Clinical Assessment: Right Ear Pain with White Discharge (2 days)

Most Likely Diagnosis: Otomycosis (Fungal Otitis Externa)

"The commonest finding [in otomycosis] is a black, grey, green, yellow or white discharge with debris that is often said to resemble wet newspaper. Occasionally, debris is seen with visible fungal hyphae."

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 2

Figure: Otomycosis with Aspergillus niger (Scott-Brown's)

Differential Diagnoses

History to Elicit

• Swimming or water exposure recently (classic predisposing factor)?
• Prior use of antibiotic ear drops (prolonged topical antibiotics predispose to fungal OE)?
• Diabetes or immunocompromise?
• Ear itching (itching is very prominent in otomycosis)?
• Any recent ear manipulation/cotton bud use?
• Upper respiratory tract infection symptoms (points toward AOM)?
• Hearing loss (conductive loss common in OE due to canal oedema/debris)?

Examination

• Otomycosis: white/grey/black fluffy debris in canal resembling "wet newspaper," edematous erythematous canal walls, visible fungal hyphae
• Bacterial OE: diffuse erythema and edema with purulent discharge
• Tympanic membrane (TM): assess integrity - if TM is intact and normal, favors OE over AOM; if perforated, it changes management

• Tragal tenderness on pressure (pathognomonic for OE - suggests external canal involvement)
• Preauricular/postauricular lymphadenopathy
• Periauricular erythema/swelling (rules out perichondritis)

Management

For Otomycosis (most likely)

• Thorough cleaning and removal of fungal debris under microscopy or with suction
• "Toilet remains the most effective single treatment for otitis externa" - Scott-Brown's
• Avoid syringing (risk of complications)

• Clotrimazole 1% ear drops - first-line; 3 drops TDS for 2-4 weeks
• Flumethasone with clioquinol - alternative
• Continue for at least 2 weeks after resolution to prevent recurrence

• NSAIDs (ibuprofen) are excellent analgesics for OE
• Paracetamol as alternative

• Keep ear dry - avoid swimming, use cotton wool with petroleum jelly when bathing
• Do not insert cotton buds or any objects into the ear
• Follow up in 1-2 weeks

If Bacterial OE is confirmed instead

• Topical antibiotic-steroid combination (e.g., ciprofloxacin + dexamethasone drops, or neomycin + polymyxin B + hydrocortisone)
• Fluoroquinolone drops (e.g., ciprofloxacin) are preferred if TM status is uncertain - they are safe even with TM perforation
• Aminoglycoside drops are contraindicated if TM is perforated (ototoxic) - Rosen's Emergency Medicine
• No systemic antibiotics for uncomplicated OE in an immunocompetent patient
• If canal is severely edematous (lumen obliterated): insert a Pope otowick soaked in antibiotic/steroid drops for 24-48 hours to allow drops to reach the canal

Red Flags - When to Escalate

• Patient is diabetic or immunocompromised
• Fails to respond to topical treatment after 2 weeks
• Severe unrelenting pain out of proportion
• Granulation tissue at the floor of canal (at bony-cartilaginous junction)
• Cranial nerve palsies (VII, IX, X, XII)

Summary of Management Plan

1. Otoscopy with careful TM assessment
2. Aural toilet (suction/dry mopping of debris)
3. Clotrimazole 1% ear drops TDS × 3-4 weeks (if otomycosis)
   OR Ciprofloxacin/dexamethasone drops BD × 7-10 days (if bacterial OE)
4. NSAIDs for analgesia
5. Ear dry precautions
6. Review in 1-2 weeks
7. Swab only if resistant/high-risk case