine that deals with the ear.
 1999;5(2): 81-3.

(11.) Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: Clinical features and treatment implications. Otolayngol Head Neck Surg 2006;135 (5):787-91.

(12.) Yassin A, Maher A, Moawad MK. Otomycosis: A survey in the eastern province of Saudi Arabia. J Laryngol Otol 1978;92(10):869-76.

(13.) Hueso Gutierrez P, Jimenez Alvarez S, Safiudo 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.

(15.) Rama Kumar K. Silent perforation of tympanic membrane and otomycosis. Indian Journal of Otolaryngology and Head & Neck Surgery 1984;36(4):161-2.

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

(17.) Joy MJ, Agarwal MK, Samant HC. Mycological mycological

pertaining to or arising from mycology.
 and bacteriological bac·te·ri·ol·o·gy  
n.
The study of bacteria, especially in relation to medicine and agriculture.



bac·te
 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 Oto] 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.

(22.) Yadav SP, Gulia JS, Jagat S, et al. Role of ototopical fluconazole and clotrimazole in management of otomycosis. Indian Journal of Otology 2007:13;12-15.

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

Borlingegowda Viswanatha, MS, DLO DLO
abbr.
dead letter office

DLO n abbr (= dead-letter office) → oficina de Correos que se encarga de las cartas que no llegan a su destino
; Dadarao Sumatha, MBBS MBBS, MBChB n abbr (BRIT) (= Bachelor of Medicine and Surgery) → título universitario

MBBS, MBChB n abbr (Brit) (= Bachelor of Medicine and Surgery) →
; Maliyappanahalli Siddappa Vijayashree, MBBS, MS

From the Department of ENT ENT ears, nose, and throat (otorhinolaryngology).

ENT
abbr.
ear, nose, and throat



ENT

ear, nose and throat.

ENT Ears, nose & throat; formally, otorhinolaryngology
, 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: drbviswanatha@yahoo.co.in
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 factors

Ear 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%)

Table 3. Symptoms seen in study patients

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

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%)

Table 4. Fungus isolated in samples obtained from study patients

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

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%)
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Title Annotation:ORIGINAL ARTICLE
Author:Viswanatha, Borlingegowda; Sumatha, Dadarao; Vijayashree, Maliyappanahalli Siddappa
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Mar 1, 2012
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