ENT - September 2020 - 520

520
required a tympanoplasty. Hurst performed cauterization
with trichloracetic acid in a patient with a tiny perforation.8
In the study of Song et al, a patient required a fat-graft
myringoplasty.16

Discussion
Tympanic membrane perforation may occur as a complication of otomycosis. It is an infrequently reported clinical
feature of fungal otitis externa that general practitioners or
even otolaryngologists are not always aware of. At the same
time, it is one of the most misleading manifestations of
otomycosis and can lead to incorrect diagnoses.8 TM involvement is likely a consequence of fungal inoculation in the
most medial aspects of the external canal or direct extension
of disease from adjacent skin. The pathophysiology of this
complication has been attributed to avascular necrosis of the
TM as a result of mycotic thrombosis in the adjacent blood
vessels.8 Most of the perforations were behind the handle of
the malleus. There are no clinical features predictive of TM
perforation.

Rate of Tympanic Membrane Perforation
Although the association of TM perforation with otomycosis
has been a known clinical problem for many decades, its
incidence has never been precisely quantified. Data derived
from epidemiological studies carried out to evaluate the incidence, clinical aspects, and outcomes of otomycosis are conflicting in this regard. The range of TM perforation rates in
patients with otomycosis is quite wide.11,14 This may be
related to the fact that the diagnosis of TM perforation secondary to fungal otitis externa is based on clinical examination and can be difficult. First, complete removal of the
fungal and epithelial debris using a microscope is required
so that the entire TM can be visualized. Moreover, the size of
perforation is usually quite small, making its detection difficult.
Due to the abovementioned factors, it could be assumed that
many cases are misdiagnosed. Additionally, some authors, especially in older studies, used to attribute the presence of TM
perforation to chronic otitis media, without taking into consideration that the defect could be associated etiologically with the
fungal infection of the ear.17,18 Various factors such as the criteria used for otomycosis diagnosis and recording practices can
significantly influence the reported incidence of otomycosis TM
perforation. Viswanatha et al found that TM perforation is more
in immunocompromised patients than in immunocompetent
patients.19,20 Another possible reason for the wide range of
TM perforation incidence may be the small sample size in some
of the studies.
However, it should be underlined that there is a number
of clinical studies that reported similar rates of TM
perforation.6,7,12-14 According to them the incidence of TM
perforation secondary to otomycosis is over 10%. Thus, it
cannot be considered as an uncommon complication.

Ear, Nose & Throat Journal 99(8)

Difficulties With Regard to Conservative Treatment
The most widely used treatment regimen for otomycosis
includes mechanical debridement of the ear canal along with
local antifungal agents. However, the presence of TM perforation is associated with 2 problems: antimycotic solutions are
irritant to middle ear and may be ototoxic to the cochlea.
Namely, direct instillation of antifungal agents with a dropper is associated with stinging and burning sensation.21 Clotrimazole, which is the most commonly used antimycotic
medication, is practically insoluble in water. Solvents used in
dermatologic solution are propylene glycol, isopropyl alcohol,
and polyethylene glycol. Although they have a good drying
effect, they are irritant to middle ear mucosa and cause burning
or stinging sensation. In order to prevent this unpleasant condition, many authors have proposed alternative topical therapeutic options. Insertion of an ear wick saturated with
antifungal solution or cream may be used to increase the contact time with meatal skin and to limit the seepage of the irritant
solution to the middle ear. In the study done by Hurst, a gauze
wick saturated with hydrocortisone, clotrimazole, framycetin,
and gramicidin was inserted.8 Abou-halawa et al proposed selfmedication with clotrimazole solution on Q-tips.21
Moreover, otolaryngologists should be aware of the ototoxic
potential of some antifungal agents.22 These medications may
reach the inner ear by perfusion via the round window membrane.23 Arguably, some of the antimycotic agents have been
implicated as a cause of sensorineural hearing loss by inflicting
damage to the inner hair cells of the organ of corti.24 It should
be emphasized that apart from the active ingredient, all commercially available antifungal otic drops contain alcohol, solvents, acids, and antiseptics. Tom et al performed a controlled
animal study in which the ototoxicity of commonly used topical antifungal agents was investigated by measurement of hair
cell loss.24 Five readily available topical antimycotic preparations were instilled into the middle ears of test animals during a
7-day period. This study suggested that clotrimazole, miconazole, and tolnaftate are potentially safer antimycotic choices
than nystatin for the treatment of otomycosis in patients with a
perforated eardrum. Moreover, it was found that gentian violet
has the potential for severe damage in inner ear. Ho et al
observed transient sensorineural hearing loss associated with
the use of cresylate otic drops.6 Unfortunately, a small number
of antifungals and other major ingredients (solvents) have been
tested for ototoxicity in experimental animals. There have not
been any clinical studies on humans for sensorineural hearing
loss after the use of otic antimycotic drops. Making comparisons of ototoxicity between experimental animals and humans
requires caution.

Rate of Persistent Tympanic Membrane
Prognosis of otomycosis with perforated TM in general is
favorable, Namely, most perforations, especially small, tend
to resolve with proper medical treatment.19 Restoration of the
unique milieu of deep part of external auditory meatus seems to



ENT - September 2020

Table of Contents for the Digital Edition of ENT - September 2020

The Creation of a Sustainable Otolaryngology Department in Malawi Nathan Douglas Vandjelovic, Eric Masao Sugihara, Wakisa Mulwafu, and David Nathan Madgy
Hazardous Grilling Due to Wire Brushes Nima A. Vahidi, Brenna A. Keane, Paul J. Whalen, and Anita Jeyakumar
Guns n’ Noses: Endoscopic Removal of an Air-Gun Pellet Retained in the Frontal Sinus Dylan A. Levy, Andrew Y. Lee, Waleed M. Abuzeid, and Nadeem A. Akbar
Vitamin D Status in Egyptian Children With Allergic Rhinitis Khaled Saad, Abobakr Abdelmoghny, Mohamed Diab Aboul-Khair, Yasser Farouk Abdel-Raheem, Eman Fathalla Gad, Ahmed El-Sayed Hammour, Bahaa Hawary, Asmaa M. Zahran, Mohamd A. Alblihed, and Amira Elhoufey
Pediatric Epistaxis and Its Correlation Between Air Pollutants in Beijing From 2014 to 2017 Ying-Xia Lu, Jie-Qiong Liang, Qing-Long Gu, Chong Pang, and Chun-Lei Huang
Otomycosis With Tympanic Membrane Perforation: A Review of the Literature Petros Koltsidopoulos and Charalampos Skoulakis
Simultaneous Bilateral Same-Day Endoscopic Myringoplasty Using Tragal Cartilage From One Ear Baklaci Deniz, Kuzucu Ihsan, Guler Ismail, Kum Rauf Oguzhan, and Ozcan Muge
A Preliminary Report on the Investigation of Prestin as a Biomarker for Idiopathic Sudden Sensorineural Hearing Loss Changling Sun, Xiaolin Xuan, Zhi Zhou, Yuan Yuan, and Fei Xue
A Retrospective Study to Identify the Relationship Between the Dimension of Osseous External Auditory Canal and Chronic Otitis Media Yi-Fang Lee, Pei-Yin Wei, Chia-Huei Chu, Wen-Huei Liao, An-Suey Shiao, and Mao-Che Wang
Investigation of the Effectiveness of Surgical Treatment on Respiratory Functions in Patients With Obstructive Sleep Apnea Syndrome Burak Kersin, Murat Karaman, Engin Aynacı, and Ahmet Keles
Changing Trends of Color of Different Laryngeal Regions in Laryngopharyngeal Reflux Disease Chen Du, Paige Thayer, Yan Yan, Qingsong Liu, Li Wang, and Jack Jiang
ENT - September 2020 - Intro
ENT - September 2020 - Cover1
ENT - September 2020 - Cover2
ENT - September 2020 - 489
ENT - September 2020 - 490
ENT - September 2020 - 491
ENT - September 2020 - 492
ENT - September 2020 - 493
ENT - September 2020 - 494
ENT - September 2020 - 495
ENT - September 2020 - 496
ENT - September 2020 - 497
ENT - September 2020 - 498
ENT - September 2020 - 499
ENT - September 2020 - 500
ENT - September 2020 - The Creation of a Sustainable Otolaryngology Department in Malawi Nathan Douglas Vandjelovic, Eric Masao Sugihara, Wakisa Mulwafu, and David Nathan Madgy
ENT - September 2020 - 502
ENT - September 2020 - Hazardous Grilling Due to Wire Brushes Nima A. Vahidi, Brenna A. Keane, Paul J. Whalen, and Anita Jeyakumar
ENT - September 2020 - 504
ENT - September 2020 - Guns n’ Noses: Endoscopic Removal of an Air-Gun Pellet Retained in the Frontal Sinus Dylan A. Levy, Andrew Y. Lee, Waleed M. Abuzeid, and Nadeem A. Akbar
ENT - September 2020 - 506
ENT - September 2020 - 507
ENT - September 2020 - Vitamin D Status in Egyptian Children With Allergic Rhinitis Khaled Saad, Abobakr Abdelmoghny, Mohamed Diab Aboul-Khair, Yasser Farouk Abdel-Raheem, Eman Fathalla Gad, Ahmed El-Sayed Hammour, Bahaa Hawary, Asmaa M. Zahran, Mohamd A. Alblihed, and Amira Elhoufey
ENT - September 2020 - 509
ENT - September 2020 - 510
ENT - September 2020 - 511
ENT - September 2020 - 512
ENT - September 2020 - Pediatric Epistaxis and Its Correlation Between Air Pollutants in Beijing From 2014 to 2017 Ying-Xia Lu, Jie-Qiong Liang, Qing-Long Gu, Chong Pang, and Chun-Lei Huang
ENT - September 2020 - 514
ENT - September 2020 - 515
ENT - September 2020 - 516
ENT - September 2020 - 517
ENT - September 2020 - Otomycosis With Tympanic Membrane Perforation: A Review of the Literature Petros Koltsidopoulos and Charalampos Skoulakis
ENT - September 2020 - 519
ENT - September 2020 - 520
ENT - September 2020 - 521
ENT - September 2020 - Simultaneous Bilateral Same-Day Endoscopic Myringoplasty Using Tragal Cartilage From One Ear Baklaci Deniz, Kuzucu Ihsan, Guler Ismail, Kum Rauf Oguzhan, and Ozcan Muge
ENT - September 2020 - 523
ENT - September 2020 - 524
ENT - September 2020 - 525
ENT - September 2020 - 526
ENT - September 2020 - 527
ENT - September 2020 - A Preliminary Report on the Investigation of Prestin as a Biomarker for Idiopathic Sudden Sensorineural Hearing Loss Changling Sun, Xiaolin Xuan, Zhi Zhou, Yuan Yuan, and Fei Xue
ENT - September 2020 - 529
ENT - September 2020 - 530
ENT - September 2020 - 531
ENT - September 2020 - A Retrospective Study to Identify the Relationship Between the Dimension of Osseous External Auditory Canal and Chronic Otitis Media Yi-Fang Lee, Pei-Yin Wei, Chia-Huei Chu, Wen-Huei Liao, An-Suey Shiao, and Mao-Che Wang
ENT - September 2020 - 533
ENT - September 2020 - 534
ENT - September 2020 - 535
ENT - September 2020 - 536
ENT - September 2020 - Investigation of the Effectiveness of Surgical Treatment on Respiratory Functions in Patients With Obstructive Sleep Apnea Syndrome Burak Kersin, Murat Karaman, Engin Aynacı, and Ahmet Keles
ENT - September 2020 - 538
ENT - September 2020 - 539
ENT - September 2020 - 540
ENT - September 2020 - 541
ENT - September 2020 - 542
ENT - September 2020 - Changing Trends of Color of Different Laryngeal Regions in Laryngopharyngeal Reflux Disease Chen Du, Paige Thayer, Yan Yan, Qingsong Liu, Li Wang, and Jack Jiang
ENT - September 2020 - 544
ENT - September 2020 - 545
ENT - September 2020 - 546
ENT - September 2020 - 547
ENT - September 2020 - 548
ENT - September 2020 - 549
ENT - September 2020 - 550
ENT - September 2020 - 551
ENT - September 2020 - 552
ENT - September 2020 - Cover3
ENT - September 2020 - Cover4
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