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.