How to treat otomycosis?

Treatment of Otomycosis

For otomycosis, the first-line treatment should consist of thorough mechanical cleansing of the external auditory canal followed by topical antifungal therapy with solutions of boric acid, acetic acid, or azole creams. 1

First-Line Treatment Approach

• Begin with thorough mechanical cleansing of the external auditory canal to remove debris, which is crucial for effective treatment 1
• Apply topical antifungal agents after cleansing:
  • Boric acid solution irrigations 2
  • Acetic acid solution irrigations 2, 3
  • Topical azole creams (clotrimazole, miconazole, bifonazole) 1, 4

Treatment Selection Based on Tympanic Membrane Status

• For intact tympanic membrane:

  • Any topical antifungal can be used (boric acid, acetic acid, or azole creams) 1
  • Clotrimazole has shown good effectiveness against most fungi and yeasts causing otomycosis 5

• For perforated tympanic membrane:

  • Use only non-ototoxic preparations such as clotrimazole and miconazole 1, 6
  • In refractory cases with perforated tympanic membranes, oral antifungals may be considered:
    • Voriconazole, posaconazole, or itraconazole 2

Duration of Treatment

• Treatment typically continues for 2-3 weeks 1
• Most patients show clinical resolution within 2 weeks 1, 4

Special Considerations

• Immunocompromised patients:

  • Require closer monitoring due to increased risk of invasive fungal infections 1
  • May need systemic antifungal therapy if local therapy fails 2
  • More likely to have bilateral infections 7

• For recurrent otomycosis:

  • Address underlying predisposing factors (e.g., excessive moisture, trauma, immunocompromised state) 7
  • Maintain good ear hygiene to prevent recurrence 1
  • Consider longer duration of treatment 4

Potential Complications and Pitfalls

• If left untreated, fungal elements may extend into the mastoid sinus, creating chronic fungal mastoiditis 2, 1
• Using topical antibiotics alone may promote fungal overgrowth 1
• Failing to consider fungal etiology in patients who don't respond to antibiotics for presumed bacterial otitis externa can lead to delayed diagnosis 1
• Using ototoxic preparations in patients with perforated tympanic membranes can cause further damage 1, 6

Efficacy of Different Antifungal Agents

• Clotrimazole has shown good effectiveness against most fungi and yeasts causing otomycosis 5
• Nystatin has demonstrated a wide spectrum of activity among antifungals 5
• Topical azoles (clotrimazole, miconazole, bifonazole) are generally effective and safe choices 6
• The evidence comparing different azole treatments is of very low certainty, but they appear to have similar clinical efficacy 8