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How to manage the perforation with otomycosis is best☆
ARTICLE INFO
Keywords:
Myringoplasty
Chronic tympanic membrane perforation
Otomycosis
Compound ketoconazole
Dear Editor,
I read with great interest the article entitled: “The evaluation of
endoscopic cartilage myringoplasty to repair perforations with otomy­
cosis” by Lou [1]. The authors evaluated the graft success rates and
hearing gains of tympanic membrane (TM) perforations with otomy­
cosis undergoing endoscopic cartilage myringoplasty and local appli­
cations of antimycotic cream. They found that Endoscopic cartilage
myringoplasty effectively treats persistent perforations with otomycosis
[1]. The repairing of the TM perforations with otomycosis is intractable
issue and technical challenge in otologic clinic. The pre-, intra-, and
post-operative local applications of antimycotic cream are re­
commended in this study. The authors raise the well therapy ideas for
the reader, however, I just want to declare some points that limit the
power of this study. Further study should be considered for the treat­
ment strategy.
How to determine the duration of used local applications of anti­
mycotic cream at pre- and post-operative. Although the authors de­
scribed that the cream was re-applied once a week until no otomycosis
was evident in the deep EAC, and then myringoplasty was scheduled
after the persistent clean EAC for two weeks, two weeks of dry ear is too
short, the residual fungal mycelia couldn't be eradicated and hidden in
the middle ear cavity and mastoid process [2–4]. In addition, surgery
can have immunoparetic effect which can stimulate pathogenicity in
previously quiescent fungi, if antifungal treatment is not sufficient [5].
Usually, dry ear for 2- months prior to myringoplasty should be re­
commended in most of cases. Similarly, although the authors described
that the compound ketoconazole cream was applied to the EAC and
graft surface at each follow-up visit within 4 weeks of surgery [1], we
believed that the duration of postoperative application should be dif­
ferent but not constant for the individual patients. The authors reported
that seven (9.5%) ears had recurrent otomycosis after 4 weeks followed
by re-perforations despite topical application of compound ketocona­
zole cream [1]. The results also confirmed our speculation. In addition,
for the application procedure of compound ketoconazole cream, the
authors described that the EAC and the middle ear cavity were filled
☆
In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, the author(s) undersigned transfers, assigns and otherwise
conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology.
https://doi.org/10.1016/j.amjoto.2020.102744
Received 29 August 2020
0196-0709/ © 2020 Elsevier Inc. All rights reserved.
with compound ketoconazole cream commencing at the lateral surface
of the remnant TM [1]. The overmuch cream is accumulated in the
EAC, that may further result in the wet environment and thereby
worsen the otitis externa with otomycosis [6,7]. In our otology clinic,
the mixture of ofloxacin otic solution and dexamethasone or 3% boric
acid alcohol ear drops was firstly used to reach the dry ear for the
otomycosis with otorrhea, subsequently, the compound ketoconazole
cream was spreaded on the wall of EAC but not the whole EAC lumen.
Another concern is the absence of randomized controlled trial and
short follow up. The authors didn't compare the outcome between
compound ketoconazole cream and other antifungal drug. In our clinic,
intraoperative lavage of 1% Povidone iodine solution is applied for
10–15 min. Previous studies suggested that use of the povidone iodine
in recalcitrant otomycosis is an effective and well-tolerated treatment
[8,9]. The Povidone iodine lavage is simple and convenient. In addi­
tion, the compound ketoconazole cream was packed in the middle ear
cavity, that could irritate the middle ear and may be ototoxic to the
cochlea [7]. In this study, the ABG closure was > 20 dB in 20.3% of all
patients, hearing recovery after surgery was poor in some patients [1].
Thus, ototoxicity of compound ketoconazole cream couldn't completely
excluded. The follow up time is only 6 months in this study [1]. Kim
et al. [10] found that re-perforation occurred in 8.7% in the inlay
cartilage tympanoplasty group and 23.1% in the underlay cartilage
tympanoplasty group.
It thus appears that the re-perforation is inevitable even if the car­
tilage tympanoplasty, the long-term re-perforation could be higher for
the perforations with otomycosis. Thus, the long-term follow up at least
one year should be encouraged.
Funding source
No.
Declaration of competing interest
No.

References
[1] Lou Z. The evaluation of endoscopic cartilage myringoplasty to repair perforations
with otomycosis. Am J Otolaryngol 2020;41:102493. https://doi.org/10.1016/j.
amjoto.2020.102493.
[2] Gupta N, Baghotia KS, Rabha M, et al. Comprehensive community screening of
otological patients by trained technicians using a telemedicine device: An efficient
and cost-effective way to triage patients with ear diseases [published online ahead of
print, 2020 Aug 26]. Ear Nose Throat J 2020:145561320950992.
[3] Singh GB, Solo M, Kaur R, Arora R, Kumar S. Mycology of chronic suppurative otitis
media-cholesteatoma disease: an evaluative study. Am J Otolaryngol
2018;39:157–61.
[4] Murakami A, Tutumi T, Watanabe K. Middle ear effusion and fungi. Ann Otol Rhinol
Laryngol 2012;121:609–14.
[5] Bhatt YM, Pahade N, Nair B. Aspergillus petrous apicitis associated with cerebral and
peritubular abscesses in an immunocompetent man. J Laryngol Otol
2013;127:404–7.
[6] Otón T, Carmona L. The epidemiology of established rheumatoid arthritis. Best Pract
Res Clin Rheumatol 2019;33:101477.
Am J Otolaryngol xxx (xxxx) xxxx
[7] Koltsidopoulos P, Skoulakis C. Otomycosis with tympanic membrane perforation: a
review of the literature. Ear Nose Throat J 2020;99:518–21.
[8] Mofatteh MR, Naseripour Yazdi Z, Yousefi M, Namaei MH. Comparison of the re­
covery rate of otomycosis using betadine and clotrimazole topical treatment. Braz J
Otorhinolaryngol 2018;84:404–9.
[9] Swain SK, Behera IC, Sahu MC, Das A. Povidone iodine soaked gelfoam for the
treatment of recalcitrant otomycosis - our experiences at a tertiary care teaching
hospital of eastern India. J Mycol Med 2018;28:122–7.
[10] Kim MB, Park JA, Suh MJ, Song CI. Comparison of clinical outcomes between
butterfly inlay cartilage tympanoplasty and conventional underlay cartilage tym­
panoplasty. Auris Nasus Larynx 2019;46:167–71.
Xiao-Ling Wu
Department of Operating Theater, Affiliated Yiwu Hospital of Wenzhou
Medical University, No. 519 Nanmen street, Yiwu City 322000, Zhejiang
provice, China
E-mail address: wuxiaoling2019102@126.com.