Comparison with other studies
The largest case series from a single institution is that by Lou et al.
in which a prospective case series of 74 patients with unilateral
chronic tympanic membrane perforations due to otomycosis were treated
with ketoconazole cream and this was reapplied weekly until no
otomycosis were visible for 2 consecutive weeks and then scheduled for
cartilage myringopalsty. They reported a 83.8% graft take at 6 months
with 6.8% developing post-operative otorhhoea and reperforations and
9.5% have recurrent otomycosis. 8
Abou-Halawa et al, performed a prospective study within an ambulatory
setting of 40 patients with otomycosis and tympanic membrane
perforations. This demonstrated the efficacy of self-medicated
clotrimazole using Q-tips versus physician inserted wicks coated with
clotrimazole. The follow up of 3 months demonstrated recurrence of
otomycosis in 5 patients in the ear wick group compared to zero in the
self-medicated group. Three patients in Q-tip group and one in ear wick
group had closure of their tympanic membrane perforation.9
Hurst produced a case series of 22 patients, who typically presented
with a discrete white and opaque area on the tympanic membrane which
after a week disintegrates to leave a perforation. Treatment was that of
microsuction of epithelial and fungal debris from the ear canal and use
of gauze wick coated in clotrimazole, hydrocortisone, framycetin,
gramicidin every 2 days until resolution. Resolution of the otitis
externa allows the perforation to heal with a normal tympanic membrane
within a month and had no residual hearing loss in the majority (86.3%)
of cases. Three of this cohort required intervention: 2 myringoplasty
and 1 cauterisation to fully close. 10
Rutt reported a case of an immunocompromised patient with chronic left
otitis media and multiple recurrent tympanic membrane perforations. This
was initially treated with antibiotics and antifungal drops, then had a
transcanal tympanoplasty and resection of middle ear cholesteatoma. The
graft failed but the patient respond well to oral fluconazole and
clotrimazole drops with no further recurrences. The paper concluded that
treatment should be vigorous, especially in immunocompromised patients
to prevent complications such as hearing loss and invasive temporal bone
infections.3
A prospective clinical study by Viswanatha compared 50 cases of
otomycosis in immunocompetent versus 50 cases of immunocompromised
patients. The 21-30 age group had the highest incidence in
immunocompetent patients, whereas 41-50 year olds were more frequently
affected in the immunocompromised group. Three percent of patients had
tympanic membrane perforation, all of which were in the
immunocompromised group. All patients were initially treated with
clotrimazole ear drop for 3 weeks, 4 in immunocompromised group didn’t
respond and so were treated successfully with fluconazole drops.
Patients were advised regarding ear water precautions for 3
weeks.6
A case series of 11 patients; 8 men and 3 women aged 18-70 (mean 46)
presenting with chronic, treatment-refractory otitis externa found that
63% had no prior ear complaints. Treatment was debridement and topical
antifungal application (boric acid, nystatin, oral fluconazole or
Ciprofloxacin, chloramphenicol, amphotericin and hydrocortisone). Full
resolution and closure of the tympanic membrane was found in 8 of 11
cases, 2 had tympanoplasty procedures and 1 had a fat graft
myringoplasty. Song concluded that most cases of tympanic membrane
perforations secondary to fungus resolve with medical
treatment.1
Ho presents a retrospective review of 132 patients with otomycosis, 18
of which had a perforation and only 1 required tympanoplasty. Topical
ketoconazole for a period of up to 3 weeks was found to have higher
resolution and lower recurrence rate than other
treatments.4
A retrospective study over 6 years, identified 103 patients with
mycological diseases of the ear canal based on microscopic examination
and culture.2
Kurnatowski treated 381 cases of otitis externa with daily aural toilet
and instillation of fluconozole three times a day and led to a 89% cure
with no response in 5.77% of cases.5