Chronic Otitis Externa and Otomycosis

Author: Kevin T Kavanagh, MD, MS, FACS. Clinical Associate Professor, University of Kentucky, Department of Surgery, Division of Otolaryngology. Somerset, KY, USA.

Abstract: A treatment protocol for chronic otitis media is described using Gentian Violet, Ketoconazole Cream and iodine and dexamethasone drops. Because of the ototoxic nature of Gentian Violet. It should not be used in patients with tympanic membrane perforations.

Clinical Note: Chronic Otitis Externa and itchy ears is a common patient complaint. Often the symptoms are longstanding and very disturbing. These patients respond well to treatment aimed at eliminating fungal disease. Patients typically present with one of two types of clinical exams.

The first is with dry scaly ear canals (see picture on the right). I have not had success using fungal desensitization or allergy shots but have relieved over 90% of patients with this three step protocol.

#1. Using the operative microscope, the ear canal is cleaned and using a pair of micro-cup forceps and a wisp of cotton the eardrum and ear canal are painted with Gentian Violet. Be careful, gentian violet stains and nothing will take it off of clothes. Rubbing alcohol will remove from the skin.

An important caveat is that 1% Gentian Violet is very ototoxic^1,2 and this treatment should not be used in patient's with an eardrum perforation or a mastoid bowl.

#2. One week after Gentian Violet has been applied, the patient is placed on a compounded mixture of 1% Iodine and 0.1% Dexamethasone in Propylene Glycol. This mixture was coined "Iodex drops" by Dr Coyle Shea from Memphis Tennessee, USA. The drops are prescribed four drops, four times a day for two weeks.

#3. Clotrimazole or Tolnaftate solution is then used. Four drops four times a day for two weeks.

The second is used in patients with otomycosis or wet canals (see picture on the right). Steps #1 and #3 can also used in patients with dry canals if a perforation or mastoid bowl is present (Iodex drops should not be used in these patients).

#1. Using the operative microscope the ear canal is cleaned. A syringe with a blunt needle is then used to fill the ear canal with Ketoconazole Cream. The cream is left in place for one week. If granulation tissue is present a course of Fluconazole, 100 mg po.qd for one week is given.

#2. A week after the Ketoconazole cream is placed, the patient is given Iodex drops, four drops four times a day for two weeks. Iodex Drops are compounded with 1% Iodine and 0.1% Dexamethasone in Propylene Glycol.

#3. Clotrimazole or Tolnaftate solution is then used. Four drops four times a day for two weeks.

Using this protocol, I have found that the vast majority of patients with itchy ears can be helped. Other treatments such as allergy desensitization have been advocated but in my hands have not been as effective in treating this disorder.

Consultation with a medical doctor for an accurate diagnosis and discussion of risks and complications is needed in order to determine the best treatment options for a patient's condition.

Decision Table for the Treatment of Dry Itchy Ears and Otomycosis

Perforation of Eardrum or Mastoid Bowl.	#1. Ketoconazole Cream #2. Clotrimazole or Tolnaftate Drops
Dry Eardrum and Ear Canal.	#1. Gentian Violet #2. Iodex Drops #3. Clotrimazole or Tolnaftate Drops
Wet Debris with Fungal Growth without Granulation Tissue.	#1. Ketoconazole Cream #2. Iodex Drops #3. Clotrimazole or Tolnaftate Drops
Wet Debris with Fungal Growth with Granulation Tissue.	#1. Ketoconazole Cream plus Fluconazole 100mg po qd for 7 days. #2. Iodex Drops #3. Clotrimazole or Tolnaftate Drops

Generic and Brand Names

Clotrimazole	Lotrimin
Tolnaftate	Tinactin
Ketoconazole	Nizoral
Fluconazole	Diflucan
1% Iodine, Dexamethasone & Proplyene Glycol	Iodex

References:

#1. Spandow O, Anniko M, Moller AR., The round window as access route for agents injurious to the inner ear. Am J Otolaryngology, 1988 Nov-Dec;9(6):327-35.

#2. Tom LW., Ototoxicity of common topical antimycotic preparations. Laryngoscope, 2000 Apr;110(4):509-16.