From the Guidelines
The recommended treatment for fungal otitis externa typically involves topical antifungal medications, with first-line therapy consisting of thorough ear cleaning followed by application of antifungal drops such as clotrimazole 1% solution, applied 3-4 times daily for 7-14 days 1.
Key Considerations
- Fungal otitis externa, also known as otomycosis, is common in tropical countries, humid locations, after long-term topical antibiotic therapy, and in those with diabetes, HIV infection, or an immunocompromised state 1.
- Symptoms include pruritus and thickened otorrhea, which may be black, gray, bluish green, yellow, or white, and fungal otitis externa should be suspected if a patient fails to respond to initial topical therapy 1.
- Management may include debridement plus topical antifungal therapy, rarely systemic antifungal therapy, or both, and topical antibiotic therapy is contraindicated in managing otomycosis because it is ineffective and may promote further fungal overgrowth 1.
Treatment Approach
- The ear canal should be cleared of inflammatory debris, obstructing cerumen, or any foreign object, and aural toilet may be performed by the clinician with a gentle lavage using body-temperature water, saline solution, or hydrogen peroxide 1.
- Alternative methods of aural toilet include physically removing the obstructing debris with suction or dry mop (blotting with cotton tipped applicator), and adequate visualization for suctioning may be facilitated by using an otoscope with an open head or a binocular otologic microscope 1.
- For more resistant cases, fluconazole or amphotericin B solutions may be used, and it's crucial to keep the ear canal dry during treatment by avoiding swimming and using ear plugs during showers 1.
Adjunctive Therapy
- Acidifying agents like 2% acetic acid solutions can create an unfavorable environment for fungal growth and may be used as adjunctive therapy, and if the ear canal is significantly swollen, a physician may insert a wick to facilitate medication delivery 1.
- Treatment should continue for at least 7 days after symptoms resolve to prevent recurrence, and oral antifungals are rarely needed but may be considered in severe cases or in immunocompromised patients 1.
From the Research
Treatment of Fungal Otitis Externa
The recommended treatment for fungal otitis externa includes:
- Intense débridement and cleansing of the ear canal 2
- Topical antifungals, such as clotrimazole, miconazole, bifonazole, ciclopiroxolamine, and tolnaftate 2
- Oral triazole drugs, such as itraconazole, voriconazole, and posaconazole, for severe cases or in patients with compromised immune systems 2
Treatment Outcomes
Studies have shown that:
- Most cases of fungal otitis externa can be resolved with thorough debridement and antifungal medication 3
- Eight out of 11 patients in a case series experienced complete resolution of symptoms, including closure of the tympanic membrane perforation, with antifungal treatment 3
- Topical antibiotics may not be necessary in the management of otitis externa, as they do not convey significant benefit in this condition 4
Important Considerations
- Fungal infections of the external auditory canal can range from common to life-threatening, and proper identification of fungal pathogens is necessary to guide appropriate therapy 5
- Certain populations, such as patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients, may be more susceptible to fungal infections of the ear canal 5