Fungal Malignant Otitis Externa: A Systematic Review

Malignant otitis externa (MOE) is a rare but serious condition primarily caused by Pseudomonas aeruginosa. Fungi, particularly in immunocompromised individuals, can also be a contributing factor. A systematic review was conducted, following PRISMA guidelines, to evaluate the literature on fungal malignant otitis externa (FMOE), focusing on its etiology, patient demographics, clinical presentation, and treatment. Out of 464 articles identified, 10 were analyzed in detail, involving 197 patients with a mean age of 65.9 years. Of the total patients, 143 were male (72.6%), 52 were female (26.4%), and the gender of the remaining two was not specified. One hundred and fifty-five patients (78.7%) had underlying immunosuppressive conditions such as diabetes mellitus, chronic kidney failure, corticosteroid use, chemotherapy, and AIDS. Fungal cultures were positive in 107 cases (54.3%), with Candida and Aspergillus species being present in nearly equal proportions. There were no significant differences between fungal and non-fungal MOE in terms of clinical presentation and diagnostic methods. Conservative treatment was used in 179 patients (90.8%), with 172 of them (87.3%) receiving antifungals. Itraconazole and voriconazole were the most common antifungals, while amphotericin B was less frequently used due to side effects. In some cases, antifungals were combined with antibiotics. Surgical interventions were performed in 35 patients (17.8%), and hyperbaric oxygen therapy was used in 34 of them (17.3%). Eight patients with FMOE died, and the mortality rate was 4%. Late diagnosis, cranial nerve involvement, and inadequate treatment may contribute to higher mortality. Given the potential underdiagnosis of FMOE, early incorporation of antifungal medications into empirical treatment protocols could improve outcomes for patients with a poor prognosis.