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Fungal otitis externa as a cause of tympanic membrane perforation: a case series.

Abstract

We describe a series of 11 patients--8 men and 3 women, aged 18 to 70 years (mean: 46.0)--who had fungal otitis externa that had been complicated by a tympanic membrane perforation. These patients had been referred to us for evaluation of chronic, mostly treatment-refractory otitis externa, which had manifested as otorrhea, otalgia, and/or pruritus. Seven of the 11 patients had no history of ear problems prior to their current condition. Five patients had been referred to us by a primary care physician and 4 by an otolaryngologist; the other 2 patients were self-referred. All patients were treated with a thorough debridement of the ear and one of two antifungal medication regimens. Eight of the 11 patients experienced a complete resolution of signs and symptoms, including closure of the tympanic membrane perforation. The other 3 patients underwent either a tympanoplasty (n = 2)or a fat-graft myringotomy (n = 1) because the perforation did not close within a reasonable amount of time. This series demonstrates that the nonspecific signs and symptoms of fungal otitis externa can make diagnosis difficult for both primary care physicians and general otolaryngologists. This study also demonstrates that most cases of tympanic membrane perforation secondary to fungal otitis externa will resolve with cleaning of the ear and proper medical treatment. Therefore, most patients with this condition will not require surgery.

Introduction

Fungal otitis externa, also known as otomycosis, is frequently seen in primary care and otolaryngology practices. As this case series will demonstrate, fungal otitis externa often presents with (1) edema and serous transudate of the external canal skin, (2) erythema and perforation of a thickened tympanic membrane, and (3) serous drainage from the middle ear space into the external auditory canal (EAC). As such, primary care physicians and even otolaryngologists may find these clinical features more suggestive of bacterial otitis media and mastoiditis, when in fact these findings can represent a fungal infection of the EAC.

The most common causes of fungal otitis externa are Candida and Aspergillus spp. (1-4) Fungal pathogens have been reported to cause 9% of all cases of otitis externa, but this figure appears to be on the rise, presumably because of the increased use of topical antibiotics. (5,6)

Although fungal otitis externa is a well-established entity, tympanic membrane perforations--the clinical feature that physicians find most misleading--is an infrequently reported complication. (5,7) The diagnosis of otomycosis is usually made on clinical grounds, as the characteristic appearance of the fungal fruiting bodies are easily recognizable through an office microscope. Given the rapid response to antifungal treatment in affected patients, cultures are generally not obtained because they are not considered to be cost-effective in this setting. The most widely used treatment regimen for otomycosis is mechanical debridement of the ear canal along with antifungal medication. (3)

In this article we describe the clinical presentation, course, treatment, and outcomes in a series of patients with otomycosis that was complicated by a tympanic membrane perforation.

Patients and methods

During a 6-year period, we treated 11 patients--8 men and 3 women, aged 18 to 70 years (mean: 46.0)--who had fungal otitis externa that had been complicated by a tympanic membrane perforation. In addition to demographic data, we compiled information on the referral source and reason for referral, each patients history of ear disease, the presence or absence of EAC and tympanic membrane edema and EAC drainage, the type and duration of antifungal therapy, and outcomes.

The diagnosis of fungal otitis externa had been based on clinical signs and symptoms and by the characteristic appearance of fungal fruiting bodies. Cultures were not routinely obtained at the time of examination. The tympanic membrane perforations were identified at each patient's initial clinic visit.

Patients were followed until their signs and symptoms completely resolved. The duration of medical treatment was based on our clinical judgment. If no considerable improvement occurred with medical management, surgical intervention was eventually chosen.

Results

Five patients had been referred to us by a primary care physician and 4 by an otolaryngologist; the other 2 patients were self-referred. At presentation, all patients had chronic otitis externa of 2 weeks' to 12 months' duration (table). Their condition was marked by otorrhea, otalgia, and/or pruritus. All 9 patients who had been referred by a physician had been treated with some form of antibiotic treatment prior to referral.

It is significant that 7 of our patients had no history of ear disease prior to the current condition (table). Two of the 11 had previously undergone an otologic procedure--one tympanoplasty and one mastoidectomy. The tympanoplasty patient had a history of chronic otitis media as well as otitis externa; this patient went on to experience recurrent episodes of fungal otitis externa on the same side where the tympanoplasty had been performed, which resulted in a perforation of the tympanic membrane. The mastoidectomy patient had undergone a canal-wall-down procedure.

On physical examination, all 11 patients exhibited evidence of EAC and tympanic membrane edema, and 9 also had drainage from the affected ear (table). Black and white debris, most likely representing fungal hyphae, was consistently found in the EAC upon inspection with an office microscope. After the canal was cleaned, the tympanic membrane perforation could be visualized.

All patients were treated with one of two medical regimens; 7 patients received a combination of boric acid powder, nystatin powder, and oral fluconazole, and 4 received a powdered combination of ciprofloxacin, chloramphenicol, amphotericin, and hydrocortisone (CCAH).

The duration of drug treatment ranged from 1 to 9 months. Six of the 7 patients who received the boric acid/nystatin/fluconazole regimen experienced a complete resolution of signs and symptoms and healing of the tympanic membrane perforation. The remaining patient, a 47-year-old woman, had presented to our office with chronic otalgia, otorrhea, and decreased hearing in her right ear. After she had taken multiple courses of antibiotics for 3 months without improvement, she was eventually diagnosed with fungal otitis externa. By the time she was diagnosed with otomycosis, she had developed a subtotal tympanic membrane perforation and she subsequently underwent tympanoplasty and ossiculoplasty (table).

Of the 4 patients who received the CCAH regimen, 2 experienced a complete resolution of signs and symptoms and closure of the tympanic membrane perforation. The other 2 patients required surgery because their perforation failed to heal; 1 underwent a fat-graft myringoplasty and the other a tympanoplasty (table).

The 3 patients whose tympanic membrane did not heal initially continued to receive drug treatment until no residual inflammation was left. Once the affected ear was free of infection, they underwent surgery.

Discussion

Fungal otitis externa can be a difficult diagnosis for primary care physicians and even general otolaryngologists, since its signs and symptoms often mimic those of bacterial otitis externa and otitis media. Unfortunately, an incorrect diagnosis can lead to a prolonged course and to complications such as tympanic membrane perforations.

When such a perforation does occur, otolaryngologists may be tempted to close it surgically. However, as this case series demonstrates, most cases of fungus-caused tympanic membrane perforations will resolve on their own with proper medical treatment. We speculate that these perforations tend to heal once the fungal infection is cleared because they arose in the setting of normal eustachian tube function. It must be mentioned, however, that treatment of fungal otitis externa with medical management is not without risk, especially in patients who have a tympanic membrane perforation.

Although medical treatment is generally considered to be safe, there have been reports of inner ear ototoxicity with some of the agents used in our patients. Boric acid in particular has been implicated as a cause of sensorineural hearing loss by inflicting damage to the inner hair cells of the organ of Corti. However, most of these studies were conducted in animal models, and the boric acid powder was prepared with 70% alcohol. There is a great body of evidence now that supports the safety of boric acid when it is prepared in distilled water. (8)

Furthermore, a survey of more than 2,000 otolaryngologists in the United States conducted by Lundy and Graham found that the vast majority of respondents were comfortable using these regimens in patients with tympanic membrane perforations. (9) In view of the acidic nature of boric acid, it may also cause some pain and discomfort, but patients usually tolerate it well.

In this series, we presented 11 cases of fungal otitis externa that were complicated by a tympanic membrane perforation. Our series demonstrates two points:

* First, fungal otitis externa often manifests with otorrhea, canal edema, and tympanic membrane perforation, which can mislead general practitioners and even general otolaryngologists. Indeed, 4 of our referrals were made by fellow otolaryngologists who did not expect otomycosis to manifest with otorrhea and a tympanic membrane perforation. The absence of previous ear problems in 7 of our patients served as a clue that the problem was an infection of fungal origin rather than a bacterial infection that caused eustachian tube dysfunction.

* Second, perforations of the tympanic membrane caused by fungal otitis externa can be treated with adequate mechanical debridement and a topical antifungal regimen with or without an oral regimen. This is in agreement with the findings of Ho et al, who studied 18 patients with a tympanic membrane perforation caused by otomycosis who were treated with antifungal medications; the authors found that only 1 of these patients required tympanoplasty to close a persistent perforation. (5) Hurst reported similar findings, as 19 of 22 patients with a tympanic membrane perforation secondary to otomycosis healed without surgery. (7) Unfortunately, the clinical microscope is a necessity for cleaning these ears, and this impedes effective treatment by primary care physicians.

In summary, adequate cleaning and medical treatment were sufficient to resolve most of our tympanic membrane perforations, thereby obviating the need for surgery.

References

(1.) Pontes ZB, Silva AD, Lima Ede O, et al. Otomycosis: A retrospective study. Braz J Otorhinolaryngol 2009;75(3):367-70.

(2.) Hawke M, Wong J, Krajden S. Clinical and microbiological features of otitis externa. J Otolaryngol 1984;13(5):289-95.

(3.) Kurnatowski P, Filipiak A. Otomycosis: Prevalence, clinical symptoms, therapeutic procedure. Mycoses 2001;44(11-12):472-9.

(4.) Dyckhoff G, Hoppe-Tichy T, Kappe R, Dietz A. Antimycotic therapy in otomycosis with tympanic membrane perforation [in German], HNO 2000;48(1):18-21.

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

(6.) Munguia R, Daniel SJ. Ototopical antifungals and otomycosis: A review. Int J Pediatr Otorhinolaryngol 2008;72(4):453-9.

(7.) Hurst WB. Outcome of 22 cases of perforated tympanic membrane caused by otomycosis. J Laryngol Otol 2001;115(11):879-80.

(8.) Ozturkcan S, Dundar R, Katilmis H, et al. The ototoxic effect of boric acid solutions applied into the middle ear of guinea pigs. Eur Arch Otorhinolaryngol 2009;266(5):663-7.

(9.) Lundy LB, Graham MD. Ototoxicity and ototopical medications: A survey of otolaryngologists. Am J Otol 1993;14(2):141-6.

James Eingun Song, MD; Thomas J. Haberkamp, MD; Riddhi Patel, MD; Miriam I. Redleaf, MD

From the Department of Dermatology, University of California, Irvine (Dr. Song); the Department of Otolaryngology, Cleveland Clinic (Dr. Haberkamp); the Department of Surgery, University of Chicago Medicine (Dr. Patel); and the Illinois Eye and Ear Infirmary, Chicago (Dr. Redleaf). The study described in this article was conducted at the Illinois Eye and Ear Infirmary.

Corresponding author: James Eingun Song, MD, Department of Dermatology, University of California, Irvine, 118 Med Surge I, Irvine, CA 92697. Email: Esong812@gmail.com
Table. Demographic data, clinical characteristics, and outcomes

           Referral   Reason for    History of    EAC and      EAC
Age/sex     source     referral     ear disease   TM edema   drainage

18/M         PCP      OE (9 mo)         Yes         Yes        Yes
32/F         PCP      OE (2.5 mo)       Yes         Yes        Yes
38/M         PCP      OE (1.5 mo)       No          Yes         No
41/M         ENT      OE (1 mo)         Yes         Yes        Yes
47/F         ENT      OE (3 mo)         No          Yes        Yes
47/M         Self     OE (2 wk)         Yes         Yes         No
50/M         ENT      OE (12 mo)        No          Yes        Yes
50/M         Self     OE (2 mo)         No          Yes        Yes
55/M         ENT      OE (1 mo)         No          Yes        Yes
58/M         PCP      OE (1 mo)         No          Yes        Yes
70/F         PCP      OE (6 mo)         No          Yes        Yes

           Type and
           duration
Age/sex    of therapy   Outcome

18/M       1.5 mo *     Closure of the TM perforation
32/F       9 mo *       Closure of the TM perforation
38/M       3 mo         Closure of the TM perforation
41/M       8 mo         Closure of the TM perforation
47/F       3 mo         Tympanoplasty and ossiculoplasty
47/M       1 mo         Closure of the TM perforation
50/M       4 mo         Closure of the TM perforation
50/M       3 mo         Closure of the TM perforation
55/M       3 mo *       Fat-graft myringoplasty
58/M       2 mo         Closure of the TM perforation
70/F       7.5 mo *     Tympanoplasty

* These 4 patients received CCAH (ciprofloxacin, chloramphenicol,
amphotericin, and hydrocortisone) powder; the other 7 patients
received boric acid powder, nystatin powder, and oral fluconazole

Key: EAC = external auditory canal; TM = tympanic membrane;
PCP = primary care physician; OE = otitis externa;
ENT = otolaryngologist.
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Title Annotation:ORIGINAL ARTICLE
Author:Song, James Eingun; Haberkamp, Thomas J.; Patel, Riddhi; Redleaf, Miriam I.
Publication:Ear, Nose and Throat Journal
Date:Aug 1, 2014
Words:2186
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