From the Guidelines
Fungal otitis externa should be treated with topical antifungal medications rather than antibacterial agents. The recommended treatment is clotrimazole 1% solution or cream applied to the ear canal twice daily for 7-14 days 1. Alternatively, you can use miconazole or nystatin preparations. Before application, the ear canal should be thoroughly cleaned of debris and discharge, which may require gentle irrigation with saline or hydrogen peroxide solution diluted 1:1 with water. For severe cases with significant inflammation, adding a short course of topical steroid like hydrocortisone 1% can help reduce swelling and discomfort.
Key Considerations
- Fungal infections typically present with more intense itching than bacterial infections, often with white or gray debris resembling wet newspaper in the ear canal 1.
- They frequently occur after prolonged antibiotic treatment for bacterial infections or in humid environments 1.
- Treatment may need to continue for up to three weeks in some cases to completely eradicate the fungal infection.
- It is essential to keep the ear dry during treatment by avoiding swimming and using earplugs during showers.
Patient Factors
- Patients with diabetes, an immunocompromised state, or both require special consideration because they are susceptible to otomycosis and necrotizing otitis externa 1.
- These conditions may present similar to AOE but require different management, and systemic antibiotics may be necessary in addition to topical therapy 1.
From the Research
Fungal Otitis Externa
Fungal otitis externa, also known as otomycosis, is a common infection worldwide. The diagnosis of otitis externa relies on the patient's history, otoscopic examination under microscopic control, and imaging studies 2.
Causes and Treatment
The most frequently isolated fungi in patients with otomycosis are Aspergillus and Candida spp 2. Treatment for noninvasive fungal otitis externa includes intense débridement and cleansing, and topical antifungals such as clotrimazole, miconazole, bifonazole, ciclopiroxolamine, and tolnaftate 2.
Topical Azole Treatments
Topical azole treatments are commonly used for otomycosis, with compounds such as clotrimazole, miconazole, and bifonazole being effective against fungal infections 3. A study comparing sertaconazole versus clotrimazole and miconazole creams in the treatment of otomycosis found that sertaconazole had comparable results with miconazole and clotrimazole, and was more efficacious when considering complete and partial responses together 4.
Key Points
- Fungal otitis externa is a common infection worldwide 2, 4, 3, 5
- Aspergillus and Candida spp are the most frequently isolated fungi in patients with otomycosis 2
- Treatment includes intense débridement and cleansing, and topical antifungals such as clotrimazole, miconazole, bifonazole, ciclopiroxolamine, and tolnaftate 2
- Topical azole treatments are effective against fungal infections, with sertaconazole being a potentially safe choice 4, 3
- Clotrimazole, miconazole, and fluconazole have similar therapeutic efficacy in treating otomycosis 5
Treatment Options
- Topical antifungals:
- Clotrimazole
- Miconazole
- Bifonazole
- Ciclopiroxolamine
- Tolnaftate
- Oral triazole drugs:
- Itraconazole
- Voriconazole
- Posaconazole
- Sertaconazole cream 4