Otolaryngology–Head and Neck Surgery (2006) 135, 787-791
ORIGINAL RESEARCH
Otomycosis: Clinical features and treatment
implications
Tang Ho, MD, MSc, Jeffrey T. Vrabec, MD, Donald Yoo, BS,
and Newton J. Coker, MD, Houston, Texas
OBJECTIVES: To determine the clinical presentation, predispos-
ing factors, complications, and treatment outcomes of otomycosis.
STUDY DESIGN AND SETTING: Retrospective review of
132 patients with a clinical diagnosis of otomycosis treated from
1998 to 2004 in an academic otology practice.
RESULTS: Otalgia and otorrhea were the most common pre-
senting complaints (48%). Prior otologic procedures increase the
risk of developing otomycosis. Residual disease was observed in
13% and recurrence in 15% of the subjects. The presence of a
mastoid cavity was associated with higher recurrent and residual
disease rates. Topical ketoconazole, cresylate otic drops, and alu-
minum acetate otic drops were all relatively effective with ⬎80%
resolution rate on initial application, although topical ketoconazole
had a higher resolution rate and lower rate of disease recurrence.
CONCLUSIONS AND SIGNIFICANCE: Otomycosis can
usually be diagnosed by clinical examination and often occurs in
the setting of persistent otorrhea. Complications are not uncom-
mon but usually resolve with application of appropriate topical
antifungal agents. Eradication of disease is more difficult in the
presence of a mastoid cavity.
© 2006 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
O tomycosis or fungal otitis externa has typically been
described as fungal infection of the external auditory
canal with infrequent complications involving the middle
ear. Although rarely life-threatening, the disease process
presents a challenging and frustrating entity for both pa-
tients and otolaryngologists for it frequently requires long-
term treatment and follow-up, yet the recurrence rate re-
mains high.
Otomycosis is one of the common conditions encountered
From the Bobby R. Alford Department of Otolaryngology–Head and
Neck Surgery, Baylor College of Medicine, Houston, Texas.
Presented at the Annual Meeting of the American Academy of Otolar-
yngology–Head and Neck Surgery, Toronto, Canada, September 17-20,
2006.
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2006.07.008
in a general otolaryngology clinic setting and its prevalence has
been quoted to be as high as 9% among patients who present
with signs and symptoms of otitis externa.1 Although there has
been controversy with respect to whether the fungi are the true
infective agents versus mere colonization species as a result
of compromised local host immunity secondary to bacterial
infection, most clinical and laboratory evidence to date
supports otomycosis as a true pathologic entity, with Can-
dida and Aspergillus as the most common fungal species
isolated.2-4
Various factors have been proposed as predisposing fac-
tors for otomycosis, including a humid climate, presence of
cerumen, instrumentation of the ear, immunocompromized
host, and recently increased use of topical antibiotic/steroid
preparations.5 Treatment recommendations have included
local debridement, discontinuation of topical antibiotics,
and local/systemic antifungal agents. In this study, we aim
to characterize the clinical presentation, predisposing fac-
tors, and complications of otomycosis in a tertiary otology
referral practice as well as to evaluate the efficacy of various
outpatient treatments.
METHODS
A retrospective review of all outpatient visits from 1998 to
2004 to an academic otology practice was performed after
approval from the Institutional Review Board. Medical
records of 154 patients with documented diagnosis of oto-
mycosis based on clinical microscopy examination were
reviewed. Twenty-two patients were excluded because of
Reprint request: Jeffrey T. Vrabec, MD, Neurosensory Center, 6501
Fannin, Rm NA 102, Houston, TX 77030-3498.
E-mail address: jvrabec@bcm.tmc.edu.
788 Otolaryngology–Head and Neck Surgery, Vol 135, No 5, November 2006

insufficient clinical data documentation, leaving a total of Table 1

132 patients in the final analysis.
Data collected and analyzed include duration of follow-
up, number of recurrences, presenting symptoms, disease
complications, comorbidities, fungal species identified, his-
tory of prior otologic procedures, prior treatments, and out-
come after current treatments. Statistical analysis was car-
ried out using Fisher’s Exact Test.
The diagnosis of otomycosis was made on the basis of
the recognizable and characteristic appearance of fungal
mats and fruiting bodies under microscopy such as that
shown in Figure 1. Cultures are not routinely obtained
because there is generally a rapid response to treatment. The
typical treatment regimens for the most commonly used
agents in our practice are as follows. Ketoconazole cream is
applied in the clinic directly onto the involved external
auditory canal skin after cleaning the canal with the use of
the microscope. Application is facilitated with a small sy-
ringe (1 or 3 cc) and an 18-gauge or larger IV catheter. The
ketoconazole cream is held in place largely by its innate
viscosity and the shape of the external auditory canal. The
ear canal is inspected 1 week later and residual cream is
removed. A second application for persistent disease is
necessary in one-third of cases. Cresylate is applied topi-
cally, three times daily, though it cannot be used in the
presence of a tympanic membrane (TM) perforation. Ap-
plication is continued until no visible disease remains.
Duration of follow-up was defined as time elapsed from
date of diagnosis to the last date of clinic visit. Comorbidi-
ties were identified as other medical conditions listed in
medical records at the time of diagnosis. Prior treatments
included ototopical or oral preparations received before
presentation. Successful treatment outcome was defined as
resolution of all evidence of fungal infection on physical
examination. Residual disease was defined as a condition
that failed to respond to our initial choice of treatment.
Recurrent disease was defined as a condition that occurred
in patients who had resolution of disease after initial treat-
ment but recurred in the same ear at a later date.
Symptoms at time of diagnosis
Number of Percentage
Symptom patients (n) (%)
Otalgia 63 48
Otorrhea 63 48
Hearing loss 59 45
Aural fullness 44 33
Pruritus 20 23
Tinnitus 5 4
RESULTS
A total of 132 patients with documented diagnosis of oto-
mycosis were included in the analysis. The group consisted
of 57 (43%) females and 75 (56%) males. The age at
diagnosis ranged from 6 to 91 years with a mean of 47.6
years and a median of 46.2 years. Mean follow-up time was
1.4 years, and median follow-up time was 25 days. Al-
though usually only one ear was affected, bilateral disease
was observed in 9 (7%) patients on initial presentation.
The presenting complaints at the time of diagnosis are
tabulated in Table 1. As shown, otalgia and otorrhea were
the most common symptoms at time of diagnosis, followed
by hearing loss, aural fullness, and pruritus. Physical exam-
ination findings that suggest otomycosis include a thick
fibrinous accumulation of debris, the absence of significant
edema of the canal skin, and small well-circumscribed areas
of granulation tissue within the external canal or on the TM.
Treatments received before diagnosis are listed in Table 2.
As indicated in the table, nearly half (45%) of the patients
had been treated with ototopical medications before diag-
nosis; ciprofloxacin and neomycin-polymyxin B-hydrocor-
tisone were the most frequently prescribed. The duration of
treatment ranged from days to years. Nearly 1 of 4 patients
had been taking oral antimicrobials for treatment of pre-
sumed otitis media before diagnosis.
Disease complications included serous otitis media in 17
(13%) patients, TM perforation in 18 (14%) patients, and

Table 2
Treatment received before diagnosis

Number of Percentage
Treatment patients (%)

Ototopical drops 59 45
Ciprofloxacin 14 11
Neomycin-polymyxin
B-hydrocortisone 14 11
Ofloxacin 9 7
Other* 8 6
Unknown 14 11
Oral antimicrobials 32 24
*Includes acetic acid, alcohol, clotrimazole, and other anti-
microbial otic drops.
Figure 1 Clinical appearance of otomycosis.
Ho et al Otomycosis: Clinical features and treatment . . . 789

generally very well tolerated with few adverse effects.

Table 3
Treatment received after diagnosis There were two cases of documented external auditory
canal dermatitis as a result of local irritation from cresylate
Number of Percentage otic drops in one patient and aluminum acetate otic drops in
Treatment types patients (%) another.
Culture results were available for eight patients. Among
Ototopical therapy
Cresylate otic 51 39 these, four were positive for Aspergillus species, and two
Ketoconazole ointment 48 36 were positive for Candida species. Culture on one patient
Aluminum acetate otic 18 14 yielded Aureobasidium species and another yielded Acre-
Clotrimazole otic 7 5 monium species.
Acetic acid otic 3 2 Forty-eight (36%) patients had a history of otologic
Gentian violet 2 2
Oral therapy procedures in the affected ear that ranged from tympa-
Antimicrobials 5 4 nostomy tube placement to tympanomastoidectomy. Twen-
Fluconazole 2 2 ty-two (17%) patients had canal wall down (CWD) proce-
dures that resulted in a mastoid cavity. Among these
patients, 15 (68%) were treated initially with cresylate otic
drops and 6 (27%) with topical ketoconazole. The distribu-
external auditory canal osteitis in 2 patients. Tympanic tion of topical agents differed from the other 110 patients
membrane perforations were considered a complication of with an intact canal wall, of whom 36 (33%) were treated
otomycosis if they were present during the initial presenta- with cresylate initially, 18 (17%) with aluminum acetate,
tion and healed with the resolution of infection or if they and 42 (38%) with topical ketoconazole. Residual fungal
were observed to occur during the course of treatment. Only disease after initial treatment was seen in 5 (23%) of the 22
1 patient in this series required tympanoplasty for closure of patients with a CWD cavity and 6 had recurrent disease
a persistent perforation. Of the 2 patients with osteitis, 1 had (27%).
a known history of diabetes. Among all subjects, diabetes
was a documented comorbidity in 7 (5%) patients, though
this is not significantly different from the reported preva-
lence of diabetes in the general population.6 DISCUSSION
The most common therapeutic options used in our prac-
tice are listed in Table 3. The therapeutic agents were Otomycosis is an entity frequently encountered by otolar-
always used in conjunction with thorough mechanical de- yngologists and can usually be diagnosed by clinical exam-
bridement of visible fungal elements in the external auditory ination. However, the correct diagnosis requires a high
canal. Ketoconazole and cresylate appeared to be equally index of suspicion given that the most common presenting
effective; treatment duration ranged from 1 to 3 weeks. symptoms of otalgia and otorrhea, as shown in this study,
Overall, 106 (80%) patients improved with initial treatment. are relatively nonspecific. In addition, hearing loss and aural
Nine (7%) patients were lost to follow-up after initiation of fullness are also frequent symptoms as a result of accumu-
treatment and 17 (13%) failed initial treatment. Among the lation of fungal debris in the canal. Although pruritus has
106 subjects that responded to initial treatment, 16 (15%) been frequently cited as one of the hallmark symptoms, up
patients had recurrent disease. to 93% in 1 study, it was reported among the chief com-
The efficacy of the three most common treatment mo- plaints in only 23% of the current study population.5,7
dalities are shown in Table 4. In our practice, we saw that Aspergillus and Candida species are the most commonly
topical ketoconazole ointment application yielded the high- identified fungal pathogens in otomycosis.8,9 This is con-
est (95%) resolution rate on initial application and the low- sistent with the limited mycology data available in this
est (10%) recurrence rate, although the difference was not series. Infection with Candida can be more difficult to
statistically significant (P ⬎ 0.05). The treatments were detect clinically because of its lack of a characteristic ap-

Table 4
Treatment success and failure rates

Number of Resolution rate Residual disease Recurrent disease

Treatment type patients* (percentage) (percentage) (percentage)

Cresylate otic 44 38 of 44 (86%) 6 of 44 (14%) 9 of 38 (24%)

Ketoconazole ointment 44 42 of 44 (95%) 2 of 44 (5%) 4 of 42 (10%)
Aluminum acetate otic 7 6 of 7 (86%) 1 of 7 (14%) 2 of 6 (33%)
*Includes only those patients treated with the selected agent alone and with available follow-up information.
790 Otolaryngology–Head and Neck Surgery, Vol 135, No 5, November 2006
pearance like Aspergillus and can present as otorrhea not
responding to aural antimicrobials. Otomycosis attributed to
Candida is often identified by culture data.
Although multiple in vitro studies have examined the effi-
cacy of various antifungal agents, there is no consensus on the
most effective agent.10,11 Various agents have also been used
clinically with variable rates success.12-14 Nevertheless, ap-
plication of appropriate topical antifungal agents coupled
with frequent mechanical debridements usually results in
prompt resolution of symptoms, although recurrence or re-
sidual disease can be common. In this series, more than 80%
of the patients had resolution of the infection with initial
treatment, often in less than 2 weeks. Topical ketoconazole
is our preferred antifungal agent for its efficacy against both
Aspergillus and Candida species. There were no cases of
local sensitivity to ketoconazole, and the infections seemed
to resolve faster and display a lower recurrence rate. The use
of cresylate otic drops should be avoided in patients with
TM perforation given its potential complications. In our
practice, we have observed transient sensorineural hearing
loss associated with such use.
Complications such as TM perforation and serous otitis
media as a result of otomycosis are not uncommon and tend
to resolve with treatment. The pathophysiology of the TM
perforations may be attributed to avascular necrosis of the
TM as a result of mycotic thrombosis in the adjacent blood
vessels.15 The rate (14%) of TM perforation in this series is
similar to that observed by Pradhan et al7 (16%) and Kur-
natowski and Filipiak12 (12%). There were no clinical fea-
tures predictive of TM perforation. TM involvement is
likely a consequence of fungal inoculation in the most
medial aspects of the external canal or direct extension of
disease from adjacent skin.
There appears to be little consensus with respect to the
predisposing factors for otomycosis. For instance, the pres-
ence of cerumen has been speculated to be supportive of
fungal growth by some yet inhibitory by others.1,5,14 There
have also been reports of autoinoculation of the ear canal
that result in otomycosis by patients with untreated der-
matomycoses.16 However, autoinoculation of the external
canal does not appear to be a significant factor in our patient
population as the history of fungal infections of the skin or
nails was rare.
More recently, there has been increasing concern with
respect to increasing incidence of otomycosis from wide-
spread use of fluoroquinolone otic drops.17-19 It is interest-
ing to note that similar concerns had been raised nearly 2
decades ago with the introduction of topical antibiotic/ste-
roid preparations, yet they have subsequently been shown to
have little or no effect on the incidence of otomycosis.1,14 In
this series, ciprofloxacin and neomycin-polymyxin B-hy-
drocortisone drops were the most frequently prescribed oto-
topical therapy before presentation. Although the chronic
use of ototopical antimicrobial preparations remains a po-
tential predisposing risk factor, no specific preparation ap-
pears to convey an increased risk for development of oto-
mycosis.
Prior otologic procedures were noted in more than one-
third of the patients in the study and appear to increase the
risk for developing otomycosis. This is higher than that
reported in other series such as that by Pradhan et al7 where
4.6% of the subjects were postmastoidectomy patients. Al-
though this may represent a referral bias inherent to a
tertiary otology practice, the data appear to support prior
otologic procedures, particularly those that result in a mas-
toid cavity, as a potential risk factor for otomycosis. Several
factors may contribute to development of otomycosis in the
previously operated ear. First, recurrent drainage or subse-
quent antibiotic/antiseptic application may alter the local
environment of the external canal and allow superinfection
by nosocomial fungi. Second, alteration of the anatomy by
CWD procedures may also produce changes in cerumen
production or relative humidity that favor fungal growth.
The incidence of both recurrent and residual fungal dis-
ease for postmastoidectomy patients in this series is higher
than that in patients with an intact canal wall (residual, 23%
vs 13%; recurrent, 27% vs 12%); this suggests that eradi-
cation of disease is more difficult in the presence of a
mastoid cavity. Further analysis found that the patients with
CWD cavities were more likely to receive cresylate as
initial therapy. However, treatment of CWD cavities with
ketoconazole was also more difficult and more prone to
recurrence. Because both agents were highly effective over-
all, as demonstrated by the ⬎80% resolution rate after initial
treatment (Table 4), we conclude that the anatomic differ-
ences imposed by CWD surgery are responsible for the
doubling of residual/recurrent disease rates. One obvious
explanation for this finding is the difficulty in applying
topical medications in the relatively large surface area of the
cavity. This is especially problematic when the focus of
infection is in the superior or posterior aspects of the cavity.
In this situation we recommend filling the cavity with top-
ical ketoconazole cream and then packing the cavity with
gauze to ensure the topical medication stays in contact with
the infected epithelium. The addition of oral antifungals is
reserved for cases with severe disease and poor response to
therapy, though it is rarely necessary. We have observed
patients treated with oral agents before referrals that con-
tinued to have persistent disease. We believe oral antifun-
gals are unlikely to succeed in the absence of adequate local
care.
The limitations of this study include the possible selec-
tion bias given the referral pattern of our practice. Never-
theless, to our knowledge this series is one of the largest
otomycosis surveys reported. In addition, the increased heat
and humidity in our geographical region may limit the
applicability of these findings in regions with a more tem-
perate climate. Future research may include better charac-
terization of the effective treatment dose and duration of the
various available antifungal agents.
Ho et al Otomycosis: Clinical features and treatment . . .
In summary, this study demonstrates that the diagnosis of
otomycosis requires vigilance from clinicians given its non-
specific symptoms. Treatment regimens such as ketocon-
azole and cresylate coupled with mechanical debridement
are generally effective. However, recurrence is not uncom-
mon and eradication of disease can be particularly difficult
in postmastoidectomy patients.
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