Abstract
Otomycosis is a commonly encountered otological disorder in otorhinolaryngology practice. It has several predisposing factors such as habitual use of cotton buds, water in the ear, hot humid atmospheric condition or high temperature. Diagnosis of otomycosis frequently relies on the patient’s history, otoscopic examination and ascertained clinical features and therefore posing diagnostic and therapeutic challenges. Data on otomycosis in Tanzania are scarce. A hospital based descriptive cross-sectional study was conducted at a private hospital from January to June 2022 in Dar es Salaam, Tanzania. All the clinically diagnosed cases were enrolled in the study with typical symptoms and characteristic fungal debris in the external auditory canal. Data was collected using semi-structured questionnaires and analyzed using Statistical Package for Social Sciences version 23. A total of 250 patients were recruited in this study. Majority were females, 153(81.2%) while males were 97(38.8%). Otomycosis was found to be predominantly unilateral in 203 (81.2%) patients. The commonest presenting complaint was ear itching (94.0%) followed by earache (78.6%), hearing loss (75.6%), ear fullness (74.4%), ear discharge (61.2%) and ringing sensation (14.0%). Based on the type of fungal debris on Otoendoscopy, whitish debris was more predominant in 191 (76.4%) patients followed by yellowish debris, 37 (14.8%), blackish debris, 15 (6.0%) and mixed (whitish-black) debris in 7 (2.8%) patients. The commonest risk factor was earbud use (40.8%) and the least one was comorbid conditions (4.4%). Females were more affected by otomycosis. The commonest otological complaint was ear itching while the least one was ringing sensation. Unilateral presentation of otomycosis predominated and the left ear was more affected. The commonest type of fungal debris was whitish debris and the least one was the mixed type (whitish-black). The commonest risk factor for otomycosis was earbud use and the least was comorbid conditions.
Keywords: Otomycosis, Otological complaints, Clinical profile, Fungal infection
Introduction
Otomycosis also known fungal infection of the ear is one of the commonest diseases among patients visiting otorhinolaryngologists for consultations during routine clinical practice [1–3]. It is a superficial mycotic infection of the external auditory canal and with infrequent complications involving the middle ear [4, 5]. The disease is often secondary to prolonged treatment with topical antibiotics or steroid ear drops though there are other predisposing factors such as diabetes mellitus, immunocompromised state due to HIV/AIDS, trauma to the external auditory canal or instrumentation of the ear, exposure to hot humid atmospheres, and close contact with water [3, 6].
Otomycosis has remained to be a challenge for both patients and otolaryngologists as it frequently requires long -term treatment and follow up. On the other hand, the recurrence rates remains high despite thorough treatment and follow up [4]. It is a global disease and more common in tropical and subtropical zones [4, 7, 8].
Regarding the aetiology of otomycosis, Aspergillus species are the most commonly identified organisms compared with Candida species. Globally, Aspergillus niger and Candida albicans are the most commonly implicated aetiological agents for otomycosis in Africa [3].
The clinical profile of otomycosis has been invariably reported in different parts of the world. A study that was done in Nepal found female predominance (64.9%) and the commonest presenting complaint was ear itching (77.9%) and the least one was hearing loss (31.2%). Pertaining the type of fungal debris, the predominant debris was blackish debris (49.4%) followed by whitish debris (35.1%) and yellowish debris (15.6%) [5].
A study done in India to characterize otomycosis found the commonest isolate to be Candida tropicalis (34%) [1] whereas three studies in the same country found Aspergillus species (34%,77% and 60.19%) as the commonest isolates respectively [7, 9, 10].
Data on the etiological profile, clinical features and risk factors for otomycosis in Tanzania remains scarce despite the remarkable number of patients with such disease attending regular otorhinolaryngology outpatient clinics. This study aimed to address such gap.
Methods
Study Design, Area and Duration
It was a hospital based descriptive cross-sectional study that was conducted in outpatient clinic in the department of otorhinolaryngology at Ekenywa specialised hospital, which is a private health facility in Dar es Salaam, Tanzania. Data was collected from January to June 2022.
Sampling Technique
Convenience sampling technique was utilized to recruit the study participants.
Inclusion Criteria
All patients diagnosed clinically to have otomycosis and with typical symptoms and characteristic fungal debris in the external auditory canal were enrolled.
Exclusion Criteria
Patients with otomycosis but did not consent to participate.
Data Collection Tools
Semi-structured questionnaires adopted from previously published studies [1, 2, 4, 5, 11–14] and thereafter modified to suit the objectives of this study were utilized to collect data. Socio-demographic characteristics, presenting complaints, lateralization, type of fugal debris and predisposing factors were recorded in semi-structured questionnaires. No samples were collected for testing but rather characteristic features of the debris were documented after Otoendoscopy.
Data Processing and Analysis
The collected data were cleaned and analyzed using Statistical Package for Social Sciences version 23 software package. Descriptive statistics were performed to present frequency distribution for age and sex of patients, aetiological and clinical profile and also risk factors for otomycosis.
Ethical Approval and Consent to Participate
Ethical Approval
to conduct the study was sought from the Ekenywa Specialized Hospital Research Ethics Committee. Individual informed consent both verbal and written was obtained from the study participants after they have been fully informed about the set goals for the study. For those under 18 years had their consent being obtained from their parents/guardians. No names of the study participants were recorded but rather coding was done using numbers on the questionnaires to maintain anonymity.
Results
Age and Sex Distribution of Patients with Otomycosis
A total of 250 patients were recruited where majority were females, 153(61.2%) and males were 97 (38.8%). Majority of the females were aged 21–25 years, 76(49.7%) while most males were aged < 5 years, 43(44.3%). (Table 1)
Table 1.
Distribution of patients with otomycosis according to age and sex
| Sex | Age groups (years) (%) |
Total (%) | ||||||
|---|---|---|---|---|---|---|---|---|
| < 5(%) | 6–10 (%) | 11–15 (%) | 16–20 (%) | 21–25 (%) | 26–30(%) | 31+ | ||
| Male | 43 (44.3) | 7 (7.2) | 21 (21.6) | 6 (6.2) | 4 (4.1) | 7(7.2) | 9(9.4) | 97(38.8) |
| Female | 15 (9.8) | 10 (6.5) | 8(5.2) | 20 (13.1) | 76 (49.7) | 13(8.5) | 11(7.2) | 153(61.2) |
| Total | 58 (23.2) | 17(6.8) | 29 (11.6) | 26 (10.4) | 80 (32.0) | 20(8.0) | 20(8.0) | 250 (100) |
Lateralization of Otomycosis
Unilateral presentation of otomycosis predominated, 203(81.2%) while bilaterality of the disease was found in 47(18.8%) patients. Of the patients with unilateral otomycosis, the left ear was affected in 173(85.2%) patients while the right ear was affected in 30(14.8%) patients. (Table 2)
Table 2.
Lateralization of otomycosis
| Lateralization | Frequency, n(%) |
|---|---|
| Unilateral | 203 (81.2) |
| Bilateral | 47 (18.8) |
| Total | 250 (100) |
Distribution of the Otological Complaints of Patients with Otomycosis
In this study, the commonest presenting complaint was ear itching (94.0%) followed by earache (78.6%), hearing loss (75.6%), ear fullness (74.4%), ear discharge (61.2%) and ringing sensation (14.0%). (Table 3)
Table 3.
Distribution of the otological complaints of patients with otomycosis (n = 250)
| Otological complaint | Frequency, n(%) |
|---|---|
| Ear itching | 235 (94.0) |
| Earache | 198 (78.6) |
| Ear fullness | 186 (74.4) |
| Ear discharge | 153 (61.2) |
| Hearing loss | 189 (75.6) |
| Ringing sensation | 35 (14.0) |
Type of Fungal Debris among Patients with Otomycosis
Based on the type of fungal debris on Otoendoscopy, whitish debris was the predominant pattern in 191 (76.4%) patients followed by yellowish debris, 37 (14.8%); blackish debris, 15 (6.0%) and mixed (whitish-black) debris in 7 (2.8%) patients. (Table 4)
Table 4.
Distribution of fungal debris among patients with otomycosis
| Type of fungal debris | Frequency, n(%) |
|---|---|
| Whitish (Candida species) | 191 (76.4) |
| Blackish (Aspergilus niger) | 15 (6.0) |
| Yellowish (Aspergillus flavus) | 37 (14.8) |
| Mixed (Whitish-black) | 7 (2.8) |
| Total | 250 (100 |
Predisposing Factors for Otomycosis
The commonest predisposing factor for otomycosis was earbud use (40.8%) followed by ear drops usage (18.8%) and water entry in the ear (14.0%). The least predisposing factor was comorbid conditions (4.4%) and these were namely diabetes mellitus and immunocompromised state due to HIV/AIDS. (Table 5)
Table 5.
Predisposing factors for otomycosis (n = 250)
| Predisposing factors | Frequency, n(%) |
|---|---|
| Earbud use | 102 (40.8) |
| Water entry in the ear | 35 (14.0) |
| Oil in the ear | 13 (5.2) |
| Ear drops usage | 47 (18.8) |
| Comorbid conditions e.g. Diabetes mellitus, immunocompromised state | 11 (4.4) |
Discussion
Being a superficial mycotic infection of the external auditory canal, otomycosis is a common otorhinolaryngological disease that is encountered in routine clinical practice. This study aimed to describe the aetiological profile, clinical features and risk factors for otomycosis at a private health facility in Dar es Salaam, Tanzania.
Regarding gender distribution of otomycosis, this study has found females (61.2%) to be more affected than males (38.8%). This observation appear to be consistent to what has been found in Nepal and India respectively where female predominance has been similarly reported [5, 9] but in disagreement to other studies done in India where male predominance has been reported [1, 2, 4]. Female predominance in the studies from Nepal and India may be due to study population in both studies being predominantly females.
Pertaining lateralization of the disease in this study, otomycosis was found to be predominantly unilateral in 81.2% of patients. This finding appears to be in line to what has been found in India where the disease was unilateral in 92% of patients and in Egypt where it was found to be unilateral in 97% of patients [1, 4]. Another study from Nigeria found otomycosis to be unilateral in 68.7% of patients [15]. In this study among patients with unilateral otomycosis, the left ear was affected in 85.2% of the patients while the right ear was affected in 14.8% of the recruited patients. Same findings can be observed in the study that was done in India where the left ear was predominantly affected by otomycosis in 64.07% of the patients while the right ear was affected in 32.03% of the patients [10].
Regarding the symptomatology of otomycosis, the commonest presenting complaint was ear itching (94.0%) followed by earache (78.6%), hearing loss (75.6%), ear fullness (74.4%), ear discharge (61.2%) and ringing sensation (14.0%). These findings appears to correlate to those from a study done in Nepal where ear itching was present in 77.9% of the cases followed by earache (72.7%), aural fullness in (29.0%), ear discharge (46.8%) and hearing loss (31.2%) [5]. Findings different from those depicted in this study were also found in the study from Nigeria where pruritus, earache and hearing loss were the commonest complaints among patients with otomycosis and these were followed by tinnitus, aural fullness and discharge [15]. Dissimilar findings can be depicted in the study done in Pakistan where the most common presenting symptom was hearing loss (77.7%) followed by pruritus (68.8%) and otalgia (40%) [16].
Based on the type of fungal debris on Otoendoscopy in this study, whitish debris was the predominant pattern, (76.4%) followed by yellowish debris, (14.8%), blackish debris, (6.0%) and mixed (whitish-black) debris in 2.8% of patients. Such findings appear to be in line to what has been found in India where the most common otoscopic finding was white creamy debris in 30.3% of the patients and this was followed by greyish white debris (25.7%), black headed filamentous growth (22.4%), yellowish mass (14.5%) and dark brown mass (7.2%) [17]. A study from Nepal found similar findings where blackish debris was the commonest pattern in 49.4% of patients followed by whitish debris (35.1%) and yellowish debris (15.6%) [5]. These findings were contrary to those from India where the commonest isolate was Aspergillus niger followed by Aspergillus flavus, Candida albicans, Aspergillus terreus, and Aspergillus fumigatus [18]. Similar discrepancy can be observed in the study done in Tehran where Aspergillus niger (37.59%) was the commonest etiologic agent and Candida glabrata (18.8%) was the predominantly isolated. Mixed fungal infection accounts for 13.67% of cases. The majority of mixed cases were due to Aspergillus niger and Candida glabrata (5.98%) followed by Aspergillus niger and Aspergillus flavus (3.4%) [19]. A study from India also had different findings where Aspergilli were the most common isolates (80%) followed by Penicillium (8%), Candida albicans (4%), Rhizopus (1%), and Chrysosporium (1%). Among aspergilli, A. niger complex (38%) was the most common followed by A. fumigatus complex (27%) and A. flavus complex (15%) [11]. Observed differences may be attributed by the employed methodology where this study established the type of debris based on observation only whereas the mentioned studies with no resemblance yielded results based on microbiological analysis of the type of debris.
When the predisposing factors for otomycosis are to be considered, this study has found the commonest risk factor to be earbud use (40.8%) followed by ear drops usage (18.8%) and water in the ear (14.0%). The least predisposing factor was comorbid conditions (4.4%) and these were namely diabetes mellitus and immunocompromised state due to HIV/AIDS. Resemblance of the findings can be observed in the study done in India where the commonest predisposing factor was earbud usage (26.21%) followed by water in the ear (23.30%), oil in the ear (16.50%), ear drops (13.59%) and none predisposing factor for otomycosis was reported by 2.91% of the patients [10]. Different findings can be observed in the study done in India where instillation of coconut oil (42%), use of topical antibiotic eardrops (20%), and compulsive cleaning of external ear with hard objects (32%) appeared to be the main predisposing factors in otomycosis [11]. A study done in the same country, India found the commonest predisposing factor for otomycosis to be use of antibiotics/antibiotics + steroids ears drops or oils (60%) followed by trauma to the external auditory canal (48%), systemic disease (30%), chronic suppurative otitis media (23%) and swimming (8%) [7].
Pertaining the treatment provided to patients with otomycosis, ototopical (candibiotic ear drops) and systemic (griseofulvin and terbinafine) antifungal drugs were provided to patients after thorough aural toilet was done.
The limitation of the study is the fact that the results emanate from a single health facility and therefore the results cannot be generalized countrywide.
Conclusion
Females were more affected by otomycosis in this study. The commonest otological complaint was ear itching while the least one was ringing sensation. Unilateral presentation of otomycosis predominated and the left ear was the commonly affected ear. Regarding the type of fungal debris by Otoendoscopy, the commonest type was whitish debris and the least one was the mixed type (whitish-black). The commonest risk factor for otomycosis was earbud use and the least predisposing factor was comorbid conditions (diabetes mellitus and HIV/AIDS).
Author Contributions
The sole author contributed to conception, design of the work, data acquisition, analysis, drafting the manuscript. The author also approved the version to be published and agreed to be accountable for all aspects of the work.
Funding
No funding source to be declared.
Data Availability
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
Declarations
Compliance with Ethical Standards
Individual informed consent both verbal and written was obtained from the study participants after they have been fully informed about the set goals for the study. For those under 18 years had their consent being obtained from their parents/guardians. Ethical approval to conduct the study was sought from the Ekenywa Specialized Hospital Research Ethics Committee. The research adhered to the Declaration of Helsinki since it involved human participants.
Consent for Publication
Not applicable.
Competing Interests
The author declare to have no competing interests.
Footnotes
Publisher’s Note
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Associated Data
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Data Availability Statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.