When to suspect. If patients show no improvement or further deterioration after 3–4 weeks of antibiotics and multiple swabs remain negative, fungal NOE should be suspected. Tissue biopsy or bone biopsy is recommended for early diagnosis, as most fungal species do not grow on initial swabs or culture. Advanced disease—indicated by facial nerve paralysis, bilateral involvement, or radiologic findings such as temporomandibular joint destruction—warrants prompt anti-fungal initiation.

Which anti-fungal to use. Voriconazole was the most commonly used anti-fungal in this cohort (22/32 studies), favored for its excellent bone and central nervous system penetration and lower nephrotoxicity compared to Amphotericin B. However, limitations include hepatotoxicity, drug interactions, and resistance in non-Aspergillus species such as Scedosporium apiospermum, which may require combination therapy. Species identification and susceptibility testing are essential for guiding treatment.

How long to treat. The mean treatment duration was 14.7 weeks, with authors recommending a minimum of 12 weeks. Complex cases may require extended therapy. Management necessitates a multidisciplinary team approach, alongside regular aural toileting, multiple ear swabs, and imaging follow-up. All recommendations are derived from case reports and retrospective studies; prospective research is needed to establish formal guidelines.

The work titled “An Update on the Current Practice on the Management of Fungal Necrotizing Otitis Externa: A Systematic Analysis of the Literature”, was published on Eye & ENT Research (published on June 27, 2026).