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