Mycology of chronic suppurative otitis media-cholesteatoma disease: An evaluative study

Accepted Manuscript Mycology of chronic suppurative otitis media-cholesteatoma disease: An evaluative study

Gautam Bir Singh, Medozhanuo Solo, Ravinder Kaur, Rubeena Arora, Sunil Kumar PII: DOI: Reference:

S0196-0709(17)30740-8 doi:10.1016/j.amjoto.2017.12.001 YAJOT 1939

To appear in: Received date:

17 September 2017

Please cite this article as: Gautam Bir Singh, Medozhanuo Solo, Ravinder Kaur, Rubeena Arora, Sunil Kumar , Mycology of chronic suppurative otitis media-cholesteatoma disease: An evaluative study. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajot(2017), doi:10.1016/ j.amjoto.2017.12.001

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ACCEPTED MANUSCRIPT MYCOLOGY OF CHRONIC SUPPURATIVE OTITIS MEDIA-

Dr. Gautam Bir Singh. MS1 Professor

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CHOLESTEATOMA DISEASE: An Evaluative Study

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Dr Medozhanuo Solo. MBBS2 Junior Resident

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Dr.Ravinder Kaur. MD3 Director Professor & Chief

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Dr. Rubeena Arora. MS, DNB4 Senior Resident

1,2,4,5,

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Dr.Sunil kumar. MS, DNB5 Director Professor & Chief

Department of Otorhinolaryngology-Head & Neck Surgery 3 Department of Microbiology

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Lady Hardinge Medical College & Associated Hospitals Shaheed Bhagat Singh Marg, New Delhi-110001. INDIA

#Address for Communication: Professor (Dr) Gautam Bir Singh House No: 1433/Sector: 15 Faridabad-121007 [NCR]. Haryana. INDIA Mobile: +91-9818836242 E-Mail: [email protected] Phone: +91-0129-4012368/ 4007550

ACCEPTED MANUSCRIPT ABSTRACT

Aims & Objectives:To detect the prevalence of fungus in chronic suppurative otitis mediacholesteatoma disease and to evaluate its clinical significance. Study Design: Prospective observational study conducted in a sample size of 46 patients at

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a tertiary care university teaching hospital.

Materials & Methods: Forty six patients suffering from chronic suppurative otitis media-

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cholesteatoma disease were recruited in this prospective study. Data was duly recorded.

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Cholesteatoma sample was procured at the time of mastoid surgery and microbiologically analysed for fungal infestation. Clinical correlation to fungus infestation of cholesteatoma

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was statistically analysed.

Results: Out of the recruited 46 patients, post-operatively cholesteatoma was seen in 40 cases only. Seventeen i.e. 42.5% of these cases had fungal colonization of cholesteatoma.

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Further a statistically significant correlation between persistent otorrhoea and fungal infestation of cholesteatoma was observed. Three cases of fungal otomastoiditis were also recorded in this study, but a statistically significant correlation between complications and

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fungus infestation of cholesteatoma could not be clearly established.

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Conclusions: There is fungal colonization of cholesteatoma which is pathogenic and can

KEY WORDS

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cause persistent otorrhoea.

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Cholesteatoma; Mycosis

ACCEPTED MANUSCRIPT INTRODUCTION Chronic suppurative otitis media [CSOM] is broadly classified as cholesteatoma and mucosal disease. Bacteriologically, both aerobic and anaerobic bacteria are found in cholesteatoma. However, standard text mentions nothing about the fungal colonisation of cholesteatoma. Fungal infections of the ear in immunocompetent patients are mainly observed and described as mycosis within the external auditory canal. It is assumed that

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fungus has no significant role to play in CSOM It would be pertinent to note that chronic diseases generally show a tendency for

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fungal colonisation. Chronic rhinosinusitis in ENT is a classical example of this.[1] Thus; chronic suppurative otitis media should be no exception to this dictum. Moreover,

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Cholesteatoma contains keratinous debris, which is probably an ideal medium for saprophytic fungal colonisation.[2,3] In addition, the rampant use of topical steroids for

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treatment of CSOM may also be an important predisposing factor for fungal infection in ear. Inspite of the aforementioned facts, the subject of fungal colonization of

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cholesteatoma has not been extensively researched.In a massive internet search by MEDLINE/PUBMED services; authors could find only two studies which have cultured fungus from cholesteatoma.[2,4] Furthermore, fungus is a growing phenomenon with huge

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social and economic implications due to increase morbidity, mortality and cost of treatments, and in terms of hospital stay. It is necessary; therefore to decipher the clinical impact of

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fungus colonization of cholesteatoma. With this background, we present this study on the fungal colonization of cholesteatoma in a prospective study design and discuss its clinical

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implications.

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MATERIALS AND METHODS This prospective observational study on fungal colonisation of cholesteatoma was carried out at the ENT department of our tertiary care university teaching hospital during the period October 2015 to April 2017. The study was approved by the Medical Division of the University Board of Studies. The study sample comprised 46consecutive patients of either sex in the age group of 7-50 years diagnosed clinically as CSOM- cholesteatoma disease. An informed consent was mandatory. Further, patients with previously operated ear, any congenital anomalies(eg. cleft lip, cleft palate and syndromal diagnosis) and pregnant females were excluded from the study design.

ACCEPTED MANUSCRIPT All patients underwent a detailed clinical evaluation and data was recorded in a Proforma. Cholesteatoma was clinically diagnosed by microscopic examination of the ear. Prior to surgery, CT scan and Pure tone audiometry were done in all the patients. All the patients underwent mastoid ear surgery under general anaesthesia after the requisite investigations and anaesthetic clearance. Canal wall up or down mastoid surgery was done according to the extent of the cholesteatoma in each case. Patients also underwent tympanoplasty using temporalis fascia and cartilage graftin the same sitting.

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MICROBIOLOGICAL CULTURE TECHNIQUE:

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The cholesteatoma debris were collected by a sterile forceps during surgery and transported to the Microbiology department in a sterile container. Bacterial and mycological analysis was

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done in all the samples.

Fungal analysis: Microscopic examination was done using 10% KOH and Gram’s stain to

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look for fungal hyphae/elements at 40x and 10x microscopy. The remainder specimen was cultured on two sets of Sabouraud’s Dextrose Agar with chloramphenicol 0.05g/L and

Bacterial analysis:

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gentamycin 0.02mg/ml and incubated at 370C and 250C for 6 weeks for fungal growth.[5] Microscopic examination was done using Gram’s stain at 10x

incubated at 370C for 24 hrs.

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microscopy. The remainder specimen was cultured on blood agar and Mac Conkey’s agar,

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Identification of cultures was done on the basis of colony morphology, microscopy, biochemical and other tests as per standard procedures.[5]

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Clinical interpretation of the collected data was statistically done using chi-square test

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[SPSS version 20], in accordance with evidence based medicine.

RESULTS :

Of the 46 patients with a presumptive diagnosis of CSOM-cholesteatoma disease, which were recruited in the study design, only 40 patients were found to have cholesteatoma after surgical intervention. The data analysis is being presented for these 40 casesas per study protocol. Out of the 40 patients, 24 were males and 16 were females. The clinical presentation of these cases is summarized in Table 1. All the cases presented had otorrhoea. Out of these, 11 cases had persistent otorrhoea (i.e these cases did not respond to culture specific antibiotic therapy or their culture was sterile). It would be prudent to note that 6 of these 11

ACCEPTED MANUSCRIPT cases had extracranial complications: 4 had post auricular abscess, and one case each of Facial palsy and Bezold’s abscess was detected. No case of intracranial complication was noted in this series. Based on the extent of cholestetoma: 37 patients underwent CWD mastoid surgery and 3 patients underwent CWU mastoid surgery: with tympanoplasty as mentioned earlier. The patients with extracranial complications were also addressed with requisite surgical

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intervention in the same sitting. A regular follow-up was maintained for 6 months in all the cases. Three cases were

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detected to have failed tympanoplasty. All these cases refused revision tympanoplasty surgery (probably due to dry ear effect). None of the cases had any residual disease at this

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time. All the patients who had fungal infestation were put on antifungal drops (clotrimazole+steroid) for duration of 4 weeks post operatively. Patients with fungal

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otomastoiditis (3 cases in this study) were treated with systemic antifungal drugs along with surgery.

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Out of 40 samples, fungus was isolated in 11 cases (27.5%), bacteria in 22 cases (55%), both fungi and bacteria in 6 cases (15%) and no growth was obtained in 1 case. Details of bacterial and fungal growth are given in Table 2 and Table 3respectively.Proteus

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and Pseudomonas were the commonest bacteria to be isolated from cholesteatoma. Fungal microbiology revealed that Aspergillosis and Candida were the two commonest types of

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DISCUSSION

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fungal isolates in this study.

There is marked paucity of literature on mycology of cholesteatoma. A brief synopsis

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of the studies on mycology of cholesteatoma is given in Table 4. From the table it is evident that the incidence of fungal infestation in cholesteatoma varies from as low as 1.4% to as high as 89%.However, it would be important to note that only two studies: Effat & Madany and Vennewald et al. have cultured fungus from keratin debris in small sample size of 19 & 15 patients respectively.[2,4] Other studies have analysed fungus in conventional ear swabs.6,7,8,9 Routine cultures from the ear are not conclusive and therefore do not indicate the real pathogens. Histopathological examinations and/or intra-operative cultures are the gold standard. In this study using the aforesaid methodology, fungal species were detected in 17 of our 40 cases who underwent primary mastoid surgery for cholesteatoma disease i.e. 42.5% cases had a positive fungal culture. This high prevalence in Indian subcontinent may

ACCEPTED MANUSCRIPT be attributed to two important factors: population explosion and advances in medical care leading to increase in the incidence of opportunistic fungi. [A] Source of Fungal infestation in cholesteatoma Four routes of entry of fungal infection to the middle ear are mentioned in the literature: tympanogenic, meningogenic, hematogenic and nasopharyngeal.[10] As most of our cases belong to the mold category, it is reasonable to conclude that

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cholesteatoma got infected as a result of environmental spores.[2,4,7,10,11] This fungal spore infestation may be from external auditory canal or via the eustachian tube. Further, the

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use of topicalsteroids in chronic suppurative otitis media [CSOM] may also act as an

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important predisposing factor for colonization of cholesteatoma with fungus. All our cases had protracted CSOM with a history of long term use of antibiotics & steroid ear drops. Ear discharge in CSOM may itself lead to maceration of the meatal epithelium leading to a

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favourable environment for fungal colonization of external auditory canal as some species use discharged mucus as a nutrient.[4]Thisinfection may later on transcend to the middle

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ear.

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[B] Pathogenicity of fungal infestation in Cholesteatoma

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It is difficult to conclude whether fungal colonization of cholesteatoma is a clinically relevant infection or a mere colonization. Hall and Farrior classified Aspergillus infection in temporal bone as:[12,13]

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1. Non invasive-localized and does not invade tissue, responds to conservative removal.

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2. Invasive-bony invasion with granulomatous response and fibrosis. Occurs in immunocompetent patients.

3. Fulminant-tissue and angioinvasion with no granulomatous response. Occurs in immunocompromised patients.

The current principles of mycological infection state that any fungus is capable of becoming an opportunistic pathogen. This depends on the virulence factor of the fungus which is determined by[14] 1. Size of the organism 2. Ability to grow at 370 centigrade at neutral pH. 3. Toxin production

ACCEPTED MANUSCRIPT 4. Conversion of Fungus from mycelium form to corresponding yeast or spherule form. Hence, the fungus infestation of ear should be viewed seriously, as every fungus has the potential to cause fungal disease in ear. The predominance of thermophillic Aspergillus and Candida species in our series is related to the inflammatory process. Cholesteatoma is a keratin containing sac surrounded by matrix [keratinising epithelial layer] and an adjacent sub epithelial connective tissue with

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mucosal epithelial layer boundary [peri-matrix].[2,15] A chronic inflammatory reaction in the perimatrix may be caused by bacterial invasion.[16,17] The presence of pathogenic fungi in

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this perimatrix may be responsible for the progression of CSOM in immunocompetent

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patients by the following mechanisms:

1. Mycotoxicosis: by toxic metabolites released by the fungus.

acquired immune responses.[18]

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2. Common saprophytic fungi release pro-inflammatory cytokines through innate and

3. Fungi and bacteria may interact symbiotically against the host defences and

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antimicrobials.[19]

4. Fungal products may cause epithelial cell desquamation.[20] 5. Hypersensitivity reactions. Type I & Type III.

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growth and expansion.

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In general, fungi enhance the pathogenicity of the cholesteatoma by maintaining its

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[C] Clinical implication of fungal infestation of cholesteatoma We believe that there are clinical implications of fungus in cholesteatoma perimatrix:

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1. It may be responsible for a persistently discharging ear as antibiotic therapy would be inadequate to eradicate the fungal infection. In this study, out of 40 cases, 11 had persistent ear discharge and 9 had fungal presence in cholesteatoma. Rest of the 8 cases which tested positive for fungus had no persistent discharge. A statistical analysis [Table 5] of this data reveals a significant “p” value, thereby implying that fungal infestation of cholesteatoma might lead to persistent ear discharge. However, we cannot exclude the fact that the association between fungus and CSOMcholesteatoma disease in this study might be the result of and not the cause of CSOM, as persistent ear discharge itself serves as an ideal saprophytic medium for fungal growth.

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2. It may be responsible for malodorous ear discharge. Usually the cause of fetor is attributed to anaerobic infection.[21]However anaerobic bacteria have seldom been cultured from middle ear with cholesteatoma.[2] We failed to culture anaerobic bacteria in this study as well. Interestingly, it would be imperative to note that the offensive odour in atrophic rhinitis has been attributed to saprophytic fungus.[22]

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3. Though sporadic, complications have been reported in medical literature secondary to fungal infestation of cholesteatoma in immunocompetent patients. Otomastoiditis

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with facial nerve palsy, allergic fungal otomastoiditis and fungal petrous apicitis have been mentioned in literature.[12,23-26]In this context, it would be imperative to note

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that we recorded fungal infestation in 3 out of the 6 cases of extracranial complications in this study. No case of intracranial complication was recorded in this study. These were all cases of fungal Otomastoiditis which presented as post

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auricular abscess, “Bezold’s” abscess and facial nerve palsy. All our patients were immunocompetent and had protracted CSOM with persistent ear discharge as

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reported in medical literature for fungal otomastoiditis.

All these patients were

treated with systemic antifungal drugs and canal wall down mastoid surgery. This data was statistically analysed [Table 6] by “Chi-Square test” to detect any causal

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relationship with mycology of cholesteatoma. The value of “p” [p=0.68] was not found

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to be significant. Hence, the present study failed to elucidate any relationship between complications and fungal infestation of cholesteatoma. Nevertheless, a high index of suspicion is necessary for early diagnosis of fungal otomastoiditis, especially

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in patients with protracted CSOM presenting with extracranial complications.

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4. Although evaluating the role of fungi in recurrent cholesteatoma was not a part of this study, some facts merit mention. Cholesteatoma epithelium has

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characteristic of migration: this may lead to dissemination of fungal infection in the middle ear cavity.[27]A study by Gluth et al. evaluated the microbiological profile of tympanomastoid cavities in 121 cases of revision mastoid surgery.[28] Their study had 78 cases of cholesteatoma. Over all, they found 10 cases [14%] of fungal infestation: 6 Candida and 4 Aspergillosis. However, their study failed to establish any causal relationship between fungus infestation and cholesteatoma. Insufficient and delayed epithelization of the mastoid cavity post-operatively could be due to fungal infestation. However, we recorded no residual/recurrent cholesteatoma in this case study. In this context, we would like to highlight that all our patients with fungal

ACCEPTED MANUSCRIPT infestation of cholesteatoma were treated with topical antifungals for duration of 4 weeks post-operatively and patients with fungal otomastoiditis were given a course of systemic antifungals along with requisite surgery. Our study thus leads us to speculate whether antifungal treatment should be given post-operatively in cases where fungus is detected in cholesteatoma to eradicate the residual fungal disease? It would also be important to note that surgery can have immunoparetic effect which can stimulate pathogenicity in previously quiescent fungi, if antifungal treatment is not

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given. This so called ‘Forest Fire Phenomenon” is an important cause of Fungal

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Petrous Apicitis.[26]

To our knowledge this comprehensive study has the largest number of cholesteatoma

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cases analysed for fungal infestation in the contemporary medical literature. Our observations are robust, on account of prospective study design. The statistical evaluation of

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data is in accordance with evidence based medicine. This cohort study has increased statistical power because of high case volume. Finally, a relatively unique finding of this study is the correlation of persistently discharging ear to fungus infestation of cholesteatoma,

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hitherto unreported in medical literature.However, there are caveats to the study design. The sample represents a population referred to a tertiary care centre. Thus, the prevalence rates may not be representative of the general population. Moreover, being an observational

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study, potential bias (e.g. selection bias) and confounding may have crept in. Clearly, more

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prospective evidence based studies are required to detect the prevalence and incidence of fungus in cholesteatoma as it has a strong geographical bias. Nevertheless, the study amalgates the realities of clinical practice with rigors of scientific analysis of data and thus may invite future research on some key queries inherent to the study:Should all cases of ear

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discharge recalcitrant to antibiotic treatment be tested for fungal aetiology? What should be the role of antifungal treatment if fungi are found infesting cholesteatoma? Can such cases

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be potential cases of residual/recurrent cholesteatoma?

CONCLUSIONS From the above discussion we conclude that microbiologically fungus too is an intrinsic and pathologically significant contaminentof CSOM-cholesteatoma disease, though the exact mechanism by which chronic inflammation and fungal infection promote each other remains unclear.

ACCEPTED MANUSCRIPT REFERENCES Healy DY, Leid JG, Sanderson AR, Hunsaker DH. Biofilms with fungi in chronic rhinosinusitis. Otolaryngol Head Neck Surg.2008;138(5):641-7.

[2]

Effat KG, Madany NM. Mycological study on cholesteatoma keratin obtained during primary mastoid surgery. J Laryngol Otol. 2014;128(10):881-884.

[3]

Bottone EJ, Hong T, Zhang DY. Basic mycology underscoring medically important fungi. OtolaryngolClin North Am. 1993;26(6):919-40.

[4]

Vennewald I, Schönlebe J, KlemmE.Mycological and histological investigations in humans with middle ear infections. Mycoses. 2003;46(1-2):12-18.

[5]

Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC, Jr.Color atlas and textbook of diagnostic microbiology. 5th ed. Philadelphia. Lippincott Williams & Wilkins; 1997.983-1057 p.

[6]

Ho AJ, Kim MN, Suk AY, Moon BJ. Preoperative, intraoperative, and postoperative results of bacterial culture from patients with chronic suppurative otitis media. OtolNeurotol. 2012;33(1):54-9.

[7]

Madana J, Yolmo D, Kalairasi R, Gopalakrishnan, Sujatha S. Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J PediatrOtorhinolaryngol. 2011;75(9):1104-8.

[8]

Ricciardiello F, Cavaliere M, Mesolella M, Iengo M. Notes on the microbiology of cholesteatoma: clinical findings and treatment. ActaOtorhinolaryngol Ital. 2009;29(4):197-202.

[9]

Attallah MS. Microbiology of chronic suppurative otitis media with cholesteatoma. Saudi Med J. 2000;21(10):924-7.

[10]

Murakami A, Tutumi T, Watanabe K. Middle ear effusion and fungi. Ann OtolRhinolLaryngol. 2012;121(9):609-14.

[11]

Neeff M, Biswas K, Hoggard M, Taylor MW, Douglas R. Molecular Microbiological Profile of Chronic Suppurative Otitis Media.JClinMicrobiol. 2016;54(10):2538-46

[12]

Hall PJ, Farrior JB. Aspergillusmastoiditis.Otolaryngol Head Neck Surg. 1993;108(2):167-70.

[13]

Westerberg BD, Kozak FK, Thomas EE, Blondel-Hill E, Brunstein JD, Patrick DM.Is the healthy middle ear a normally sterile site?OtolNeurotol. 2009;30(2):1747.

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[1]

ACCEPTED MANUSCRIPT Tille PM. Overview of Fungal Identification Methods and Strategies. In: Tille PM, editor. Bailey and Scott’s Diagnostic Microbiology. 13th ed. South Dakota: Elsevier; 2014.709,712 p.

[15]

LouwL.Acquiredcholesteatoma pathogenesis: stepwise explanations.JLaryngol Otol. 2010;124(6):587-93.

[16]

Albert RR, Job A, Kuruvilla G, Joseph R, Brahmadathan KN, John A.Outcome of bacterial culture from mastoid granulations: is it relevant in chronic ear disease?JLaryngol Otol. 2005;119(10):774-8.

[17]

Saunders J, Murray M, Alleman A. Biofilms in chronic suppurative otitis media and cholesteatoma: scanning electron microscopy findings.Am J Otolaryngol. 2011;32(1):32-7.

[18]

Inoue Y, Matsuwaki Y, Shin SH, Ponikau JU, Kita H.Nonpathogenic, environmental fungi induce activation and degranulation of human eosinophils.JImmunol. 2005;175(8):5439-47.

[19]

Healy DY, Leid JG, Sanderson AR, Hunsaker DH. Biofilms with fungi in chronic rhinosinusitis.Otolaryngol Head Neck Surg. 2008;138(5):641-7.

[20]

Kauffman HF, Tomee JFC, van de Riet MA, Timmerman AJB, Borger P.Proteasedependent activation of epithelial cells by fungal allergens leads to morphologic changes and cytokine production. J Allergy ClinImmunol. 2000;105(6):1185-93.

[21]

Chole RA, Sudhoff HH. Chronic otitis media, mastoiditis, andpetrositis. In: Cummings CW, Harker LA, editors. CummingsOtolaryngology-Head and Neck Surgery. Vol.6. 4th ed.Philadelphia: Elsevier Mosby: 2005.2988–3012 p.

[22]

Effat KG, Madany NM. Microbiological study of role of fungi in primary atrophic rhinitis.JLaryngol Otol. 2009;123(6):631-4.

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Varghese R, Nair RM, Kavalakkat FJ. Fungal otomastoiditis: a case series in immunocompetent adults. Indian J Otolaryngol Head Neck Surg. 2014;66(1):1103.

[24]

Van Tol A, Van Rijswijk J.Aspergillusmastoiditis, presenting with unexplained progressive otalgia, in an immunocompetent (older) patient.Eur Arch Otorhinolaryngol. 2009;266(10):1655-7.

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Chen CM, Chiang CW.Allergic fungal otomastoiditis: a case report.Laryngoscope. 2013;123(4):1040-2.

[26]

Bhatt YM, Pahade N, Nair B. Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man. J Lryngol Otol;127(4):404-7.

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[14]

ACCEPTED MANUSCRIPT Michaels L. Biology of cholesteatoma. Otolaryngolclin North Am1989;22:869-881.

[28]

Gluth MB, Tan BYB, Santa Maria PL, Atlas MD. Unique microbiology of chronically unstable canal wall down tympanomastoid cavities: considerations for surgical revision. J Laryngol Otol. 2013;127(5):458-62.

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[27]

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TABLE 1: CLINICAL PRESENTATION CASES

PERCENTAGE

Otorrhoea

40

100%

Hearing loss

36

90%

Vertigo

3

7.5%

Tinnitus

1

Extracranial complications

6

Post auricular swelling

4

Facial palsy

1

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Bezold’s abscess

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1

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SYMPTOM

2.5%

15% 10% 2.5% 2.5%

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TABLE 2: BACTERIAL ISOLATES CASES

PERCENTAGE

E.Coli

1

3.6%

Klebsiella

3

10.7%

Proteus spp.

10

35.7%

Pseudomonas spp.

8

Staphylococcus aureus

6

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28

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Total

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ORGANISM

28.6% 21.4%

100%

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TABLE 3: DIFFERENT TYPE OF FUNGAL ISOLATES MORPHOLOGY

NO. OF CASES

PERCENTAGE

Aspergillusniger

Mold

3

17.65%

Aspergillusflavus

Mold

2

11.8%

Aspergillusnidulans

Mold

1

5.9%

Aspergillusteneus

Mold

1

Candida albicans

Yeast

2

Candida non albicans

Yeast

Alternaria spp.

Mold

Fusarium spp.

Mold

Monilia spp.

Mold

Penicillium spp.

Mold

Scedosporium spp. Syncephalastrum spp.

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11.8% 11.8%

1

5.9%

1

5.9%

1

5.9%

1

5.9%

Mold

1

5.9%

Mold

1

5.9%

17

100%

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5.9%

2

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Total

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FUNGUS

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TABLE 4. REVIEW: MYCOLOGY IN CHOLESTEATOMA

Author

Sample/Remarks

Fungal Result

Study design Prospective

46 [40 with cholesteatoma] Keratin debris analysed]

17[42.5%]

2. Effat & Madany [2014]4

Prospective

19 [18 with cholesteatoma] Keratin debris analysed

17[89%]

3. Ho et al. [2011]6

Retrospective

244 [84 with cholesteatoma] Conventional ear swab

4. Madana et al. [2011]7

Retrospective

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1. This study [2017]

8[4%]

Prospective

150 [cholesteatoma cases] Conventional ear swab

3[1.4%]

6. Vennewald et al. [2003]9

Prospective

128 [15 with cholesteatoma] Keratin debris analysed

4

7. Attallah et al. [2000]10

Prospective

88 [with cholesteatoma] Conventional ear swabs

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5. Ricciardiello et al. [2009]8

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223 paediatric patients [1-14years] Conventional ear swab

4 [4.8%]

[26.6%]

15[17.04%]

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TABLE 5. STATISTICAL ANALYSIS: Fungal relation to discharging ear No of patients

Fungal positive

11

9

29

8

Persistent ear discharge [wet ear at the time of surgery]

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Dry ear

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[at the time of surgery]

Chi square test value=9.598

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P=.002 [significant]

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TABLE 6. STATISTICAL ANALYSIS: Fungal relation to Extracranial complications No of patients

Fungal positive

6

3

Patients with no complications

34

14

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Patients with Extracranial complications

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Chi square test value=0.162

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P=.68 [Not Significant]