Role of oral antifungal in treatment of malignant otitis externa in diabetic patients
DOI:
https://doi.org/10.61529/idjp.v35i2.525Keywords:
Fungal malignant otitis externa, diabetes mellitus, oral antifungal, voriconazole, itraconazole, HRCT temporal bone, Gallium scan, Technetium scan, otorrhea, treatment failureAbstract
Background: To assess specific oral antifungal therapy effectiveness in diabetic patients with fungal malignant otitis externa (FMOE) not responding to early intravenous antibacterial treatment.
Material and Methods: This cross-sectional study was conducted at Nishtar Hospital Multan (September 2025–February 2026) on 78 diabetic patients with confirmed FMOE. Inclusion criteria included persistent otorrhea despite ≥7 days of IV ceftazidime, positive fungal culture, and HRCT evidence of temporal bone osteitis. After failed ceftazidime therapy, patients received oral voriconazole or itraconazole based on susceptibility testing. Response was assessed clinically and with Technetium-99m and Gallium-67 scans at 6 and 10 weeks.
Results: Out of 78 patients, 67 (85.9 percent) had clinical improvement using oral antifungals by week 6. Mean days to symptom improvement were 9.3 ±2.7 days. Radiological resolution of Technetium and Gallium scans correlated strongly with clinical response (p < 0.001). No major significant difference existed in results of diabetes types (p = 0.42) or genders (p = 0.61). Side effects were not severe, notably showing increased LFTs in 6 patients managed with regular dose adjustment.
Conclusion: Oral antifungal therapy is overall effective in diabetic patients with fungal malignant otitis externa unresponsive to traditional antibacterial treatment. Technetium-99m and Gallium-67 scans remain further useful when measuring response to therapeutic use in an outpatient clinical environment.
Keywords: Diabetes mellitus, fungal malignant otitis externa, Gallium scan, HRCT temporal bone, Itraconazole, otorrhea, Oral antifungal, Voriconazole, Technetium scan, Treatment failure
References
Treviño González JL, Reyes Suárez LL, Hernández de León JE: Malignant otitis externa: An updated review. Am J Otolaryngol. 2021, 42: 102894. DOI: https://doi.org/10.1016/j.amjoto.2020.102894
Qin S, Xiao W, Zhou C. Pseudomonas aeruginosa: Pathogenesis, virulence factors, antibiotic resistance, interaction with host, technology advances and emerging therapeutics. Signal Transduct Target Ther. 2022, 7: 199. DOI: https://doi.org/10.1038/s41392-022-01056-1
Hasibi M, Ashtiani MK, Motassadi Zarandi M. A treatment protocol for management of bacterial and fungal malignant external otitis: A large cohort in Tehran, Iran. Ann Otol Rhinol Laryngol. 2017, 126: 561-7. DOI: https://doi.org/10.1177/0003489417710473
Page MJ, McKenzie JE, Bossuyt PM. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021, 372: n71. 10.1136/bmj.n71. DOI: https://doi.org/10.1136/bmj.n71
Abu Eta R, Gavriel H, Stephen K, Eviatar E, Yeheskeli E. The significance of tissue biopsy for fungi in necrotizing otitis externa. Eur Arch Otorhinolaryngol. 2018, 275: 2941-5. DOI: https://doi.org/10.1007/s00405-018-5151-9
Korbi AE, Houas J, Kolsi N. Fungal necrotizing external otitis: Diagnosis, management and outcomes of 15 cases. Pan Afr Med J. 2022, 42: 306. DOI: https://doi.org/10.11604/pamj.2022.42.306.27168
Hamzany Y, Soudry E, Preis M. Fungal malignant external otitis. J Infect. 2011, 62: 226-231. DOI: https://doi.org/10.1016/j.jinf.2011.01.001
Cho WS, Bonduelle Q, Ghasemi A. Prognosticating patients with necrotising otitis externa based on response to treatment. Ann R Coll Surg Engl. 2021; 103: 285-90. DOI: https://doi.org/10.1308/rcsann.2020.7133
Peled C, Novoa R, El-Saied S, Sadeh R, Novack V, Kaplan DM. Computer tomography findings in necrotizing otitis externa based on the offending pathogens. Eur Arch Otorhinolaryngol. 2021, 278: 4707-13.
DOI: https://doi.org/10.1007/s00405-020-06583-7
Halwani C, Mtibaa L, Hamdi ME, Baccouchi N, Benmhamed R, Jemli B, et al. A retrospective study of 43 cases of fungal malignant external otitis. Pan Afr Med J. 2022, 41:287. DOI: https://doi.org/10.11604/pamj.2022.41.287.29585
Marchionni E, Parize P, Lefevre A. Aspergillus spp. invasive external otitis: Favourable outcome with a medical approach. Clin Microbiol Infect. 2016, 22: 434-7. DOI: https://doi.org/10.1016/j.cmi.2015.12.027
Yigider AP, Ovunc O, Arslan E, Sunter AV, Cermik TF, Yigit O. Malignant otitis externa: How to monitor the disease in outcome estimation?. Medeni Med J. 2021; 36:23-9. DOI: https://doi.org/10.5222/mmj.2021.36528
Sideris G, Latzonis J, Avgeri C, Malamas V, Delides A, Nikolopoulos T. A different era for malignant otitis externa: The non-diabetic and non-immunocompromised patients. J Int Adv Otol. 2022; 18: 20-4. DOI: https://doi.org/10.5152/iao.2022.21313
Walton J, Coulson C. Fungal malignant otitis externa with facial nerve palsy: tissue biopsy AIDS diagnosis. Case Rep Otolaryngol. 2014, 2014: 192318. DOI: https://doi.org/10.1155/2014/192318
Ahmed AA, Rashid S, Gupta VK, Molony NC, Gupta KK. The diagnostic conundrum in necrotizing otitis externa. World J Otorhinolaryngol Head Neck Surg. 2024, 10:59-65. DOI: https://doi.org/10.1002/wjo2.100
de Souza SA, Laurindo RS, Gutfilen-Schlesinger G, Felix F, Amarante Junior JL, Gutfilen B. The use of (99m) Tc-mononuclear leukocyte scintigraphy for necrotizing external otitis diagnosis. Diagnostics (Basel). 2023, 13 (3): 570. DOI: https://doi.org/10.3390/diagnostics13030570
Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005, 87: 2464-71. DOI: https://doi.org/10.2106/jbjs.d.02691
Hedayati MT, Pasqualotto AC, Warn PA, Bowyer P, Denning DW. Aspergillus flavus: human pathogen, allergen and mycotoxin producer. Microbiology (Reading). 2007; 153: 1677-92.
DOI: https://doi.org/10.1099/mic.0.2007/007641-0
Vitiello A, Ferrara F, Boccellino M. Antifungal drug resistance: an emergent health threat. Biomedicines. 2023, 11 (4): 1063. DOI: https://doi.org/10.3390/biomedicines11041063
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Muhammad Sharif Shahid
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
