Picture 2.1. Anatomy Ear

Definition

Otomycosis is an inflammation of the external auditory canal caused by fungi. It can also be associated with chronic ear disease and an open mastoid cavity. The most common causes are Aspergillus and Candida. ^1,6,7

The incidence rate of otomycosis is not known for certain, but it often occurs in areas with hot and humid weather, as well. in people who enjoy water sports. One in 8 cases of external ear infections are caused by fungi. Much literature mentions that otomycosis comes from tropical and subtropical countries. According to Dundar, 5-20% of cases of otitis externa come to the polyclinic. In general, otitis externa is caused by infection bacteria but there are 9-25% of cases caused by fungal infections. ⁴

Etiology And Pathogenesis

This infection is caused by several species of saprophytic fungi, especially Aspergillus Nigeria . Agent reason other covering A. flavus,

A. fumigatus, Allescheria boydii, Scopulariopsis, Penicillium, Rhizopus, Absidia, and Candida Spp. Ninety percent of these fungal infections are caused by Aspergillus spp , and the rest are Candida spp . In addition, otomycosis can be a secondary infection from certain predispositions such as otitis externa caused by bacteria treated with corticosteroids and swimming. ^6,7

Aspergillus niger is reported to be the most common cause of otomycosis. Other Aspergillus species are associated with otomycosis is that A. fumigatus and A. flavus . Penicillum was also reported by Pavalenko. Other fungi associated with the occurrence of otomycosis are C. albicans and C. parapsilosis . In a study conducted by Ali Zarei in Pakistan in 2006, A. niger was found to be the main cause followed by with A.flavus . ^9,10 Aspergillus niger , has also been reported as a cause of otomycosis in immunocompromised patients, who do not respond to various therapeutic regimens that have been given. ^6,7

Factor predisposition the occurrence otomycosis covering No existence earwax, high humidity, increased temperature, and local trauma usually often caused by cotton buds and hearing aids. Earwax itself has a pH ranging from 4-5 which functions to suppress the growth of bacteria and fungi. Water sports such as swimming and surfing are often associated with this condition because repeated exposure to water causes the discharge of earwax, and dryness of the external auditory canal. It can also be caused by invasive procedures on the ear. Other predispositions include a history of suffering from eczema, allergic rhinitis, and asthma. ^6,7

There are many factors that cause this saprophytic fungus to change into a pathogenic fungus, but what is the mechanism for this? is currently not understood. Several of the following factors are thought to play a role in the occurrence of infection, such as epithelial changes, increased pH levels, qualitative and quantitative disturbances of cerumen, systemic factors such as immune system disorders, corticosteroids, antibiotics, cytostatics, neoplasia, environmental factors such as high heat and humidity, history of previous otomycosis, chronic suppurative otitis media, post mastoidectomy, or use of substances such as broad spectrum antibiotics in the ear. ^6,7

Diagnosis

Diagnosis enforced based on on anamnesis, inspection physique and inspection laboratory. From anamnesis can obtained existence complaint dominant itching, pain in the ear, fullness and discharge from the ear. The most important thing is the tendency to do activities related to water, such as swimming, diving, and so on. ^8,9

As research conducted by Li Y and He L in 2019, ² In 256 cases of otomycosis, the percentage of each symptom of otomycosis was obtained as described in table 2.1 below:

Table 2.1 Symptoms Otomycosis

The ear canal will appear red, covered in scales, and this abnormality can spread to the outside to the ear canal. ear canal and inner earlobe. The infected area becomes red and covered with fine scales. If it spreads inward, to the tympanic membrane, it can produce serosanguinous fluid. ⁹

On examination of the ear suspected of otomycosis, there is a thick accumulation of fibrin debris, the growth of long, white filamentous hyphae from the skin surface, the disappearance of significant swelling in the canal wall, and a circular area of granulation tissue between the external canal or on the tympanic membrane. ^8,9

Laboratory examinations that are carried out can be in the form of examination of direct preparations or by culturing. In direct preparation examinations, scales from ear canal skin scrapings are examined with KOH 10% and wide hyphae will appear, septum, and sometimes small spores with a diameter of 2-3 u can be found. ^6.9 In culture, the squama is cultured on Saboraud Agar media, and incubated at room temperature. The colony will grow in one week in the form of a white filament colony. With a microscope, wide hyphae are visible and at the ends of the hyphae, sterigmata and spores can be found in rows attached to the surface. ^6,9

Management

Treatment is aimed at keeping the ear canal dry, do not moist, And recommended For No digging around ear with dirty items such as matches, ear scratchers, or cotton. The first therapy that can be done for otomycosis is to treat the causative factors. initiators such as control diabetes mellitus and stop the use of prolonged antibiotic ear drops. Cleaning of fungal debris is more advisable using suction and keeping the ear dry. ^11,12 Treatment that can be given such as a 2-5% acetic acid solution in alcohol dripped into the ear canal can usually cure. ^4,10 . A 2% thymol solution in dilute spirits (70% alcohol) or dripping one or two drops of 5% burrowi solution and then cleaning with a disinfectant usually gives satisfactory treatment results. Neosporin and 1-2% gentian violet solution can also be given. ^8,11 Recently, specific topical fungicides have been used frequently, such as preparations containing nystatin , ketoconazole, clotrimazole, And antifungal Which given systemically. ¹⁰ Topical antifungal use can be done by using ear drops or by using antifungal cream. The use of antifungal cream has a longer contact time with the skin in the ear canal so it is sufficient to use it once a day. While the use of ear drops needs to be repeated three to four times a day. ¹³

Topical treatment with drugs can be done with various types of antifungals. Polyenes are macrolide ingredients from streptomyces species including amphotericin B, natamycin and nystatin. This drug works by inhibiting sterol synthesis in the fungal cell membrane. Nystatin and natamycin are used for superficial mycoses while amphotericin B is for systemic mycoses. Nystatin inhibits the growth of various fungi and bacteria, but is not active for bacteria, protozoa and viruses. Nystatin is not absorbed through the digestive tract, skin and mucous membranes. Nystatin will only be bound by sensitive fungi or yeast. Antifungal activity depends on the presence of bonds with sterols in the fungal or yeast cell membrane, especially ergosterol. As a result of the formation of these bonds, there will be changes in the permeability of the cell membrane so that cells lose various small molecules. Nystatin is said to be more effective when used on infection mold Candida compared to Aspergillus. Natamicin used for keratitis caused by fungi because it is less irritating to the eye, it is the drug of choice for Fusarium solani infections. ^10,11

Imidazole antifungals have a strong antifungal spectrum broad. Included in this group are miconazole, clotrimazole, econazole, isoconazole, tioconazole, bifonazole. Because the properties and uses are practically the same, only miconazole and clotrimazole will be described in more detail. continued. Clotrimazole and miconazole are also most widely used topical. ¹⁰

Miconazole is a synthetic imidazole derivative that is relatively stable, has a strong anti-fungal spectrum broad against both systemic fungi and dermatophytes. The mechanism of action of this drug is not fully understood. Miconazole inhibits ergosterol synthesis which causes increased fungal membrane permeability. It is also possible that there is interference with the synthesis of ergosterol. nucleic acid or accumulation of peroxide in fungal cells causing damage cells. The drug that has penetrated the horny layer of the skin will remain for four days. Miconazole inhibits the activity of the fungi Trichophyton, Epidermophyton, Microsporum, Candida and Malassezia furfur. This drug available in the form of 2% cream and loose powder used twice a day for 2-4 weeks. Side effects include irritation, burning and maceration. ¹⁰

Clotrimazole has antifungal and antibacterial effects with a mechanism of action similar to miconazole. Cotrimazole will inhibit the growth of mold by inhibiting the production of ergosterol and biosynthesis. Used for topical fungal infections caused by T. rubrum, T. mentagrhyte, E. floccosum, M. canis, tinea versicolour and infections caused by C. albicans . This drug is available in the form of cream and solution with a concentration of 1%. Topical use can cause burning, erythema, edema, itching and urticaria. ^10.2

Itraconazole is a antifungal triazole derivatives that closely related to ketoconazole, can be used systemically. Its antifungal activity is thought to be greater while the side effects are smaller compared to ketoconazole. ¹⁰

Miscellaneous antifungal drugs include tolnaftate, a combination of benzoic acid and salicylic acid, gentian violet, merthiolate and flucytosine. Tolnaftate is a thiocarbamate which is effective for the treatment most dermatomycosis but not effective against candida. First used for the treatment of otomycosis in army veterans in remote jungles. ^8,10

A combination of benzoic acid and salicylic acid in a ratio of 2:1, usually 6% to 3%, known as Whitfield ointment. Salicylic acid provides a keratolytic effect while benzoic acid provides a fungistatic effect. Because benzoic acid only has a fungistatic effect, healing is only achieved after the infected horny layer has peeled off completely, so the use of this drug takes several weeks to several months. Mild irritation may occur at the site of application. ^8,10

Gentian violet is a mixture of rosaniline, especially hexamethyl rosaniline, also penta and tetra methyl rosaniline. Its strength is based on the amount of hexa methyl pararosaniline. There is a preparation in a dark green powder and shiny like metal, moderately soluble in water, alcohol and glycerin. Gentian violet is toxic to gram-positive bacteria and some fungi, but resistant to gram-negative bacteria and acid-fast bacteria. In concentrations of 0.5 and 1% it is irritating to mucosa and injured skin. In vitro gentian violet interacts with DNA so it is feared to be potentially carcinogenic. This drug is quite effective for otomycosis therapy but dirty when used. Merthiolate is usually No cause irritation local, odorless and colorless. ^8,10

Flucytosine exhibits a rather narrow antifungal spectrum. This drug is effective for the treatment of cryptococcosis, candidosis, chromomycosis, toluropsis and aspergillosis. Flucytosine enters the fungal cell with the help of the enzyme cytosin permease and in the cytoplasm will combine with RNA after undergoing deamination into 5-fluorouracil and then into 5-fluorodeoxyuridine monophosphate and fluorouridine trisphosphate which inhibit the synthesis of RNA and DNA. This condition No occurs in cells mammals because in the mammalian body flucytosine is not converted to fluorouracil. ^8,10

The use of antifungal ear drops reduces the feeling of fullness in the ear, especially after using excessive antifungal cream. Antifungal cream should be applied by a health worker to prevent excessive cream buildup that will cause discomfort to the ear. Antifungal drops currently available include nystatin, fluconazole and clotrimazole. ^2,4 In Indonesia itself, antifungal ear drops are still very difficult to find on the market.

Prognosis

Treatment with antifungal does not completely cure otomycosis, so the disease can recur. Therefore, in addition to providing topical antifungal, clinicians must also understand the physiology of the external auditory canal itself, namely by reducing exposure to water so as not to increase humidity, getting adequate therapy when suffering from otitis media, and avoiding any situation that can change normal conditions. If carried out properly, it will provide a complete cure for this disease. ^8,10

Complications of otomycosis that have been reported are perforation of the tympanic membrane and serous otitis media, but these are very rare. occurs, and tends to heal with treatment. The pathophysiology of tympanic membrane perforation may be related to avascular necrosis of the tympanic membrane as a result of thrombosis in the blood vessels. The incidence of membrane perforation reported from various studies ranges from 12-16% of all cases of otomycosis. No There are early symptoms to predict the occurrence of perforation, involvement of the tympanic membrane seems to be a consequence of fungal inoculation on the medial aspect of the external ear or a direct extension of the infection from the surrounding skin. ^8,10

DISCUSSION

Otomycosis is a fungal infection of the external auditory canal. Diagnosis enforced when in a way clinical found hyphae, spores mushrooms or mycotic plug in the external auditory canal. Fungal colonies grew in culture and on microscopic examination the fungus was identified. ^1,8,9

The laboratory examination conducted aims to determine whether the causative agent of infection is a fungus because sometimes patients come with complaints such as infections caused by bacteria. Infection by both agents simultaneously can also occur. Furthermore, to determine the type of causative fungus, it can be a direct examination or by culture. ^7,8,9

Direct examination is usually done to examine smears, skin scrapings, debris or biopsy material. The material is examined by making a KOH preparation. A KOH preparation is made by placing the material in a drop of 10% KOH solution on a glass slide and then covering it with a cover glass. Under the microscope, fungal hyphae or spores will be visible. To find out the causative fungus, a culture must be carried out. The type of causative fungus is an organism that is classified as a type of fungus based on species. The structure of fungi is more complex than bacteria, possibly unicellular or multicellular. Typical fungal cells are eukaryotic, including a nucleus with one nucleolus, a nuclear membrane and linear chromosomes. The chemical structure of the fungal cell wall is very different from bacteria in that it does not contain peptidoglycan, glycerol or lipopolysaccharides. The types of fungi that cause it can be Aspergillus niger , A. flavus, A. fumigatus, Allescheria boydii, Scopulariopsis, Penicillium, Rhizopus, Absidia, and Candida Spp. ^7,8

The principle of treatment is to eliminate the causative agent by cleaning the ear as clean as possible without any residue, can be done with topical anesthesia with the help of an otoscope or even a microscope and the use of antifungal drugs. If there is residual fungal debris in the ear canal, it will increase the risk of recurrence. Various types of topical antiseptic and antifungal fluids can be given in this condition. Patient education then also plays a role role important Because condition This can repetitive return especially to those with various habits that support the occurrence infection by fungus. Information is given and aimed at keeping the ear canal dry, not moist, and it is suggested not to dig the ear with dirty items such as matches, ear scratchers, or cotton. Patients with otomycosis are expected to see a doctor immediately to prevent secondary infection by bacteria and complications. ^1,8,9,12

There is no agreement on standard therapy for the treatment of otomycosis among experts. Many drugs have been tried, including: nystatin, tolnaftate, iodochlorhydoxyquin, aqueous mertiolate 1/1000 and others. However, as one of the principles of treatment, it is recommended to clean the ear canal and remove the fungal mass before using the drug. Antifungal. Theoretically, the treatment of superficial fungi including otomycosis uses topical antifungals. ^9,10 Based on research conducted by Mishra et al., the use of ear drops and antifungal creams are equally good for treating otomycosis. The use of clotrimazole cream provides a full sensation in the ear but is preferred because it is used once a day. ¹³

KAE can be cleaned in various ways, for example by using cotton stalks give results pretty good. This action can be performed anywhere on the surface cotton should be rough And attached minimum 2 cm on the stem so it doesn't come off easily when used. The cotton applicator is inserted into the KAE when the KAE is clearly visible. The KAE is then cleaned of debris by rotating the applicator handle. If The applicator cotton has been wet, the cotton is then replaced with new cotton. This is done repeatedly until the KAE is clean. To facilitate cleaning of the KAE, hydrogen peroxide is used. If a blockage is found by debris that is quite large, a cerumen hook with a ring-shaped tip can be used. slightly bent. Irrigation can be done. This method cannot be done if there is an acute inflammatory process in the EAC. After irrigation the EAC must be dried. ^9,10

SUMMARY

Otomycosis is a fungal infection of the external ear canal characterized by inflammation, itching, and discomfort in the ear. This disease occurs mainly in tropical and hot climates. The ear canal is an ideal place for the growth of saprophytic organisms such as certain fungi because the ear canal is connected to the outside air by a narrow hole, so it can function as a culture tube and is an excellent medium for fungal growth.

Otomycosis is mainly caused by fungi of the Aspergillus and Candida species . Aspergillus niger is the most common fungal species that causes infection. Mixed bacterial and fungal infections are also common. There are several factors that facilitate the emergence of otomycosis, namely the change in the pH of the ear canal epithelium which was originally acidic to alkaline, temperature and humidity, trauma, the habit of digging the ear with materials that are not clean, or digging the ear too hard so that it causes scratches on the skin of the ear canal, foreign bodies or foreign objects in the ear such as water, accumulation of earwax or insects, congenital abnormalities, namely the shape of the ear canal which is narrow and curved more sharply so that it prevents cleaning of earwax or causes high humidity in the ear canal, long-term use of antibiotics and steroids in the ear, and conditions of decreased body resistance,

Symptom beginning otomycosis is feeling full on ear And flavor itching in the ear canal. Sometimes fluid is also found. Blockage of the ear canal can cause hearing loss and ringing. On otoscopic examination shows a collection of dirt, appears inflamed and swollen ear canal. If the cause is Aspergillus niger often found blackish spores. The most important management is to clean the fungus from the ear canal as clean as possible then eliminate the predisposing factors, use of topical antifungal using antifungal ear drops and maintain cleanliness of the ear canal.

REFERENCE

1. Prasanna V, Hemlata MV, Kannan I. Study of etiological factors, mycological profile and treatment outcome of otomycosis. Research Article International Journal of Medical Research and Reviews. 2014; 4: 355-360

2. Lee Y, Hey L. Diagnosis and treatment of otomycosis in southern China. Mycoses. 2019;62(11):1064–8.

3. Linstrom CJ. Lucente FE. Infections of the External Ear. In Bailey, B.J.; Johnson, J.T.; Newlands, SD, Editor. Head & Neck Surgery - Otolaryngology, Edition 4th. Philadelphia : Lippincott Williams & Wilkins; 2006: (135).

4. Dundar R, İynen İ. Single dose topical application of clotrimazole for the treatment of otomycosis: Is this enough? Journal of Audiology and Otology. 2019;23(1):15–9.

5. Edward Y. Irfandy D. Otomycosis. Part Ear Nose Throat Head and Neck Surgery (ENT-KL) Faculty of Medicine, Andalas University, Padang.

6. Panchal et al. Analysis of various fungal agents in clinically suspected cases of otomycosis. Indian Journal of Basic & Applied Medicine Research; 2013: 8(2), pp. 865-869

7. Kumar A. Fungal Spectrum in Otomycosis Patients; JK Science Journal; 2005:7(3). p.152- 155

8. Ho T. et al. Otomycosis: Clinical features and treatment implications. Otolaryngology–Head and Neck Surgery; 2006: 135. p.787-791

9. Alnawaiseh S. et al. Treatment of Otomycosis: A Comparative Study Using Miconazole Cream with Clotrimazole Otic Drops. Journal of The Royal Medical Services. 2011; 18(3): p.34-37

10. Chalabi YE. The Role of Various Out Patients Aural Toileting Procedures in the Treatment of Otomycosis. (JZS) Journal of Zankoy Sulaimani. 2010; 13(1): 34- 48

11. Adhavan, E., Gopakumar K.P. Prevalence and Aetiology of Otomycosis in Sree Mookambika Institute of Medical Science [Internet]. Sree Mookambika Institute of Medical Science, Kulaskharam. 2022 [cited 2023Mar28]. Available from: https://smims.sreemookambikainstitute.com/departments/clinical/ent/

12. Truth M, Deshmukh P. Reviews of recurrent otomycosis and clotrimazole in its treatment. Cureus. 2022;

13. Mishra P, Sachdeva S, Kaushik M, Agrawal D. Otomycosis treatment: Topical Drops versus Cream – A prospective random study. Arch Otolaryngol Rhinol. 2017;3(3): 106-108.