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Topical antibiotic induced otomycosis

Article in International Journal of Pediatric Otorhinolaryngology July 2005
Impact Factor: 1.19 DOI: 10.1016/j.ijporl.2005.01.022 Source: PubMed

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International Journal of Pediatric Otorhinolaryngology (2005) 69, 857860

www.elsevier.com/locate/ijporl

CASE REPORT

Topical antibiotic induced otomycosis

Alexis Jackman a,b, Robert Ward a,b, Max April a,b, John Bent a,b,*
a
b

Department of Otolaryngology, Neck York University Medical Center, New York, NY, USA
Department of Otolaryngology, Lenox Hill Hospital, New York, NY, USA

Received 15 July 2004; received in revised form 3 January 2005; accepted 11 January 2005

KEYWORDS
Otomycosis;
Otorrhea

Summary Prior to 1999, the diagnosis of otomycosis as a cause of persistent

otorrhea was rare. An increase incidence has been seen in among our outpatient
pediatric otolaryngology practice. The purpose of this study is to assess the contribution of ototopical antibiotic drops to the development of otomycosis. Design: Retrospective study. Setting: Pediatric otolaryngology outpatient center. Methods: Chart
review of all patients diagnosed with otomycosis between June 1999 and September
2001. Twenty-six patients (ages 17 months29 years) were diagnosed with otomycosis
based on clinical and microbiological findings after treatment with topical ofloxacin
antibiotic drops. All patients had used ototopical antibiotics, including ofloxacin in
every case, for presumed bacterial otorrhea. Once the fungal source was recognized,
therapy succeeded in each case (26/26). Physicians need an elevated suspicion of
otomycosis as a cause of persistent otorrhea, especially following treatment with
topical antibiotic drops. Appropriate treatment of otomycosis eliminates otorrhea.
Ofloxacin remains an excellent choice for bacterial otorrhea, but it appears to
increase the incidence of otomycosis. Thus, its usage warrants careful post-treatment
follow-up.
# 2005 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Otomycosis represents a fungal infection of the
external auditory canal skin, characterized by pruritis and low-grade discomfort of the external auditory canal (EAC). Both Candida albicans and
Aspergillus fumigatus classically appear as a
fluffy white discharge, whereas Aspergillus niger
produces black colonies, which are described as
* Corresponding author. Present address: 186 East 76th Street,
New York, NY 10021, USA. Tel.: +1 212 327 3000;
fax: +1 212 327 3004.
E-mail address: bent@i2000.com (J. Bent).

pepper like [1]. The prevalence and fungal genera depend greatly on the patients geographic
location. The highest prevalence of otomycosis
occurs in the hot and humid climates. In temperate
climates, such as where this study took place, the
prevalence decreases. A large study of otitis externa
in Great Britain, reported that fungus was the cause
of otitis externa in 9% cases [2]. The most common
fungal species isolated from temperate climates are
Candida and Aspergillus [3].
Candida and Aspergillus are both ubiquitous
organisms and normal skin flora that can cause
opportunistic infections in the EAC. When either
the skin barriers to infection or the metabolic equi-

0165-5876/$ see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2005.01.022

858

librium of the skin flora in the EAC are altered,

colonizing fungi and bacteria can proliferate and
disrupt the normal floral hemostasis. Skin barriers to
prevent otomycosis include an intact surface as well
as normal secretions from sweat, sebaceous, and
cerumen glands. These secretions maintain the protective properties of the keratin layers of the skin by
preventing hydration as well as provide an acidic
environment, which is bacteriostatic and fungistatic
[4,5]. Also, the constant lateral migration of EAC
skin aids in removal of resident microbes and allows
the replacement of damaged epithelium with
healthy new tissue [6].
Since 1999, our practice has observed an
increased incidence of otomycosis as a cause of
persistent otorrhea. This study seeks to review this
experience and assess the contribution of ototopical
antibiotic drops to the development of otomycosis.

2. Materials and methods

The charts of patients suspected of having otomycosis from September 1998 to December 2000 were
reviewed. The records were carefully examined for
topical and systemic antibiotic usage before the
diagnosis of otomycosis. A total of 26 patients were
identified, 12 of which were male and 14 female.
The average age was 9 years (range: 1729 years).
No patient had a medical predisposition to a mycosis. Some patients had either a tympanic membrane
perforation or a tympanostomy tube. Often, it was
unclear if their initial otorrhea was of middle ear
origin, but it was confirmed that their middle ears
were free of disease in order to diagnose otomycosis.

3. Results
Twenty-six patients were diagnosed with otomycosis
based on clinical and microbiological findings. All
patients in this study had used ototopical antibiotics, including ofloxacin in every case for a presumed
episode of either acute otitis media or acute otitis
externa. Treatments included only topical ofloxacin
drops in 22 cases (84%), topical ofloxacin and oral
amoxicillin-clavulanate in two cases (8%) and topical ofloxacin following initial treatment with ciprofloxacin/hydrocortisone in two cases (8%). In all
cases, the initial purulent discharge resolved, but
cheesy white debris was noted in EAC on follow-up
examination. Cultures of the otorrhea were done in
22 of the 26 cases. Fourteen cultures grew yeast,
and eight were negative. C. albicans was the species
cultured in six cases, and A. fumigatus was cultured

A. Jackman et al.

Fig. 1

Results of fungal cultures.

in two cases. In six cases,budding yeast was

reported but the species of fungus was not indicated
(see Fig. 1).
Once treatment was directed towards otomycosis, all cases of otorrhea resolved, although in several cases, multiple topical and oral medications
were used before recalcitrant infection resolved.
The most frequent first line treatment was topical
acetic acid/propylene glycol otic drops (15/26), the
second most common first line treatment was clotrimazole (8/26), nystatin was used as first line
therapy in two cases, and acetic acid/aluminum
acetate drops in one case. Of the 15 patients treated
with acetic acid/propylene glycol, 6 resolved. Three
resolved after gentian violet staining of the EAC was
done in addition to using acetic acid/propylene
glycol drops, three resolved after both gentian violet and oral diflucan were included in the regimen,
and two resolved after clotrimazole followed acetic
acid/propylene glycol, and one resolved with acetic
acid/propylene glycol followed by acetic acid/aluminum acetate drops and gentian violet. Of the
eight patients treated with clotrimazole, four cases
of otorrhea resolved with clotrimazole only. Two
cases resolved when acetic acid/aluminum acetate
drops followed clotrimazole. Two cases were successfully treated when oral fluconazole was given in
addition to clotrimazole. One patients otorrhea
resolved with nystatin alone, and one patient
required oral fluconazole in addition to nystatin.
The one patient, who was started on acetic acid/
aluminum acetate drops, was given oral fluconazole
additionally before resolution of the otorrhea
occurred.
In only 12 cases (46%), otorrhea resolved with the
first line treatment. Six cases (35%) resolved after
two different medications were given, and in eight
cases (19%) three different medications were used
before otorrhea resolved. Additional medications
included gentian violet, acetic acid/aluminum acetate, and oral fluconazole (see Fig. 2).

Topical antibiotic induced otomycosis

Fig. 2

Treatment of otomycosis.

4. Discussion
In each case of otomycosis, antibacterial therapy
was given for a presumed bacterial otorrhea. The
purulent drainage resolved with topical ofloxacin
drops exclusively in 22 cases and in combination
with other antibiotics in four cases, but all these
patients subsequently developed a nonpainful,
pruritic, white otorrhea. The otorrhea was consistently reported in these charts as thick and
cheesy. The physical characteristics of the otorrhea led to the clinical diagnosis of otomycosis.
Fungal cultures were taken in the majority of cases.
As swabs of the EAC were not placed in the optimal
medium for fungal growth, Stuarts medium, prior to
transport to the lab, a negative report of fungal
growth did not rule out the diagnosis of otomycosis.
In all of these cases, otomycosis occurred after
treatment with topical ofloxacin antibiotics drops.
Physicians frequently choose ofloxacin because has
not been shown to cause otoxicity and it provides
good coverage of common otologic pathogens. Also,
patients tolerate ofloxacin well, because it has a
neutral pH (6.5  0.5) and has a physiologic osmolality (285343 mOsm), which minimize middle ear
mucosa irritation and swelling.
Several possible factors increase the risk of otomycosis in these patients. Bacterial contamination
of the EAC skin occurred initially by either suppurative otitis media or acute otitis externa. This introduced new virulent strains of bacteria, which could
adhere to and enter into epithelial cells lining the
canal, causing cellular damage and disruption of
intracellular bridges. The disrupted epithelial surface is able to be breached by the microorganisms
and provides a good medium for growth. Also,
epithelial damage also leads to a decrease in excretion from apocrine and cerumen glands, which
changes the normally acidic (pH 34) EAC environment to one that more hospitable to microbial

859

growth. Ofloxacin may contribute to the development of otomycosis in two ways. First, ofloxacin is
bacteriocidal to most bacteria in the EAC, and
fungal proliferation may occur unchecked because
of lack competing bacterial growth. Additional antibiotic therapies in four patients would have further
altered the EAC microbial equilibrium. In contrast to
other topical otic antibiotics, which typically have a
pH of 34, ofloxacin has a pH 7. This more basic
solution elevates of the pH of the EAC skin, making it
a more optimal environment for fungal proliferation. For example, Aspergillus, one of the most
common fungal pathogens, grows optimally at a
pH 6. These two properties of topical ofloxacin
may explain the development of otomycosis in this
series. The possibility also exists that ofloxacin only
appears suspect due to its popularity and large
market share, and that the recent increase in otomycosis is related to other unidentified factors.
Resolution of the otorrhea occurred in all cases
when the therapy was directed toward a fungal
etiology. Several studies have reported on the effectiveness of various antifungal treatments both in
vivo and in vitro, but a consensus on the most
effective therapy remains controversial. Clotrimazole was found to be the most effective in in vitro
studies for common fungal organisms by Stern et al.
[7] Other clinical studies have found clotrimazole to
be the most effective in vivo antifungal agent followed by gentian violet and nystatin [1]. The greatest efficacy of an initial antifungal medication in this
study was also seen with clotrimazole. However, the
percent of cases that resolved with clotrimazole
(50%) and other antifungal agents was less than that
reported in other studies [1]. In several cases, multiple drug therapies were utilized and required multiple follow-up visits before infection was cleared.
The recalcitrant nature of these cases of otomycosis
was noteworthy. Our antidotal impression, which
cannot be substantiated by this limited and retrospective data, has been that systemic fluconazole
most reliably eliminates otomycosis. Because the
risk of side effects increases with use of systemic
antifungals, we have been reluctant to use oral
fluconazole as a first line agent.

5. Conclusion
Physicians should maintain an elevated suspicion of
otomycosis as a cause of persistent otorrhea, especially following treatment with topical antibiotic
drops. Appropriate treatment of otomycosis eliminates otorrhea. Ofloxacin remains an excellent
choice for bacterial otorrhea, but our experience
has implicated it as a potential cause of otomycosis.

860

Thus, its usage warrants careful post-treatment

follow-up.

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[2] T. Mugliston, G. ODonoghue, Otomycosisa continuing problem, J. Laryngol. Otol. 99 (1985) 327333.

A. Jackman et al.

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