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Table of Content - Volume 21 Issue 2 - February 2022


 

Clinico-mycological profile of otomycosis cases in a tertiary care Hospital

 

Maya S Kale1*, Shalini Gore2, Medha Despande3, Rita Shrivastav4

 

1,2,3,4Assistant Professor, Department of Microbiology, Terna Medical College and Hospital, INDIA.

Email: drmayakale@yahoo.co.in, drmayakale1@gmail.com

 

Abstract              Background: Otomycosis is an acute, subacute or chronic fungal infection of the Pinna, the external auditory meatus and the ear canal. Otomycosis is challenging for both patients and otolaryngologist as it frequently requires a long-term treatment and follow up. The present study was aimed to elucidate the predisposing factors, clinical presentations, mycological agents and associated bacterial infections encountered in clinically diagnosed otomycosis cases at a tertiary hospital. Material and Methods:Present study was hospital based, prospective and observational study conducted in patients, > 15 years age, diagnosed with otomycosis based upon history and physical examination, willing to participate in study were considered for study. Results: In present study, 76 cases diagnosed with otomycosis based upon history and physical examination were included. Majority of them were female (64.47 %), male to female ratio was 0.56:1. Majority of patients were from 21-30 years age group (30.26 %), followed by age group of 31-40 years (25 %). Common symptoms noted were hearing loss (73.68 %), pruritus (64.47 %), earache (47.37 %), otorrhoea (38.16 %) and tinnitus (9.21 %). In present study, common predisposing factors noted were self-cleaning (38.16 %), no cerumen (15.79 %), use of local and systemic antimicrobials (15.79 %) and history of chronic suppurative otitis media (11.84 %). Common fungal isolates from otomycosis patients were Aspergillus niger (51.32 %), Aspergillus flavus (34.21 %), Aspergillus fumigatus (6.58 %) and Candida species (5.26 %). Conclusion: Self-cleaning, lack of cerumen, use of local and systemic antimicrobials, history of chronic suppurative otitis media were common probable predisposing factor of otomycosis. Species like Aspergillus and Candida were common isolates involved in such cases.

Keywords: lack of cerumen, chronic suppurative otitis media, otomycosis, Aspergillus. Species

 

INTRODUCTION

Otomycosis is an acute, subacute or chronic fungal infection of the Pinna, the external auditory meatus and the ear canal.1 The infection is usually unilateral and characterized by inflammation, pruritis, scaling and severe discomfort such suppuration and pain. Predisposing factors such as a failure in the ear’s defense mechanisms (changes in the coating epithelium, changes in pH, quantitative and qualitative changes in ear wax), bacterial infection, instillation of oil, hearing aid or a hearing prosthesis, self-inflicted trauma, swimming, broad spectrum antibiotic agents, steroids and cytostatic medication, neoplasia and immune disorders, all of which can render the host susceptible to the development of Otomycosis.2 Its incidence has been increasing due to the increased use of antibiotics, immunocompromised host conditions such as diabetes and more recently increased use of topical antibiotics plus steroid combination and bad aural hygiene.3 Aspergillus niger and Candida albicans are more common offenders with nearly sixty one fungal species being involved in external fungal otitis.4 Otomycosis is challenging for both patients and otolaryngologist as it frequently requires long term treatment and follow up. Inspite of proper treatment and follow up, the recurrence rate remains high. The present study was aimed to elucidate the predisposing factors, clinical presentations, mycological agents and associated bacteria encountered in clinically diagnosed otomycosis cases at a tertiary hospital.

              

MATERIAL AND METHODS

Present study was hospital based, prospective and observational study conducted in department of microbiology, at Terna Medical Ccollege and Hhospital, Nerul, Navi-Mumbai, India. Study duration was of 1 years (January 2021 to December 2021). Study was approved by institutional ethical committee. Patients, > 15 years age, diagnosed with otomycosis based upon history and physical examination, willing to participate in study were considered for study. Study was explained and written informed consent was taken. Age, sex, socio-economic status and occupation of the patients were recorded. Any history of use of wooden sticks use of oral and topical antibiotic/steroids were noted. The symptoms (pruritus of the ear, otalgia, hearing impairment, tinnitus, discharge and sensation of having an ear blockage), examination/otoscopic findings (soft, white, cheese-like sebaceous material or finely sprinkled or matted masses of hyphae and/or spores) were noted in proforma. Ear discharge samples were collected aseptically using two sterile cotton swabs. One swab was used for direct microscopic examination. Direct microscopic examination of the specimens were carried out by Gram’s staining and 10% KOH mount. The other swab was inoculated on Sabouraud Dextrose Agar with chloramphenicol, which was incubated at 25°C and 37°C aerobically for a period of four weeks. Identification was done on the basis of Colony morphology and Lactophenol Cotton Blue Mount microscopy. Aspergillus isolates were identified by LCB mount, which shows sporulating vesicles, abundant black spores, varying length of conidiophores and biseriate phialides. Candida species were identified by germ tube test, growth at 44°C, Dalmau plate culture as well as sugar fermentation and assimilation studies. Colonies were inoculated on HiChrome agar for identification of species of Candida.

Data was collected and compiled using Microsoft Excel, statistical analysis was done using descriptive statistics.


 

RESULTS

In present study, 76 cases diagnosed with otomycosis based upon history and physical examination were included. Majority of them were female (64.47 %), male to female ratio was 0.56:1. Majority of patients were from 21-30 years age group (30.26 %), followed by age group of 31-40 years (25 %).

Table 1: Age and sex wise distribution of Otomycosis patients

Age (in years)

Male

Female

Total (n=76)

16-20

4 (5.26 %)

7 (9.21 %)

11 (14.47 %)

21-30

8 (10.53 %)

15 (19.74 %)

23 (30.26 %)

31-40

7 (9.21 %)

12 (15.79 %)

19 (25 %)

41-50

4 (5.26 %)

7 (9.21 %)

11 (14.47 %)

51-60

3 (3.95 %)

6 (7.89 %)

9 (11.84 %)

>60

1 (1.32 %)

2 (2.63 %)

3 (3.95 %)

Total

27 (35.53 %)

49 (64.47 %)

76

Common symptoms noted were hearing loss (73.68 %), pruritus (64.47 %), earache (47.37 %), otorrhoea (38.16 %) and tinnitus (9.21 %).

Table 2: Symptoms at the time of diagnosis

Clinical Symptom

Number of patients (n=76)

Percentage (%)

Hearing loss

56

73.68

Pruritus

49

64.47

Earache

36

47.37

Otorrhoea

29

38.16

Tinnitus

7

9.21

In present study, common predisposing factors noted were self-cleaning (38.16 %), no cerumen (15.79 %), use of local and systemic antimicrobials (15.79 %) and history of chronic suppurative otitis media (11.84 %).

Table 3: Predisposing factors for otomycosis

Predisposing Factors

Number of patients (n=76)

Percentage (%)

Self-cleaning

29

38.16

No cerumen

12

15.79

Use of local and systemic antimicrobials

12

15.79

Chronic suppurative otitis media

9

11.84

Any history of discharge

7

9.21

Instillation of coconut oil/ Oiling

6

7.89

Swimming

6

7.89

Diabetes

3

3.95

Common fungal isolates from otomycosis patients were Aspergillus niger (51.32 %), Aspergillus flavus (34.21 %), Aspergillus fumigatus (6.58 %) and Candida species (5.26 %).

Table 4: Fungal isolates from otomycosis patients

Fungal isolates

Number of patients (n=76)

Percentage (%)

Aspergillus niger

39

51.32

Aspergillus flavus

26

34.21

Aspergillus fumigatus

5

6.58

Candida species

4

5.26

Mucor

1

1.32

Penicillium species

1

1.32

 


DISCUSSION

Otomycosis, also called fungal otitis externa is one of the frequently encountered fungal infections of external auditory canal.5 This is commonly seen in tropical and subtropical regions of the world. The frequency of otomycosis depends upon different climatic conditions with higher prevalence in the hot, humid and dusty areas.6 Otomycosis can be diagnosed clinically on the basis of symptoms like pruritus, otalgia, discharge, blockage, hearing loss and presence of musky debris resembling wet newspaper in the external auditory meatus.7 Prasad et al.8 conducted an experiment on otomycosis in a rainy and humid coastal city of South India and identified the isolated organisms of otomycosis, which include fungi and bacteria and also compared them with the normal ears. In their study instillation of coconut oil (42%), use of tropical ear drops (20%), and compulsive cleaning of external ear with hard objects (32%) appeared to be the main predisposing factors in otomycosis. Similar findings were noted in present study. Haja AN et al.,9 studied 100 clinically suspected patients, otomycosis was found to be more common among females (58.54%) and majority in the age-group 21-30 years (35.36%). Pruritis was the most commonly presenting symptom seen in 77% of the otomycotic patients. Instillation of coconut oil was found to be predominating predisposing factor for Otomycosis (36.59%), followed by self-cleaning (32.93%). Aspergillus niger 39(47.56%) was the predominant species isolated. second most common species isolated was Aspergillus flavus 25(30.49%). Aspergillus fumigatus 9(10.97%), Candida species 7(8.54%), Mucor 1(1.22%) and Penicillium species 1(1.22%) were other species isolated. Similar findings were noted in present study. Nitin A et al.,10 studied 108 samples of symptomatic otomycosis, fungal pathogens were isolated in 89 samples, 18 samples were negative and 1 sample was reported as being contaminated. Fungi belonging to genus Aspergillus was isolated in 92.11% of cases of which Aspergillus niger was commonest isolated in 38(41.57%) followed by Aspergillus flavus 32(35.95%) and Aspergillus fumigatus 7(7.86%). Candida species were found in 2(2.24%) and Mucor in 1(1.12%). The most common symptom was Itching 91(84.25%). In this study ear discharge was the commonest finding (44.44%) followed by Black mycotic plug (28.70%). Amit Prakash11 studied 200 Patients chronic otitis media, to detect the potassium hydroxide (KOH) mount positive in ear discharge of chronic otitis media. Most of the patients from 20-30 years 69 (34.5%) and followed by 30-40 years 59 (29.5%). Females 115(57.5%). were found to be more common than males 85(42.5%). Over all prevalence rate KOH positivity was found to be 20.5%. 41 (20.5%) patients showed KOH positivity which is clinically and statistically found to be significant and probability of KOH positive in future will be in between 9.2-22.6%. Most common fungal pathogen was found to be Aspergillus 26 (63.41%), and followed by Candida species 11(26.83%), other saprophytes 4(9.76%). Similar findings were noted in present study. Babita Kumari et al.,12 studied 50 clinically diagnosed cases of otomycosis. 9 cases were found to have contamination or bacterial isolates. Aspergillus species was the predominant fungi followed by Candida spp and Penicillium. In our study male preponderance was seen with 52% cases than female with 48% cases. Incidence of otomycosis was high in age group of 15- 35 years followed by 35-55 years of age group. Ahuja S, et al.,13 noted that, history of wooden stick or any other object used to remove wax (68%), use of oil (44%), swimming (28%) and history of trauma (23%) were the common predisposing factors in otomycosis. Pruritus and otalgia (89% each) were the most common complaints. Statistical association (p value<0.001) was found between isolation of fungi and otomycosis. The fungi isolated were mainly Aspergillus niger (77.0%) followed by A. flavus (12.6%), A. terreus (4.6%), Candida guilliermondii and C. krusei (1.1% each). Bacterial isolates were Staphylococcus epidermidis (21%), S. aureus (7%), Klebsiella pneumoniae (2%) and Enterobacter aerogenes (1%). Fungal pathogens were isolated from external auditory canal of 8% of controls. In order to treat otomycosis, the external auditory canal should be cleaned of the debris and discharge as these lower the pH of the external auditory canal and hence reduce the activity of aminoglycoside ear drops (used in those patients who showed signs and symptoms suspicious of bacterial otitis externa). Antifungal ear drops, suction is useful. Ear should be kept dry and scratching of the ear with cotton bud should be avoided.

 

CONCLUSION

Self-cleaning, lack of cerumen, use of local and systemic antimicrobials, history of chronic suppurative otitis media were common probable predisposing factor of otomycosis. Species like Aspergillus and Candida were common isolates involved in such cases. Microbiological diagnosis helps to start early and directed antifungal treatment.

 

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