INTRODUCTION
Otomycosis, a fungal infection of the external auditory canal, is increasingly common in general practice and ENT clinics, accounting for up to 20% of ENT outpatient consultations in some regions (1,2). Fungi are believed to cause from 2 to 15% of cases of otitis externa (3-5).
Otomycosis is more prevalent in warm and humid climates and among aquatic sports enthusiasts. Other postulated predisposing factors include frequent or prolonged use of antibiotic and steroid ear drops, regular ear manipulation, aural hygiene measures that disturb the acidic pH of the ear canal, sharing of earphones and stethoscopes, presence of hearing aids, chronic skin conditions, acute or chronic otitis media with otorrhoea, anatomical abnormalities, previous ear surgery, evidence of fungal infection elsewhere, immunosuppression and working in mouldy environments (6). Otomycosis is less common in children compared to adults in temperate climates. However, children and adults are affected to similar extents in tropical places - possibly due to families sharing swimming pools.
Itchy ear is a common presentation. Other symptoms include aural fullness, deafness, otalgia, discomfort, wetness, otorrhoea and tinnitus (7). In its florid form, the ear canal is full of moist fungal mycelia, hyphae, conidiophores, spores, desquamated epithelial cells, pus and bloody discharge. Microsuction of debris may reveal pustules, polyps and ulcerations of the ear canal skin and tympanic membrane. Inflammation of the tympanic membrane can lead to sequential breakdown of its layers leading to a perforation. Tympanic membrane perforation is an infrequently reported feature of otomycosis which physicians are not always aware of, but yet is not uncommon (8). Some authors have attributed perforations to mycotic thrombosis of blood vessels supplying the tympanic membrane (8,9).
Studies have identified Aspergillus and Candida species as the frequent culprits (10). The diagnosis of otomycosis requires a high index of suspicion. Usually, an empirical diagnosis is made based on clinical features and treatment is instituted without microbiological confirmation (5). Otolaryngologists are more likely to take a microbiological swab if patients have not responded to initial treatment (5).
The literature shows a wide variety of medications being used in the management of otomycosis with no general consensus (11,12). The aim of this review was to investigate the treatment strategies and antifungal agents used in various institutions and to highlight current trends.