Administration of 1% topical voriconazole drops was effective and safe in the treatment of refractory otomycosis without tympanic membrane perforation

Abstract

Background: Refractory otomycosis is a common condition that is difficult to treat. Objectives: This study aimed to evaluate the effectiveness of 1% topical voriconazole drops in the treatment of otomycosis. Methods: This retrospective analysis was conducted from November 2017 to November 2019. Patients who had refractory otomycosis without tympanic membrane perforation confirmed by microbial culture and fluorescent staining were included in the study. All patients were treated with 1% topical voriconazole drops hourly at daytime for 2 weeks. Evaluation of effectiveness was conducted 1 month after the completion of topical voriconazole treatment. Before and after topical voriconazole treatment, hearing tests were performed in all patients. Results: Fifty-five patients were included in this study. The reasons for refractoriness were resistant recurrence to imidazole drugs (50 cases, 90.9%) and difficulty in cleaning the external auditory canal (5 cases, 9.1%). The most common strain was Aspergillus terreus (50.9%), followed by Aspergillus flavus (29.1%), Aspergillus niger (10.9%), and Aspergillus fumigatus (9.1%). After 2 weeks of treatment with 1% topical voriconazole drops, otomycosis in all patients was resolved. There was no significant change in bone conduction before and after topical voriconazole treatment (paired t-test, P = 0.5023; linear correlation analysis, R2 = 0.98; equation, y = 1.003 x−0.284). Adverse effects, such as blurred vision and phototoxicity, were not observed in any patient. Conclusions: Administration of 1% topical voriconazole drops was effective and safe in the treatment of refractory otomycosis without tympanic membrane perforation within 2 weeks.

Identification of the Fungal Community in Otomycosis by Internal Transcribed Spacer Sequencing

“…Therefore, a longer observation may be needed in the future. Previously, the effects of antifungal agents are studied mostly by observing clinical symptoms and signs ( Lee et al, 2021 ; Zhang et al, 2021 ). The present study evaluated the efficacy of bifonazole not only through clinical symptoms and signs but also fungal community detection.…”

“…However, fungal communities in otomycosis may vary in different areas and in patients with or without underlying conditions. For example, according to studies in Iran ( Sabz et al, 2019 ; Kiakojuri et al, 2021 ), Aspergillus tubingensis (18/45 cases), not A. niger (6/45), is dominant in otomycosis in western China ( Zhang et al, 2020 ), while Aspergillus terreus is a dominant fungus in Hangzhou, a city in southeast China ( Zhang et al, 2021 ). In a coastal city in India, both A. niger and Aspergillus fumigatus are dominant ( Prasad et al, 2014 ).…”

Relapsing Aspergillus otomycosis despite prolonged systemic antifungal therapy and resolution after topical voriconazole administration: A case report

“…While topical voriconazole has been utilised in occasional case reports for the treatment of refractory Aspergillus otomycosis [ 5 , 6 ], to the best of our knowledge, this is the first report of topical voriconazole succeeding in eradication of otomycosis where systemic triazole antifungals have failed. In previous cases, topical voriconazole was utilised after failure of repeated treatments with other topical antifungals (eg.…”

“…In previous cases, topical voriconazole was utilised after failure of repeated treatments with other topical antifungals (eg. nystatin, clotrimazole) [ 5 , 6 ]; systemic triazoles were not utilised due to concern regarding tolerability and side effects. Our patient could not tolerate systemic voriconazole due to side-effects, and alternative systemic triazoles (posaconazole, isavuconazole) were utilised instead.…”

“…While favourable outcomes have been reported in the literature with usage of oral voriconazole for Aspergillus otomycosis [ 3 , 4 ], systemic antifungal treatment is often utilised only after topical therapy has failed, due to concerns of tolerability and side effects. Topical voriconazole has been utilised in case reports as an alternative option for treating refractory otomycosis failing to respond to usual therapeutic options [ 5 , 6 ]; though otic administration of topical voriconazole is not a conventional mode of drug delivery, and at present is not licensed for such use [ 7 ]. We report a case of intractable Aspergillus otomycosis with multiple relapses despite conventional topical and systemic antifungal treatment, and adjunctive usage of hyperbaric oxygen therapy.…”