An Update on the Current Practice on the Management of Fungal Necrotizing Otitis Externa: A Systematic Analysis of the Literature

Malignant otitis externa (MOE), necrotizing otitis externa (NOE), or skull base osteomyelitis (SBO) is a severe ear infection, primarily caused by Pseudomonas aeruginosa with 5%–20% of cases due to fungal species. Fungal NOE affects immunocompromised patients. This study systematically reviews fungal NOE management, addressing: (1) when to suspect it and start treatment; (2) the most appropriate anti‐fungal; (3) treatment duration. We searched Medline, the Cochrane Library, PubMed, and Embase for English articles up to June 2024, supplemented by Google Scholar and manual reference checks. Using PRISMA, 516 articles were identified in which 387 were screened, 54 full texts reviewed, and 32 included after excluding duplicates and irrelevant studies. Fungal NOE is hard to diagnose. Suspect it with aggressive symptoms and sterile cultures unresponsive to antibiotics. Voriconazole is effective due to bone penetration. Treatment should be continued for > 12 weeks with multiple swabs, aural toileting, and thorough examinations.