An overview of Fungal infections affecting the external ear

1. Otitis Externa
Dr. Kripa Jacob
ENT Specialist
ATLAS Hospital
Ruwi

3. Anatomy and Physiology
• Consists of the auricle and EAM
• Skin-lined apparatus
• Approximately 2.5 cm in length
• Ends at tympanic membrane
• Auricle is mostly skin-lined cartilage
• External auditory meatus
– Cartilage: ~40%, Bony: ~60%
– S-shaped, Narrowest portion at bony-cartilage junction

4. Anatomy and Physiology
• EAC is related to various
contiguous structures
– Tympanic membrane
– Mastoid
– Glenoid fossa
– Cranial fossa
– Infra-temporal fossa

5. Anatomy and Physiology
• Innervation: cranial nerves V, VII, IX, X,
and greater auricular nerve
• Arterial supply: superficial temporal,
posterior and deep auricular branches
• Venous drainage: superficial temporal and
posterior auricular veins
• Lymphatics

6. OTITIS EXTERNA

7. DEFINITION
• An acute or chronic infection of the whole
or a part of the skin of the external ear
canal

8. CAUSES OF OTITIS EXTERNA
INFECTIVE REACTIVE
Bacterial Fungal Viral
Staph. arues
Pseudomonos
Others
Aspirigillus Niger
Candida Albicans
Herpes zoster
Others
Eczematous Seborrheic

9. Speculum findings:
• the canal may be so swollen that a view
into the ear is impossible
• In swimmers, divers and surfers, chronic
water exposure can lead to the growth of
bony swellings in the canal known as
exostoses. These can interfere with the
drainage of wax and predispose to
infection.

10. Organisms
1. Pseudomonas species
2. Staphylococci
3. Streptococci/Gram negative rods
4. Fungi (Aspergillus/Candida species)

11. Acute Otitis Externa (AOE)
• “swimmer’s ear”
• Pre-inflammatory stage
• Acute inflammatory stage
• Mild
• Moderate
• Severe

12. Factors contributing to AOE
• High humidity
• Water exposure
• Maceration of canal skin
• High environmental temperature
• Local trauma
• Perspiration
• Allergy
• Stress
• Removal of normal skin lipids
• Absence of cerumen
• Alkaline pH of canal

13. AOE: Pre-inflammatory Stage
• Oedema of stratum corneum and plugging
of apopilosebaceous unit
• Symptoms: pruritus and sense of fullness
• Signs: mild edema
• Starts the itch/scratch cycle

14. AOE: Mild to Moderate Stage
• Progressive infection
• Symptoms
• Pain
• Increased pruritus
• Signs
• Erythema
• Increasing edema
• Canal debris, discharge

15. AOE: Severe Stage
• Severe pain, worse
with ear movement
• Signs
• Lumen obliteration
• Purulent otorrhoea
• Involvement of peri-
auricular soft tissue

16. AOE: Treatment
• Most common pathogens: P. aeruginosa and S. aureus,
E.coli and proteus.
• Four principles
• Frequent canal cleaning; swab or suction
• With sever EO, placement of a wick made of
sponge or gauze provides a pathway for drops to
be delivered to the EAC wall skin for 48-72 hours!
• Topical antibiotics, and if severe>> Systemic or
PO-ABT
• Pain control
• Instructions for prevention

17. AT A GLANCE. . .
• Otalgia
• Tenderness on palpation or manipulation
(Tragus sign)
• Ear fullness
• Conductive hearing loss.
• Erythema of meatus and canal
• Swelling and obstruction of canal
• Crusting and discharge
• Odor!

18. Furunculosis
• Acute localized infection
• Lateral 1/3 of posterosuperior canal
• Obstructed apopilosebaceous unit
• Pathogen: S. aureus

19. Furunculosis: Symptoms
• Localized pain
• Pruritus
• Hearing loss (if lesion occludes canal)

20. Furunculosis: Signs
• Edema
• Erythema
• Tenderness
• Occasional
fluctuance

21. Furunculosis: Treatment
• Local heat
• Analgesics
• Oral anti-staphylococcal antibiotics
• Incision and drainage reserved for
localized abscess
• IV antibiotics for soft tissue extension

22. Erysipelas
• Acute superficial
cellulitis
• Group A, beta hemolytic
streptococci
• Skin: bright red; well-
demarcated, advancing
margin
• Rapid treatment with
oral or IV antibiotics if
insufficient response

23. Otomycosis
• Acute Fungal infection of EAC skin
• 10% of OE caused by fungi, not bacteria
• Primary or secondary
• Two most common pathogens
• 80%-90% caused by Aspergillus
• Candida
• Mostly in patients who have previously been
treated with antibacterial or corticosteroid ear
drops

24. OTOMYCOSIS

25. Otomycosis: Symptoms
• Pruritus deep within the ear
• Dull pain
• Hearing loss (obstructive)
• Tinnitus
• Symptoms are similar to bacterial otitis
externa, but otomycosis is often
associated with less pain and more
pruritus

26. Otoscopic examination : Signs
• Swollen and
erythematous EAC
• Abundant fungal debris
containing filamentous
elements (white, gray,
yellow, or black) in
cheesy material
• White, or black fungal
debris

27. Otomycosis

28. Otomycosis: Treatment
• Thorough cleaning and drying of canal
• Topical antifungals (clotrimazole for eg.,
amphotericine B, oxytetracycline-polymyxin, and
nystatin are very effective!)
• Acidifying of the EAC with drops like 2% acetic acid,
3% boric acid are also helpful in the t/t of fungal
infections.

29. Necrotizing (malignant) External Otitis(NEO)
• Potentially lethal infection of EAC and
surrounding structures
• Pseudomonas aeruginosa is the usual
culprit
• Risk Factors:
- Diabetes Mellitus
- Elderly
- Immunocompromised state
- Human Immunodeficiency Virus (HIV)
• Typically seen in diabetics and
immunocompromised patients

30. NEO: Signs & Symptoms
• Similar to Otitis Externa except
• Severe, unrelenting Ear Pain and Headache
• Persistent discharge
• Does not respond to topical medications
• Commonly associated with Diabetes Mellitus
• Granulation tissue in posterior and inferior canal
• Pathognomonic for necrotizing otitis
• Occurs at bone-cartilage junction
• Extra-auricular findings
• Cervical Lymphadenopathy
• Trismus (TMJ involvement)
• Facial Nerve Palsy or paralysis
• (Bell's Palsy)
• Associated with poor prognosis

31. NEO: Diagnosis, Prevention
and Treatment:
• Prognosis; Reportedly mortality 20-53%
• Diagnosis : History, Physical Examn, Labs and
Imaging:
- Labs; FBC, Culture of discharge, ESR, Serum glucose,
Serum creatinine.
- Radiology; CT, or MRI (ear)
• Prevention:
- Avoid use of cotton swabs in ear and other canal trauma.
- Use caution when irrigating ear of high risk patients.
- Treat eczema of ear canal and other pruritic dermatitis

32. NEO: Treatment
• Intravenous antibiotics for at least 4 weeks
– with serial gallium scans monthly
• Local canal debridement until healed
• Pain control
• Use of topical agents controversial
• Hyperbaric oxygen experimental
• Surgical debridement for refractory cases

33. NEO: Mortality
• Death rate essentially unchanged despite
newer antibiotics (37% to 23%)
• Higher with multiple cranial neuropathies
(60%)
• Recurrence not uncommon (9% to 27%)
• May recur up to 12 months after treatment

34. Perichondritis/Chondritis
• Infection of perichondrium/cartilage
• Result of trauma to auricle
• May be spontaneous (overt diabetes)
• Usual pathogens include pseudomonas
species and mixed flora

35. Perichondritis: Symptoms
• Pain over auricle and deep in canal
• fever
• Pruritus
Perichondritis: Signs
• Tender auricle
• Induration
• Oedema
• erythaema
• Advanced cases
• Crusting & weeping
• Involvement of soft
tissues

36. Perichondritis: Treatment
• Aspiration of the pus
• Use antibiotics of gram-negative coverage, specifically
anti-pseudomonals.
• If frank chondritis develops, incisions should be made
in the cartilage in order to provide adequate drainage.
• Mild: debridement, topical & oral antibiotic
• Advanced: hospitalization, IV antibiotics
• Chronic: surgical intervention with excision of necrotic
tissue and skin coverage

37. Herpes Zoster Oticus
(Ramsay Hunt Syndrome)
• J. Ramsay Hunt described in 1907
• Viral infection caused by varicella zoster
• Infection along one or more cranial nerve
dermatomes (shingles).
- herpes zoster of the pinna with otalgia.
- facial paralysis
- sensorineural hearing loss
- Bullus myringitis
- A vesicular eruption of the concha of the
pinna and the EAC.

38. Symptoms
• Early: burning pain in one ear,
headache, malaise and fever
• Late (3 to 7 days): vesicles, facial
paralysis
Treatment
• Corneal protection
• Oral steroid taper
(10 to 14 days)
• Antivirals (e.g. Valacyclovir)
• Facial nerve decompression
(controversial)!

39. Bullous Myringitis
• Viral infection
• Confined to tympanic membrane
• Primarily involves younger children

40. Bullous Myringitis: Symptoms
• Sudden onset of severe pain
• No fever
• No hearing impairment
• Bloody otorrhoea (significant) if rupture
Bullous Myringitis: Signs
• Inflammation limited to TM & nearby canal
• Multiple reddened, inflamed blebs.
• Hemorrhagic vesicles

41. Bullous Myringitis: Treatment
• Self-limiting
• Analgesics
• Topical antibiotics to prevent secondary
infection
• Incision of blebs is unnecessary

42. Chronic Otitis Externa
• Acute otitis externa occurs in 4 of every 1000 people
per year
• Otitis externa is defined as chronic when the duration
of the infection exceeds 4 weeks or when more than
4 episodes occur in 1 year
• Bacterial, fungal, dermatological aetiologies
COE: Symptoms
• Unrelenting pruritus
• Mild discomfort
• Dryness, Crusting, and flaking of canal skin

43. COE: Signs
• Asteatosis
• Dry, flaky skin
• Hypertrophied skin
• Muco-purulent otorrhoea
(occasional)

44. COE: Treatment
• Similar to that of AOE
• Topical antibiotics, frequent cleanings
• Topical Steroids
• Surgical intervention
• Failure of medical treatment
• Goal is to enlarge and resurface the EAC

45. Relapsing Polychondritis
• Uncommon progressive inflammatory disorder that
may affect children, but more commonly in adults.
• Episodic and progressive inflammation of cartilages
• Autoimmune etiology?
• External ear, larynx, trachea, bronchi, and nose may
be involved
• Involvement of larynx and trachea causes
increasing respiratory obstruction

46. Relapsing Polychondritis
• Fever, pain
• Swelling, erythaema
• Arthralgia!
• Tenderness of the nasal
septum may progress to
complete destruction of the
septum

47. Diagnosis and Treatment
• Weak +ve RF
• ANA +ve
• High ESR,
• Anaemia
• And definitive Diagnosis
is made by a biopsy
from the affected
cartilage
-Systemic steroids
such as prednisolone
-In resistant cases;
dapsone,
cyclophosphamide or
azithioprine may be
used

48. Radiation-Induced Otitis Externa
• OE occurring after
radiotherapy
• Often difficult to treat
• Limited infection treated
like COE
• Involvement of bone
requires surgical
debridement and skin
coverage

49. Granular Myringitis (GM)
• De-epithelization of the TM
• Localized chronic inflammation of pars
tensa with granulation tissue
• Sequelae of primary acute myringitis,
previous OE, perforation of TM
• Common organisms: Pseudomonas,
Proteus

50. GM: Symptoms
• Foul smelling discharge from one ear
• Often asymptomatic
• Slight irritation or fullness
• No hearing loss or significant pain
GM: Signs
• TM obscured by pus
• “peeping” granulations
• No TM perforations

51. GM: Treatment
• Careful and frequent debridement
• Topical anti-pseudomonal antibiotics
• Occasionally combined with steroids
• At least 2 weeks of therapy
• May warrant careful destruction of granulation tissue if
no response

52. Eczema
• External signs to OE
(atopic, contact and sebrrheoic) dermatitis
• Usual symptom is itching.
• P/E; erythaema, oedema, flaking and crusting.
• Treatment:
- Local cleansing.
- Usage of corticosteroid and drying agents.
• Metal sensitivity is the most common form of
chronic dermatitis involving the ear.!
• Nickel is the most common offending metal.
• Women are affected more than men.
- Ear piercing is an important cause
of primary sensitization to nickel.