ORIGINAL

ARTICLE
VISWANATHA,
SUMATHA,
VIJAYASHREE

Otomycosis in immunocompetent
and immunocompromised patients:
Comparative study and literature
review
Borlingegowda Viswanatha, MS, DLO; Dadarao Sumatha, MBBS;
Maliyappanahalli Siddappa Vijayashree, MBBS, MS

Abstract

A comparative clinical study was carried out that included

50 cases of otomycosis in immunocompetent patients and
50 cases of otomycosis in immunocompromised patients.
Clinical presentation, predisposing factors, mycologic
profile, and treatment outcomes were compared. Aspergillus spp were the most commonly isolated fungi in the
immunocompetent group, and Candida albicans in the
immunocompromised group. Bilateral involvement was
more common in the immunocompromised group. All the
patients were treated with topical clotrimazole ear drops.
Four patients in the immunocompromised group did not
respond to treatment with clotrimazole but were treated
successfully with fluconazole ear drops. Three patients had
a small tympanic membrane perforation due to otomycosis.
Introduction

Otomycosis is a superficial, subacute, or chronic infection of the outer ear canal, usually unilateral, that is
characterized by inflammation, pruritis, and scaling.1
It occurs because the protective lipid/acid balance of
the ear is lost.2
Fungi cause 10% of all cases of otitis externa.2 In recent years, opportunistic fungal infections have gained
greater importance in human medicine, perhaps because
of the huge number of immunocompromised patients.
However, such fungi may also produce infection in
immunocompetent hosts.1 In immunocompromised
patients, treatment of otomycosis should be vigorous to

From the Department of ENT, Victoria Hospital and Bangalore Medical

College and Research Institute, Bangalore, India.
corresponding author: Dr. Borlingegowda Viswanatha, MS, DLO, #716,
10th Cross, 5th Main, M.C. Layout, Vijayangar, Bangalore - 560 040,
Karnataka, India. Email: drbviswanatha@yahoo.co.in
114 www.entjournal.com

prevent complications such as hearing loss and invasive

temporal bone infection.3
We conducted a comparative clinical study involving
50 immunocompetent and 50 immunocompromised
patients with otomycosis. Clinical presentation, predisposing factors, mycologic profile, and treatment
outcomes were compared.
A review of the literature revealed no reported case
series of otomycosis in immunocompromised patients.
Patients and methods

This prospective study was carried out in 100 patients

with otomycosis50 who were immunocompetent and
50 who were immunocompromised. In the immunocompromised group, 36 patients were diabetic, 9 patients
had AIDS, and 5 patients were undergoing radiation
therapy. The patients clinical profiles regarding age, sex,
laterality, and clinical presentation were documented.
Only cases of otomycosis in patients with positive
cultures were included in this study. Patients with otomycosis associated with otitis media and those already
using antifungal ear drops were excluded.
The outer part of patients external auditory canals
was cleaned using sterile swabs, taking material from
the deeper portion of the ear canal that was sent for
fungus culture. After microscopic suction clearance,
antifungal ear drops were given for 3 weeks. All patients
were followed for a minimum of 6 weeks.
Swabs were also taken from the external auditory
canals of 10 immunocompetent and 10 immunocompromised individuals without otomycosis. No fungi were
isolated on fungal culture of these swabs.
Treatment of patients with otomycosis includes
microscopic suction clearance of the fungal mass, disENT-Ear, Nose & Throat Journal March 2012

VISWANATHA, SUMATHA, VIJAYASHREE

continuation of topical antibiotics,

and treatment with antifungal ear
drops for 3 weeks. Our patients
initial treatment regimen consisted
of clotrimazole ear drops for 3 weeks.
Those whose otomycosis did not respond to clotrimazole were switched
to fluconazole ear drops. Patients
were also advised to keep their ears
dry for 3 weeks.
Results

Table 1. Age and sex distribution of patients participating in the present

study

Immunocompetent Immunocompromised

group group

(n = 50)
(n = 50)
Age (yr)
0-10

0 (0%)

0 (0%)

11-20

6 (12%)

0 (0%)

21-30

24 (48%)

2 (4%)

31-40

10 (20%)

18 (36%)

41-50

3 (6%)

26 (52%)

Demographics. In the immunocom51-60

4 (8%)
2 (4%)
petent group, patients ages ranged
61-70
3 (6%)
1 (2%)
from 18 to 65 years, and the peak
0 (0%)
1 (2%)
incidence (48%) was seen in the third 71-80
decade of life. In the immunocompromised group, ages ranged from Sex
38 (76%)
32 (64%)
26 to 74 years, and peak incidence Male
(52%) was seen in the fifth decade Female
12 (24%)
18 (36%)
of life (table 1). In both groups, a
higher incidence was seen in male patients; there were seen more in the immunocompromised than in the
more female patients in the immunocompromised group immunocompetent group (table 3).
(36%) than the immunocompetent group (24%) (table 1).
Clinical examination revealed canal skin erythema and
Laterality. Right ear involvement was more common fungal debris in all cases. Three immunocompromised
in both the groups: in 26 (52%) of the immunocompe- patients had a small central perforation of the tympanic
tent patients and in 18 (36%) of the immunocompro- membrane behind the handle of the malleus. They had
mised patients. The left ear was involved in 16 (32%) not previously experienced ear pain or otitis media.
and 12 (24%), respectively, of these groups. Bilateral
Fungus isolated. In immunocompetent patients Asperinvolvement was seen more in 20 (40%) of the immu- gillus niger was isolated in 28 (56%) of cases, Aspergillus
nocompromised patients compared with 8 (16%) of the fumigatus in 9 (18%), Candida albicans in 8 (16%), and
immunocompetent patients.
Penicillium chrysogenum (previously known as PenicilPredisposing factors. Ear cleaning with sticks and lium notatum) in 5 (10%) (figure). In immunocomproswabs, the use of topical antibiotic
or steroid ear drops, and the use of Table 2. Predisposing factors for the development of otomycosis in
nonsterile oil in the ear were seen study patients
in more immunocompetent pa
Immunocompetent Immunocompromised
tients than immunocompromised
group group
patients (table 2). No predisposing
(n = 50)
(n = 50)
factors were seen in 8 (16%) of the Predisposing factors
31 (62%)
23 (46%)
immunocompetent and 12 (24%) of Ear cleaning with
sticks & swabs
the immunocompromised patients.
Symptoms and complications. Use of nonsterile oil in ear 15 (30%)
11 (22%)
Itching and ear discharge were seen
9 (18%)
more in the immunocompetent Use of topical antibiotic or 16 (32%)
steroid ear drops
than in the immunocompromised
patients, while ear pain was pres- Swimming habits
4 (8%)
1 (2%)
ent in more immunocompromised
patients. A blocked sensation, de- None
8 (16%)
12 (24%)
creased hearing, and tinnitus were
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VISWANATHA, SUMATHA, VIJAYASHREE

Table 3. Symptoms seen in study patients

Discussion

Otomycosis is described as a fungal

infection of the external ear canal.
Immunocompetent
Immunocompromised
This infection is worldwide in disgroup
group
(n = 50)
(n = 50)
tribution, but it is more common
in tropical and subtropical regions.4
Symptoms
Otomycosis is sporadic and caused
Itching
46 (92%)
40 (80%)
by a wide variety of fungi, most of
Ear discharge
38 (76%)
32 (64%)
which are saprobes occurring in
Ear pain
20 (40%)
24 (48%)
diverse types of environmental mateBlocked sensation
16 (32%)
22 (44%)
rial.1 In his review of the literature,
Decreased hearing
9 (18%)
14 (28%)
Wolf stated that no less than 53
Tinnitus
5 (10%)
12 (24%)
different species of fungi had been
reported to cause the disease.5 Otomised patients, A niger was isolated in 17 (34%) cases, mycosis affects 10% of the population in their lifetime.2
A fumigatus in 5 (10%), C albicans in 26 (52%), and P
Fungi are abundant in soil or sand that contains dechrysogenum in 2 (4%) (table 4).
composing vegetable matter. This material is desiccated
Treatment outcomes. All the patients in our immu- rapidly in tropical sun and blown in the wind as small
nocompetent group responded well to treatment, and dust particles. The airborne fungal spores are carried by
there were no recurrences. In our immunocompromised water vapors, a fact that correlates the higher rates of
group, 4 patients did not respond to treatment with infection with the monsoon, during which the relative
clotrimazole ear drops, but they were successfully treated humidity rises to 80%.6
with fluconazole ear drops.
A fungal mass does not protrude from the external
ear canal, even in most chronic cases.
A
B
This is because the fungus does not
find its nutritional requirements
outside the external ear canal. In
the present study, the Aspergillus
growth rate was found to be higher
at the temperature of 37C, a fact
that is clinically supported by the
predilection of fungi to grow in the
inner one-third of the external ear
canal.7
An immunocompromised host
is more susceptible to otomycosis.
D
C
Patients with diabetes, lymphoma,
or AIDS and patients undergoing
or receiving chemotherapy or radiation therapy are at increased risk
for potential complications from
otomycosis.8
Literature review. Incidence by
age and sex. In our study, the highest incidence of otomycosis in the
immunocompetent patients was
seen in the age group of 21 to 30
years (48%), which agreed with the
Figure. Photomicrographs (original magnification 40) show Aspergillus niger (A),
8
Aspergillus fumigatus (B), Candida albicans with budding cells (C), and Penicillium findings of Chander et al, Paulose
9
10
et al, Mohanty et al, and Ho et
chrysogenum (D) fungi.
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VISWANATHA, SUMATHA, VIJAYASHREE

al.11 The higher incidence in these Table 4. Fungus isolated in samples obtained from study patients
patients may be due to the fact that
these people are more exposed to
Immunocompetent
Immunocompromised
group
group
the mycelia (due to occupational
(n = 50)
(n = 50)
exposure, traveling, etc.), whereas
older and younger age groups are Fungus
not as exposed to these pathogens.
Aspergillus niger
28 (56%)
17 (34%)
The highest incidence in our immuAspergillus fumigatus
9 (18%)
5 (10%)
nocompromised patients was found
Candida albicans
8 (16%)
26 (52%)
in the age group of 41 to 50 years
5 (10%)
2 (4%)
(52%). This may be due to the fact Penicillium chrysogenum
that immunocompromised states
high temperature that closely approximates body
are less common in younger age groups.
In both our immunocompetent and immunocompro- temperature; and
general diseases, such as diabetes mellitus.
mised patients, the incidence of otomycosis was higher in
male patients, which agreed with the findings of Paulose
Mohanty et al,10 Rama Kumar et al,15 and Than et al16
et al,9 Ho et al,11 Yassin et al,12 and Hueso Gutirrez et al.13
Laterality. Paulose et al,9 Yassin et al,12 and Yehia et found trauma to be the most common predisposing fac14
al found that otomycosis is predominantly a unilateral tor, as it was in both groups in the present study. Joy et
disease and that the right ear is affected more often than al17 conducted an experimental study for the production
the left, which also was true in both groups of our pa- of otomycosis in human volunteers. The results were
tients. Bilateral involvement was more common in our more positive when trauma was inflicted, and ear wax
immunocompromised than in our immunocompetent was absent in most of the cases. Wax probably has an
patients (2.5:1). This may be due to bilateral ear canal inhibitory effect on fungal growth.9
Symptoms. The most common symptoms in our pasusceptibility to fungal infection in immunocomprotients were itching, ear pain, ear discharge, a blocked
mised patients.
All our patients with bilateral otomycosis had similar sensation, decreased hearing, and tinnitus. These were
findings in both the ears, and the same fungus was iso- also the symptoms observed by Paulose et al, Mohanty
lated on culture from each ear. Chander et al also found et al, and Ho et al.9-11 It should be noted that the correct
that the same fungus was responsible in both ears in diagnosis of otomycosis requires a high index of suspicion, given that the most common presenting symptoms,
bilateral otomycosis.8
Predisposing factors. Ear cleaning and the use of otalgia and otorrhea, are nonspecific.3
In our study, itching and ear discharge were seen
topical ear drops or oils were seen more often in our
immunocompetent than in our immunocompromised more in immunocompetent patients than in immunopatients. The use of topical antibiotics and nonsterile oil compromised patients. Pain was present in 24 (48%)
changes the physiochemical environment of the ear and immunocompromised patients and in 20 (40%) immunocompetent patients. A blocked sensation, decreased
thus favors fungal growth and colonization.
Ear cleaning habits may contribute to pathogenesis hearing, and tinnitus were also seen in more immunobecause traumatized external ear canal skin can present compromised than immunocompetent patients. The
a favorable condition for fungal growth.12 Mechanical duration of symptoms varied from 5 to 21 days. There
was no significant difference in duration of symptoms
trauma also aids in the colonization of fungus.
Yassin et al stated that airborne fungi are responsible between immunocompetent and immunocompromised
for otomycosis.12 They considered many factors in the patients.
Fungi isolated. In the studies conducted by Chander
external ear canal to contribute to a favorable condition
et al, Paulose et al, Mohanty et al, and Yassin et al, Asfor the establishment of many fungi, including12:
pergillus spp were the most common fungi isolated, and

C albicans was the next most common.8-10,12
trauma;
In our group of immunocompetent patients, A niger
relatively high humidity in the external ear canal;
epithelial debris in various stages of chemical was isolated in 28 (56%) cases, A fumigatus in 9 (18%)
cases, C albicans in 8 (16%) cases, and P chrysogenum
breakdown;
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Otomycosis in immunocompetent and immunocompromised patients: Comparative study and literature review

in 5 (10%) cases. In our immunocompromised patients,

A niger was isolated in 17 (34%) cases, A fumigatus in 5
(10%) cases, C albicans in 26 (52%) cases, and P chrysogenum in 2 (4%) cases.
In tropical countries, Aspergillus spp are considered
the predominant organisms implicated in the etiology of
otomycosis.1 In separate clinical studies, Rama Kumar15
and Jaiswal18 found C albicans to be responsible for the
majority of cases, and it was isolated in 47 and 46%,
respectively, of their cases.
Treatment. Bassiouny et al studied the effects of antifungal agents and found that clotrimazole and econazole
were effective antifungal agents in the treatment of otomycosis.19 According to Stern et al and Jackman et al,
clotrimazole is an effective antifungal agent against most
yeasts and fungi, and nystatin has the widest spectrum
of activity among the antifungals.20,21 In a study by Yadav
et al, fluconazole was found to be an effective antifungal
agent in the treatment of otomycosis.22
Complications. Tympanic membrane perforation may
occur as a complication of otomycosis that starts in an
ear with an intact ear drum.3 In the study by Rama Kumar, the incidence of tympanic membrane perforation
in otomycosis was found to be 11%.15 He also stated
that perforations were more common with otomycosis
caused by C albicans. Most of the perforations were
behind the handle of the malleus. The mechanism of
perforation has been attributed to mycotic thrombosis
of the tympanic membrane blood vessels, resulting in
avascular necrosis of the tympanic membrane.3,23
Three patients in our immunocompromised group
experienced tympanic membrane perforation. The
perforations were small and situated in the posterior
quadrant of the tympanic membrane. They healed
spontaneously with medical treatment.
Rarely, fungi can cause invasive otitis externa, especially in immunocompromised patients. Aggressive systemic
antifungal therapy is required in these patients, and a
high rate of mortality is associated with this condition.2
In conclusion, C albicans and Aspergillus spp were
the most commonly isolated fungi seen in immunocompromised and immunocompetent patients,
respectively. Bilateral involvement was seen more in
the immunocompromised group. Clotrimazole is an
effective treatment for otomycosis, and fluconazole is
a good alternative for patients in whom clotrimazole is
not effective. Rarely, tympanic membrane perforations
can occur as a complication of otomycosis in immunocompromised patients.
Volume 91, Number 3

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