REFLEKSI KASUS

Case presentation :OtomycosisGroup D-13.2Niko, Ferdina, Sarah, Irhash, Rona, NafsaModerator: dr. Hafifah

Clinical RotationDept. of Otorhinolaryngology and Head Neck Surgery

Introduction Otomycosis is fungal infection to the Canalis Auditorius ExternalAlthough rarely life threatening, the disease is a challenging and frustrating entity for both patients and otolaryngologists as it frequently requires long-term treatment and follow up. And, there often be case recurrences.

(Bailey, 2014)The external ear(Bailey, 2014)1. the auricle2. external auditory canal.Elastic cartilage derived from mesoderm

Subcutaneous tissue

Skin with its adnexal appendages

Fat but no cartilage in the lobule.

External Auditory canalLength: + 2,5 cmThe outer 40% is cartilaginousa thin layer of subcutaneous tissue between the skin and cartilage.The inner 60% is osseoussoft tissue between the skin, periosteum, and bone. (Bailey, 2014)

Defense mechanisms of the external earthe tragus and antitragusform a partial barrier to the entrance of macroscopic foreign bodiesthe skin with its cerumen coatHair cells Sebaceous glandsapocrine glands such as cerumen glandsthe isthmus of the canalThe junction of the cartilaginous and bony portions of the canal is a narrowed section termed the isthmusapopilosebaceous unit(Bailey, 2014)Arterial supply branches of the external carotid artery

(Feneis et al,2000)

a. superficial temporal a. posterior auricular Innervation the auriculotemporal branches of the trigeminal (V), facial (VII), glossopharyngeal (IX), and vagus (X) nerves the greater auricular nerve from the cervical plexus.The vestigial extrinsic muscles of the ear, anterior, superior, and posterior auricular, are supplied by the facial nerve (VII)(Feneis et al,2000)

Lymphatic drainage of head and neck

Lymphatic drainage Anteriorly and superiorlyInferiorlyPosteriorlythe preauricular lymphaticsin the parotid gland infra-auricular nodes near the angle of the mandible deep cervical nodes.the postauricular nodes and the superior deep cervical nodes(Feneis et al,2000)

Physiology of external earAuriculeThe external flap of cartilage surrounding the entrance to the earThe shape causes a resonance effect alter the amplitude of the pressure wave at different frequencies

Physiology of external earAuditory CanalActs as a resonator that further shapes the spectrumamplifies the spectrum between 2 kHz and 5 kHz range for speech recognition

Physiology of external earTympanic membranecollect air vibrations at the end of the auditory canalconvert into mechanical movement in the middle earsensitive instrument with an operating range of more than 100 dB. DefinitionOtomycosis is a fungal infection of the external auditory canal and its associated complications sometimes involving the middle ear. Incidence and epidemiologyOtomycosis occured on 9% of external otitis case and on 30,4% of the case with the otitis symptomThe prevalence is quite high at tropic and subtropic areaAlthough it can occur in any age, otomycosis often occured at adult age, especially in woman.And nowadays, the prevalence raised quite high as in the higher rate of immunocompromised patient.

etiology Fungal agent that often cause otomycosisAspergillus nigerCandida albicansActinomycesTrichophytonAspergillus fumigatusAsperfillus flavusCandida tropicalisPREDISPOSITION factorsDefense mech failure (change of epithelial coating, pH, humidity, quality and quantity of cerumen)Bacterial infectionUse of hearing aid deviceSelf inflicted trauma (e.g. cotton bud)Swimming in contaminated poolUse of broad spectrum antibioticsUse of steroid and/or cytostatic drugsImmunocompromised underlying disease18Pathophysiology Symptoms Signs Diagnosis Diagnosis is usually made from anamnesis, physical examination, and microscopic examinationMicroscopic:Microscopic discharge/debris exam with KOH 10% fungal element (hypha or spores)Classical appearance : grayish white plug resembling wet blotting paper, yellowish spores, a whitish, furry structure, or blackish spores covering the canals and sometimes the tympanic membrane

Microscopic finding in otomycosis.KOH preparation showed hypha and sporeTreatment Avoidance/ellimination of contributing factorAural toilet removal of debrisSpecific topical antifungal : clotrimazole, miconazole, econazole, nystatin, tolnaftate, potassium sorbate; or non specific topical antifungal (acetic acid, alcohol, boric acid, m-acetil acetate, gention violet)Treatment Aural toilet is the essential first stepMedication is better not reach middle ear irritationDo not give water based ear drop water is a good media for the fungi to growCASE REPORTIDENTITyName: Mr. RSSex: MaleAge : 26 y.oDate Birth: Nov 8, 1988Address : Sambeng Wetan, Kembaran, Banyumas

Date of examination : December 22, 2014ANAMNESISChief complaint: itching of the right ear

Present illness history: Since a week before entering the hospital, the patient complained that his right ear felt itchy and fullness. He sometimes felt pain. The complaints started 2 days after swimming in the public pool. There were no complaint about discharge coming out from the ear, buzzing, or dizziness. There were no complaint about his nose and throat either. The patient has a habit of cleaning his ear by using cotton buds. The patient routinely swims twice a week.ANAMNESISPast illness history: No similar case history, hypertension, diabetes mellitus, allergy, malignancy, long-term drugs and antibiotic uses (especially ear drops), and hearing aid uses. Family case history: No similar case history, hypertension, diabetes mellitus, and allergy.ANAMNESIS resumePruritus/itchingOtalgiaAural fullnessHearing lossRight earPhysical ExaminationGeneral status : medium, compos mentis, adequately nourishedVital signs:BP 120/75 mmHgHR 78x/mntRR 20 x/mntTemp36.5 CHead-neck : anemic (-), lymph node unpalpableThoraxCor : normalPulmo : normalAbdomen : normalEkstremities : normalPhysical ExaminationENT examinationEARDEXTRASINISTRAAuriculaPain (-)NormalPlannum MastoideumNormalNormalLymphatic GlandNot palpableNot palpableCAEHyperemic (+), edema (-), covered by black debris (wet newspaper app)NormalTympanic MembraneHard to visualizeIntact, cone of light (+)Tympanic membrane (after aural-toilet)Intact, cone of light (+)

Intact, cone of light (+)

ADASHyperemiccanalBlack debrisNo abnormalities foundASTympanic membrane could not be visualised due to black debrisTympanic membrane intact, cone of light (+)After aural toiletADBefore aural toilet

ADClear, Tympanic membrane intact, cone of light (+)Nose and sinusesDekstraSinistraDischargeNoNoConchaHyperemic (-) edema (-)Hyperemic (-) edema (-)Nasal SeptumDeviation (-)Deviation (-)TumorNoneNoneParanasal sinusPain (-)Pain (-)DSNo abnormalities

ENT EXAMINATIONENT EXAMINATIONNASOPHARYNXDEXTRASINISTRAPosterior WallNormalNormalChoanaNormalNormalEustachian tube openingNormalNormalAdenoidNot visibleNot visibleTumor Not visibleNot visibleENT EXAMINATIONOROPHARYNXPalateNormalUvulaNormalPalatine tonsilT1 T1Lingual tonsilNot enlargingPosterior wallHyperemic (-) Granul (-) PND (-)DSNo abnormalities present

ENT EXAMINATIONLARYNGOPHARYNXLARYNXPosterior wallNormalEpiglottisNormalParapharynxNormalArytenoidNormal Plica vovalisNormal Plica vocalis movementNormal TumorNoTracheaNormal DSNo abnormality found

Resume of OTORHINOLARINGOLOGY STATUSEar (AD)Hyperemic (+), and blackish debris like wet newspaper (+) on the right external auditory canal.Ear (AS): n.a.p

Nose : n.a.p Throat : n.a.pDiagnosisOtomycosis, Aural DextraTherapyAural toilet, local debridement with perhidrol drop

Miconazole cream 2% twice a day, external usefor 14 days

educationPROGNOSISPROBLEMMicroscpic examination by using KOH 10% should be done to diagnose otomycosisDISCUSSIONAbout 5-20% of the visits to ENT section are related to otitis externa.Most cases bacteria, and fungi 9 25%Otomycosis mostly happens in tropical and subtropical areas which have high humidity, and can be found more in adults than in children. Prevalence of otomycosis is also found higher in women than in men (Khan et.al., 2013).Some fungi that cause otomikosis are Aspergillus niger, Candida albicans, Actinomyces, Tricophyton, Aspergillus fumigatus, and Candida tropicalis (Khan et.al., 2013). Pontes et.al. research in (2009) showed some fungi causing otomycosis: Candida albicans, Candida parapsilosis, Aspergillus niger, Aspergillus flavus, Candida tropicalis, Trycophyton asahii, Aspergillus umigatus, dan Scedosporium apiospermum.Otomycosis is usually unilateral and characterized by inflammation, pruritus, scaling, and severe discomfort such as pain and suppuration (Khan, 2013). But in Pontes et.al. research (2009), Candida albicans, Candida parapsilosis, and Aspergillus niger could manifested as bilateral infection.

Predisposing factors : bacterial infections, use of hearing aid or a hearing prosthesis, self inflicted trauma (such as scratching of the ears with a cotton bud), swimming in a contaminated pool, broad spectrum antibiotic therapy, steroid or cytostatic medication, neoplasia, and immune disorder. Otomycosis is seen more frequently in patients with immunocompromised compared to immunocompetent persons. The symptom of otomycosis are variable and usually not specified. The most presenting complaints in Khan et.al. research (2013) were otalgia, aural fullness, itching, otorrhea, and hearing loss. After clinical examination, it is possible to confirm diagnosis through direct microscopic examinationConsidering that the inner and middle ears are sterile, the external ear bears a skin commensal microbiota. Before material collection, it is important to clean the external auditory canal with a moist swab. In case there was secretion in the canal, used a sterile swab for the collection and skin scales were collected with the help of a sterile loop.The samples were processed through direct microscopic exam with KOH 10% and culture in agar Sabouraud dextrose eith chloramphenicol 0,05 mg/mL. The cultures were cultivated at 25-370 C with weekly observation during 30 days. Hypha and spores on microscopic examination are typical to fungal infection.The classical appearance of fungi on otoscope is whether grayish white debris resembling wet blotting paper (or wet newspaper), yellowish spores, a whitish furry structure, or blackish spores covering the canals and sometimes the tympanic membrane. A grayish or blackish debris usually refers to Aspergillus infection while whitish is refer to Candida. Treatment options for otomycosis include elimination of predisposing factor, through canal cleansing and antifungal agents. Ear-toilet is the first important step to treat otomycosis. This medication should not reaching the middle ear because it was irritating.On otomycosis therapy, it is important to not giving the homogenized ear drop, because water is a suitable media for fungal growingTopical antifungals are specific (clotrimazole, miconazol, econazole, hystatin, tolnaftate, potassium sorbat) andnon-spesifik (acetic acid, alcohol, boric acid, m-cresyl acetate, and gentian violet).

Alnawaiseh et.al., 2011; Khan et.al., 2013; Satish et.al., 2013Azole group has been shown to be quite effective in treating otomycosis. The efficacy of azoles seems to depend on the duration of treatment.It is reported that 2 weeks of treatment with oxiconazole cured only 27% of patients, 1 week of treatment with clotrimazole cured only 35% of patients whereas 4 weeks of treatment with clotrimazole cured 70%.Clotrimazole is the most widely used topical azole. It is available as powder, lotion, and solution. It is considered free of ototoxic effects. Some studies showed that clotrimazole was one of most effective agents for management of otomycosis, with reported rate of effectiveness that varies from 90 to 100%.

Khan et al., 2013Conclusion A male patient, aged 26 years old, with complaints of itchy and fullness on the right ear was diagnosed otomycosis auris dextra, based on the blackish debris like wet newspaper appearance. Ear-toilet was done and the patient was given miconazole 2% cream to be used twice a day for 2 weeks. We asked the patient not to scratching his ears by anything, keep the ears dry, dont swim until the disease resolves . Patient was also asked to come a week later to evaluate the therapy REFERENcesAlnawaiseh S., Almomani, O., Alassaf S., Elessis A., Shawakfeh, N., Altubeshi, K., Akaileh, R. 2011. Treatment of Otomycoisis: A Comparative Study Using Miconazole Cream with Clotrimazole Otic Drops. J Royal Med Serv 2011:18(3):34-37.Khan, F., Muhammad, R., Khan, M.R., Rehman, F., Iqbal, J., Khan M., Ullah G. 2013. Efficacy of Topical Clotrimazole in Treatment of Otomycosis. J Ayub Med Coll Bbottabad 2013;25(1-2).Pontes, Z.B.V.S., Silva, A.D.F., Lima, E.O., Guerra, M.H., Oliveira N.M.C., Carvalho, M.F.F.P., Guerra, F.S.Q. Otomycosis: A Retrospective Study. Braz J Otorhinolaryngol 2009:75(3):367-70.Satish, H.S., Viswanatha, Manjuladevi. 2013. A Clinical Study of Otomycosis. J Dental Med Sci 2013:5(2):57-62THANK YOUsuggestions pleaseREFERRED PAIN (10 T )

A. CN V: 1. Teeth (caries, eruption) 2. TMJ (arthritis, luxatio) 3. Tick facialisB. CN IX: 4. Tongue (glositis, ulcus) 5. Tonsil (abcess,tonsilitis) 6. Throath (pharyngitis, ulcus) 7. Tuba (infection, Ca )C. CN X: 8. Trachea 9. ThyroidD. Cervical 2-3: 10. TrapeziusTHT UI, 201256