That darn ear’s been hurting and draining, for a while. The drainage looks a bit weird, colors ranging from clear to yellow to a grayish brown and even black. You’re not sure what you might have done prior. Was it after falling asleep in the hot tub for 4 hours? Or was it the time you and your drunken pals dove into the hotel pool that crazy night, fully clothed? Or perhaps you cleaned your ear with a Q-tip despite what everyone had told you about not using Q-tips but, oh my, it felt so good. Or did it occur after that bout of swimmer’s ear (acute otitis externa) that made you cry like a baby? The pain improved to a milder dull ache, but darn! Why is it draining and itching so?
You might have an infection in your ear called otomycosis (oto- is the medical prefix for “ear” and mycosis means “fungus”). Yeah, you might have ear fungus.
Well, that’s a bummer.
Worried the fungus may grow and extend tentacles deep into the confines of your cranium—the space that holds your brain—you seek your doctor because a moldy brain is undesirable, and the last thing you need is fodder for friends and family to crack more jokes at your expense.
Relax. Unless you’re severely immunocompromised (you’d be hospitalized in isolation) or have diabetes that is completely out of control (i.e., you’re in ketoacidosis) the fungus will not invade your brain or other parts of your central nervous system. But, you could pretend it has and use it as an excuse to explain away all the stupid things others have accused you of doing in the past.
Otomycosis occurs due to trapped water or moisture in the ears. The moist environment is a great milieu for fungus, normally present in or on the body, to really proliferate. It can occur after a bout of acute bacterial otitis externa (acute OE). The antibiotic drops used for acute OE does not kill fungus, and once the bacterial infection resolves, there often is dead skin that sloughs off during the infection that mixes with wax (cerumen) along with residual moisture, a perfect gathering place for fungus. If the ear is irrigated with water, this may flush some of the fungus and debris out, but often only worsens the situation since the fungus just regrows.
The fungus can locally invade the skin of the ear canal or of the surface of the tympanic membrane. Fortunately, the fungus typically does not get into the blood stream or invade deeper into underlying bone or cartilage.
The clinical findings vary. When looking into the ear, one might see fungal spores of varying colors: black, brown, yellow, light tan. Also fungal hyphae may be noticed, especially under microscope examination, which look like fine, white filaments or wisps of cotton. Sorry to burst your bubble, but mushroom caps, tasty Morels and Shintakis are not found, and unfortunately you cannot eat the fungus from your ear, since it probably tastes awful and more importantly—it’s just plain gross. The debris that forms can be yellow or have a grayish color, with a texture resembling crumpled wet paper. This is the fungus with sloughed-off dead skin, and all of this must be removed.
Treatment requires removal of the fungus and the moist debris, including any residual wax or sloughed dead skin, best done in the office under a microscope, where tiny suctions and other nifty ear instruments are used to microdebride (micro- for microscope and “debride” means “removing all the stuff that oughtn’t be there”). Sometimes the skin of the ear canal and tympanic membrane (TM) are inflamed with some degree of swelling (though typically not as bad as acute OE), and many times shallow ulcerations or raised areas of inflamed tissue are seen. After a thorough microdebridement, I often apply gentian violet, a deep purple solution that sticks to tissue for days or weeks; it’s an antiseptic that kills fungus and bacteria. It’s been used for decades and is quite effective in shortening the healing time for otomycosis.
Since gentian violet stains anything it contacts, I advise patients to place an old towel on their pillow when sleeping to avoid staining their linen, and avoid wiping the ear with fingers and then rubbing fingers onto clothes, furniture, your dog, other people, etc. It can be messy, with purple stains in places you don’t want purple stains, unless you have a penchant for weirdness. And a dog with purple stains might make you famous.
Additional treatment usually is required after the ear is microdebrided. Sometimes a simple mixture of alcohol and acetic acid (isopropyl or rubbing alcohol mixed with white vinegar mixed 1:1) is all that is needed, using it 1-2 times a day, filling the ear canal with the solution using a dropper or squeezing a cotton ball saturated with the solution as a make-shift dropper. Both ingredients kill fungus, and the alcohol aids in removing any residual water or moisture to further dry the ear.
Clotrimazole (Lotrimin) in a solution is often used, 4 drops three times a day for 1-2 weeks. Alternatively, miconazole (ie, Desenex) or tolnaftate (Tinactin) powder can be used if you can find an insufflator (such as a baby bulb syringe) or a device such as a DeVilbis puffer device (think of an old style perfume bottle with a small compressible bulb at one end) to gently blow the powder into your ear. The powder is more difficult to apply, which makes the ear drops comparatively easier to use. And by the way, these are the same meds used for athlete’s feet.
Avoid getting water in the ear. Keep the ear dry by placing a cotton ball with a layer of petroleum jelly (Vaseline) when bathing. Try to avoid swimming, hot tubs or steam rooms due to the humidity that can enter the ears. If you simply must dunk your head in water despite your doctor’s instructions to the contrary, then use a water-tight ear plug such as silicon putty, purchased at most stores and pharmacies.
It usually takes more than one visit to your ENT doc to fully heal the ear, with microdebridement, applying antifungal meds at home, microdebridement in another 1-2 weeks, etc. Usually this can be accomplished in 2-3 visits. Some of the luckier folks may require more.
Rarely, an invasive fungal infection can occur, typically called mucormycosis or invasive aspergillosis, for the types of fungi involved. This occurs in patients with extremely uncontrolled diabetes, requiring hospitalization, or in severely immunocompromised patients, such as those receiving chemotherapy or who have had bone marrow transplants. Such patients are often hospitalized in isolation for their immunocompromised states in the first place. In these rare cases, the fungus invades deep into soft tissues, often causing a devitalized and necrotic tissue that has little bleeding when debrided. Usually the source is a sinus infection rather than ear, but any break into tissue including skin can be involved with these invasive forms of fungus. Nonetheless, these patients often need surgical removal of the devitalized tissue to remove the invading fungus, which can lead to large open wounds. Antifungal medications given i.v. are used. Fortunately, these are rare, and the vast majority of patients with otomycosis only need clinic-based treatment as discussed above.
So if your ear has been bothering
you with a persistent, nagging irritation, itching or drainage, please see your
doctor since something’s obviously not right.
You might be one of the lucky ones with otomycosis!
©Randall S. Fong, M.D.
For
more topics on medicine, health and the weirdness of life in general, check out
the rest of the blog site at randallfong.blogspot.com
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