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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 www.jbscience.org 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 www.jbscience.org 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. www.jbscience.org DOI: 10.5780/jbm2012.24 | Page 3 Case