DOI: 10.7860/JCDR/2017/25865.

10068
Original Article

Otomycosis in a Rural Community

Microbiology Section
Attending a Tertiary Care Hospital:
Assessment of Risk Factors
and Identification of Fungal and
Bacterial Agents

Priti Agarwal1, Leimapokpam Sumitra Devi2

ABSTRACT complaints and clinical findings of clinically diagnosed patients

Introduction: Otomycosis is one of the frequently encountered were evaluated and analyzed. Samples were collected,
fungal infections of external auditory canal, commonly seen transported and evaluated by both direct examination and culture
in tropical and subtropical regions of the world. Various host method for bacteriological and mycological examination.
(local, systemic) and environmental factors can predispose a Results: Male to female ratio in study participants was 1.3:1.
person to otomycosis. Although clinical presentations along Mycological examination yielded 346 fungal isolates in 310
with otoscopic findings of the patients are well suggestive of samples from a total of 350 clinically diagnosed cases of
fungal infection, proper identification of causative agents is otomycosis. Self cleaning, instillation of mustard oil and use
mandatory in order to prevent recurrences and complications. of ear drops appeared to be common predisposing factors in
Aim: To define the aetiology of clinically diagnosed otomycosis otomycosis. Significant association was observed between
in rural population, to derive association of risk factors with these practices and otomycosis. Aspergillus species was the
otomycosis, to isolate and identify fungal and bacterial agents predominant fungi followed by Candida spp., Penicillium, Mucor
and to analyze the association between them. and Trichophyton mentagrophyte. 11% of the cases were found
to have mixed fungal and bacterial infections.
Materials and Methods: A prospective study was conducted
in the Department of Microbiology and Department of Ear, Conclusion: The present study highlights the highest isolation of
Nose and Throat (ENT), SGT hospital over eight months period. Aspergillus complex in cases of clinically diagnosed otomycosis
A total of 350 consecutive patients of more than five years of in a rural community with higher practice of self cleaning and
age with clinical diagnosis of otomycosis were included in the using home remedies and eardrops to get relief from sensation
study. Demographic profile, predisposing factors, presenting of blocked ear and itching.

Keywords: Aspergillus species, Candida species, Fungal otitis externa, Mixed infections, Predisposing factors

Introduction Candida spp., Staphylococcus aureus, Staphylococcus epidermidis,

Otomycosis or fungal otitis externa has been described as chronic Streptococcus species, Micrococcus, Corynebacterium species,
superficial fungal infection of the External Auditory Canal (EAC). Bacillus species, Pseudomonas aeruginosa, Escherichia coli,
It is worldwide in distribution with prevalence ranging from 9% to Haemophilus influenzae, Moraxella catarrhalis etc. Commensal flora
30% among patients presenting with signs and symptoms of otitis is not pathogenic as long as the balance between bacteria and fungi
externa and discharging ears in otolaryngology settings [1-4]. The is maintained in the EAC [10].
frequency of otomycosis depends upon different climatic conditions Despite the fact that climatic conditions in Haryana, India predispose
with higher prevalence in the hot, humid, and dusty areas of the the people to develop otomycosis, literature search reveals that not
tropics and subtropics [2-4]. Overview of the literature reveals much work has been carried out in this region. The present study
otomycosis to be a common medical problem in India [5, 6]. is designed with an objective to elucidate the predisposing factors,
Various local and systemic host factors have been proposed to clinical presentations, mycological agents and associated bacteria
be predisposing for otomycosis as instrumentation, relatively high encountered in clinically diagnosed otomycosis cases.
humidity in EAC, accumulation of epithelial debris, long term use
of broad spectrum antibiotics or steroid preparations, immuno- Materials and methods
compromised status, co-morbid conditions like diabetes and A prospective study was conducted in the Department of
dermatological diseases [7]. Patients suffering from otomycosis Microbiology and Department of Ear, Nose and Throat, SGT hospital,
commonly present with pruritus, otalgia, aural fullness, tinnitus, located in a rural area of District Gurgaon, Haryana, India. A total
hearing impairment, blocking sensation and ear discharge [4,7,8]. of 350 patients, attending outpatient Department of Ear, Nose and
Aspergillus niger and Candida albicans are more common offenders Throat, were chosen for the study. The study was performed over
[3-6,8,9] with nearly sixty one fungal species being involved in eight month period from March to October 2016.
external fungal otitis. The flora found in the EAC is made up of a Ethical clearance was obtained from Institutional ethical committee.
series of microorganisms viz. genus Aspergillus or yeast-like fungi, A predesigned proforma was used to evaluate and analyze

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www.jcdr.net Priti Agarwal and Leimapokpam Sumitra Devi, Otomycosis in a Rural Community Attending A Tertiary Care Hospital

demographic profile, predisposing factors, presenting complaints males and 151 females with male to female ratio as 1.3:1 [Table/
and clinical findings of clinically diagnosed patients. Fig-1]. Occupation of majoirity of the males in the study population
Inclusion Criteria: 350 patients of more than five years of age was farming (58%) and construction work (30%). Most (62%) of
with clinical diagnosis of otomycosis were included in the study. the females were housewives. Average monthly family income was
Criteria for establishing the diagnosis of otomycosis was based on below INR 8,000 in 57.1% patients.
the presence of symptoms like itching, pain, feeling of blocked ear,
tinnitus, deafness, discharge and otoscopic findings revealing wet Predisposing factors and Clinical features
or dry matted masses of hyphae/spores or thick, white cheesy Involvement of one ear was observed in 96.6% patients, presented
material [11,12]. with suspected otomycosis. Right ear was involved in majority of
the cases. Majority of the patients gave the history of frequent self
Exclusion Criteria: All patients with history of chronic otitis
cleaning of the ear with the help of unsterile pointed objects like
media, tympanic membrane perforations, prior ear surgery or aural
match sticks and hair pins (in females). Practice of putting mustard
procedures were excluded. Diabetics and patients with chronic and
oil and use of antibiotic ear drops were recorded in 59.4% and
serious debilitating illnesses like tuberculosis and malignancies were
40.6% patients respectively [Table/Fig-2]. Most common presenting
also excluded from the study.
complaint was blocking sensation of the ear, followed by itching,
Sputum smear examination for pulmonary tuberculosis and blood otalgia, ear discharge and tinnitus [Table/Fig-3].
sugar estimation (level above 100 mg per deciliter excluded) were
done to rule out these chronic diseases among study population. Microbiological findings
Age, sex, socio-economic status, and occupation of the patients Fungal cultures yielded 346 fungal isolates in 310 samples from a
were recorded. Any history of use of wooden sticks, metal wax total of 350 clinically diagnosed cases of otomycosis. Fungal culture
pickers or any other objects in an attempt to remove ear wax from positivity rate is 88.6%. Significant association was observed
ear, use of oil and topical antibiotic/steroid ear drops was noted. between various predisposing factors and positive samples
Clinical presentations of patients such as itching, pain, feeling of ear [p<0.05] [Table/Fig-4]. Aspergillus spp. are the predominant fungi
blockage, ear discharge and tinnitus were also recorded. (n=302;87.3%) among total fungal isolates, more frequent being
Sample Collection and Processing: EAC of each patient was A. niger complex (n=206;68.2%) followed by A. flavus complex
(n=60;19.9%) and A. fumigatus complex (n=36;11.9%). Other fungi
examined in order to look for appearance of debris suggestive of
isolated were Candida spp. (n=35;10%) Penicillium (n=5;1.4%),
fungal infection. Samples from EAC were collected with the help
Mucor (n=2;0.58%) and Trichophyton mentagrophyte (n=2;0.58%).
of sterile swabs or probe with curette and cotton carrier and
Associated bacterial infections were seen in 148(47.7%) cases.
transported to the laboratory within half an hour for mycological and
Commonest bacteria isolated were S. aureus (57.4%) followed by
bacteriological examination. Samples were collected from one ear
Pseudomonas aeruginosa (21.6%), Klebsiella spp. (16.9%), Proteus
only. All samples were evaluated by both direct examination and
spp. (2.7%) and E. coli (1.4%) [Table/Fig-5]. Out of the total 310
culture method. A portion of the sample was cultured on blood
positive samples, 32 samples yielded mixed growth with two fungi
and MacConkey agar at 37˚C for 48 hr. and examined for bacterial
and two samples with three fungi [Table/Fig-6]. Of the 32 samples
growth. Identification of the bacterial isolates was done by standard
with dual fungal growth, 14 showed coexisting growth of A. niger
bacteriological procedures [11]. For mycological identification, direct
microscopic examination was carried out by 10 % KOH examination Study population (n= 350)
and inoculation of material was done on two slants of Sabouraud’s Age
Male /Female Ratio n (%)
Dextrose Agar (SDA) with chloramphenicol (Himedia, India), which
5- 15 years 1.7:1 30 (8.6%)
was incubated at 25oC and 37oC aerobically for a period of 4 weeks.
Culture media were examined for presence of colonies every 3-4 >15- 35 years 1.2:1 232 (66.3%)

days [12]. Identification was done on the basis of colony morphology >35- 55years 1.4:1 80 (22.9%)
and Lactophenol Cotton Blue (LPCB) mount microscopy. Aspergillus >55 years 3: 1 8 (2.3%)
isolates were chracaterized by varying length of conidiophores [Table/Fig-1]: Demographic profile of study subjects.
and extent of coverage of vesicles by phialides and conidia. For
characterization of Candida isolates, germ tube test was done by
observing the production of germ tubes on isolates in serum after
1-2 hours of incubation at 37˚C and colonies were inoculated on
HiChrome agar for identification of species [12].
Post collection all patients were subjected to a thorough aural toilet,
following which patients were prescribed clotrimazole antifungal
drops, 4-5 drops to be instilled once a day for 10-14 days. All
patients were followed up after 14 days.

Statistical analysis
Categorical data was presented as frequencies and percentages. [Table/Fig-2]: Distribution of patients according to predisposing factors.
The association between the pre-disposing factors (self-cleaning,
eardrops, and oil instillation) and the prevalence of otomycosis
was analyzed with the chi-square test. p values below 0.05 were
considered significant.

Results
Demographic profile of patients
Out of the total 350 patients, maximum number of patients
belonged to the age group of >15-35 years followed by those in
the >35-55 years age group. Among 350 study subjects, 199 were [Table/Fig-3]: Distribution of patients according to presenting complaints.

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 Priti Agarwal and Leimapokpam Sumitra Devi, Otomycosis in a Rural Community Attending A Tertiary Care Hospital www.jcdr.net

[Table/Fig-4]: Association between predisposing factors and positive cases of [Table/Fig-6]: Proportion of samples with mixed fungal growth.
otomycosis.

Number
(%)
of
Fungal Associated
samples
isolates bacterial
positive
isolates (n)
for
fungi,
n = 310
[Table/Fig-7]: Distribution of fungal agents in samples with mixed fungal growth.
Aspergillus 186 (60) Staphylococcus aureus 41
niger
complex Klebsiella spp. 10
Pseudomonas aeruginosa 9
E. coli 2

Proteus spp. 4

Aspergillus 46 (14.8) Staphylococcus aureus 24

flavus
complex Pseudomonas aeruginosa 8
Klebsiella spp. 6

Aspergillus 20 (6.5) Pseudomonas aeruginosa 10

fumigatus
complex
Candida albicans 10 (3.2) Klebsiella spp. 4
Candida krusei 4 (1.3)
Candida tropicalis 2 (0.64) Staphylococcus aureus 2

Penicillium 4 (1.3) Pseudomonas aeruginosa 2

Mucor 2 (0.64) Staphylococcus aureus 1

Trichophyton mentagrophyte 2 (0.64) --

Mixed fungal With 2 fungi 32 (10.3) Staphylococcus aureus 17
infections Aspergillus spp. Klebsiella spp. 5
: 46 Pseudomonas aeruginosa 3
(A. niger
complex -20, [Table/Fig-8]: Microscopy and culture of fungal isolate.
A. fumigatus
complex -14,
A. flavus Bacteria isolated from samples with mixed (dual) fungal growth
complex -12)
Candida spp.: are S. aureus, Klebsiella spp. and Pseudomonas aeruginosa. No
18 bacteria was isolated from samples with triple fungal growth [Table/
With 3 fungi 2 (0.64) Fig-5].
Aspergillus --
spp.: 4
(A. fumigatus
Discussion
complex -2, Otomycosis is a superficial mycotic infection of EAC, highly
A. flavus prevalent in tropical and subtropical regions of the world [2-4,13].
complex -2)
Penicillium : 1 Many researchers reported this problem from India and other parts
Candida of world in the last few decades [2,4-10,14]. One of the important
tropicalis : 1
environmental factors which are responsible for increasing number
Total 346 Total bacterial isolates 148 of fungal infections of the ear is high content of suspended dust
fungal
isolates particles in the air. Fungi found abundantly on decaying plant matter,
[Table/Fig-5]: Spectrum of fungal and bacterial isolates among patients. can be blown in the wind with soil particles and carried away by water
vapours in the rainy season. This correlates well with higher rate of
complex and C. albicans, eight showed A. flavus complex and A. fungal infections during rainy season. Gurgaon, where the present
fumigatus complex, six A. niger complex and A. fumigatus complex study has been undertaken, is a city in the National Capital Region
and four A. flavus complex and C. albicans. Fungi isolated from of India. Many projects are under construction from past few years
one sample with triple fungal growth were A. flavus complex, A. in and around Gurgaon city which has increased the content of dust
fumigatus complex and Penicillium and from other were A. flavus particles in the air to many folds. Ambient temperature varies from
complex, A. fumigatus complex and C. tropicalis [Table/Fig-6-8]. 8˚C to 48˚C. Relative humidity is high during rainy season, approx 75-

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www.jcdr.net Priti Agarwal and Leimapokpam Sumitra Devi, Otomycosis in a Rural Community Attending A Tertiary Care Hospital

80%. These conditions are very conducive for fungal growth [2]. Our not different from other reports from India [4,5,16,22,23]. Though
study population mainly comprised of younger age groups which is some studies reported Candida spp. as predominant organism [3,
in accordance with other studies from India and other countries [1, 24]. Aspergillus is a saprophytic mold and is one of the primary
4-6, 15]. No age group is immune to otomycosis (known fact) but colonizers of manmade substrata. Rapid growth and production of
the incidence appeared to be more in >15-35 yrs age group (66.3%) a large number of small, dry and easily aerosolized conidia make
which goes well with other studies [2,5]. In comparison to females, it a significant contaminant with regard to air quality and potential
more males were infected, this is in agreement with other studies [1, human exposure related illnesses [16]. According to the rules of
4-6, 15]. Some studies have reported increased incidence in people International Code of Botanical Nomenclature genus Aspergillus
of lower socioeconomic group [5,16] as observed in our study. is classified into seven subgenera that are in turn sub-divided into
Most of our study subjects were outdoor laborers and farmers several sections comprised of related species [25]. Mycological
who were exposed to fungal spores along with dust owing to their findings of the present study were based on morphological
working conditions. Majority of the patients (96.6%) presented with identification methods for detection of fungal agents especially
unilateral involvement of the ear that has been reported by others Aspergillus spp., wherein the criteria of identification is based on
in immunocompetent patients [8,9,15]. Bilateral involvement is recognition of asexual structures and their characteristics such
more common in immunocompromised patients [6]. Right ear was as size, shape, arrangement etc. These characteristics are not
involved predominantly [7,10,15]. Higher frequency of the right sided helpful in clinical samples because of slow sporulation and aberrant
infection could be related to the dominant hand of study subjects. conidiophore formation. Identification of Aspergillus spp. is of utmost
Fungi can either be primary pathogens or superimposed on importance as different species have different susceptibilities to
bacterial infections of the ear [14]. In our study we tried to exclude antifungal drugs and it will affect the choice of appropriate antifungal
the patients with history of chronic otitis media, tympanic membrane therapy subsequently [26]. This problem can be solved to some
perforations, ear surgery or other aural procedures in order to study extent by inoculating samples on suitable culture media and after
the primary pathogenic status of fungal agents in causation of a period of incubation, identifying the growth by examining LPCB
otomycosis. Present study was conducted on immunocompetent mount of growth material [12] but we cannot rely completely on
patients, as immunocompromised state and diabetes are known this conventional culture based phenotypic identification method for
independent risk factors for otomycosis. Anatomical disposition speciation and DNA sequence-based identification methods must
of EAC provides ideal conditions for fungal and bacterial growth, be given a thought. Many researchers worked in this direction within
as its small meatal inlet helps in retaining moist conditions in EAC the sections Fumigati, Terrei, Usti and Emericella. International
[15]. Antimycotic and bacteriostatic properties of secretions of the group of experts recommended the comparative sequence analysis
apocrine and sebaceous glands (cerumen) protect healthy ear from of Internal transcribed spacer region and sequence comparison of β
invading organisms and fungal infections occur after the damage of tubulin region for identification of Aspergillus isolates to the section
these glands by bacteria or some other agents [17] so absence of level and for species identification within the section respectively.
cerumen increases the chances of fungal and bacterial infections Morphology based identification cannot identify species within a
as reported in a study [18] but researchers observed the growth of section so an alternative term ‘complex’ was proposed to ‘section’
A. fumigatus and A. terreus on cerumen [19]. These observations to help support laboratories in reporting the members of genus,
support our findings as cerumen was present in most of study for instance ‘A. fumigatius complex’ [26]. Our study suggested
subjects. Presence of excessive cerumen in patients with poor A. niger complex as predominant fungi, similar to other studies
personal hygiene favors germination of spores and conidia [5]. [6,14]. Some studies reported A. fumigatus and A. flavus complex
Scratching of ear canal in order to remove the cerumen and to get as most frequent fungi [5,13]. Due to non-specific presentation,
relief from itching can cause minor trauma in the skin of EAC which sometimes it is difficult to identify infections with Candida spp.
may get deposited by fungal spores that later on germinate and can clinically [7] and laboratory identification is mandatory for proper
cause fungal infection in presence of other predisposing factors. A treatment of patients. It was reported as predominant organism
popular myth that instillation of mustard oil can relieve itching and with otomycosis in immunocompromised hosts, in postoperative
cure minor ailments of ear led the people of this area to adopt this cavities and in infected middle ear earlier [6, 27]. We are reporting
habit. Our study revealed high association between otomycosis 34(11%) cases with infections due to mixed fungal flora. We tried
and instillation of mustard oil. This association was also reported but could not find such a large number of otomycotic cases with
in a study [4]. Strong association was also observed between mixed infections in the literature except for a study from South
otomycosis and use of ear drops. Normal bacterial flora of EAC India [28]. Some studies from India reported 1-6% cases of mixed
is one of the host defense mechanisms against fungal infections. infections [5, 14, 15, 29]. Mixed infections are generally scarce as
This mechanism is altered in patients using antibiotic ear drops thus fungal flora tends to inhibit the bacterial kind. These are difficult to
making them prone to otomycosis [20]. cure and tend to re-occur probably due to formation of biofilms
Maximum patients presented with feeling of blocked ear (76.6%) [21, 28, 30]. Candida has been known to form biofilms and studies
followed by itching, pain and discharge. In a study otalgia was are now suggesting biofilm formation by Aspergillus spp. [31-33]. In
the past, mixed bacterial-fungal infections have been described for
reported as the major symptom followed by otorrhoea and hearing
pneumonias and endocarditis [34, 35]. Mixed fungal infections that
loss [7]. Otoscopic findings varied from plug of black mycelial
include fungal species from different genera have been reported in
matted and brownish grey mycelial mass in Aspergillus otomycosis
a study on patients being treated for onychomycosis of the toenail
cases to soft epithelial debris and white curdy discharge in cases of
[36]. A case of otomycosis that included a mixture of A. niger and C.
dermatophytic and candidal otomycosis respectively.
albicans was also reported [37]. Identifying mixed bacterial-fungal
Isolation rate of fungi from the suspected cases was 88.6% infections necessitates both antibacterial and antifungal therapy
in the present study. Other studies reported 69%, 74.7% and for complete cure and to prevent recurrence. In our study, no A.
100% isolation rate [5,14,21]. Aspergillus spp. turned out to be fumigatus was associated with S. aureus, which is in accordance
predominant fungus isolated from 92.3% [Aspergillus spp. turned with other study. This has been attributed to antibiotic activity of
out to be predominant fungus isolated from 92.3% patients A. fumigatus against S. aureus [1]. In the past, many researchers
followed by Candida spp. (11.3%).] {186+46+20+34=286 patients/ have tried to elucidate the relationship of bacteria and fungi in
samples with Aspergillus, 28600/310= 92.3%}. This finding is mixed infections [38, 39]. English and Stanley [40] observed the

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 Priti Agarwal and Leimapokpam Sumitra Devi, Otomycosis in a Rural Community Attending A Tertiary Care Hospital www.jcdr.net

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PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Microbiology, SGT University, Budhera, Gurgaon, Haryana, India.
2. Tutor, Department of Microbiology, SGT University, Budhera, Gurgaon, Haryana, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Priti Agarwal,
Associate Professor, Department of Microbiology, SGT University, Budhera, Gurgaon, Haryana, India. Date of Submission: Dec 07, 2016
E-mail: dragarwalpriti@gmail.com Date of Peer Review: Jan 07, 2017
Date of Acceptance: Apr 10, 2017
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Jun 01, 2017

18 Journal of Clinical and Diagnostic Research. 2017 Jun, Vol-11(6): DC14-DC18