Key points
A high index of suspicion is needed when otitis externa not improving and there are symptoms of significant pruritis.
Signs of fungal debris, either obvious spores or black particles in debris should alert one to take a microbiology swab for fungal culture, which may yield Candida or Aspergillus species.
Treat patients with regular and prompt microsuctioning and application of topical antifungals for up to a month: Aspergillus can be particularly aggressive and lead to tympanic membrane erosions, ulceration and perforation.
Flumetasone/Clioquinol drops are effective in Aspergillus fungal otitis externa
Consider surgical repair if tympanic membrane not healed with medical treatment.