What is the recommended treatment for a 69-year-old male with a fungal ear infection who wears a hearing aid (HA)?

Treatment of Fungal Ear Infection in a 69-Year-Old Male Hearing Aid User

For fungal otitis externa (otomycosis) in a 69-year-old male hearing aid user, thorough mechanical cleansing of the external auditory canal followed by topical antifungal treatment with clotrimazole or other azole preparations is strongly recommended as first-line therapy. 1

Diagnosis and Initial Assessment

• Otomycosis typically presents with:

  • Pruritus (itching)
  • Otalgia (ear pain)
  • Otorrhea (ear discharge) - often whitish or colored
  • Sensation of fullness
  • Visible fungal debris (may appear as white, black, or colored material)

• Risk factors present in this patient:

  • Advanced age (69 years)
  • Hearing aid use (creates warm, humid environment favorable for fungal growth)
  • Possible history of antibiotic eardrops (common predisposing factor)

Treatment Algorithm

Step 1: Ear Canal Cleaning

• Thorough mechanical cleansing of the external auditory canal is essential
• Gentle suction or irrigation to remove fungal debris
• Cleaning should be performed by a healthcare provider to avoid trauma

Step 2: Topical Antifungal Therapy

• First-line treatment: Topical antifungal preparations 1, 2

  • Clotrimazole solution/cream
  • Miconazole
  • Nystatin
  • Topical azole preparations

• Application instructions:

  • Remove hearing aid during treatment
  • Apply drops 2-3 times daily for 7-14 days
  • Keep ear canal dry during treatment period
  • Warm drops to body temperature before application

Step 3: Hearing Aid Management

• Clean and disinfect hearing aid thoroughly
• Consider temporary discontinuation of hearing aid use during acute treatment phase
• If continued use is necessary, ensure proper cleaning and drying of the device daily

Special Considerations

If Tympanic Membrane is Perforated:

• Use non-ototoxic preparations (avoid aminoglycoside-containing products)
• Clotrimazole solution has been shown to be safe in patients with tympanic membrane perforation 3

If Treatment Fails:

• Obtain fungal cultures to identify specific pathogen
• Consider oral antifungal therapy with:
  • Itraconazole
  • Voriconazole
  • Posaconazole

For Immunocompromised Patients:

• Consider longer duration of treatment (14-21 days)
• More vigilant follow-up is required
• Consider oral antifungal therapy in addition to topical treatment 4

Prevention of Recurrence

• Keep ears dry
• Remove hearing aid at night and when not needed
• Clean and dry hearing aid regularly
• Consider periodic prophylactic treatment with acidifying agents (e.g., 2% acetic acid)
• Avoid self-cleaning of ears with cotton swabs

Follow-up

• Follow-up within 1 week to assess response to treatment
• If no improvement after 48-72 hours, reassess diagnosis and consider alternative therapy 2
• Complete resolution may take 2-3 weeks

Potential Complications

• Persistent infection
• Extension to middle ear if tympanic membrane is perforated
• Tympanic membrane perforation
• Secondary bacterial infection
• Hearing loss

The treatment of fungal otitis externa in hearing aid users requires thorough cleaning, appropriate topical antifungal therapy, and proper hearing aid management to prevent recurrence. Systemic antifungals are rarely needed unless the infection is invasive or the patient is immunocompromised.