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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 107-110

Evaluation of the rate of tympanic membrane perforation in otomycosis


Department of Otorhinolaryngology, Pacific Institute of Medical Science, Udaipur, Rajasthan, India

Date of Submission24-Sep-2020
Date of Decision30-Oct-2020
Date of Acceptance26-Jan-2021
Date of Web Publication21-Sep-2022

Correspondence Address:
Dr. Rajendra Kumar Teharia
C-1402, Mangaldeep Apartment, Near Pal Balaji Temple, Pal Road, Jodhpur - 342 008, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_208_20

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  Abstract 


Introduction: Otomycosis (OM) is an external ear infection of fungi and sometimes associated with tympanic membrane perforation (TMP). In this study, we analyzed and discussed the rate of TMP in otomycotic patients with no other associated pathology. Materials and Methods: In this prospective observational study, a total of 120 cases of OM were seen from August 2017 to April 2018 and microscopy with local cleaning was done. Fungal material was collected from all patients individually and sent for Gram staining and histopathological confirmation of fungus species and looked for TMP. Topical clotrimazole (1%) drops were given as empirical treatment with weekly microscopy and follow up to 12 weeks. Results: Eleven cases (9%) had tympanic perforation at the time of the first examination. In all cases with the TMPs, the causative organism was the Aspergillus species. Persistent TMP was present in 6 cases (5%). A total of three persistent TMPs required surgical intervention after 12 weeks. Conclusion: In OM, TMP is not infrequent and it requires careful examination especially under a microscope to identify it.

Keywords: Aspergillus, otomycosis, tympanic membrane perforation


How to cite this article:
Teharia RK, Rathore VS. Evaluation of the rate of tympanic membrane perforation in otomycosis. Indian J Otol 2022;28:107-10

How to cite this URL:
Teharia RK, Rathore VS. Evaluation of the rate of tympanic membrane perforation in otomycosis. Indian J Otol [serial online] 2022 [cited 2022 Sep 28];28:107-10. Available from: https://www.indianjotol.org/text.asp?2022/28/2/107/356448




  Introduction Top


Otomycosis (OM) is frequently seen in the day-to-day practice of otorhinolaryngology. It is seen throughout the world. The prevalence of this disease is especially high in hot and humid climates.[1] It accounts for 5%–20% of all cases of infective otitis externa worldwide.[2] OM is often related to canal edema, pain, ear discharge, tympanic membrane congestion, and sometimes with perforation of tympanic membrane and hearing loss. Diagnosis is usually made by clinical examination and otoscopy. White, gray, black, or cheese-like material and inflammation of the ear is the hallmark of OM.[3] Aspergillus and Candida's species are the most common saprophytic species causing OM.[4] The most recommended treatment is local debridement with local and systemic antifungal medications.[5] The complications of OM are rarely fatal and are occasionally associated with tympanic membrane perforation (TMP).[6],[7] In this study, we evaluated the rate of TMP in otomycotic patients with no other associated pathology.


  Materials and Methods Top


This prospective observational study was done from August 2017 to April 2018 in the department of otorhinolaryngology of the tertiary care center in the north Indian state of Rajasthan, India. Informed consent was obtained from all the patients who were enrolled in the study. Ethical clearance for the study was obtained from an ethical committee. Patients who had fungal otitis externa on local examination and otoscopy were included in this study. Patients with a history of ear discharge (any type) before the current illness were excluded from the study to rule out associated pathology.

Patients with an open mastoid cavity or ear surgery, diabetics, and hearing aid bearers were also excluded from the study because these patients have a higher incidence of OM compared to normal persons.

In all patients who had fungal growth on clinical examination and otoscopy, suction and cleaning were done under a microscope to remove all fungal material that was sent for Gram staining and histopathological examination to confirm fungal species. After tissue processing and embedding, paraffin blocks were prepared, the sections were stained with hematoxylin and eosin stain. PAS staining was done wherever necessary. Various morphological parameters such as size, the predominant form of the fungus (yeast, hyphae, or pseudohyphae), presence or absence of capsule, the thickness of the hyphae, budding, presence or absence of septae, and branching pattern in hyphae were noted. Thin slender, septate, dichotomously branching at the acute angle was classified as Aspergillus species. Broad, hyaline aseptate/pauciseptate hyphae branching irregularly or at right angles were classified as Mucorales species; Pseudohyphae with yeast forms were classified as Candida species.

Culture and sensitivity tests were not obtained because they are not considered cost-effective in our setting.

After cleaning off all fungal material under a microscope, tympanic membranes were looked for any presence of perforation and defined for site and size of perforation if present.

TMP was leveled as central or marginal based on their location and as small (size <25% area of the tympanic membrane), medium (size 25%–50% tympanic area involvement), or large (when involving more than 50% area of the tympanic membrane).

After complete suction and cleaning, all the patients were given antifungal drops of clotrimazole (1%) for empirical treatment.

All patients were asked to follow up weekly and were examined under a microscope for fungal growth and TMP. In all patients, local debridement with suction cleaning was repeated at each follow-up until all signs and symptoms of OM were completely resolved.

If TMP persisted even after resolution of all signs and symptoms of OM, then it was leveled as persistent perforation and followed until spontaneous healing. If the tympanic membrane did not heal even after 3 months, then surgical closure was employed to close persistent TMP.


  Results Top


A total of 156 patients of OM were seen in our outpatient department during the study period. Out of which, 36 patients were excluded due to various reasons (history of ear discharge and ear surgery – 17 cases, diabetics – 11 cases, and hearing aid bearer – 8 cases).

The remaining 120 patients (70 males and 50 females) were included in the study. Ninety patients belonged to the rural and suburban areas and 30 patients were urban. Agriculture was the main occupation on a day-to-day basis in 80 patients (50 males and 30 females).

Age-wise distribution of all patients is given in [Table 1].
Table 1: Age-wise distribution of all patients

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The highest incidence of OM was in the age group of 21–30 years and the lowest was noted in the age group of fewer than 10 years.

The frequency of TMP at the time of the first examination is given in [Table 2]. In all 11 cases, perforations were leveled, small, and central as per the criteria given previously.
Table 2: Tympanic membrane perforation at first examination

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In our study, 90% of cases (108 patients) of OM were caused by Aspergillus species, and 10% of cases (12 patients) were caused by Candia species. All cases of OM with TMP were caused by Aspergillus only.

[Table 3] shows the follow-up records of the patients for otomycotic resolution and TMP status.
Table 3: Weekly follow-up records of otomycosis with tympanic membrane perforation

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All the patients were free from OM after 4 weeks of treatment. The cases of TMP gradually resolved until 6 weeks. Six out of 11 TMP qualified as persistent TMP. Three out of these six persistent TMP did not heal even after 12 weeks and were advised surgical correction.


  Discussion Top


In our study, the male to female ratio was 1.4:1, and OM was more common among young males than females, which was similar to other studies.[8],[9],[10] The patients with OM mainly came from rural and semiurban areas and were mostly employed in agriculture. This may be because young men generally spend more time outdoors and exposure to various fungi is common in field workers.[11]

The range of incidence of TMP in otomycotic patients is quite wide (0% to 16.67%).[12],[13] In our study, the incidence was 9.1%, which is comparable with other studies.[5],[7],[13] A study done by Ram Kumar et al. showed an 11% incidence rate of TMP in OM, slightly higher than in our study.[14] TMP in OM is the consequence of the fungal invasion of the tympanic membrane from the medial aspect of the external auditory canal (EAC) or direct extension of disease from the skin. Mycotic colonies lead to thrombosis in adjacent blood vessels causing avascular necrosis of the tympanic membrane and TMP, especially behind the handle of the malleus.[7] It is an infrequently reported complication. This may be related to the fact that identifies TMP, the examination had to be done after thorough cleaning of EAC as well tympanic membrane of overlying fungal infection, otherwise, TMP may be missed. Most of the perforations in otomycotic patients are small, making its detection even more difficult. Sometimes, even the examiner misdiagnosed these perforations as preexisting perforation due to chronic suppurative otitis media rather than perforation due to recent otomycotic infection.[14],[15]

In our study, the incidence of persistent tympanic perforation was 5%, which is almost similar to the study done by Ho et al. that showed a 5.5% incidence of persistent tympanic perforation.[6] However, Song et al. reported quite high (27%) incidence of persistent tympanic perforation.[16] Most of the small perforations of the tympanic membrane heal spontaneously with proper medical treatment and local cleaning and the prognosis with the perforated tympanic membrane is favorable.[17]

In our study, Aspergillus [Figure 1] was the most common isolate (90% cases), followed by Candia [Figure 2] species (10% cases). These results were similar to other studies from the Indian subcontinent.[8],[9],[10] In our study, we included only fresh cases and excluded all cases of preexisting suppurative otitis media cases (dry and active both cases) that's why we did not get bacterial isolates on Gram staining. In our study, all the cases of TMP were due to Aspergillus. Aspergillus is the primary colonizer of the EAC[13],[18] and capable of growing even in nutrient-depleted environments. The human EAC is an ideal environment for this fungus to grow.[12],[19] When compared to Aspergillus, Candida is more commonly found in postoperative cavities, infected middle ears,[5],[7],[20]and in immunocompromised individuals.[10],[17] In our study, we excluded immunocompromised patients and previous operative patients. This may be the reason that in our study all patients with TMP were associated with Aspergillus.
Figure 1: Histological section of a case of Aspergillus species diagnosed on H and E stain highlighting septate, slightly bulbous hyphae branching at acute angles (H and E, ×400)

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Figure 2: Histopathology section showing budding yeast forms and pseudohyphae of Candida (H and E, ×1000)

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To differentiate between subspecies of Aspergillus, clinical microbiologists heavily relied on morphology-based identification criteria include the recognition of sexual and asexual structures and their characters (shape, size, color ornamentation, and mode of attachment). Unfortunately, numerous difficulties exist in such phenotype-based classifications because these characteristics are unstable and clinically sometimes Aspergillus manifest atypically with slow sporulation and aberrant conidiophore formation.[21] Hence, microbiologists further use comparative DNA sequence-based identification which is not feasible in our setting and beyond the scope of the study.


  Conclusion Top


On the evaluation of OM patients in our study, it can be concluded that TMP in fungal otitis externa is not uncommon and often misdiagnosed. For confirming TMP in otomycotic patient's proper history with careful examination, especially examination under a microscope after a thorough cleansing is very useful. Most of the TMP tend to resolve with medical management within a few weeks. Few of the TMP would need surgical correction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fasunla J, Ibekwe T, Onakoya P. Otomycosis in western Nigeria. Mycoses 2008;51:67-70.  Back to cited text no. 1
    
2.
Rao RP, Rao R. A mycologic study of otomycosis in a tertiary care teaching hospital in Karnataka, India. Int J Contemp Med Res 2016;3:1918-20.  Back to cited text no. 2
    
3.
Mishra GS, Mehta N, Pal M. Chronic bilateral otomycosis caused by Aspergillus Niger. Mycoses 2004;47:82-4.  Back to cited text no. 3
    
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Vennewald I, Klemm E. Otomycosis: Diagnosis and treatment. Clin Dermatol 2010;28:202-11.  Back to cited text no. 4
    
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Kurnatowski P, Filipiak A. Otomycosis: Prevalence, clinical symptoms, therapeutic procedure. Mycoses 2001;44:472-9.  Back to cited text no. 5
    
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Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: Clinical features and treatment implications. Otolaryngol Head Neck Surg 2006;135:787-91.  Back to cited text no. 6
    
7.
Hurst WB. Outcome of 22 cases of perforated tympanic membrane caused by otomycosis. J Laryngol Otol 2001;115:879-80.  Back to cited text no. 7
    
8.
Pradhan B, Tuladhar NR, Amatya RM. Prevalence of otomycosis in outpatient department of otolaryngology in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Ann Otol Rhinol Laryngol 2003;112:384-7.  Back to cited text no. 8
    
9.
Kaur R, Mittal N, Kakkar M, Aggarwal AK, Mathur MD. Otomycosis: A clinicomycologic study. Ear Nose Throat J 2000;79:606-9.  Back to cited text no. 9
    
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Viswanatha B, Sumatha D, Vijayashree MS. Otomycosis in immunocompetent and immunocompromised patients: Comparative study and literature review. Ear Nose Throat J 2012;91:114-21.  Back to cited text no. 10
    
11.
Wadhwani K, Srivastava AK. Fungi from otitis media of agricultural field workers. Mycopathologia 1984;88:155-9.  Back to cited text no. 11
    
12.
Barati B, Okhovvat SA, Goljanian A, Omrani MR. Otomycosis in central Iran: A clinical and mycological study. Iran Red Crescent Med J 2011;13:873-6.  Back to cited text no. 12
    
13.
Jia X, Liang Q, Chi F, Cao W. Otomycosis in Shanghai: Aetiology, clinical features and therapy. Mycoses 2012;55:404-9.  Back to cited text no. 13
    
14.
Ozcan M, Ozcan KM, Karaarslan A, Karaarslan F. Concomitant otomycosis and dermatomycoses: A clinical and microbiological study. Eur Arch Otorhinolaryngol 2003;260:24-7.  Back to cited text no. 14
    
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Kiakojori K, Bagherpour Jamnani N, Khafri S, Mahdavi Omran S. Assessment of response to treatment in patients with otomycosis. Iran J Otorhinolaryngol 2018;30:41-7.  Back to cited text no. 15
    
16.
Song JE, Haberkamp TJ, Patel R, Redleaf MI. Fungal otitis externa as a cause of tympanic membrane perforation: A case series. Ear Nose Throat J 2014;93:332-6.  Back to cited text no. 16
    
17.
Viswanatha B, Naseeruddin K. Fungal infections of the ear in the immunocompromised host: A review. Mediterr J Hematol Infect Dis 2011;3:e2011003.  Back to cited text no. 17
    
18.
Chander J, Maini S, Subrahmanyan S, Handa A. Otomycosis – A clinico-mycological study and efficacy of mercurochrome in its treatment. Mycopathologia 1996;135:9-12.  Back to cited text no. 18
    
19.
Pahwa VK, Chamiyal PC, Suri PN. Mycological study in otomycosis. Indian J Med Res 1983;77:334-8.  Back to cited text no. 19
    
20.
Nielsen PG. Fungi isolated from chronic external ear disorders. Mykosen 1985;28:234-7.  Back to cited text no. 20
    
21.
Balajee SA, Houbraken J, Verweij PE, Hong BS, Yaghuchi T, Varga J, et al. Aspergillus species identification in clinical setting. Study Mycol 2007;59:39-46.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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