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The Journal of Bioscience and Medicine 2, 3 (2012) | Case Report
The clinical application of miconazole perfusion in the treatment of fungal otitis externa
Tao Wang, Xuekun Huang, Qintai Yang, Peng Li*
Department of Otolaryngology -Head and Neck Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou,
China 510630
* Corresponding Author: Peng Li, Department of Otolaryngology -Head and Neck Surgery, Third Affiliated Hospital, Sun
Yat-Sen University, Guangzhou, China 510630 (Email: [email protected])
Received: 6 August 2012, Accepted: 27 September 2012, Published: 11 October 2012
Abstract:
Objective: Observe the clinical effect of the treatment of the fungal otitis externa by perfusion of miconazole
nitrate in the external auditory canal. Method: 108 Cases of fungal otitis externa were divided into two groups. The perfusion
group underwent miconazole nitrate cream perfusion in the external auditory canal, and the control group used ear canal
smear method. The treatment time was 9 days and follow-up time was one month. Result: The effective rate for perfusion
group was 94.4% and for control group it was 66.67%. There was significant difference between the two groups (P <0.05).
Conclusion: Perfusion of miconazole nitrate in external auditory canal can improve the cure rate of fungal otitis externa and
reduce the relapse. This method is simple and easy to operate.
KEYWORDS: Otitis externa, fungi, miconazole
T
he external auditory canal fungal disease, also
known as fungal otitis externa, is an external auditory canal fungal infection disease. The major
pathogenic fungal species are Candida, Aspergillus,
Penicillium[1-2]. Because Fungi are easy to breed in wet conditions, there is high incidence in hot and humid southern region in China. However, with the widespread use of antimicrobial treatment of otitis externa, or due to other reasons for
long-term use of immunosuppressants and glucocorticoids, it
is also increasingly common in northern China region. Traditional treatment of external auditory canal fungal disease
mostly uses 3% salicylic alcohol ear drops or topical antifungal ointment for local treatment, but the effect is poor. To
improve the efficacy, reduce the occurrence of adverse reactions and fungal resistance, 108 cases of external auditory
canal fungal disease were treated through miconazole nitrate
cream perfusion in external auditory canal. Satisfactory results were obtained by clinical observation, which are summarized as follows.
Materials and Methods
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DOI: 10.5780/jbm2012.24 | Page 1
Materials: A total of 108 cases of external auditory canal
fungal disease were treated in our hospital from February
2008 to February 2010, including 46 male and 62 female patients, aged 14 to 65, with an average of 37. Clinical manifestations were various degrees of the external auditory canal
flea itch symptoms associated with repeated ear occlusion,
earache, tinnitus and external auditory canal discharge. Ear
endoscopy showed typical intensive powdered, villous or
granular material accumulation in external auditory canal of
78 patients, 22 cases of wet mold-like clumps of matter, skin
and (or) the tympanic membrane congestion or edema. There
were 8 cases with ear canal secretions as brown or dark
brown tubular or membrane-like necrotic material. In the 108
cases, there were 28 cases with ear canal skin thicker and
external auditory canal narrower. Pathogenic examination of
the external ear canal secretions showed 82 cases of Aspergillus infection, 21 cases of Candida species, Penicillium 5
cases and 11 cases of other genus.
Inclusion criteria: Patients with external ear canal secretions etiology (smear + culture) check positive, clinical symptoms and signs of the external auditory canal fungal disease,
Case
Tao Wang, et al.| The clinical application of miconazole perfusion in the treatment of fungal otitis externa
over the age of 14, male or female, willing to cooperate and
comply with doctor's orders. Exclusion criteria: patients with
drug allergy, pregnant and lactating women, non-compliance
with doctor's orders; patients who are in combination with
other antifungal agents or interrupt treatment, psychiatric patients; Patients with incomplete data, which can affect the
efficacy or safety judgment; patients with interruption of treatment due to adverse events.
Table 1: Two groups of patients treatment results (P<0.05)
Groups
Effective
Ineffective
Total
Efficient rate(%)
Perfusion group
51
3
54
94.44
Smear group
36
18
54
66.67
Total
86
22
108
79.6
Treatment method
108 Cases were divided into two groups, 54 cases in the
external auditory canal perfusion group and 54 patients in the
external auditory canal smear group.
External auditory canal perfusion group: under the ear
endoscope or head mirror, patients first underwent external
ear canal clean-up to remove the fungal clumps and cerumen
like material as much as possible within the external auditory
canal. The operation should be as gently as possible to protect the ear canal skin tissue and avoid all side injury. After
the external auditory canal wiped clean, 2-3ml of miconazole
nitrate was primed into the ear canal by syringe, once every
three days, a total of three times. Each time prior to the perfusion it was required to clean out the secretions and residues
within the ear. Referral was followed after 9 days. External
auditory canal smear group: the first time ear canal cleanup is the same as above. Patients applied miconazole nitrate
in ear canal once a day themselves, a total of nine days and
referral was followed after nine days.
Both groups of patients did not need oral nystatin and
other antifungal agents. Patients with diabetes should strictly
control blood sugar and supportive therapy should be
strengthened for the elderly and infirm.
Evaluation standards
Cured: clinical symptoms disappear completely; the external auditory canal is clean and dry, no congestion; fungal
smear microscopy check is negative. Effective: clinical
symptoms disappear; external auditory canal is still with mild
congestion and erosion; fungal smear microscopy check is
negative. Improvement: signs and symptoms improve compared to before treatment; positive fungal smear microscopy
check. Ineffective: no improvement in signs and symptoms;
positive fungal smear microscopy check. The total efficiency
is calculated according to heal + effective (Table 1).
Discussion
It was found in the study of fungi, mold itself does not
have dismutase, so mold on nature and organism surface
cannot penetrate healthy tissues, but exists in saprophytic
state. The state of the body and biological characteristics of
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DOI: 10.5780/jbm2012.24 | Page 2
mold determine the process of fungal disease. Aspergillus is
the most common pathogen in the non-invasive fungal sinusitis. Healthy mucosal can inhibit the growth and reproduction
of Aspergillus spores, so only when the immune system declines Aspergillus induces disease. Therefore it is a conditional pathogen.
Fungus Causing otitis externa is a conditional pathogen,
mainly for the following reasons: 1) There is a higher incidence in wet climate than drier regions. The narrow, deep,
warm and humid environment of the external auditory canal
provides a good living environment for fungal growth. 2) Decreased body resistance, long-term abuse of antibiotics as
well as chronic metabolic diseases or immune dysfunction. 3)
Repeated ear digging can weaken the normal cerumen protection in external auditory canal; inhibit the cerumen gland
secretory function and damage the normal external auditory
canal defense function. When the external auditory canal skin
or tympanic membrane has varying degrees of scrapes and
scratches, fungi and other pathogens attached to the surface
of dirty ear tools can directly enter the ear, and play a role in
dissemination for fungal growth and reproduction. The exudates or blood from external auditory canal wall abrasions
provide the culture medium for fungal growth and reproduction, so under this environmental condition the growth and
reproduction of fungal hyphae and spores are extremely
rapid, and reproduction of fungi, in turn, will increase the external auditory canal and eardrum damage.
A good therapeutic effect can be obtained through smearing of anti-fungal drug in ear canal, but it is effective only for
66.67% of patients in our observation. The analysis of its ineffectiveness is as for the following reasons: 1) Ear canal
stenosis. The colonies of external auditory canal fungal disease are more concentrated inside the external auditory canal isthmus, even located on the eardrum. The ear canal
physiological bending, combined with inflammation can lead
to swelling of the ear canal skin and aggravate ear canal
stenosis. 2）Patients with poor compliance. Such patients
often cannot regularly apply drug on time in ear canal; 3)
Tao Wang, et al.| The clinical application of miconazole perfusion in the treatment of fungal otitis externa
Lack of understanding for ear canal. When such patients
rub drug by themselves in ear canal, they have heavy psychological burden and worry the side injury of ear canal and eardrum. The above factors make the drugs not fully reach the
affected area, and eventually lead to recurrence and disease
cannot be cured.
After perfusion of miconazole nitrate cream in ear canal,
clinical symptoms apparently disappeared compared to smear
group of patients, and recovery was faster. There was significant difference in treatment effect between the two groups (P
<0.05). We think advantages of miconazole nitrate cream perfusion are：1）Children's normal range is 0.5 ~ 1.0ml, with
average 1.3ml; adult is 0.6 to 2.0ml [3]. This dose can meet the
full coverage of the fungal lesion in the ear canal, not blind.
2）The poor physical mobility of cream makes it remain in the
external auditory canal for a long time, which can effectively
play the anti-fungal role in ear canal. 3）It can play the effective softening and anti-fungal role for residual fungal secretions; weaken adhesion of secretions, so it can be easily
washed out or naturally drained out. 4）Miconazole is a triazole antifungal drug, and it has broad antifungal spectrum,
with low toxicity, strong penetrating power and low price. 5）
With reduced treatment process, after the ear canal perfusion,
patients don’t have to do daily self ear canal smear. It can be
avoided that drugs fail to apply to the affected area, causing
repeated episodes. Therefore it can alleviate the suffering of
patients and the psychological burden.
Overall, good therapeutic effect can be obtained with ear
canal perfusion, and it is worth the attention of specialists.
References
1. Yongquan Tian, Aihua Sun, Otolaryngology - Head and Neck
Surgery [M]. 6th edition. Beijing: People's Health Publishing
House, 2006, 344.
2. Demin Han. Otolaryngology, head and neck science [M]. First
edition. Beijing: Peking University Medical Press, 2004, 3-64.
3. Xuanzhao Huang, Jibao Wang. Practical otorhinolaryngology
[M]. First edition, People's Health Publishing House. 2005,
738.
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