Journal Reading: Effectiveness of Oral Itraconazole in The Management of Otomycosis With Tympanic Membrane Perforation

Journal Reading
Effectiveness of Oral Itraconazole in The Management of

Otomycosis With Tympanic Membrane Perforation
Rizki Fauzia
30101507547
Advisor :
dr. Afif Zjauhari, Sp. THT-KL
KEPANITERAAN KLINIK ILMU THT-KL
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG SEMARANG
Journal Identity
Journal Identity
Publisher
Researcher
Single health centre

ABSTRACT ABSTR
Prospective design
• Otomycosis can be a difficult problem - 34 Otomycosis with Perforated TM
to treat in a patient who already has a - Oral itraconazole + Ofloxacin ear drop
TM perforation - Therapy effect & side effect after 1,3 &
• Oral Itraconazole effective? 6 week
Backgrounds Methods
12
Result
34
Conclussions
- 25 patients fully cured in 1 weeks

Oral itraconazole therapy is
- 6 patients were cured in 2 weeks
- 3 patients were cured in 3-4 weeks an effective treatment for
otomycosis with tympanic
no side effect after 6 weeks membrane perforation
BACKGROUNDS
BACKGROUNDS
• Otomycosis Prevalence ↑
• Immunocompromised patien  refractory otomycosis
Many cases of chronic otitis media with a tympanic membrane

perforation have associated otomycosis due to the constant moisture
in the ear canal.
Topical treatment
Antifungal ear drops Cream coated ear wick
intense pain and changed every few days till complete cure
severe burning sensation
discomfort of a blocked ear till the
treatment is over and also has to visit the
ENT clinic multiple times
BACKGROUNDS
Topical treatment
Antifungal ear drops Cream coated ear wick
intense pain and changed every few days till complete cure
severe burning sensation
discomfort of a blocked ear till the
treatment is over and also has to visit the
ENT clinic multiple times
METHODS
METHODS
• Prospective study design

• November 2014 – November 2016
• Single Medical Centre (Malabar, Kerala –
India)
METHODS
Inclusion criteria :
• Otomycosis + Perforated TM
Diagnosed clinically by the presence of fungal hyphae
in the ear canal by examining under the microscope. An
ear swab was obtained and the same sample sent for
fungal culture to confirm the diagnosis and to identify the
organism.
METHODS
Exclusion criteria :
• Chronic liver disease
• Renal diseases
• allergy to Itraconazole
• having squamous type of chronic otitis media
METHODS
Inclusion & Exclusion criteria
Assessed for : Blood test :

• Symtom • Blood sugar
• Duration • Liver function
• Recurrence
• Otoscopic finding
Remove the fungal debris

by Microscopic suctioning
Cont……
Itraconazole tab 100mg 2x1 (7 days)
+
Ofloxacin ear drop 3x1 gtt 2 (7 days)
1 Week
Observed
Side effect of itraconazole Effect of therapy
3 Week
Feature of fungal
Infection
Follow up
6 Week
Follow up
RESULTS
RESULTS
Total 37 Patients  34 Patient

3 patient lost of follow up
Male to female ratio was 1.13:1

with 18 males against 16 females
RESULTS
Before Oral itraconazole treatments :

The prominent symptoms :
• Earache,
• Otorrhea,
• Ear blockage
• Pruritus.
Nine of patients with diabetes mellitus 

already on medication
RESULTS
Before Oral itraconazole treatments :

Otoscopy examination :
Fungal debris with hyphae in varying degrees :
• From little in the floor of the canal to completely
filling the canal
MT Perforation :
• 16 patients large central perforation.
• 14 patients moderate central perforation
• 4 patients had small central perforation.
Culture result :
• Aspergillus species (A.niger and A.fumigatus)
• Candida species.
RESULTS
After 1 week treatments :

• Almost all patients had good relief of the symptoms
• Fungal material was completely

absent in 25 patients (74%),
• 9 patients repeat suctioning and
continuation of Itraconazole
therapy was done for one more Fungal material
otoscopic examination
week.
• At the end of 2nd week, 31 patients
(91%) completely free of symptoms
and cure done.
RESULTS
• The three patients who did not respond to

the treatment had uncontrolled diabetes 
further treatment with Itraconazole.
• 1 patient had a cure after three weeks of
treatment
• 2 patient had a cure after four weeks of
• All other patients were followed up after 6
treatment
weeks with no recurrence of otomycosis.
• No side effects were reported from

Itraconazole by any of these patients.
DISCUSSION
DISCUSSIONS
Otomycosis
●
Acute or chronic superficial fungal infection of the external ear canal.
●
± 7-15% of the total cases of otitis externa are due to otomycosis
Characterisedby :
●
inflammation
●
Pruritis
●
scaling
●
severe discomfort in the ear.
DISCUSSIONS
More prevalent in :
• Warm and humid climate
• 2nd - 3rd decades of life
• poor hygiene
Pedisposing Factor :
• frequent swimming with poor hygiene
• eczema
• excessive use of cotton tips
• narrow ear canal
• allergy
• chronic drainage
• irradiation
• obstructing ear wax
• radical cavity after mastoidectomy
• use of earplugs
• secondary to prolonged use of topical antibacterial treatment.
DISCUSSIONS
Otomycosis
• More virulent in the diabetic and
immunocompromised patients.
• May involve the middle ear in case of tympanic
membrane perforation and may also involve
the auricle in some cases.
DISCUSSIONS
Etiology
Kurnatowski and Filipiak
studied 249 patients with external otitis and found that
• mixed bacterial and fungal (15%)
• caused by fungus alone (13%)
Ashish kumar., et. al.

• Aspergillus niger (52.43%)
• Aspergillus fumigatus (34.14%)
• Candida albicans (11%)
DISCUSSIONS
Treatment Topical antifungal ear drops
Antifungal
ointments
Ear wicks for packing

the canal
Oral antifungal drugs
DISCUSSIONS
The problems of having a tympanic membrane perforation

with otomycosis, include the severe stinging pain and
ototoxicity of the topical antifungal drops, which directly
reach the middle ear through the perforation.
So the alternative in such case is to apply medicated antifungal

cream to completely fill the ear canal or use a medicated ear
wick.
Patient has a discomfort of having a blocked
ear for many days and also the need for
revisits to get it removed and reapplied.
DISCUSSIONS
A good option  oral antifungal drugs, which gives a good cure.

Itraconazole is an antifungal drug with a broad spectrum of
activity than Fluconazole and is effective specifically Aspergillus
and Candida.
In this study, given Itraconazole and antibiotic ear drops for the
middle ear bacterial infection after thorough microscopic suction.
it was found that majority of the patients responded to the

treatment in the first week and most of the patients were fully
cured by the end of the second week.
Cases complicated by diabetes had to undergo a prolonged

treatment for three or four weeks
Itraconazole was found to be very effective and safe, with no

patients complaining of any major side effects after 6 week.
DISCUSSIONS
Study Limitation
The main limitation of this study is that the number of patients is
comparatively less than that required for an effective
epidemiological study and there is no comparison with other
methods of treatment.
CONCLUSSIONS
CONCLUSSIONS
• Several treatment options are available for

otomycosis, some of them have limitations
when it comes to a case of otomycosis with
tympanic membrane perforation.
• This study concludes that two weeks therapy
with oral Itraconazole has been found to be
very effective option in the management of
otomycosis, in the presence of a tympanic
membrane perforation.
• It can also be tried in refractory/ recurrent
cases of otomycosis with no perforation of
tympanic membrane.
THANK YOU

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Journal Reading

Effectiveness of Oral Itraconazole in The Management of

Single health centre

- 25 patients fully cured in 1 weeks

Many cases of chronic otitis media with a tympanic membrane

Antifungal ear drops Cream coated ear wick

Antifungal ear drops Cream coated ear wick

• Prospective study design

Inclusion & Exclusion criteria

Assessed for : Blood test :

Remove the fungal debris

Side effect of itraconazole Effect of therapy

Total 37 Patients  34 Patient

Male to female ratio was 1.13:1

Before Oral itraconazole treatments :

Nine of patients with diabetes mellitus 

Before Oral itraconazole treatments :

After 1 week treatments :

• Fungal material was completely

• The three patients who did not respond to

• No side effects were reported from

Ashish kumar., et. al.

Treatment Topical antifungal ear drops

Ear wicks for packing

The problems of having a tympanic membrane perforation

So the alternative in such case is to apply medicated antifungal

A good option  oral antifungal drugs, which gives a good cure.

it was found that majority of the patients responded to the

Cases complicated by diabetes had to undergo a prolonged

Itraconazole was found to be very effective and safe, with no

• Several treatment options are available for

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