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Otomycosis in Iran: a Review

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Otomycosis in Iran: a Review Mycopathologia DOI 10.1007/s11046-015-9864-7 Otomycosis in Iran: A Review Maral Gharaghani • Zahra Seifi • Ali Zarei Mahmoudabadi Received: 20 November 2014 / Accepted: 16 January 2015 Ó Springer Science+Business Media Dordrecht 2015 Abstract Fungal infection of the external auditory ranged from 5.7 to 81 %, with a mean value of 51.3 %. canal (otitis externa and otomycosis) is a chronic, Our results showed that 78.59 % of otomycosis agents acute, or subacute superficial mycotic infection that were Aspergillus, 16.76 % were Candida species, and rarely involves middle ear. Otomycosis (swimmer’s the rest (4.65 %) were other saprophytic fungi. Among ear) is usually unilateral infection and affects more Iranian patients, incidence of infection was highest in females than males. The infection is usually symp- summer, followed by autumn, winter, and spring. In tomatic and main symptoms are pruritus, otalgia, aural Iran, otomycosis was most prevalent at the age of fullness, hearing impairment, otorrhea, and tinnitus. 20–40 years and the lowest prevalence was associated Fungal species such as yeasts, molds, dermatophytes, with being\10 years old. The sex ratio of otomycosis and Malassezia species are agents for otitis externa. in our study was (M/F) 1:1.53. Among molds, Aspergillus niger was described as the most common agent in the literature. Candida albi- Keywords Otomycosis Á Aspergillus niger Á Yeasts Á cans was more prevalent than other yeast species. Iran Otomycosis has a worldwide distribution, but the prevalence of infection is related to the geographical location, areas with tropical and subtropical climate showing higher prevalence rates. Otomycosis is a Introduction secondary infection and is more prevalent among swimmers. As a result, a higher incidence is reported External ear infections (otitis externa) are one of the in summer season, when more people interested in most common diseases that ear specialists deal with. swimming. Incidence of otomycosis in our review Otitis externa (swimmer’s ear) is a common condi- tion affecting the auricle, auditory canal, eardrum, and middle ear with itches that become painful, M. Gharaghani Á A. Zarei Mahmoudabadi edematous, and red [1]. Swimmer’s ear is prevalent Department of Medical Mycology, School of Medicine, among swimmers due to exposure to water for a long Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran time [2]. The ears are constantly exposed to biotic elements of biosphere and may thus be infected by Z. Seifi Á A. Zarei Mahmoudabadi (&) various microorganisms such as bacteria, viruses, and Health Research Institute, Infectious and Tropical fungi. The cause of otitis externa may be either Diseases Research Centre, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran infection due to microorganisms or non-infectious e-mail: [email protected] (eczema and psoriasis) or both. Otomycosis or fungal 123 Mycopathologia otitis externa is a superficial mycotic infection and the rest infected the left ear [13]. In another sometimes involving middle ear [3], which com- study conducted at southwest Iran, 19.23 % of prises more than 10 % of all otitis externa infections studied patients had bilateral otomycosis [14]. [4]. Bacterial infections of ears are usually acute, Prasad et al. [15] reported that only 5 % of patients whereas fungal infections may be either acute or with otomycosis presented bilateral infection. In subacute and due to inflammation and pruritus [5]. addition, they concluded that the infection in Severe infections are usually due to bacteria and females is more prevalent in the right ear. possibly result in secretion of pus. Although otomy- The most prominent disease symptoms are itch- cosis cannot be taken seriously in most of the cases, ing, inflammation of external ear canal, otalgia, immune compromise resulting from otomycosis is otorrhea, pruritus, feeling of fullness, tinnitus, and life-threatening to the patients. hearing impairment [5, 9, 16]. Fungus balls (densely Otomycosis has the highest incidence in hot and impacted wax comprising fungal mycelia and epi- humid seasons (summer) and the lowest in cold season thelial cells) are produced in the tympanic mem- (winter). Several fungal agents cause otomycosis, brane due to developing diseases [2, 10]. Fungal including yeasts (Candida), molds (Aspergillus and masses can partially block the external canal and Mucor), dermatophytes and Malassezia species [4, 6, lead to hearing loss or even deafness in some 7]. In patients with otomycosis, dermatophytes are the patients [7, 12]. At physical examination using most common causes of tinea capitis and tinea barbae. otoscope, white, gray, black, or creamy (wet news- In rare cases, dematiaceous fungi such as Epicoccum, paper) caseous debris masses can be found in the Exophiala and Nattrassia mangiferae (Pycnidial syn- external auditory meatus (Fig. 1). Fluffy white anamorph: Hendersonula toruloidea) cause otomy- discharges were present when C. albicans and cosis [8–10]. Literature search reveals that not much Aspergillus fumigatus are etiologic agents, whereas work has been done on Iranian patients with otomy- A. niger produces black colonies (pepper-like). cosis. In addition, a true distribution pattern for Otomycosis due to dermatophytes in adults is otomycosis is not available. As a result, in this review, usually associated with tinea barbae, whereas in we collected all available published papers about children, it is associated with tinea capitis [10] otomycosis (epidemiology, diagnosis, treatment, and (Fig. 2). Otomycosis with Malassezia species has in vitro assessment tests) in Iran from different been rarely reported in the literature [17]. international resources (ISI, PubMed, Google Scholar, Scopus, and Google) and local databases (Magiran, ISC, and Journal sites). All data were extracted carefully and analyzed using Microsoft Excel. In addition, distribution maps of otomycosis and some of its etiologic agents were drawn. Clinical Features Otomycosis may occur as an acute, subacute, or chronic noninvasive infection (chronic colonization) with inflammation and exudate. The infection rarely involves tympanic membrane and the middle ear and is unilateral in approximately 90 % of the immunocompetent patients, without any preponder- ance of the right or left side [11]. On the other hand, the infection is occasionally considered bilateral among immunocompromised patients [12]. In an epidemiological study in Kashan, Iran, 25 % of the infection was bilateral, 40.4 % infected the right ear Fig. 1 Otoscopic image of ear canal with otomycosis [18] 123 Mycopathologia showed that all studied cases of otomycosis occurred after treatment with topical ofloxacin antibiotics drops. Several researchers reported that worldwide the prevalence of otomycosis is highest in summer due to dry dusty winds in this season [23, 26, 27]. Etiologic Agents Approximately 61 species of different fungi (molds, yeasts, dermatophyte, and Malassezia) have been identified as the cause of otomycosis [9]. In the literature, several saprophytic fungi and A. niger were described as the most common agents for otomycosis [3]. In addition, A. awamori and A. tubingensis are other black Aspergillus involved in otomycosis [28]. Fig. 2 Otomycosis due to dermatophytes Other agents include A. flavus, A. fumigatus, Scedos- porium apiospermum (sexual state: Petriellidium boy- Risk Factors for Otomycosis dii), Scopulariopsis, Penicillium, Chrysosporium, Rhizopus, Absidia, and Cryptococcus species [7, 10, Otomycosis is a secondary infection due to several 13, 15, 29]. Pigmented fungi, Alternaria, and Clado- predisposing factors such as swimming, warm condi- sporium species were also reported as causative agents. tions, foreign bodies into ear canal, traumatic inocu- Although nearly all of the saprophytic fungi are lation, loss of cerumen, alternation in immunity, presented in the atmosphere as airborne fungi, their working in dry dusty environment, poor hygiene, concentration differs according to location, altitude, using hearing aids, diabetes mellitus, external ear time of day, season, and climatic conditions [30]. In seborrheic dermatitis, genetic factors, history of addition, endogenous organisms such as C. albicans, tympanic membrane perforation, ear surgery, open C. guilliermondii, C. parapsilosis, Malassezia, and mastoid cavity, cleaning external ear canal with Rhodotorula species contributed to the infection in matchsticks, and instilling coconut oil and earwax in some cases [9, 31]. Most researchers from around the the external ear canal [1–3, 5, 15, 19–21]. One of the world showed that A. niger served as the most common most important factors for otomycosis is long-term otomycosis agent [3, 15, 23, 32–35]. On the other hand, exposure to moisture: the prevalence of infection was C. albicans was identified as the first isolated agent in reported to be five times higher in swimmers than in some reports [36]. Moreover, Viswanatha et al. [12] non-swimmers [6]. Zarei Mahmoudabadi et al. [19] reported C. albicans as the commonest agent (52 %) reported the infection with different species of sapro- among immunocompromised patients. phytic fungi such as A. niger, A. flavus, Rhizopus, Dermatophytes rarely cause otomycosis (dermato- Penicillium, and Candida albicans in hearing aid mold phytosis of the external ear); however, some reports wearers. In addition, Sturgulewski et al. [22] reported show that Microsporum canis complex, Trichophyton that hearing aids can act as a potential source of rubrum complex,
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