Ss Otomycosis All In

5/8/2018 Ss Otomycosis All In - slidepdf.com

http://slidepdf.com/reader/full/ss-otomycosis-all-in 1/10

1

BAB I. INTRODUCTION

1.1 Background

Otomycosis is a fungal infection of the external auditory canal.1

It is a common source of

concern to the otolaryngologist, is commonly found throughout the world. Its prevalence is

greatest in hot humid and dusty areas of the tropics and subtropics. Otomycosis is a common

condition in countries like Indonesia where the weather is conducive for the growth of fungi.

The incidence of otomycosis is not known but it is more common in hot climates and in those

who indulge in aquatic sports. About 1 in 8 of otitis external infections is fungal in origin.

Most of fungal infections involve Aspergillus sp. and the rest Candida sp. The prevalence

rate has been quoted as 9% of patients presenting with signs and symptoms of otitis externa.2

The early symptoms of otomycosis tend to become chronic if the disease is unrecognised or

treatment is inadequate. In addition the onset of secondary bacterial invasion further

compounds the problem. In study of Sicilian patients with otomycosis, found that aside from

climatic conditions, instrumentation of the canal was the most prominent risk factor for the

development of the disease.2

Otomycosis is, effectively, an endemic disease of a tropical climate country. Clinical follow

up and mycological diagnosis are important since symptoms (pruritus, otalgia, otorrhea and

hypacusis) are not specific.3

The objective of this study is to understand the predisposing factors, clinical presentation and

diagnosis and prognosis of this disease. The method of this study is a review of literature and

write it systematically within the context of otomycosis disease.

1.2 Problems Identification

The problems identification found in this writing are

1. What is the predisposing factors for otomycosis?

2. What is the the commonest modes of presentation and various types of fungi

causing otomycosis?

3. How to diagnose otomycosis?

4. What is the effect of various antifungal agents on diagnosed cases of otomycosis?



2

5. How is the prognosis of otomycosis?

1.3 Aims

The aims of this writing are

1. To study the various predisposing factors for otomycosis.

2. To study the commonest modes of presentation and various types of fungi causing

otomycosis.

3. To study the diagnose otomycosis.

4. To study the effect of various antifungal agents on diagnosed cases of otomycosis.

5. To study the prognosis of otomycosis.

1.4 Benefits

The benefits of this writing are:

1. Help the medical student to study otomycosis.

2. Enriching medical literature in Indonesia and the world in an effort management of

otomycosis.



3

BAB II. LITERATURE REVIEW

2.1 Etiology and Risk Factor

Otomycosis is fungal infection of the external auditory canal. In a study, species were various

isolates from external auditory canal. It is evident from observations that aspergillus niger

(44.8%) was the commonest isolate followed by aspergillus fumigatus (17.9%). Candida

albicans (11.9%), penicillum species (4%) and fusarium species (4%).2

Picture 1 Ulceration of deep Canal and Congested Tympanic Membran Due to Invasion by

Aspergilus Niger2

Picture 2 Aspergilus niger microscopic apperance2



4

Classifies the pre disposing factors as follows:

i) Genetic:

a. Narrow external canal Inherited tendency to eczema

ii) Environmental:

a. Increase in temperature and humidity of environment, the temperature exceeds

100° F and relative humidity exceeds 70%, the skin tends to become

macerated predisposing this structure to infection.

b. swimming, a high incidence of excessive negative middle ear pressure in

patients suffering from recurrent otitis externa . The impaired tubal function

and the negative pressure that has set in tempts the patient to scratch his

auditory canal.

c. poor personal hygiene.

iii) Traumatic : the act of cerumen removal may be traumatic and leads to breaks in

the fragile canal skin. Also cerumen has an antimicrobial role through physical

protection of the canal skin , establishing a low pH .which serves as in hospitable

environment for pathogens and producing anti microbial compounds such as

lysozymes, so that its absence leaves the canal vulnerable to infection.

a. use of hair pin, match sticks,

b. previous unsuccessful operative procedures,

c. aural syringing,

d. applying oil or fatty acids to the ear canal.

iv) Infection :

a. Bacterial,

b. fungal or viral

Frequently each pre disposing factor seems to overlap the other.2

2.2 Clinical Sign and Symptom

Although the symptoms of otomycosis may vary from patient to patient the general

distribution has been summarised by a study of 193 patients in whom the presenting

symptoms noted were as follows ;

· Itching 88%

· Blocked sensation of the ear 87%

· Discharge 30%

· Tinnitus &Deafness 11.4%



5

The same symptoms may occur in other conditions affecting the external auditory canal,

including neoplasms. As a result careful physical examination and appropriate cultures are

frequently needed to make a definitive diagnosis.

The most cardinal complaint in otomycosis is an itching sensation, tenderness to palpation

and pain deep inside the canal; patients report an irresistible urge to scratch the ear canal with

finger tip or instruments. As mentioned earlier this facilitates sub epidermal invasion of the

fungi. The itching sensation generally progresses to a dull and deep seated pain that may be

associated with ear discharge. Accumulation of fungal debris in the inflamed and narrowed

canal frequently produces hearing loss.2

2.3 Examination and Laboratorium

Examination of the patient with otomycosis generally demonstrates canal erythema and the

presence of fungal debris within the canal . In the early phase of the disease the debris in the

canal wall may be minimum and with progress the canal wall may be plugged with fungal

debris in the form of cotton woolly mass or a wet newspaper like debris.

Although oedema of the canal skin may be seen it is usually not as severe as in advanced

stages of bacterial otitis externa. In the early stages of otomycosis the debris may be minimal

and difficult to detect. In more long standing cases the debris may totally occlude the canal

resembling a cotton like mass. Often this fungal debris was found adherent to the postero-

superior canal wall of the osseous part of the external canal. The skin lining this part appears

hyperaemia and occasionally ulcerated. Aural toilet of the ear reveals the hyperaemia of the

canal wall and excoriated bleeding epithelium. The tympanic membrane was often similarly

affected. The other terms used to identify the gross appearance of the fungal debris are "

blotting paper" and "wet newspaper" like debris. The simultaneous presence of cerumen

gives the debris a yellow brown colour.

The debris may be having a bluish discoloration owing to admixture with blood during

instrumentation or trauma to canal wall. At times otomycosis may be associated with

bacterial infection to complicate the clinical picture. The canal is cleaned gently with a

suction, efficient cleaning of the canal is a prerequisite for the proper treatment of the

condition. Attention is given towards removal of disease from the anterior recess (near the



6

tympanic membrane). The cleaning of the canal wall should be thorough and later on the

canal wall is dried, because retained humidity may promote further fungal growth.

For confirmation the sample of debris is sent for micro-biological evaluation. A moist 10%

potassium hydroxide preparations is used for microscopic identification of the fungus .

Isolation of the causal fungal organism can be done by inoculation and incubation of the

debris into Sabourad-Dextrose Agar plates at 30°centigrade for ten days.

The clinical presentation according to Yousuff and Abdou (Cairo) were as follows:

i) Auricle: There were presence of small ulceration and crust formation. In a few

severely infected cases early perichondritis and cellulitis may also be present.

ii) Mycological presentation in the external canal : the picture of otomycosis depends on

various factors such as the type of species, duration, degree of fungal development of

growth at the time of examination.

a. Mycologic plug : This is the most common finding (65%). It presents as a huge

wet mass of mycelial mat occluding the whole part of the external canal.

b. Wet mycelial mat: this is relatively common presentation (25%), this appears in

the form of a thick wet greyish or brownish membrane lining some part or whole

of the meatal wall.

c. Soft debris : it appears as moist flakes of dirty white colour. The meatus appears

relatively dry and itching is the main complaint in this presentation.

d. Dry mycelial mat: it consists of thin greyish white or light brown dry membrane

resembling cotton wool lining the deep part of the external canal.

iii) Meatal skin : after a proper aural toilet the meatal skin is found to be congested and

inflamed. Occasionally the skin is found to be ulcerated or excoriated. In a few cases

there occurs meatal stenosis and exposure of periosteum

iv) Tympanic membrane : this was found to be congested and ulceration of epithelial

layer of the drum was present in 16% of cases.2

2.4 Diagnose and Differential diagnosis

The diagnosis of otomycosis would be made only in those cases where a fungus was seen to

be growing actively in a sample of debris taken from the external auditory meatus. 4



7

The various differential diagnosis is mentioned as follows.

i) Eczematous otitis externa is a non contagious inflammatory disease of the skin in

response to endogenous or exogenous stimuli, characterised by erythema, oedema,

vesiculation, oozing, weeping and crusting. This reaction occurs as a result of

sensitisation of the skin cells. This sensitisation may be produced by an infecting

organism or by contact with an allergic material. Microscopically there is an intra

epidermal vesiculation, it is due to an antigen antibody reaction where the shock

tissue is the epidermis. Eczema begins with erythema and oedema of the skin

followed by appearance of minute vesicles and papules in the area. The vesicles

rupture and result in oozing of serous fluid. Alternatively it may dry up with scaling

and crusting. After healing of the eruptions there is a residual pigmentation left

however some times it does become chronic in which the skin is thickened with

exaggerated skin markings and hyperpigmentations.

ii) C ontact dermatitis is a type of eczema that can occur in the external canal due to

contact with an external agent like soaps, creams, chromium in ear rings nickel

jewellery or antibiotics like Neomycin etc. The topical application of any antibiotic

may result in a sensitivity reaction and result in the formation of vesicles, the eruption

of the vesicles is usually accompanied by intense irritation. Eczemataous otitis externa

is usually bilateral and involves outer 1/3 of the external canal where as otomycosis

involves the inner 1/3 of the canal and is mostly unilateral. Proper diagnosis and

treatment will relieve the patient of this eczematous condition where as proper aural

toilet and use of an antifungal is the modality of the latter.

iii) S eborrhoeic dermatitis occurs usually behind and below the ear lobes and else where

over the face and scalp. The main feature of the disease is a scaly condition of the

scalp usually referred to as Dandruff. This condition is associated with scaling in the

external canal, postauricular sulcus and below the lobe of auricle. When the ear is

involved secondary infection may be introduced by scratching resulting in a diffuse

otitis externa.

iv) I mpetigo contagiosa is a staphylococcal infection of the superficial layers of the skin,

vesicles filled with serum arise on a reddish purple base. Later the vesicles burst to

exude serum which dries to form a semi-adherent amber crusts. This condition is most

commonly seen in young children and may be secondary to the otorrhoea of the

middle ear infection. Although this condition may involve the whole auricle it does

not extend into the external canal.



8

v) F urunculosis arises from staphylococcal infection of the hair follicle. This condition

occurs only in the cartilaginous part of the external canal as hair follicles are not

found in the skin of the bony meatus. These lesions may be multiple and recur

frequently. The early symptoms of a furunculosis are tenderness in the meatus and

pain which is aggravated by movements of the jaw. As the condition progresses the

pain becomes more severe and the meatus may become occluded by the swelling

causing deafness. In severe cases the oedema may spread to the post auricular sulcus

producing forward displacement of the pinna. Examination of the ear reveals the

tender swelling in the cartilaginous portion of the meatus with a normal deep canal

and tympanic membrane beyond it. Tragal tenderness is present and there may be

peri-auricular lymphadenopathy.5

2.5 Treatment

A standard treatment regimen for otomycosis has not yet been established meticulous

cleaning of the ear canal may be sufficient in most of the patients.

Otomycosis is a chronic recurring mycosis. The ear canal should be cleared of debris and

discharge as this lowers the pH and reduces the activity of aminoglycoside ear drops. Suction

can be used if available. Cleaning may be required several times a week. Analgesia is

required. If there is an irritant or allergen it must be removed. Keep the ear dry and avoid

scratching it with cotton wool buds. Avoid cotton wool plugs in the ear unless discharge is so

profuse that it is required for cosmetic reasons. If used, keep them loose and change often.

Burrow's solution or 5% aluminum acetate solution should be used to reduce the swelling and

remove the debris. An aqueous solution of 1% thymol in metacresyl acetate, or

iodochlorhydroxyquin should be considered if drying the ear does not work satisfactorily.

Antifungal ear drops are of value. There is no consensus on treatment but evidence supports

the use of topical ketoconazole. Clotrimazole and econazole drops are very effective but may

be needed for 1 to 3 weeks. Clioquinol is both antibacterial and antifungal and may be used

as ear drops with hydrocortisone in the formulation.

Cleaning of the ear can represent a problem in the presence of a perforated eardrum and a

specialist may need to be involved.6



9

2.6 Prognosis

Once antifungal therapy is started there is usually good resolution in the immunologically

competent. However, the risk of recurrence is high if the factors which caused the original

infection are not corrected and the normal physiological environment of the external auditory

canal remains disturbed. These include avoiding sudden manoeuvres in the external auditory

canal (e.g. frequent cleaning with a cotton bud), taking care to avoid excessive moisture by

not going in the water and receiving appropriate medical or surgical treatment for otitis

externa.6



10

BAB III. CONCLUSION

3.1 Conclusion

y Otomycosis is fungal infection of the external auditory canal. In a study, species were

various isolates from external auditory canal. It is evident from observations that

aspergillus niger

y Predisposing factors as follows: genetic, environmental, traumatic, and infection

y The typical presentation is with inflammation, pruritus, scaling and severe discomfort.

y The diagnosis of otomycosis would be made only in those cases where a fungus was

seen to be growing actively in a sample of debris taken from the external auditory

meatus.

y The management of otomycosis is meticulous cleaning of the ear canal, antifungal ear drops, analgesia, burrow's solution or 5% aluminum acetate, aqueous solution of 1%

thymol in metacresyl acetate, or iodochlorhydroxyquin.

Ss Otomycosis All In

Documents

Transcript of Ss Otomycosis All In