From the Guidelines
The treatment for fungal otitis externa primarily involves topical antifungal medications, with debridement and topical antifungal therapy being the recommended management approach. According to the clinical practice guideline for acute otitis externa 1, 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. The guideline suggests that management may include debridement plus topical antifungal therapy, rarely systemic antifungal therapy, or both.
Key Considerations
- Aspergillus species (60%-90%) and Candida species (10%-40%) are often cultured in cases of fungal otitis externa 1.
- Symptoms include pruritus and thickened otorrhea, which may be black, gray, bluish green, yellow, or white.
- Fungal otitis externa should also be suspected if a patient fails to respond to initial topical therapy.
- Topical antibiotic therapy is contraindicated in managing otomycosis because it is ineffective and may promote further fungal overgrowth.
Treatment Approach
- Debridement to remove debris and discharge from the ear canal is essential to allow for effective penetration of antifungal medications.
- Topical antifungal therapy, such as clotrimazole 1% solution or fluconazole 0.2% solution, can be used to treat fungal otitis externa.
- In severe cases, oral antifungals like fluconazole 200mg daily for 7-14 days may be added to the treatment regimen.
- Patients should keep the ear dry, avoid swimming, and use earplugs or cotton balls coated with petroleum jelly when showering to prevent further irritation and infection.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Shake well before use. The external ear should be thoroughly cleaned and dried before the initiation of treatment. Verify that the eardrum is intact. Instill 5 drops of SUROLAN in the ear canal twice daily and massage the ear. Therapy should continue for 7 consecutive days. INDICATIONS SUROLAN is indicated for the treatment of canine otitis externa associated with susceptible strains of yeast (Malassezia pachydermatis) and bacteria (Staphylococcus pseudintermedius).
The treatment for fungal otitis externa is miconazole (OTIC), with a recommended dosage of:
- 5 drops in the ear canal
- Twice daily
- For 7 consecutive days
- After cleaning and drying the external ear, and verifying the eardrum is intact 2 It is indicated for the treatment of otitis externa associated with yeast (Malassezia pachydermatis) 2
From the Research
Treatment Options for Fungal Otitis Externa
- The treatment of fungal otitis externa, also known as otomycosis, typically involves intense débridement and cleansing, and topical antifungals 3.
- Topical antifungals, such as clotrimazole, miconazole, bifonazole, ciclopiroxolamine, and tolnaftate, are potentially safe choices for the treatment of otomycosis, especially in patients with a perforated eardrum 3.
- Oral triazole drugs, such as itraconazole, voriconazole, and posaconazole, are effective against Candida and Aspergillus, with good penetration of bone and the central nervous system, and are essential in the treatment of patients with malignant fungal otitis externa complicated by mastoiditis and meningitis 3.
Comparison of Topical Antifungals
- A clinical trial compared the efficacy of sertaconazole versus clotrimazole and miconazole creams in the treatment of otomycosis, and found that sertaconazole had comparable results with miconazole and clotrimazole, and was more efficacious when considering complete and partial responses together 4.
- The study found that all three topical antifungals were effective in treating otomycosis, with significant differences in response to treatment compared to the placebo group 4.
Treatment of Invasive Fungal Otitis Externa
- Voriconazole has been shown to be an effective and well-tolerated therapeutic option for the management of Aspergillus invasive otitis externa, with favorable outcomes reported in patients treated with this medication 5.
- Itraconazole is also a useful agent in the prevention and treatment of fungal infections, including invasive and allergic mycoses, and has a broad-spectrum of activity 6.