Blog: How not to deal with a non-ocular fungal infection
The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM.
A fungal infection in my left ear last spring left me pondering topics relevant to all would-be healers, such as:
• Dangers of self-treatment by healthcare professionals
• Appropriate use of opioids
• Procedural pain management
• Empirical versus culture-guided treatment.
How it all began
My problems had begun the previous fall. My left ear felt full, and my ear canal itched like mad and burned like fire.
Naturally, I decided to keep scratching and self-treat. The ear really isn’t that far away from the eye, so what could possibly go wrong?
After two rounds of oral antibiotics and Medrol Dosepaks, I had my answer: nearly everything.
I was just like all “those other people” who rub their eyes and use whatever eyedrops they can get their hands on, including Uncle Butch’s 5-year-old unidentifiable bottle of “allergy drops” with the faded, yellowing label.
After a bit, there was a break in the storm. It turns out it was just the eye of the hurricane.
Previously by Dr. Brown: Blog: How to avoid professional burnout as an OD
Painful experience
Early one Sunday morning, I awoke to the most intense pain I had ever felt in my life. It not only seemed like someone was stabbing me with an icepick in my left ear but also heating it on a blacksmith’s anvil prior to insertion.
A pain scale of 0-10? Pshaw! Just like Nigel Tufnel’s amplifier volume knob in the 1984 cult classic mockumentary This Is Spinal Tap, my pain went “up to 11.”
A few hours later, the physician assistant at the walk-in clinic looked into my ear with her otoscope and gasped, “Whoa!” (Students and residents: Don’t do that).
“I’m not sure what that is, but it’s pretty funky” (Students and residents: See above).
I looked at my Rxs: another oral antibiotic, plus, this time, the magic elixir-antibiotic/steroid combination eardrops. Wait a sec-where’s my pain med? If there was ever a time and place for the “good stuff,” this was it.
“Oh, we can’t do that here. You can just use ibuprofen and acetaminophen,” opined the MD without Satan’s red-hot poker sticking out of her left ear.
I had been swallowing fistfuls of both all night. “Can’t, or won’t?” I shot back.
That’s when I played the “I’m a doctor, too” card.
I understand the opioid crisis, I told her, but this was some serious acute pain!
You can check the records-I haven’t had any since my vitrectomy in 2012-and, if we healthcare professionals can’t treat a five-alarm fire with six or so measly Lortab 5/325s, then the pendulum was swinging too far in the other direction!
Related: How to handle non-ophthalmolic emergencies
On my way out, I picked up my Rx for six Lortab 5/325s.
But it made me think about other patients in acute pain who don’t know the system as well as I do and who don’t have an “in” like me and what they must be experiencing.
Well, that course of treatment didn’t work either.
Diagnosis
In one last desperate stand against the mystery superbug attempting to eat through my tympanic membrane and invade my brain, I finally turned to “The Specialist,” an ENT.
“Looks like a fungus,” she said. “We’ll take a culture, clean and debride, and get you on the right medicine.”
Remember those words because we will return to them shortly.
Cleaning and debriding was rough. It hurt, but no pain, no gain, right? What’s a little jerk nystagmus and oscillopsia between friends? She prescribed a ciprofloxacin/steroid solution, along with-get this-ophthalmic gatafloxacin!
You see any kind of antifungal treatment in there? Yeah, neither did I.
I’m sure you also remember how an undertreated infection can turn supercharged with steroids.
Follow-up visit
At my one-week follow-up, I was miserable and grumpy.
The fresh-out-of-school nurse practitioner looked into my ear with her otoscope and said, “Yup, that’s definitely a fungus. I can even see the spores now.”
I halfway expected her to say, “My God, it’s full of spores!” á la the 1968 classic science fiction film 2001: A Space Odyssey.
Also by Dr. Brown: 5 reasons I went back to school as an OD
Students and residents, must I keep repeating myself?
My first thought was: If it’s a fungus this week, it was a fungus last week (and, after all, they suspected as much).
So why did they pussyfoot around and give me peashooter meds when I needed the Big Guns?
Friends and colleagues, if you suspect a certain type of condition, and it’s causing tremendous pain and dysfunction for your patient, go big or go home.
“What did the culture show?” I asked the ENT when she entered the room.
“What culture?” she asked.
“The one that you said you were going to do last week,” I answered with just a hint of malice in my voice.
“Oh, this is definitely a fungus. There’s really no need to culture, and it could take up to four weeks to grow something. But if you insist…”
She seemed irritated that I had asked the question.
She then proceeded to scrape out the blackish funk with those instruments of torture common to her trade.
After a few more weeks of appropriate and targeted antifungal treatment, the pain began to ease and my hearing was nearly back to normal. I had to return for one more cleaning and debridement during that period, and it turns out they’d had topical lidocaine on tap all along.
When I complained about the previous experience, the nurse pulled out a long hose and filled my ear canal with the numbing solution as easily as someone might dispense a Diet Coke. It made all the difference in the world. Although I would never debride a cornea or remove a foreign body without topical anesthesia, I guess some ENTs expect you to beg.
Conclusion
Why am I telling you my terrible, horrible, no good, very bad ear story in an eyecare publication?
So you won’t make the same mistakes that I, and my well intentioned, but bumbling, caretakers did.
Like the Bible says, “He who has ears to hear, let him hear.”
