Section 6

45-year-old man presents to the emergency clinic with an itchy ear. On otoscopy you see an inflamed ear canal lined by grey filamentous hyphae.

What is the diagnosis?

  • Otomycosis / fungal otitis externa

Name two possible causative organisms.

  • Candida albicans
  • Aspergillus niger

Describe 5 possible risk factors or predisposing condition.

  • Topical antibiotic use
  • Moisture – humidity, swimming, perspiration
  • Trauma e.g. cotton bud use
  • Chronic dermatological conditions e.g. eczema, psoriasis
  • Foreign body use e.g. hearing aids, ear plugs

Describe how you would manage this.

  • Water precautions
  • Microsuction to remove debris
  • Topical antifungals e.g. clotrimazole
  • May need systemic antifungals e.g. fluconazole, itraconazole
  • 2% acetic acid 
  • Analgesia

Supporting Information

Otitis Externa

Diffuse inflammation of the skin lining the external auditory canal. Can be bacterial or fungal. 

Risk factors:

  • Getting ears wet – daily hair washing, swimming, surfers
  • Trauma
  • Humidity/heat
  • Skin disease – eczema/psoriasis
  • Diabetes or other immunocompromised state

Features; moderately tender ear, discharge (can be offensive), swollen canal. 

The most common organisms – 

  1. Bacterial (90%) – staphylococcus aureus, pseudomonas aeruginosa
  2. Fungal – otomycosis – aspergillus niger (black spores), aspergillus albicans

Management:

  • Topical drops – if used for a long time can develop otomycosis and ototoxicity if tympanic membrane perforation:
    • Gentisone – gentamicin and hydrocortisone
    • Sofradex – framycetin, gramicidin, dexamethasone
  • Wick/ribbon gauze with some ointment i.e. Tri-Adcortyl
  • Therapy adjusted according to swab results
  • Fungal infection- amphoterecin/miconazole/canestan topically

Complications:

  • Malignant otitis externa – Severe OE with bony erosion and cranial nerve palsy. Frequently occurs in elderly diabetics. It requires CT head and histology to diagnose. 

Treatment – IV abx for a long time, topical drops, aural toilet. 

  • Gradenigo’s syndrome – spread to the petrous apex of the temporal bone leading to pain and 6th cranial nerve palsy. (LR6SR4)
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