Fungal Otitis Externa As A Cause of Tympanic Membrane Perforation: A Case Series

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Fungal otitis externa as a cause of
tympanic membrane perforation: A
case series
August 27, 2014 by James Eingun Song, MD; Thomas J. Haberkamp, MD; Riddhi
Patel, MD;
Miriam I. Redleaf, MD
Abstract
We describe a series of 11 patients-8 men and 3 women, aged 18 to
70 years (mean: 46.0)-who had fungal otitis externa that had been
complicated by a tympanic membrane perforation. These patients
had been referred to us for evaluation of chronic, mostly treatmentrefractory otitis externa, which had manifested as otorrhea, otalgia,
and/or pruritus. Seven of the 11 patients had no history of ear
problems prior to their current condition. Five patients had been
referred to us by a primary care physician and 4 by an
otolaryngologist; the other 2 patients were self-referred. All patients
were treated with a thorough debridement of the ear and one of two
antifungal medication regimens. Eight of the 11 patients
experienced a complete resolution of signs and symptoms, including
closure of the tympanic membrane perforation. The other 3 patients
underwent either a tympanoplasty (n = 2) or a fat-graft
myringotomy (n = 1) because the perforation did not close within a
reasonable amount of time. This series demonstrates that the
nonspecific signs and symptoms of fungal otitis externa can make
diagnosis difficult for both primary care physicians and general
otolaryngologists. This study also demonstrates that most cases of
tympanic membrane perforation secondary to fungal otitis externa
will resolve with cleaning of the ear and proper medical treatment.
Therefore, most patients with this condition will not require surgery.
Introduction
Fungal otitis externa, also known as otomycosis, is frequently seen in

primary care and otolaryngology practices. As this case series will
demonstrate, fungal otitis externa often presents with (1) edema and
serous transudate of the external canal skin, (2) erythema and perforation
of a thickened tympanic membrane, and (3) serous drainage from the
middle ear space into the external auditory canal (EAC). As such, primary
care physicians and even otolaryngologists may find these clinical
features more suggestive of bacterial otitis media and mastoiditis, when in

fact these findings can represent a fungal infection of the EAC.
The most common causes of fungal otitis externa are Candida and
Aspergillusspp.1-4 Fungal pathogens have been reported to cause 9% of
all cases of otitis externa, but this figure appears to be on the rise,
presumably because of the increased use of topical antibiotics.5,6
Although fungal otitis externa is a well-established entity, tympanic
membrane perforations-the clinical feature that physicians find most
misleading-is an infrequently reported complication.5,7 The diagnosis of
otomycosis is usually made on clinical grounds, as the characteristic
appearance of the fungal fruiting bodies are easily recognizable through
an office microscope. Given the rapid response to antifungal treatment in
affected patients, cultures are generally not obtained because they are
not considered to be cost-effective in this setting. The most widely used
treatment regimen for otomycosis is mechanical debridement of the ear
canal along with antifungal medication.3
In this article we describe the clinical presentation, course, treatment, and
outcomes in a series of patients with otomycosis that was complicated by
a tympanic membrane perforation.
Patients and methods

During a 6-year period, we treated 11 patients-8 men and 3 women, aged
18 to 70 years (mean: 46.0)-who had fungal otitis externa that had been
complicated by a tympanic membrane perforation. In addition to
demographic data, we compiled information on the referral source and
reason for referral, each patient's history of ear disease, the presence or
absence of EAC and tympanic membrane edema and EAC drainage, the
type and duration of antifungal therapy, and outcomes.
The diagnosis of fungal otitis externa had been based on clinical signs and
symptoms and by the characteristic appearance of fungal fruiting bodies.
Cultures were not routinely obtained at the time of examination. The
tympanic membrane perforations were identified at each patient's initial
clinic visit.
Patients were followed until their signs and symptoms completely
resolved. The duration of medical treatment was based on our clinical
judgment. If no considerable improvement occurred with medical
management, surgical intervention was eventually chosen.
Results
Five patients had been referred to us by a primary care physician and 4 by
an otolaryngologist; the other 2 patients were self-referred. At
presentation, all patients had chronic otitis externa of 2 weeks' to 12
months' duration (table). Their condition was marked by otorrhea, otalgia,
and/or pruritus. All 9 patients who had been referred by a physician had
been treated with some form of antibiotic treatment prior to referral.
Table. Demographic data, clinical
characteristics, and outcomes

Hist
ory
of
ear
dise
ase
EAC
drain
age
Outcome
Closure of
the TM
perforation
Refe
rral
sour
ce
18/M
PCP
OE
(9
mo)
Yes
Yes
Yes
1.5
mo*
32/F
PCP
OE
(2.5
mo)
Yes
Yes
Yes
9
mo*
Closure of
the TM
perforation
38/M
PCP
OE
(1.5
mo)
No
Yes
No
3 mo
Closure of
the TM
perforation
41/M
ENT
OE
(1
mo)
Yes
Yes
Yes
8 mo
Closure of
the TM
perforation
ENT
OE
(3
mo)
3 mo
Tympanopl
asty and
ossiculopla
sty
47/M
Self
OE
(2
wk)
Yes
Yes
No
1 mo
Closure of
the TM
perforation
50/M
ENT
OE
(12
mo)
No
Yes
Yes
4 mo
Closure of
the TM
perforation
50/M
Self
OE
(2
mo)
No
Yes
Yes
3 mo
Closure of
the TM
perforation
55/M
ENT
OE
(1
mo)
No
Yes
Yes
3
mo*
Fat-graft
myringopla
sty
PCP
OE
(1
mo)
2 mo
Closure of
the TM
perforation
Age/sex
47/F
58/M
No
No
EAC
and
TM
ede
ma
Type
and
dura
tion
of
ther
apy
Reas
on
for
refer
ral
Yes
Yes
Yes
Yes
70/F
PCP
OE
(6
mo)
No
Yes
Yes
7.5
mo*
Tympanopl
asty
It is significant that 7 of our patients had no history of ear disease prior to

the current condition (table). Two of the 11 had previously undergone an
otologic procedure-one tympanoplasty and one mastoidectomy. The
tympanoplasty patient had a history of chronic otitis media as well as
otitis externa; this patient went on to experience recurrent episodes of
fungal otitis externa on the same side where the tympanoplasty had been
performed, which resulted in a perforation of the tympanic membrane.
The mastoidectomy patient had undergone a canal-wall-down procedure.
On physical examination, all 11 patients exhibited evidence of EAC and
tympanic membrane edema, and 9 also had drainage from the affected
ear (table). Black and white debris, most likely representing fungal
hyphae, was consistently found in the EAC upon inspection with an office
microscope. After the canal was cleaned, the tympanic membrane
perforation could be visualized.
All patients were treated with one of two medical regimens; 7 patients
received a combination of boric acid powder, nystatin powder, and oral
fluconazole, and 4 received a powdered combination of ciprofloxacin,
chloramphenicol, amphotericin, and hydrocortisone (CCAH).
The duration of drug treatment ranged from 1 to 9 months. Six of the 7
patients who received the boric acid/nystatin/fluconazole regimen
experienced a complete resolution of signs and symptoms and healing of
the tympanic membrane perforation. The remaining patient, a 47-year-old
woman, had presented to our office with chronic otalgia, otorrhea, and
decreased hearing in her right ear. After she had taken multiple courses of
antibiotics for 3 months without improvement, she was eventually
diagnosed with fungal otitis externa. By the time she was diagnosed with
otomycosis, she had developed a subtotal tympanic membrane
perforation and she subsequently underwent tympanoplasty and
ossiculoplasty (table).
Of the 4 patients who received the CCAH regimen, 2 experienced a
complete resolution of signs and symptoms and closure of the tympanic
membrane perforation. The other 2 patients required surgery because
their perforation failed to heal; 1 underwent a fat-graft myringoplasty and
the other a tympanoplasty (table).
The 3 patients whose tympanic membrane did not heal initially continued
to receive drug treatment until no residual inflammation was left. Once
the affected ear was free of infection, they underwent surgery.
Discussion
Fungal otitis externa can be a difficult diagnosis for primary care
physicians and even general otolaryngologists, since its signs and
symptoms often mimic those of bacterial otitis externa and otitis media.
Unfortunately, an incorrect diagnosis can lead to a prolonged course and
to complications such as tympanic membrane perforations.
When such a perforation does occur, otolaryngologists may be tempted to

close it surgically. However, as this case series demonstrates, most cases
of fungus-caused tympanic membrane perforations will resolve on their
own with proper medical treatment. We speculate that these perforations
tend to heal once the fungal infection is cleared because they arose in the
setting of normal eustachian tube function. It must be mentioned,
however, that treatment of fungal otitis externa with medical
management is not without risk, especially in patients who have a
tympanic membrane perforation.
Although medical treatment is generally considered to be safe, there have
been reports of inner ear ototoxicity with some of the agents used in our
patients. Boric acid in particular has been implicated as a cause of
sensorineural hearing loss by inflicting damage to the inner hair cells of
the organ of Corti. However, most of these studies were conducted in
animal models, and the boric acid powder was prepared with 70% alcohol.
There is a great body of evidence now that supports the safety of boric
acid when it is prepared in distilled water.8
Furthermore, a survey of more than 2,000 otolaryngologists in the United
States conducted by Lundy and Graham found that the vast majority of
respondents were comfortable using these regimens in patients with
tympanic membrane perforations.9 In view of the acidic nature of boric
acid, it may also cause some pain and discomfort, but patients usually
tolerate it well.
In this series, we presented 11 cases of fungal otitis externa that were
complicated by a tympanic membrane perforation. Our series
demonstrates two points:
First, fungal otitis externa often manifests with otorrhea, canal edema, and
tympanic membrane perforation, which can mislead general practitioners
and even general otolaryngologists. Indeed, 4 of our referrals were made
by fellow otolaryngologists who did not expect otomycosis to manifest
with otorrhea and a tympanic membrane perforation. The absence of
previous ear problems in 7 of our patients served as a clue that the
problem was an infection of fungal origin rather than a bacterial infection
that caused eustachian tube dysfunction.
Second, perforations of the tympanic membrane caused by fungal otitis
externa can be treated with adequate mechanical debridement and a
topical antifungal regimen with or without an oral regimen. This is in
agreement with the findings of Ho et al, who studied 18 patients with a
tympanic membrane perforation caused by otomycosis who were treated
with antifungal medications; the authors found that only 1 of these
patients required tympanoplasty to close a persistent perforation.5 Hurst
reported similar findings, as 19 of 22 patients with a tympanic membrane
perforation secondary to otomycosis healed without surgery.7
Unfortunately, the clinical microscope is a necessity for cleaning these
ears, and this impedes effective treatment by primary care physicians.
In summary, adequate cleaning and medical treatment were sufficient to
resolve most of our tympanic membrane perforations, thereby obviating
the need for surgery.
References
1
2
3
4
5
6
7
8
9
Pontes ZB, Silva AD, Lima Ede O ,et al. Otomycosis: A retrospective study.
Braz J Otorhinolaryngol 2009; 75 (3): 367-70.
Hawke M, Wong J, Krajden S. Clinical and microbiological features of otitis
externa. J Otolaryngol 1984; 13 (5): 289-95.
Kurnatowski P, Filipiak A. Otomycosis: Prevalence, clinical symptoms,
therapeutic procedure. Mycoses 2001; 44 (11-12): 472-9.
Dyckhoff G, Hoppe-Tichy T, Kappe R, Dietz A. Antimycotic therapy in
otomycosis with tympanic membrane perforation [in German]. HNO 2000;
48 (1): 18-21.
Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: Clinical features and
treatment implications. Otolaryngol Head Neck Surg 2006; 135 (5): 78791.
Munguia R, Daniel SJ. Ototopicalantifungals and otomycosis: A review. Int J
PediatrOtorhinolaryngol 2008; 72 (4): 453-9.
Hurst WB. Outcome of 22 cases of perforated tympanic membrane caused
by otomycosis. J LaryngolOtol 2001; 115 (11): 879-80.
Oztrkcan S, Dndar R, Katilmis H ,et al. The ototoxic effect of boric acid
solutions applied into the middle ear of guinea pigs. Eur Arch
Otorhinolaryngol 2009; 266 (5): 663-7.
Lundy LB, Graham MD. Ototoxicity and ototopical medications: A survey of
otolaryngologists. Am J Otol 1993; 14 (2): 141-6.
From the Department of Dermatology, University of California, Irvine (Dr.
Song); the Department of Otolaryngology, Cleveland Clinic (Dr.
Haberkamp); the Department of Surgery, University of Chicago Medicine
(Dr. Patel); and the Illinois Eye and Ear Infirmary, Chicago (Dr. Redleaf).
The study described in this article was conducted at the Illinois Eye and
Ear Infirmary.
Corresponding author: James Eingun Song, MD, Department of
Dermatology, University of California, Irvine, 118 Med Surge I, Irvine, CA
92697. Email: [email protected]
Ear Nose Throat J. 2014 August;93(8):332-336

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(entjournal.

Fungal otitis externa, also known as otomycosis, is frequently seen in

features more suggestive of bacterial otitis media and mastoiditis, when in

Patients and methods

Table. Demographic data, clinical

characteristics, and outcomes

It is significant that 7 of our patients had no history of ear disease prior to

When such a perforation does occur, otolaryngologists may be tempted to

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