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Treatment of Otomycosis Due to Aspergillus Niger with Tolnaftate Pierre J

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Treatment of Otomycosis Due to Aspergillus Niger with Tolnaftate Pierre J TREATMENT OF OTOMYCOSIS DUE TO ASPERGILLUS NIGER WITH TOLNAFTATE PIERRE J. DAMATO M.D. (MALTA). F.R.C.S. (E:.!G.). D.L.O. (L0ND.) Senior Surgeon, E.N. T. Dept. St. Luke's Hospital Lecturer in Otorhinolaryngology, Royal University of Malta Otomycosis, chronic or recurrent in The development of fungal external nature, has been observed most frequently otitis (Gavin, Hildrick, Smith and Sokra­ in tropical or subtropical countries (Sen­ ny) is associated with local itching which turia 1957), but it would seem that its inci­ coincides with the proliferation of the or­ dence is increasing (Scott Brown); this, ganism in the external auditory canal and perhaps, also as a result of widespread use is followed by the progression of the con­ of topical antibiotic preparations, in the dition to produce varying degrees of pain treatment of otitis externa. The fungi and a clinical picture of mild to severe most frequently found in otomycosis are local inflammation associated with ~ se­ Aspergillus niger and Candida albicans; rous discharge. Untreated advanced le­ fungi thrive in moist conditions and in the sions are sometimes accompanied by the presence of epithelial debris. overgrowth of the fungi which give the A large majority of fungal infections appearance of a cotton-like mass of mate­ arose during the topical use of broad spec­ rial, similar to damp or macerated blotting trum antibiotics, the probability of fungal paper, lodged in the external auditory implication in an infection appearing to canal. Smyth (1961) claimed that Asper­ be proportional to the duration of the anti­ gillus niger infections appear to be regu­ biotic treatment (Smyth). larly accompanied by pain and are difficult The exudate occuring in bacterial ear to eradicate completely. infections seems likely to provide a degree Patients complain of itching and ful­ of humidity favourable to fungal prolIfera­ ness in the ear (Senturia 1957) and slight tion and it is clear that bacteria and fungi difficulty in hearing. In more severe cases can coeixst in the same clinical condition. the patient complains of intense pain in Antibiotic therapy then might suppress the ear when chewing, and of deafness the bacteria primarily responsible, leaving and tinnitus. In Aspergillus niger infec­ the fungi free to grow. It is suggested that tions the skin of the osseous meatus and the normal secretion of the meatus may tympanic membrane is covered with a have an inhibiting effect on fungal proli­ velvety grey, blotting paper like mem­ feration. Senturia (1957) quotes several brane, marked with black spots and giving authorities who state that most of the the appearance of having been sprinkled saturated and unsaturated fatty acids have with fine coal dust. The membrane which some inhibitory effect on the majority of may be washed out of the ear canal has fungi. a whitish or dirty grey colour. After the Aspergillus niger is perhaps (M. P. removal of such membranes the skin of English) the most common cause of oto­ the osseous canal and the tympanic mem­ mycosis of the intact ear. Fungi are wide­ brane appears very red and swollen and spread outside the human body, being in part devoid of its epidermal layer. primarily saprophytic and of world wide From the diagnostic point of view distribution. They occur in the soil and on (Gregson and La Touche 1961) there are all sorts of decaying vegetable matter, and three features which should arouse the in the air of residential districts. It is suspicion of mycotic infection: therefore not difficult to think of possible l. Relapse after, or resistance to, sources of aural infection. standard treatment. 67 2. The symptom of irritation. this is the first record of its use in otomy­ 3. A history of local antibiotic the­ cosis. rapy. The diagnosis of otomycosis was made clinically but confirmation of infec­ Treatment tion by Aspergillus niger, was obtained by mycological studies in ten cases. Of The first rule in the case of fungus the thirty cases, two affected post ope­ infection of the ear canal is to remove rative mastoid cavities and in six cases, thoroughly all the accumulated debris in a central perforation was present. the ear canal or post operative mastoid No pain or other symptoms were cavity. This is accomplished by the remo­ complained of, when Tinaderm was used, val of the larger central masses with a except in the case of the two mastoid dull curette. In very sensitive patients the cavities and when a central perforation ear canal or mastoid cavity is syringed was present. In these cases the patient with sterile water at body temperature complained of slight stinging. and the debris removed. Debris was removed by a dull curette If the treatment is limited to simple and in nervous patients by syringing with cleansing and to the removal of detritus sterile water at body temperature. The from the canal without the use of fungi­ meatus was then mopped dry, with cotton cides and where necessary bactericides, wool tipped probes and then filled with the canal or cavity may be completely Tinaderm Solution. The external auditory refilled with the same sort of debris within canal or cavity was then packed slightly a few days. with ! inch selve edged ribbon gauze. Several prep!lrations are used in the The patient was instructed to keep the treatment of otomycosis because of their gauze moist by instilling on it, six drops fungicidal action. three times daily for three days. At the The ear canal may be wiped with a end of this period, the ribbon gauze was solution of 2% thymol in 70% alcohol. removed and the drops instilled directly This may cause exfoliation or maceration into the meatus, six drops three times daily of the skin, otorrhea occurs and treatment for a further period of three days. The has to be discontinued. Full strength meta­ patient continued with the drops, six drops cresyl acetate may be used, but the pa~ient twice daily, for another six days. may be hypersensitive to this drug. 2% The itching and irritation in the ear gentian violet in 70% alcohol is also used, disappeared within the first 48 hours of but there is the objection to the use of the commencement of treatment. All dyes in and around the ear. 2% salicylic thirty cases cleared up with this treat­ acid in absolute alcohol is also effective ment, and when seen after a month no but in several cases it causes severe pain recurrence was found in any. and irritation of the skin of the meatus. In 1960, Japanese investigators syn­ The most widely used preparation is Nys­ thetised a new group of antifungal agents tatin, which is employed as a powder or with local action. These substances were as a cream. This is fungistatic and not designated generically as Naphthiomates. fungicidal (M. P. English), and deteriorates "Tinaderm", Tolnaftate 1% solution in in warm moist conditions. Some patients Polyethylene Glycol 400 is one of these develop furunculosis while under treat­ substances. Chemically it is 0-2 Naphtyl ment with this preparation (La Touche and m N-Dimethyl-Thiocarbanilate. Gregson 1961). In vitro studies of antibacterial and Thirty patients suffering from Otomy­ antifungal activities, show Tinaderm to be cosis due to Aspergillus niger were treated a potent antifungal agent, against, among with Tinaderm, with '{ery good results. other fungi, Aspergillus niger. It is entirely Tinaderm is in extensive use for the treat­ inert against gram-positive and gram­ meant of fungal skin infections in other negative bacteria. Tinaderm is apparently parts of the body, but as far as is known of no value in the treatment of cutaneous 68 lesions due to Candida albicans. Tinaderm Corporation, U.S.A., for their generous was found to be ineffective by systemic supply of the necessary samples for this administration. It has no local or systemic work. side effects. Tolnaftates are soluble in or­ ganic solvents but are virtually insoluble References in water. These preparations are odour­ It less, colourless and greaseless. also does SCOTT BROWN, Diseases of ENT. not stain or discolour the skin, haIr or GAV1N, HILDRICK, SMITH and SORKANY, Fungus d s- clothing. The toxicity to man on topical eases and their treatment. application or on oral administration is SENTURIA (1957), Dise'l.~es of the external ear. virtually negligible. There is no primary Publication by Schering Corporation U.S.A. irritation or acquired contact sensitivity. ROBINSON, H. M. and RASKI:<f, J. (1964) J. Invest. It can be used with impunity on severely Derm. 42, 185. irritated skin. All patch tests for sensitivity MARY P. E:<fGLISH, J. Laryng. 77, 422. have been negative. GREGSON, 4.E. and LA TOUCHE, C.J. (1q6J) J. Several preparations used in the treat­ Laryng. 75, 167· SMYTH, C.D. (1961) T- Laryng., 75, 70 3. ment of fungus skin infection act by virtue Vlu" DE ERvE (1964) J. of the South Carolina Med. of the keratolytic effect produced by them. Ass., Nov. 1964- Tinaderm has proved itself to be an ex­ KAP1NSKY, KAPLAN Pt al. Paper read before the cellent fungicide acting as a chemical and Dermatology Association of Argent:na Oct. 1962. not by peeling or exfoliation. V1GLIOG1A, LINARES, GAROFOLI, Local actiou of Luedemann has tried to demonstrate Tolnaftate :n the Treatment of Dermatomycosis, Schering Publications. the antifungal activity of Tolnaftate. He EL HEF:<fAWI and RACHEED, Clinical and comparative found that the drug distorted the hyphae evaluation of Tolll'l.ftate as an Antifungal agent and stunted the mycelial growth of ger­ in tIle U.A.R., Scbering Publ:cations. minating spores of susceptible fungi. LUEDEMANN, Schering Corporation Division of B'o­ My thanks are due to Dr.
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