{'fraction_non_alphanumeric': 0.035691109669046074, 'fraction_numerical': 0.023750811161583386, 'mean_word_length': 4.772284644194756, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 2, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A CLINICAL AND MICROBIAL STUDY OF OTOMYCOSIS: AN ORIGINAL STUDY

Otomycosis or “Otitis externa myotica” refers to a fungal or yeast infection of the external auditory meatus. Fungi can be isolated in up to 40 percent of all cases of external otitis, especially “Aspergillus niger and Candida albicans”. It has a worldwide distribution with higher prevalence in the hot, humid and dusty climate of the tropical and subtropical regions and sometimes in association with immunosuppression and poor hygienic conditions. The purpose of this study is to analyse the etiology, clinical manifestations, microbial pattern of otomycosis and treatment.

For direct microscopy, a drop of 10% KOH aqueous solution (a keratolytic agent consisting of 10gms of potassium hydroxide, 10ml glycerine, distilled water 80ml mixed together and stored at room temperature) was used. Then further Gram's staining was done for identification of fungal elements.
For fungal culture SABOURAUD'S DEXTROSE AGAR MEDIA was used and the fungus was identified by the preparation of LACPHENOL-BLUE SOLUTION in MICROSLIDE culture. The pathological material was inoculated in a zig-zag manner on the SBD media and kept in incubator at 20 degree Celsius, and observed every alternated day for rate of fungal growth, general morphology of colony texture, surface pigmentation up to 6 weeks.
Micro slide culture enables the study of the arrangement of mycelium and spores at various stages during the course of growth without disturbing their natural arrangement and helps in species identification. Methods of treatment were by instillation of antifungal drops and by use of cotton wick or ribbon gauze impregnated with antifungal solution/cream. The following anti-fungal pharmacological agents were used randomly in treatment: 1. CLOTRIMAZOLE SOLUTION.
These modes of treatment were used for 7 days/3 weeks/4 weeks/6 weeks of duration. Follow up of patients were done daily for 3 days, on alternate days up to 2 weeks and once in 4 days up to 4 weeks.     They are all of the opinion that otomycosis is more prevalent during hot, humid season. The period between April to December are the summer and rainy months of Mysore. The excessive sweating during the summer months leads to the dilution of the ear wax and reduces its protective sleeve property. The pH of the E.A.C is shifted to alkaline side. All these factors favours the growth of fungi. 4 In the present study 90% of patients had otomycosis in a single ear and only 10% had the disease in both the ears. Otomycosis is more commonly present in the left ear (66%) in the present study.

RESULTS
The predisposing factors of otomycosis is trauma to E.A.C (70%) and the indiscriminate use of ear drops (65%) followed by swimming (30%), and other associated conditions (7%). In the present study, the nature of trauma to E.A.C is in the form of in advertent use of matchsticks, hair pins, safety pins, commercially available swabs, finger nails, poorly maintained mastoid cavities. The indiscriminate use of ear drops as a predisposing factor is 65% in the present study. Increased use of antibiotic-steroid drops, systemic and local steroid usage.
Increased moisture provides good environment for growth of fungi. In diabetes mellitus patients increased levels of glucose in the tissue may favour the growth of fungi in the E.A.C. in A.I.D.S patients decrease in the general and local immunity causes rapid and extensive invasion of the fungus in the deeper tissues (Munoz. A et al 1997). The incidence of swimming as predisposing factor of otomycosis in the present study is 30%. 5 In the present study 90% of patients presented with pain in the ear, 85% with itching, 70% with feeling of fullness or blocking of the ear, 42% with discharge from the ear, 40% with impaired hearing, 13% with tinnitus. The irresistible urge to scratch the ear canal with the fingertip or any sharp instruments like hair pins facilitates subepidermal invasion of fungi. 6 In present study, in 90% of cases the wax was significantly absent. Cerumen has fungicidal property. 7 In the present study the most common mycological picture was the presence of FUNGAL BALL, black mycotic plug/blotting paper like mass/wet newspaper like mass in 52 cases, greyish white material in the external auditory canal in 23 cases, yellowish coloured crusts/debris 5 cases, dry mat like appearance in 8 cases, and the other is mucopurulent discharge in 29 cases. 8 After adequate aural toilet all 100% cases showed congestion of the skin E.A.C. 52% of cases showed excoriation of EAC. 13% of cases showed narrowing of the EAC.22%of cases showed perforation of tempanic membrane as sequelae of CSOM .10% of cases showed retracted TM, 9% of cases had granulation in EAC. Auricular tenderness could be elicited in 65% of cases. In the present study tympanic membrane perforation and granulations were 22 and 9% respectively. 8 It was observed that otitis externa was associated in 72% of otomycosis cases 9 . Regarding the fungal species distribution Aspergillus species was found in 79% of cases, Aniger-61%, A. fumigatus -13%, A flavus -5%.The next predominant species was candida albicans -15%. Baruah and Agarwal (1972) found that Aspergillus was the most common fungus found in their studies of CSOM cases. 10 The present study revealed that 36% cases were associated with pathogenic bacteriae and 64% cases were bacteriologically negative. Staphylococcus aureus accounted for 31%, staphylococcus Albus accounted for 3%, Pseudomonas-16%, proteus-14%, klebsiella-13%, E.coli-6%, Streptococci-6%, Diphtheriodes-13.5%, mixed-3% of the bacteriologically positive cases. 2,3,6 TREATMENT: Clotrimazole topical ear drops were used in 60 patients. 40 patients (67%) were cured, 10 patients (17%) showed improvement, 5 patients (8%) did not improve, 5 patients (8%) did not come for follow up. According to Jordon c stern et al. (1988), clotrimazole was effective against 75% of fungi. Clotrimazole had the greatest zone of inhibition (>22mm) and also has broad spectrum of activity against fungi 2,3 .
Miconazole ear drops were also used as treatment in 25 patients of which 14 patients (56%) got cured, 5 patients (20%) showed improvement, 3 patients (12%) did not respond, 3 patients did not come for follow up. Miconazole had 19-22mm fungal growth inhibition in culture studies 6 .
It was also observed that silver sulphadiazine showed a marked degree of zone of fungal growth inhibition >22mm 11,12 .
CONCLUSION: In the present study entitled "A clinical and microbial study of otomycosis" was carried out on 100 otomycosis cases in the department of ENT Krishna Ragendra hospital, Mysore medical college, Mysore.

OTOMYCOSIS:
 Was found to b common in males in the age group between 11 -30 yrs.  Incidence was predominant during April to December months.  Predominantly unilateral in nature.  Occupational incidence was more common among agriculturist and labourers.  Trauma to EAC, indiscriminate use of antibiotic steroid ear drops and swimming are all predisposing factors.  Most common presenting complaint was pain in the ear followed by feeling of fullness or blocked sensation in the ear.  The most common otoscopic findings were the presence of wet newspaper like blackish fungal debris and congestion in the EAC.  Aspergillus Niger was the most common fungal pathogen isolated.  Meticulous cleaning of the EAC by dry mopping, suction clearance and otomicroscopic suction clearance and instillation of antifungal and antibiotic ear drops was the mainstay of treatment.  The most effective topical antifungal agent was clotrimazole eardrops followed by Miconazole ear drops, silver sulphadiazine ointment.