Otomycosis in immunocompetent and immunocompromised patients: comparative study and literature review.
A 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. Aspergillus 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.
Otomycosis is a superficial, subacute, or chronic infection 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 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, 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.
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 were 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 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 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.
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 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 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 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):
* 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, 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 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 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 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.
(1.) Jadhav VJ, Pal M, Mishra GS. Etiological 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.
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(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.
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(15.) Rama Kumar K. Silent perforation of tympanic membrane and otomycosis. Indian Journal of Otolaryngology and Head & Neck Surgery 1984;36(4):161-2.
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(18.) Jaiswal SK. Fungal infection of ear and its sensitivity pattern. Indian Journal of Otolaryngology and Head & Neck Surgery 1990;42(1): 19-22.
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(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.
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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@example.com
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|
|Date:||Mar 1, 2012|
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