ENT - September 2020 - 519

Koltsidopoulos and Skoulakis

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The found articles were analyzed with regard to the rate of
tympanic membrane perforation in patients with otomycosis.
The search focused also on the difficulties regarding the conservative treatment of otomycosis related to this complication. Finally, the included studies were analyzed regarding
the incidence of persistent TM perforation after failure of
conservative treatment.

Results
We included 10 articles concerning the clinical entity of
tympanic membrane perforation secondary to otomycosis. The
initial search using the terms ''otomycosis'' and ''tympanic
membrane perforation'' yielded 19 citations of which 6 failed
to meet the inclusion criteria and 3 were not published in the
English language. Moreover, 2 articles were excluded because
they were case reports. Finally, 3 articles were excluded
because they reported treatment of otomycosis with a previously perforated TM. The remaining 5 studies were included in
the review. The use of the rest search terms and the hand-search
yielded 5 additional studies, bringing the number of articles
meeting the inclusion criteria to 10 (Figure 1). The articles
were either case series or clinical trials.6-8,10-16

Rate of Tympanic Membrane Perforation
Table 1 summarizes the incidence of TM perforation of each
study. In total, there were 928 patients included. Rates of TM
perforation rates in patients with otomycosis varied from 0% to
16.67%.11,14
It is clear that studies in the literature use similar criteria
in order to define that a TM perforation is etiologically
associated with the fungal infection and is not a preexisting
condition. Namely, all authors agree that TM perforations
should be considered as a complication of otomycosis fungal infection if they are present during the initial presentation and healed with the resolution of infection or if they are
observed to occur during the course of treatment. Moreover,
in many studies, the absence of ear problems was considered as a clue that the complication is due to the otomycosis. Two authors did not mention the criteria on which the
causal relationship between TM perforation and otomycosis
was based.13,15

Rate of Persistent TM Perforation
In most of the studies, there was no report on the percentage
of TM perforations secondary to otomycosis that resolved
with conservative therapy. Only 3 studies evaluated the efficacy of conservative therapeutic approach.6,8,16 All of them
demonstrated that most perforations tend to heal when the
ear becomes free of fungal external otitis. Table 1 summarizes the results of each study. In total, there were 51
patients included. The range of persistent TM perforation
rates in patients with otomycosis varied from 5.5% to
27%.6,16 Most of the cases of persistent TM perforation

Figure 1. Flowchart of the reviewing process.

Table 1. Summary of Articles on Tympanic Membrane Perforation
Secondary to Otomycosis.
Author
Visvanatha et al10
Barati et al11
Anwar and Gohar 12
Pradhan et al13
Kurnatowski and Filipiak7
Jia et al14
Ozcan et al15
Ho et al6
Hurst8
Song et al16

No. of No. of Cases No. of Cases With
Ears
With TMP
Persistent TMP
100
118
180
107
96
108
87
132

3 (3%)
0 (0%)
28 (15.5%)
17 (15.8%)
12 (12.5%)
18 (16.67%)
3 (3.4%)
18 (14%)
22
11

NA
NA
NA
NA
NA
NA
NA
1 (5,5%)
3 (13,6%)
3 (27%)

Abbreviations: NA, not available; TMP, tympanic membrane perforation.

ENT - September 2020

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