CASE PRESENTATION :

OTOMYCOSIS
Group D-13.2
Niko, Ferdina, Sarah, Irhash, Rona, Nafsa
Moderator: dr. Hafifah
Clinical Rotation
Dept. of Otorhinolaryngology and Head Neck Surgery

Otomycosis is fungal infection to the Canalis Auditorius External

Although rarely life threatening, the disease is a challenging and

frustrating entity for both patients and otolaryngologists as it
frequently requires long-term treatment and follow up. And,
there often be case recurrences.

INTRODUCTION

(Bailey, 2014)

1. the auricle
2. external auditory canal.

Elastic cartilage derived from

mesoderm
Subcutaneous tissue
Skin with its adnexal appendages
Fat but no cartilage in the lobule.

THE EXTERNAL EAR

(Bailey, 2014)

Length: + 2,5 cm
The outer 40% is
cartilaginous
a thin layer of
subcutaneous tissue
between the skin and
cartilage.
The inner 60% is osseous
soft tissue between the
skin, periosteum, and
bone.

EXTERNAL AUDITORY
CANAL

(Bailey, 2014)

1.

2.

3.

the tragus and antitragus

form a partial barrier to the entrance of macroscopic
foreign bodies
the skin with its cerumen coat
Hair cells
Sebaceous glands
apopilosebaceo
apocrine glands such as cerumen glands
us unit
the isthmus of the canal
The junction of the cartilaginous and bony portions
of the canal is a narrowed section termed the
isthmus

DEFENSE MECHANISMS OF THE(Bailey, 2014)

EXTERNAL EAR

a. superficial
temporal
a. posterior
auricular

branches of the
external carotid
artery
ARTERIAL SUPPLY
(Feneis et al,2000)

the auriculotemporal branches of the trigeminal (V), facial

(VII), glossopharyngeal (IX), and vagus (X) nerves
the greater auricular nerve from the cervical plexus.
The vestigial extrinsic muscles of the ear, anterior,
superior, and posterior auricular, are supplied by the facial
nerve (VII)

INNERVATION
(Feneis et al,2000)

LYMPHATIC
DRAINAGE OF
HEAD AND NECK

Anteriorly
and
superiorly

Inferiorly

Posteriorly

the preauricular
lymphatics
in the parotid gland
infra-auricular nodes near
the angle
of the mandible deep
cervical nodes.
the postauricular nodes
and the superior deep
cervical nodes

LYMPHATIC DRAINAGE
(Feneis et
al,2000)

Auricule
The external flap of cartilage surrounding the
entrance to the ear
The shape causes a resonance effect alter
the amplitude of the pressure wave at different
frequencies

PHYSIOLOGY OF EXTERNAL EAR

Auditory Canal
Acts as a resonator that further shapes
the spectrum
amplifies the spectrum between 2 kHz
and 5 kHz range for speech
recognition

PHYSIOLOGY OF EXTERNAL EAR

Tympanic membrane
collect air vibrations at the end of the auditory
canal
convert into mechanical movement in the middle
ear
sensitive instrument with an operating range of
more than 100 dB.

PHYSIOLOGY OF EXTERNAL EAR

Otomycosis is a fungal infection of the external auditory

canal and its associated complications sometimes
involving the middle ear.

DEFINITION

Otomycosis occured on 9% of external otitis case and on

30,4% of the case with the otitis symptom
The prevalence is quite high at tropic and subtropic area
Although it can occur in any age, otomycosis often
occured at adult age, especially in woman.
And nowadays, the prevalence raised quite high as in the
higher rate of immunocompromised patient.

INCIDENCE AND EPIDEMIOLOGY

Fungal agent that often cause otomycosis

Aspergillus niger
Candida albicans
Actinomyces
Trichophyton
Aspergillus fumigatus
Asperfillus flavus
Candida tropicalis

ETIOLOGY

Defense mech failure (change of epithelial coating, pH,

humidity, quality and quantity of cerumen)
Bacterial infection
Use of hearing aid device
Self inflicted trauma (e.g. cotton bud)
Swimming in contaminated pool
Use of broad spectrum antibiotics
Use of steroid and/or cytostatic drugs
Immunocompromised underlying disease

PREDISPOSITION FACTORS

PATHOPHYSIOLOGY

SYMPTOMS

SIGNS

Diagnosis is usually made from anamnesis, physical

examination, and microscopic examination
Microscopic:
Microscopic discharge/debris exam with KOH 10%
fungal element (hypha or spores)

DIAGNOSIS

Classical appearance : grayish white plug resembling wet

blotting paper, yellowish spores, a whitish, furry structure, or
blackish spores covering the canals and sometimes the
tympanic membrane

Microscopic finding in
otomycosis.
KOH preparation
showed hypha and
spore

Avoidance/ellimination of contributing factor

Aural toilet removal of debris
Specific topical antifungal : clotrimazole, miconazole,
econazole, nystatin, tolnaftate, potassium sorbate; or non
specific topical antifungal (acetic acid, alcohol, boric acid, macetil acetate, gention violet)

TREATMENT

Aural toilet is the essential first step

Medication is better not reach middle ear irritation
Do not give water based ear drop water is a good
media for the fungi to grow

TREATMENT

CASE REPORT

Name
: Mr. RS
Sex
: Male
Age
: 26 y.o
Date Birth : Nov 8, 1988
Address
: Sambeng Wetan, Kembaran,
Banyumas
Date of examination : December 22, 2014

IDENTITY

Chief complaint: itching of the right ear

Present illness history: Since a week before entering the hospital,

the patient complained that his right ear felt itchy and fullness. He
sometimes felt pain. The complaints started 2 days after
swimming in the public pool. There were no complaint about
discharge coming out from the ear, buzzing, or dizziness. There
were no complaint about his nose and throat either. The patient
has a habit of cleaning his ear by using cotton buds. The patient
routinely swims twice a week.

ANAMNESIS

Past illness history: No similar case history, hypertension,

diabetes mellitus, allergy, malignancy, long-term drugs
and antibiotic uses (especially ear drops), and hearing aid
uses.
Family case history: No similar case history,
hypertension, diabetes mellitus, and allergy.

ANAMNESIS

Pruritus/itching
Otalgia
Aural fullness
Hearing loss

ANAMNESIS RESUME

Right ear

General status : medium, compos mentis, adequately

nourished
Vital signs:
BP
120/75 mmHg
HR
78x/mnt
RR
20 x/mnt
Temp 36.5 C

PHYSICAL EXAMINATION

Head-neck : anemic (-), lymph node unpalpable

Thorax
Cor
: normal
Pulmo : normal
Abdomen : normal
Ekstremities : normal

PHYSICAL EXAMINATION

EAR

DEXTRA

SINISTRA

Auricula

Pain (-)

Normal

Plannum Mastoideum

Normal

Normal

Lymphatic Gland

Not palpable

Not palpable

CAE

Hyperemic (+), edema (-), covered by

black debris (wet newspaper app)

Normal

Tympanic Membrane

Hard to visualize

Intact, cone of
light (+)

Tympanic membrane
(after aural-toilet)

Intact, cone of light (+)

Intact, cone of
light (+)

ENT EXAMINATION

AD

AS

Hyperemic
canal

Black debris

No abnormalities
found

After aural toilet

Before aural toilet

AD

Tympanic membrane
could not be visualised
due to black debris

AS

Tympanic membrane
intact, cone of light
(+)

AD

Clear, Tympanic
membrane intact,
cone of light (+)

Nose and
sinuses

Dekstra

Sinistra

Discharge

No

No

Concha

Hyperemic (-)
edema (-)

Hyperemic (-)
edema (-)

Nasal Septum

Deviation (-)

Deviation (-)

Tumor

None

None

Paranasal sinus

Pain (-)

Pain (-)

ENT EXAMINATION

No abnormalities

NASOPHARYNX

DEXTRA

SINISTRA

Posterior Wall

Normal

Normal

Choana

Normal

Normal

Eustachian tube
opening

Normal

Normal

Adenoid

Not visible

Not visible

Tumor

Not visible

Not visible

ENT EXAMINATION

OROPHARYNX
Palate

Normal

Uvula

Normal

Palatine tonsil

T1 T1

Lingual tonsil

Not enlarging

Posterior wall

Hyperemic (-) Granul (-)

PND (-)

ENT EXAMINATION

S
No abnormalities
present

LARYNGOPHARYNX

LARYNX

Posterior wall

Normal

Epiglottis

Normal

Parapharynx

Normal

Arytenoid

Normal

Plica vovalis

Normal

Plica vocalis
movement

Normal

Tumor
Trachea

No
Normal

ENT EXAMINATION

S
No abnormality
found

Ear (AD)
Hyperemic (+), and blackish debris
like wet newspaper (+) on the right
external auditory canal.

Ear (AS): n.a.p

Nose : n.a.p
Throat : n.a.p

RESUME OF
OTORHINOLARINGOLOGY STATUS

Otomycosis, Aural
Dextra
DIAGNOSIS

Aural
Auraltoilet,
toilet,local
localdebridement
debridementwith
withperhidrol
perhidroldrop
drop
Miconazole
Miconazolecream
cream2%
2%twice
twiceaaday,
day,external
externaluse
use
for
for14
14days
days

THERAPY

EDUCATION

PROGNOSIS

Microscpic examination by using KOH 10% should be done

to diagnose otomycosis

PROBLEM

About 5-20% of the visits to ENT section are related to otitis

externa.
Most cases bacteria, and fungi 9 25%
Otomycosis mostly happens in tropical and subtropical areas which
have high humidity, and can be found more in adults than in
children. Prevalence of otomycosis is also found higher in women
than in men (Khan et.al., 2013).

DISCUSSION

Some fungi that cause otomikosis are Aspergillus niger, Candida

albicans, Actinomyces, Tricophyton, Aspergillus fumigatus, and
Candida tropicalis (Khan et.al., 2013).
Pontes et.al. research in (2009) showed some fungi causing
otomycosis: Candida albicans, Candida parapsilosis, Aspergillus
niger, Aspergillus flavus, Candida tropicalis, Trycophyton asahii,
Aspergillus umigatus, dan Scedosporium apiospermum.
Otomycosis is usually unilateral and characterized by
inflammation, pruritus, scaling, and severe discomfort such as
pain and suppuration (Khan, 2013). But in Pontes et.al. research
(2009), Candida albicans, Candida parapsilosis, and Aspergillus
niger could manifested as bilateral infection.

Predisposing factors : bacterial infections, use of hearing

aid or a hearing prosthesis, self inflicted trauma (such as
scratching of the ears with a cotton bud), swimming in a
contaminated pool, broad spectrum antibiotic therapy,
steroid or cytostatic medication, neoplasia, and immune
disorder.
Otomycosis is seen more frequently in patients with
immunocompromised compared to immunocompetent
persons.

The symptom of otomycosis are variable and usually not

specified. The most presenting complaints in Khan et.al.
research (2013) were otalgia, aural fullness, itching, otorrhea,
and hearing loss.
After clinical examination, it is possible to confirm diagnosis
through direct microscopic examination
Considering that the inner and middle ears are sterile, the
external ear bears a skin commensal microbiota. Before material
collection, it is important to clean the external auditory canal with
a moist swab.
In case there was secretion in the canal, used a sterile swab for
the collection and skin scales were collected with the help of a
sterile loop.

The samples were processed through direct microscopic exam with

KOH 10% and culture in agar Sabouraud dextrose eith
chloramphenicol 0,05 mg/mL. The cultures were cultivated at 25-37 0
C with weekly observation during 30 days.
Hypha and spores on microscopic examination are typical to fungal
infection.
The classical appearance of fungi on otoscope is whether grayish
white debris resembling wet blotting paper (or wet newspaper),
yellowish spores, a whitish furry structure, or blackish spores
covering the canals and sometimes the tympanic membrane.
A grayish or blackish debris usually refers to Aspergillus infection
while whitish is refer to Candida.

Treatment options for otomycosis include elimination of predisposing

factor, through canal cleansing and antifungal agents.
Ear-toilet is the first important step to treat otomycosis.
This medication should not reaching the middle ear because it was
irritating.
On otomycosis therapy, it is important to not giving the homogenized ear
drop, because water is a suitable media for fungal growing
Topical antifungals are specific (clotrimazole, miconazol, econazole,
hystatin, tolnaftate, potassium sorbat) andnon-spesifik (acetic acid,
alcohol, boric acid, m-cresyl acetate, and gentian violet).

Alnawaiseh et.al., 2011; Khan et.al., 2013; Satish et.al., 2013

Azole group has been shown to be quite effective in treating

otomycosis. The efficacy of azoles seems to depend on the duration of
treatment.
It is reported that 2 weeks of treatment with oxiconazole cured only
27% of patients, 1 week of treatment with clotrimazole cured only 35%
of patients whereas 4 weeks of treatment with clotrimazole cured 70%.
Clotrimazole is the most widely used topical azole. It is available as
powder, lotion, and solution. It is considered free of ototoxic effects.
Some studies showed that clotrimazole was one of most effective
agents for management of otomycosis, with reported rate of
effectiveness that varies from 90 to 100%.
Khan et al., 2013

A male patient, aged 26 years old, with complaints of itchy and

fullness on the right ear was diagnosed otomycosis auris
dextra, based on the blackish debris like wet newspaper
appearance. Ear-toilet was done and the patient was given
miconazole 2% cream to be used twice a day for 2 weeks. We
asked the patient not to scratching his ears by anything, keep
the ears dry, dont swim until the disease resolves . Patient was
also asked to come a week later to evaluate the therapy

CONCLUSION

Alnawaiseh S., Almomani, O., Alassaf S., Elessis A., Shawakfeh, N., Altubeshi,
K., Akaileh, R. 2011. Treatment of Otomycoisis: A Comparative Study Using
Miconazole Cream with Clotrimazole Otic Drops. J Royal Med Serv
2011:18(3):34-37.
Khan, F., Muhammad, R., Khan, M.R., Rehman, F., Iqbal, J., Khan M., Ullah G.
2013. Efficacy of Topical Clotrimazole in Treatment of Otomycosis. J Ayub
Med Coll Bbottabad 2013;25(1-2).
Pontes, Z.B.V.S., Silva, A.D.F., Lima, E.O., Guerra, M.H., Oliveira N.M.C.,
Carvalho, M.F.F.P., Guerra, F.S.Q. Otomycosis: A Retrospective Study. Braz J
Otorhinolaryngol 2009:75(3):367-70.
Satish, H.S., Viswanatha, Manjuladevi. 2013. A Clinical Study of Otomycosis. J
Dental Med Sci 2013:5(2):57-62

REFERENCES

THANK YOU
SUGGESTIONS PLEASE

REFERRED PAIN (10 T )

A. CN V
B. CN IX

C. CN X
D. Cervical 2-3

: 1. Teeth (caries, eruption)

2. TMJ (arthritis, luxatio)
3. Tick facialis
: 4. Tongue (glositis, ulcus)
5. Tonsil (abcess,tonsilitis)
6. Throath (pharyngitis, ulcus)
7. Tuba (infection, Ca )
: 8. Trachea
9. Thyroid
: 10. Trapezius
THT UI, 2012