A 5-year-old girl was referred to the ear, nose and throat (ENT) clinic at a tertiary hospital with a 5-month history of right ear otalgia and foul smelling otorrhea. Symptoms had not resolved, despite two courses of oral co-amoxiclav received from a private general practitioner and local clinic, as well as a 6-week course of ciprofloxacin ear drops prescribed as three drops 8-hourly. The child was otherwise healthy with no previous history of significant illness. Screening for human immunodeficiency virus was negative. On clinical examination the patient was apyrexial and systemically well. No nasal obstruction or discharge was noted. Otoscopic examination revealed blood and pus in the right external auditory canal, from which a pus swab was sent from the outpatient department. The patient did not tolerate aural toilet in the clinic and was thus booked for examination under anaesthesia in theatre. Findings in theatre included an intact tympanic membrane on the right with prominent pus, debris, and a cotton-wool-like foreign body in the external auditory canal. The left ear had only wax visible. Both ears were cleaned in theatre, but no specimen sent to the laboratory. The child was discharged on ciprofloxacin ear drops for another 2 weeks, for a total treatment duration of 8 weeks of the fluroquinolone. A follow-up visit was booked at the ENT outpatient clinic in 6 weeks’ time. On review the discharge was reported as resolved with no specific treatment of the
Pus swabs are routinely inoculated onto 4% blood agar (anaerobic conditions), boiled blood agar (carbon dioxide conditions) and MacConkey media (aerobic conditions), incubated at 35 °C for the isolation of bacteria and non-filamentous fungi. However, if a fungus is suspected and requested for culturing on the laboratory form, additional media will be inoculated to enhance the growth of a fungus. This includes Sabouraud Dextrose (SabDex) media with amikacin, incubated at 35 °C and 25 °C, as well as brain heart infusion agar incubated aerobically at 35 °C. Furthermore, plates will be incubated for up to 3 weeks to monitor growth and up until 6 weeks if dimorphic fungi are suspected.
In this case
Characteristic black sporing heads of
Microscopic view of
Antifungal susceptibility testing is not offered for any topical agents (clotrimazole) in South Africa. In addition, no breakpoints are available for the interpretation of minimum inhibitory concentrations (MIC) of topical antifungal agents. It is likely that the delivery of an antifungal agent directly to the site of an infection will result in a very high concentration which is probably much higher than the MIC.
This article followed all ethical standards for carrying out research without direct contact with human or animal subjects.
Schwartz et al.
Otorrhoea is a common paediatric presentation, and the majority of cases can be successfully treated with dry mopping of the ear and topical acetic acid or antimicrobial eardrops. Local guidelines do not promote routine investigations in uncomplicated otitis media or otitis externa. However, in refractory cases a well-collected ear swab may assist in providing aetiological diagnosis of chronic otorrhea.
Otomycosis refers to a superficial mycotic infection involving the external ear with the auditory meatus mostly affected.
Common presenting symptoms include unilateral otalgia, persistent otorrhea, pruritus and tinnitus. Additionally, patients may report progressive hearing loss secondary to fungal debris in the ear canal. Otoscope examination may reveal a black fluffy growth in the ear canal when
No consensus exists on the most effective agent for the treatment of otomycosis with only a few publications on its treatment with topical antifungals. It is important to note that some of these studies, as reported by Vennewald and Klemm
The correct diagnosis and treatment of otomycosis requires a high level of suspicion in refractory cases of otorrhea. Routinely, pus swabs from the auditory meatus are not recommended as it yields polymicrobial overgrowth. However, in the case of chronic otorrhea or if a clinical suspicion is present of fungal growth, a well-taken pus swab can be very valuable. Clotrimazole cream is an option for the treatment of non-invasive cases of
We want to thank Professor M. Nicol, head of the division medical microbiology for his input and review of this case report.
The authors have declared that no competing interest exists.
All authors contributed equally to this work.
The research received no specific grant from any funding agent in the public, commercial or not for profit sectors.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect official policy or position of any affiliated agency of the authors.