International Journal of Medical and Health Sciences
Journal Home Page: http://www.ijmhs.net ISSN:2277-4505
Original article
A Cross sectional study for Clinico mycological Profile of Otomycosis in North
Karnataka
Channabasawaraj B Nandyal1, Archana S Choudhari2* and Netravati B Sajjan3
1
Associate Professor, Department of ENT, Mahadevappa Rampure Medical College, Gulbarga-585105, Karnataka
state, India,
2
3
Associate Professor, Tutor, Department of Biochemistry, Mahadevappa Rampure Medical College, Gulbarga585105, Karnataka state, India.
ABSTRACT
Background: Otomycosis is a commonest condition encountered in ENT practice which is a superficial fungal infection of the
External auditory canal with more prevalence in hot, humid and dusty environment of tropics and subtropics. Despite the fact that
our climatic conditions may predispose to Otomycosis literature search revealed that no much work has been carried out in this
region. So the present study is undertaken to study the Age distribution, Sex ratio, Laterality, Predisposing factors and Prevalence
of fungal agents in case of Otomycosis. Materials and Methods: The present study was conducted on 185 clinically diagnosed
cases of Otomycosis attending the ENT OPD for a period of one year. Ear discharge specimens were collected on two sterile
cotton swabs. Direct Examination of the specimen was carried out by Gram stain and10% KOH Preparation. All specimens were
inoculated on Sabouraud’s Dextrose Agar. Identification of fungi were done as per standard protocol.
Results: Out of 185 patients fungal isolates were found in 159 cases (85.94%).The highest incidence was noted in the age group
of 21-30 years, more prevalent in males (54.72%) with a sex ratio of 1.21:1 with unilateral distribution more on left ear. Use of
Unsterile materials for cleaning the ear had been found to be major predisposing factor (71.07%).Itching in the ear was most
commonest symptom (93.37%) and Most common fungi isolated were Aspergillus Niger,Aspergillus Flavus and Aspergillus
Fumigatus followed by Candida Species. Conclusion: It is concluded from our study that Otomycosis is still a common problem.
No age acts as a barrier no sex gives immunity and is usually an unilateral disease.Aspergilli were considered as predominant
fungi for Otomycosis. The study also concludes that patients have to be educated not to use unsterile materials to clean the ears
which will be effective in prevention of Otomycosis.
KEYWORDS: Aspergillus, Candida, External Auditory Canal, Otalgia, Otomycosis
INTRODUCTION
Ear is a Specialised sense organ for hearing and balance
which represents the complexity of nature’s machinations
where in the External Ear remains constantly exposed to
environment and is relatively attacked by many pathogenic
organisms, among which fungal infections of External Ear
are common. As the fungal infections are not highly
infectious and run relatively mild course and are in
unrecognised manner than do most of the bacterial
infections, cause greater morbidity than any other disease of
External Ear. Otomycosis is a superficial fungal infection of
the External Auditory Canal, however the disease may occur
in the Middle Ear if the membrane is perforated [1,2].
Int J Med Health Sci. Jan 2015,Vol-4;Issue-1
The disease is worldwide in distribution, but the hot, humid
and dusty environment of the tropics and subtropics make
Otomycosis more prevalent in these regions[3]. It is
estimated that approximately 5-25% of total cases of Otitis
Extena are due to Otomycosis [4].This is more prevalent in
2nd and 3rd decade of life. Several etiological factors
predispose to Otomycosis which include chronic ear
infections with long term use of antibiotics or steroid
eardrops, use of oils mainly coconut oil which can lead to
depletion of the protective cerumin layer maceration of
underlying skin and increase in ambient pH[5]. Swimming,
Evidence of Yeast or Fungal infections elsewhere in the
64
body, co morbid conditions like Diabetes Mellitus and
Immunocompromised host are other contributing factors.
A variety of fungi mostly the common saprophytes are the
agents responsible among which the most common
etiological agents are Aspergillus Species and Candida [6].
Despite the fact that our climatic conditions may predispose
to Otomycosis literature search reveals that no much work
has been carried out in this region. So the present study is
thus designed with a view to elucidate the Predisposing
factors, Associated conditions, Mycological pattern
encountered and Prevalence of Fungal agents in Otomycosis
at Gulbarga district, North Karnataka, India.
MATERIALS AND METHODS
The present study was carried out on 185 clinically
diagnosed cases of Otomycosis attending the ENT OPD at
Basaveshwar Teaching and General Hospital Gulbarga. The
study was conducted over a period of one year. Ethical
clearance was obtained from the Institutional Ethical
Committee. An informed consent was obtained from all the
patients before the start of study.
Criteria for selecting Patients with Otomycosis:
Inclusion criteria: Patients diagnosed with Otomycosis
based on
a). Symptoms- Pruritis, Otalgia, Otorrhea, Ear fullness and
Impaired hearing.
b).Signs-Otoscopic findings like appearance of fungal mass
or debris, blackish foul smelling discharge, wet blotting
paper appearance or creamy white debris.
Exclusion criteria: Patients on topical antifungal drops and
negative fungal isolates by direct microscopy or culture
were excluded from the study.
Collection of Sample: After clinical diagnosis of
Otomycosis was made by seeing spores or mycelia mats all
the cases were subjected for mycological examination by
taking with sterile cotton swabs from fungal mats seen in the
infected ear canal and sent immediately to microbiology
laboratory and subjected for the following examinations.
Direct Microscopy: In 10% Potassium Hydroxide (KOH)
Preparation and Grams Stain Examination.
Culture Methods: Sabouraud’s Dextrose Agar (SDA)
inoculated media were incubated at room temperature and
were followed for two weeks. For isolation of fungi growth
on media were confirmed by Lacto phenol cotton blue
(LCB) preparation and Grams Stain. Species identification
of Candida was done by Sugar Fermentation Test, Sugar
Assimilation Test, Germ Tube Test, Pigment Production on
Chrome agar and Detection of Chlamydo spore Formation
on Corn meal agar [7].
RESULTS
Out of 185 clinically diagnosed cases of Otomycosis only
159 cases produced positive fungal isolates, these
constituted 85.94% which were taken up for further studies.
The highest incidence was noted in the age group of 21-30
years (28.30%). The lowest incidence was noted in the age
group of 71-80 years, i.e. Two cases (1.25%). In the present
study youngest patient noted was 5 months old baby in
whom the mother gave the history of putting the coconut oil
in the ears before giving the head bath and the oldest was
77years male who gave the history of frequent use of
unsterile cotton rolled over the matchstick to clean the ears.
Age wise distribution of positive cases is depicted in Table
1.
In our study it has been found that the incidence of
Otomycosis was slightly higher in males 87 cases (54.72%)
than in females 72 cases (45.28%) as shown in Table 1. The
male to female ratio was 1.21:1.
It is evident from the Table 2 that the distribution of
Otomycosis is unilateral 149 cases (93.7%).Maximum
number of patients 80 cases (50.32%) have been noted to
have Otomycosis of left ear and is bilateral in only 10 cases
(6.29%).
As depicted in Table 3 it was observed in our study that
most common predisposing factor was use of unsterile
materials/swabs for cleaning the ear in 113 cases
(71.07%).The use of unsterile materials varied from Safety
pins, Hairpins, Matchsticks, Pens and Refills to Unsterile
buds. Itching in the ear was the most commonest symptom
in 149 cases (93.37%) the other symptoms observed are
depicted in Table 4.
In our study it was elucidated that Otomycosis is most
commonly associated with Chronic Suppurative Otitis
Media (CSOM) i.e 12 cases (7.55%) other associated
conditions observed were as shown in Table 5. Mycological
appearance in the infected ear canal: It was observed in our
study that wet brownish black or gray mouldy mats/spores
with epithelial debris was most common mycological
appearance in 86 cases (54.09%) as shown in Table 6.
Fungal isolates encountered in our study is shown in Table
7. Aspergillus were the most common fungi isolated in 142
cases of which 89 were Aspergillus Niger,46 were
Aspergillus Flavus and 7 were Aspergillus Fumigatus.
Table 1: Age and Sex Distribution of Otomycosis in the study subjects
Age ( years )
Male
Female
Total
0 -10
14 (16.09%)
11 (15.27%)
25 (15.72%)
11 – 20
23 (26.43%)
19 (26.38%)
42 (26.42%)
21 – 30
25 (28.73%)
20 (27.77%)
45 (28.3%)
31 – 40
10 (11.49%)
09 (12.5%)
19 (11.95%)
Int J Med Health Sci. Jan 2015,Vol-4;Issue-1
65
41 – 50
07 (8.04%)
06 (8.33%)
13 (8.18%)
51 – 60
05 (5.74%)
04 (5.55%)
09 (5.66%)
61 – 70
02 (2.29%)
02 (2.77%)
04 (2.52%)
71 – 80
01 (1.14%)
01 (1.38%)
02 (1.25%)
Total
87 (54.71%)
72 (45.28%)
159 (100%)
Table 2: Laterality of Otomycosis
Laterality
Number of Cases
Percentage
Left
80
50.32
Right
69
43.39
Bilateral
10
6.29
Total
159
100
Table 3: Predisposing Factors for Otomycosis
Predisposing factors
Number of Cases
Percentage
Use of unsterile sticks/ Swabs for cleaning the ear
113
71.07
Use of Oil or mixture of oils
107
67.3
Use of customary head cover or turbon
57
35.85
Use of topical antibiotics or steroids
31
19.49
Regular swimmers
10
6.29
Nothing suggestive
13
8.18
Number of Cases
Percentage
Itching in ear
149
93.37
Pain
135
84.9
Feeling of block sensation or something in ear
126
79.25
Ear discharge
117
73.59
Tinnitus
63
39.62
Deafness
55
34.6
Table 4: Clinical Presentation of Otomycosis
Symptoms
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66
Table 5: Associated conditions seen in Otomycosis
Associated conditions
Number of Cases
Percentage
Chronic Suppurative Otitis Media ( CSOM)
12
7.55
Scalp dandruff
10
6.3
Acute Suppurative Otitis Media (ASOM)
5
3.15
Otitis Externa
5
3.15
Modified Radical Mastoidectomy cavity infection
2
1.25
Post radiotherapy
1
0.63
Table 6: Mycological appearance in the infected Ear canal
Mycological appearance
Number of Cases
Percentage
Wet brownish black or gray mouldy mats/spores
with epithelial debris
86
54.09
Dry blackish mouldy mats with spores
47
29.56
Soft caseous material/ mats with epithelial debris
18
11.32
Wet blotting paper mats with epithelial debris
8
5.03
Total
159
100
Table 7: Fungal isolates seen in Otomycosis
Fungal isolates
Number of Cases
Percentage
Aspergillus niger
89
55.97
Aspergillus flavus
46
28.94
Aspergillus fumigatus
7
4.41
Candida albicans
11
6.93
Candida species
2
1.25
Mucor species
2
1.25
Penicillium
2
1.25
159
100
Total
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67
DISCUSSION
Apart from its main function in hearing mechanism
External Ear has another important physiological function
of production of wax or cerumin which is a mixture of
products of sebaceous and ceruminous glands It contains
various Amino acids, Fatty acids, Lysozomes and
Immunoglobulins which help in maintaining the pH of
External Meatus on acidic side and also has some
bactericidal activity potent in killing dividing bacteria[8].
Thus in normal Ear wax has an inhibitory effect on most of
the Fungi. Despite of this protective environment
Otomycosis remains one of the commonest causes for Otitis
Extena constituting about 5-25% of total cases [4]. This is
because there are certain predisposing factors and conditions
which change the protective environment in the External
Auditory Canal to a favourable environment for the Fungal
growth.
Considering the fact that Otomycosis can occur at any age ,
age does not act asa barrier to the infection, although the
most commonest age group affected in our study was 21-30
years which correlates with higher incidence seen in the
same age group in the study conducted by Mohanty JC et
al[9], Chander J et al [10] Paulose KO [11] and Kaur R[12].
The present study showed a slightly higher incidence in
males than females which is in accordance with the findings
of study conducted by Shilpa KG et al [1], Khurana et al
[13], Mohanty and associates [9] and Talwar and others
[14]. Males are more exposed to fungal spores because they
generally spend more time outdoors and it is well known
that outdoor air is an important vector for locally prevalent
Fungal Flora.
In our study it has been documented that Otomycosis is
unilateral which is in accordance with other studies carried
out by Shilpa KG[1], PrasannaV[5], Yehia MM [15] and it
supports the idea that the disease is not highly infectious.
Use of unsterile sticks and swabs for cleaning the Ear and
use of oils and mixture of oils in Ear were the commonest
predisposing factors as per our study. These results are in
accordance with the study done by Mohanty [9] and Prasad
SC[16]. Obsessive manipulation of the External Ear with
any hard objects such as matchsticks or metal wax picks to
clean the Ear of wax and vigorous rubbing of the Ear for
relief from itching may cause trauma (usually minor and
hence unnoticed) for the skin of external auditory canal and
deposition of fungi in the wound leading to Fungal
infection[17].
Lack of formal education in people in many parts of India
has led them to believe myths that coconut oil application
for Ears is beneficial for a variety of ailments our study
revealed high association of Otomycosis(67.3 %) with
instillation of coconut oil in the External Ear, which is a
sporostatic [18] and therefore may help preserve the
viability of fungal conidia deposited in the External Ear for
longer time and indirectly contribute to occurrence of
Otomycosis[16].
In our study it was seen that Otomycosis was most
commonly associated with Chronic Supparative Otitis
Media (CSOM) which is in accordance with the study
conducted by Mohanty JC [9] and Paulose KO[11]. Itching
in the ear, Otalgia were most common symptoms followed
by Fullness of Ear, Ear discharge, Tinnitus ,Deafness
confirming the findings of earlier studies[19,20,21].
Mycological appearance in the infected ear canal in our
study in majority of cases was wet brownish black or grey
mouldy mats/spores with epithelial debris which is in
accordance with the study conducted by Paulose KO et
al[11]. Most common fungal isolate determined in our study
belonged to the Taxon Aspergillus followed by Candida,
Mucar and Pencilium. Among the Aspergillus A.Niger was
the commonest isolate followed by A.Flavus and
A.Fumigatus.The moisture, warmth and acidic pH of the
External Auditory Canal provide ideal growth requirements
for the Fungi. Aspergilli have an optimum pH range of 5.7
at a temperature of 37 and this is conducive for all species
of Aspergillus. Our observations regarding mycological
isolates are in accordance with earlier studies[22,23].
CONCLUSION
It is concluded from our study that Otomycosis is still a
common problem. No age acts as a barrier no sex gives
immunity to this disease and is usually an unilateral disorder
Itching and Otalgia are the commonest symptoms.
Aspergilli and Candida are to be considered as predominant
Fungi for Otomycosis as these Saprophytic fungi thrive on
exfoliated dead epithelial cells along with humid climate in
External Auditory Canal.
The study also concludes that Patients have to be educated
not to use unsterile materials to clean the Ears which will be
effective in prevention of Otomycosis. Clinical suspicion
should always be put on Mycological confirmation to
prevent bothersome complications and morbidity of
Patients.
REFERENCES
1.
Gokhale SK, Suligavi SS, BaragundiM, Anushka D,
Manjula R. Otomycosis-A ClinicoMycological Study.
Int J Med Health Sci 2013;2: 218-223.
2.
Aneja KR,Sharma C, Joshi R.Fungal infection of the ear
A common problem in the north eastern part of Haryana.
International Journal of Paediatric Otorhinolaryngology
2010;74:604-607.
3.
Joy MJ,Agarwal MK,Samant HC. Mycological and
Bacteriological
studies
in
Otomycosis.
Indian
J
Otolaryngol 1980;32: 72-75.
4.
Jackman A, Ward R, Bent J. Topical antibiotic induced
Otomycosis. Int J Pediatric Otorhinolaryngol 2005;69:
857-860.
5.
Prasanna V, Hemlata Katiyar VM and Kannan I. Study
of Etiological factors, Mycological
profile and
Treatment outcome of Otomycosis.Int J of Medical Res
Rev 2014;2(4):355-360.
Int J Med Health Sci. Jan 2015,Vol-4;Issue-1
68
6.
7.
Conley JC.Evaluation of fungus disease of the external
auditory canal. Arch otolaryngol 1948; 47: 721-745.
Otomycosis in the Indian Subcontinent: Predisposing
Panchal P, Pethani J, Patel D Rathod S and Shah P.
Factors, Microbiology and Classification. International J
Analysis of various fungal agents in clinically suspected
of Microbiology 2014; (about9p.) Available from:
cases of Otomycosis.Indian J of Basic and Applied
http://dx.doi.org/10.1155/2014/636493
Medical Research 2013;2(8): 865-869.
8.
17. X Jia, LiangQ,Chi F and Cao W. Otomycosis in
Stone M, Fulghum RS. Bacterial activity of wet cerumin.
Shanghai:Aetiology,Clinical
Annals Of Otology, Rhinology and Laryngology
Mycoses 2012; 55: 404-409.
1984;93: 183-186.
9.
16. Prasad SC, Kotigadde S, Manisha S et al. Primary
features
and
Therapy.
18. Jain SK and Agarwal SC. Sporostatic effect of some oils
Mohanty JC, Mohanty SK, Sahoo RC, Ghosh SK et al.
against fungi causing Otomycosis. Indian Journal Of
Clinico microbial profile of Otomycosis in Berhampur.
Medical Sciences 1992;46(1):1-6.
Indian J of Otology 1999;5(2): 81-83.
19. Fasunla J, P Lbekwetank Onakoya .Otomycosis in
10. Chander J, Maini S, Subbrahmanyan S and Handa
A.Otomycosis-A
Efficiency
of
Cinicomycological
Mercurochrome
Mycopathologia 1996;135(1):
in
study
its
and
Treatment.
9-12.
11. Paulose KO,Al khalifa S,ShenoyP and Sharma RK.
Mycotic Infection of the ear(Otomycosis) A prospective
study. The J of Laryngology and Otology 1989; 103:3035.
12. Kaur R,Mittal N,Kakkar M,Aggarwal A, Mathur K.
Western Nigeria.Mycosis 2008;51: 67-70.
20. Hot vrabec JT, Yoo D and Coker NJ. Otomycosis:
clinical
features
and
treatment
implications
,otolaryngology. Head Neck surgery 2006;135: 787-791.
21. Pawla VK, Chamiyal PC and Suri PN.Mycological study
in Otomycosis. Indian J Med Res 1983;77:334.
22. Pradhan B,Tuladhar NR and Amatya RM.Prevalence of
Otomycosis in outpatient department,department of
Otolaryngology in Tribhuvan university
Teaching
Otomycosis a clinicomycologic study. Ear Nose Throat J
Hospital, Kathmandu, Nepal. Ann Otol Rhinol Laryngol
2000;79: 606-609.
2003;52: 76-80.
13. Kurana AS,Kanta S and Kumar S. Incidence of fungal
23. Ozacan M, Ozacan MK and Karaaslan A.Concomitant
infection in CSOM. Indian J of Otology1998;4(3):121-
Otomycosis and Dermatomycosis;A Clinical
123.
Microbiological
14. Talwar P,Chakrabarti A, Kaur P,Palwa RK, Mittal
A.Fungal infections of ear with special reference to
CSOM. Mycopathologica 1988;104(1): 47-50.
15. Yehia M Habib H,M Shehab NM.Otomycosis a common
Study.
Eur.Arch
And
Otorhinolaryngol
2003;260:24-27.
_______________________________________________
*Corresponding author: Dr Archana S Choudhari
E-Mail: [email protected]
problem in North Iraq. J Laryngol Otol 1990;104:387389.
Int J Med Health Sci. Jan 2015,Vol-4;Issue-1
69