Allergic Fungal Otomastoiditis in a Patient without Allergic Fungal Rhinosinusitis: A Case Report

Abstract

Patient: Female, 27 Final Diagnosis: Allergic fungal otomastoiditis – AFOM Symptoms: Left-sided otorrhea and hearing impairment for 2 years Medication: Systemic steroid course Clinical Procedure: Aural toilets and systemic steroid over 2 weeks Specialty: Otolaryngology Objective: Rare disease Background: Allergic fungal rhinosinusitis is an inflammatory condition involving the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer. In 2013 Chen et al. reported the first case of middle ear allergic otomastoiditis in a patient who tested negative for allergic sinus-nasal disease. To the best of our knowledge, this is the second such case report to be published. Case Report: Our patient was a 27-year-old immune-competent woman presenting with chronic left-side otorrhea and hearing loss for 2 years. An audiogram showed low- and middle-frequency, mild-to-moderate left-sided conductive hearing loss. A coronal view computed tomography (CT) image of the temporal bone showed coalescent air cells in the left mastoid with opacification of the left middle ear, but no evidence of bony erosion. Diagnosis confirmed by swab culture taken at a clinic showed Aspergillus flavus . The main treatment in such cases is usually a combination of surgical and medical therapy. Conclusions: We present the second case report of allergic fungal otomastoiditis, showing an allergic reaction to fungi in the middle ear and formation of mucin in a symptomatic patient. Otolaryngologists need to be aware of the presence of this sensitivity, both in the clinic and the operating theater.

A Concomitant Allergic Fungal Otomastoiditis with an Allergic Fungal Rhinosinusitis

“…As skin tests, biological and mycological results suggested in that case, Aspergillus species were involved as usually reported in AFRS [1,2], but also in AFO [3,5], when fungal elements can be identified. Firstly described by Chen et al [3] in 2013, this diagnosis is supported by seeing a sticky and sandy peanutbutter-like mucus coming out from a tympanic perforation which may have been present for several years with multiple failed surgical closure attempts [3,5]. HTCT ( Figure 1) and specifically MRI ( Figure 2) suggested cholesteatomatous chronic otitis, except dark heterogeneous T2-weighted images, as it can be seen in AFRS because of ferromagnetic elements inside the fungal mucus [1].…”

“…As there is a lack of evidence concerning AFRS medical treatment, extensive surgical debridement is still the gold standard and, as previously reported [3,5], was performed on our patient on his sinuses and ear to remove any fungal element, limit recurrence risk and improve middle ear and sinus ventilation. As AFRS [1], patients who received a combination of oral and topical corticosteroids postoperatively for AFO [3,5], had better clinical outcomes and no disease recurrence compared with those undergoing surgery alone [4].…”

“…AFO is an uncommon ear condition [4,5], whose pathogenesis is quite similar with AFRS and ABPA as it could be type 1 and type 3 hypersensitivity to multiple fungi [2] with elevated serum IgE and IgG against specific fungal antigens. As skin tests, biological and mycological results suggested in that case, Aspergillus species were involved as usually reported in AFRS [1,2], but also in AFO [3,5], when fungal elements can be identified.…”

“…AFO is an uncommon ear condition [4,5], whose pathogenesis is quite similar with AFRS and ABPA as it could be type 1 and type 3 hypersensitivity to multiple fungi [2] with elevated serum IgE and IgG against specific fungal antigens. As skin tests, biological and mycological results suggested in that case, Aspergillus species were involved as usually reported in AFRS [1,2], but also in AFO [3,5], when fungal elements can be identified. Firstly described by Chen et al [3] in 2013, this diagnosis is supported by seeing a sticky and sandy peanutbutter-like mucus coming out from a tympanic perforation which may have been present for several years with multiple failed surgical closure attempts [3,5].…”

“…The presence of that specific mucus outside the respiratory tract was first reported in 2013 when Chen and Chiang [3] described the first case of Allergic Fungal Otomastoiditis (AFO). Here, we present the fourth case [4,5], of AFO in a patient with AFRS without any history of middle ear disease.…”