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Class Test Answers - ENT

Q1. Short Note on Otomycosis (1.75 marks)

Definition: Otomycosis is a fungal infection of the external ear canal that can also affect mastoid cavities and, in complicated cases, the middle ear. It accounts for approximately 9-10% of all cases of otitis externa, with some studies reporting prevalence up to 30%.
Causative Organisms:
  • Aspergillus niger - most common (80-90% of cases)
  • Candida albicans - 10-20% of cases
  • Others: Aspergillus fumigatus, Candida tropicalis, Actinomyces, Trichophyton
Predisposing Factors:
  • Prolonged use of topical antibiotics (alters normal flora)
  • Hot, humid climate
  • Hearing aid use
  • Regular swimming in contaminated water
  • Trauma to the ear canal
  • Immunosuppression (diabetes, AIDS)
Clinical Features:
  • Itching (most prominent symptom)
  • Otalgia
  • Otorrhoea (discharge)
  • Aural fullness
  • Hearing loss
  • Tinnitus
  • Classic sign: waving conidiophores (fungal hyphae) visible on otoscopy
  • Discharge resembling "wet newspaper" - black, grey, green, yellow or white
Complications:
  • Fungal malignant otitis externa (skull base osteomyelitis) - especially in immunocompromised patients; causes cranial nerve palsies (VII, IX, X, XI, XII)
Management:
  1. Eliminate predisposing factors
  2. Thorough aural cleaning (ear toilet/suction clearance) - most effective single treatment
  3. Topical antifungal agents:
    • Azoles (first-line): Clotrimazole (95-100% efficacy), miconazole, fluconazole, ketoconazole
    • Polyenes: Nystatin (suspension/powder), Amphotericin B (for severe/invasive cases)
    • Nucleoside analogues: Flucytosine (90% efficacy)
    • Non-specific agents: Acetic acid, boric acid, gentian violet
  4. Water avoidance
  5. For fungal malignant otitis externa: systemic Amphotericin B or Voriconazole
(Scott-Brown's Otorhinolaryngology Head & Neck Surgery)

Q2. Clinical Scenario - 30-year-old female with right ear discharge (odorless, intermittent, aggravates during URTI)

(a) Diagnosis (1.0 mark)

Diagnosis: Chronic Suppurative Otitis Media (CSOM) - Tubotympanic (Safe) type
Reasoning:
FeatureSignificance
30-year-old femaleAny age affected
Odorless dischargeSuggests tubotympanic type (mucopurulent but no foul smell - no cholesteatoma)
Intermittent dischargeClassic for safe CSOM
Aggravates during URTIPatulous/dysfunctional Eustachian tube - infection ascends via tube during upper respiratory infections
Right earUnilateral
The hallmark that confirms tubotympanic CSOM over unsafe type: odorless discharge (unsafe/cholesteatoma type gives foul-smelling discharge). The aggravation during URTI points to Eustachian tube dysfunction as the underlying mechanism.

(b) Management (1.5 marks)

Conservative (Medical) Management:
  1. Dry mopping of the ear - regular aural toilet
  2. Topical antibiotic ear drops: Ciprofloxacin or framycetin (avoid aminoglycosides if TM perforation is large)
  3. Systemic antibiotics: Amoxicillin or co-amoxiclav during acute exacerbations
  4. Water precautions: Avoid water entry into ear
  5. Treat associated conditions: Treat URTI, sinusitis, adenoids (Eustachian tube-related causes)
  6. Nasal decongestants: To improve Eustachian tube function during URTI episodes
Surgical Management (definitive):
  • Myringoplasty / Tympanoplasty: Closure of tympanic membrane perforation once the ear is dry for at least 6 weeks
  • Cortical mastoidectomy: If mastoid disease is present
Aim of treatment: Control infection, close perforation, prevent complications, and restore hearing.

(c) Causes of Discharging Ear (1.0 mark)

A. External Ear:
  1. Otitis externa (bacterial or fungal/otomycosis)
  2. Furunculosis (boil in external canal)
  3. Foreign body with secondary infection
  4. Malignant otitis externa
B. Middle Ear:
  1. CSOM - Tubotympanic type (safe) - mucopurulent, odorless, intermittent
  2. CSOM - Atticoantral type (unsafe/cholesteatoma) - foul-smelling, scanty, persistent
  3. Acute suppurative otitis media (ASOM) - profuse purulent discharge after TM perforation
  4. Secretory otitis media (if Eustachian tube dysfunction leads to effusion)
  5. Acute mastoiditis with discharging sinus
C. Trauma:
  1. Temporal bone fracture - CSF otorrhoea (clear watery discharge)
  2. Blast injury
D. Neoplasia:
  1. Carcinoma of the middle ear - blood-stained discharge
  2. Glomus jugulare tumor - pulsatile, blood-stained discharge
E. Specific/Rare:
  1. Aural polyp
  2. Tuberculosis of the ear (multiple perforations, pale granulations)
Sources: Scott-Brown's Otorhinolaryngology Head & Neck Surgery (Vols 1 & 2), Cummings Otolaryngology Head and Neck Surgery, K.J. Lee's Essential Otolaryngology
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