Incidence of KOH Positive Elements in Chronic Discharging Ear –A Retrospective Study

Abstract

The term chronic suppurative otitis media (CSOM) refers to middle ear infections lasting more than three months that lead to perforated tympanic membrane. Low socioeconomic strata of the society are more likely to have the disease in developing countries. There have been many studies focusing on the bacterial flora of CSOM, but little is known about the mycological aspects, which have become increasingly important over the last few decades. The present study was aimed to speculate the presence of fungal flora responsible for the cases of CSOM among patients who attended the Ear, Nose, and Throat Department of our hospital a tertiary care center. This retrospective study was conducted in a tertiary care centre after taking the approval of the protocol review committee and institutional ethics committee. Total 100 Patients of chronic otitis media were included with no history using ear drops for last one week and using two sterile swab without touching the external auditory canal, discharge was taken from middle ear and placed in sterile container and sent for potassium hydroxide (KOH) mount and observed. The age ranged from 18 months to 87 years and the mean age was 37.27+/- 12.59 years. The study population of male is 42 (41.6%) and female is 59 (58.4%). Distribution of KOH positivity observed for 33 (32.7%) and KOH negative for the study population of 68 (67.3%). When antibacterial treatment does not seem to relieve persistent otorrhea, otologists should suspect mycotic otitis media probable cause.

Introduction

Chronic suppurative otitis media, otherwise known as chronic otitis media, occurs when there is an ongoing infection of the middle ear that does not have an intact tympanic membrane. This disease is characterized by chronic inflammation of the middle ear and mastoid cavity. A perforated tympanic membrane produces chronic or persistent otorrhoea over a period of 2 to 6 weeks [1]. Aside from viruses, bacteria often cause chronic suppurative otitis media in children. It is usually caused by a polymicrobial infection. Staphylococcus aureus (MRSA) is the most common microbe found in this pathology [2]. Pseudomonas aeruginosa, Proteus species, Klebsiella species, Bacteroides species and Fusobacterium spp are others that can cause the disease. Less common are Aspergillus spp and Candida spp seen more in immunocompromised patients.

It has been widely reported that CSOM has a diverse bacterial flora, but very little is known about its mycological aspects. Recent years have seen an increase in the importance of this issue because of the excessive use of antibiotics, corticosteroids, and cytotoxic chemotherapeutics, as well as the growing number of immune deficiency disorders [3]. A fungal superimposed CSOM is suspected when the discharging ear doesn’t respond to antibiotics [4].

There is a lack of information on the exact prevalence of CSOM cases with secondary fungal infections. CSOM can be caused by a wide range of fungi, most of which are saprobes, found in various types of organic materials. Fungi are abundant in soil which contains decaying vegetable matter. Dust particles and water vapour carry fungal spores into the air, which is why infection rates spike during monsoon when relative humidity exceeds 80%. Various fungi which contribute to otomycosis include saprophytic fungi, Aspergillus niger, A.fumigatus, A.flavus, Penicillium, Mucor, Rhizopus [5]. Furthermore, candida species are most commonly found among yeasts. Predisposing factors of otomycosis includes chronic infection of ear, use of oils, ear drops, excessive accumulation of cerumen, steroids, swimming, fungal infection elsewhere in the body like dermatomycosis or vaginitis, immunocompromised state, malnourishment in children and hormonal changes precipitating flaring up of the infection as seen during pregnancy or menstruation [6].

Due to a possible large numbers of immunocompromised patients, opportunistic fungal infections are becoming more prevalent in human medicine. Mycotic otitis media requires early diagnosis and treatment to minimize serious complications such as mastoid abscess, hearing loss, facial nerve paralysis, lateral sinus thrombosis, temporal bone infection, meningitis, and intracranial abscesses [7].

Despite its limitations, KOH mount examination remains a major diagnostic tool in mycology due to its ability to identify fungal infections rapidly and fairly reliably. In addition, it identifies whether a culture positive indicates contamination, colonization, or a true infection. Often, preliminary identification of fungal organisms on KOH mount is the only diagnostic clue when material has not been submitted for culture [8].

Hence the present study was intended to assess the prevalence of fungal elements positivity in ear discharge of the patients with COM and to treat patients with COM.

Methodology

Source of Data

This is a retrospective descriptive study in which patients of either sex in age group 18 months to 87 years with chronic otitis media were included with no history using ear drops for last one week were selected in, two tertiary care hospitals between January 2022- January 2023.

Sample Size

100 patients with chronic otitis media were included with no history using ear drops for last one week was selected retrospectively.

Sampling Procedure

Since the present study was of descriptive design,the results were not subjected for statistical analysis.

Data was analysed with IBM SPSS Version 25 for windows.

Study of design:Retrospective descriptive study.

Study duration:January 2022- January 2023.

Sampling Criteria

Inclusion Criteria

All patients of either sex attending ENT OPD with ear discharge secondary to COM and consenting for the study.

Exclusion Criteria

Patients with history of recent use of ear drops.

All patients with ear discharge which are not related to COM.

Data Collection Method

This retrospective study conducted in the Department of ENT, Bapuji Hospital attached to the JJM Medical College, Davangere after taking the approval of the protocol review committee and institutional ethics committee. A total of 100 patients of chronic otitis media were included with no history using ear drops for last one week was selected. Using two sterile swabs without touching the external auditory canal, ear discharge was taken from middle ear and placed in sterile container and sent for microbiology laboratory for potassium hydroxide (KOH) mount.

All swabs were taken by the same surgeon to maintain uniformity. In the laboratory, the samples were examined microscopically (in 10% KOH preparations smears) for the presence of pus cells, budding yeast cells, fungal hyphae (septate or aseptate) and spores, etc. Collected KOH mount reports and KOH positive reports and treated the patient with antifungal ear drops alone for 3 weeks.

Results

In this study females were found to be affected more than males with CSOM i.e., out of the 100 patients studied, 58.4% were females and 41.6% were males (Fig. 1). The age ranges from minimum 18 months to maximum 87 years and the mean value is 37.27 +/- 12.590 years. Overall prevalence rate KOH positivity was found to be 32.7 (Fig. 2).

Fig. 1.

Distribution of gender

Fig. 2.

Distribution of KOH positivity

Table 1 shows the Distribution of KOH positivity in the study. KOH mount was negative for 68 (67.3%) cases and positive for 33 (32.7%) cases.

Table 1.

Distribution of KOH positivity in the study

KOH reactivity	N	%
Negative	68	67.3
Positive	33	32.7

Discussion

Chronically draining ears in CSOM are frequently accompanied by severe hearing loss and can be challenging to cure. The existence of a fungal aetiology in CSOM was controversial in the past, but it is now recognised as a distinct clinical entity and a growing problem as the incidence of mycotic infections and the diversity of pathogenic fungi have dramatically increased in recent years as a result of the steadily rising number of immunocompromised patients. Middle ear fungal infections are more likely to occur in those who have diabetes, chemotherapy, cancer, steroid use, HIV infection, and chronic antibiotic use (topical or systemic) [9].

There aren’t many studies on the causation of CSOM by fungi. Present studies shows that a thorough search for fungi is desirable in all cases of CSOM as the rate of fungal presence among patients not respond to antibiotic therapy is very high. The second and third decades of life had the highest incidence of fungal CSOM (32.7%), and this finding was consistent with similar researches done. Young individuals may have a higher frequency because they are exposed to fungus spores more frequently than older people, who are not [10].

In addition geography and season also have an impact on where fungi are found. The rainy season is when fungal infections are most prevalent. This could be related to the hot and humid temperature, which encourages the growth of fungi. Several publications have previously noted the prevalence of ear fungus infections during damp and humid conditions [11]. The increased amount of suspended dust particles in the air is one of the significant environmental elements that may be to blame for the high frequency of fungal infections in this area.

In all CSOM scenarios, we suggest, a focused search for fungi is desirable. The formation of fungal flora may result from the long-term suppression of bacterial flora by topical antibiotics or antibiotic-steroid ear drops [12]. Due to this, fungal superinfection is presumably more common, and even less virulent fungi become more opportunistic [13]. In patients with persistent otorrhea and patients who did not respond to the antimicrobial treatment, otolaryngologists should raise the option of mycotic otitis media. Microbiological findings should prompt a quick diagnosis. This not only will increase the proper diagnosis of fungal CSOM but will also prevent the emergence of drug resistance to an extent.

Conclusion

Suspicion of mycotic otitis media should be raised if the persistent ear discharge is unresponsive to antibiotic treatment. It is quick and simple to identify fungi by evaluating KOH mounts. Further research into the various fungi that causes mycotic otitis media needs to be done to help with the proper prescription of antifungals in such cases.

Authors’ Contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr. Santosh U.P, Dr. H. jemimaparveen, Dr. Arfan Nasser, Dr. Sri Vaibhava V, Dr. Ashwini Kuruwatti. The first draft of the manuscript was written by Dr. H. Jemimaparveen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The authors have no relevant financial or non financial interest to disclose.

Data Availability

The data used in this study was not used/published in any other publications.

Code Availability

The data was compiled and analyzed using IBM SPSS STATISTICS version 22.

Declarations

Conflict of Interest

The Authors declare that there is no conflict of interest.

Ethics Approval

The study was done after approval of the Institutional Ethics committee from JJM Medical College, Davangere, Karnataka, India in accordance with ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to Participate

Written informed consent was taken from all the patient.

Consent for Publication

All authors have reviewed the manuscript and approved the version to be published.