Black fungus and COVID-19: role of otorhinolaryngologists and audiologists.

A rare form of infection called mucormycosis, commonly known as the black fungus, belonging to Mucorales order of fungus, has become a common occurrence in patients recovering from COVID-19 in the recent wave that has hit India and some parts of Russia and Pakistan in 2021. Experts from the COVID-19 task force highlight that the patients vulnerable to mucormycosis usually have uncontrolled diabetes and falling immunity. Mucormycosis usually affects many organs and, if not treated earlier, can result in fatality. Infection sites are mainly sinonasal or pulmonary.

Mucormycosis involving the ear is a rare occurrence. Despite its rarity, it is a dangerous infection. There are reports of invasive mucormycosis of the temporal bone in immunocompromised patients [1]. Mucormycosis may present as otitis externa, and the otological symptoms do not respond to conventional antibacterial treatment [2]. Out of the five cases of mucormycosis, one of them had ear pain with purulent otorrhea and hearing loss as reported by Bellazreg et al. [3], which even resulted in middle-ear polyps and granulation tissue in the middle ear. There are isolated reports of middle-ear mucormycosis along with facial palsy and oto-cerebral mucormycosis [4].

Middle ear mucormycosis is such a rare condition that it becomes difficult for the clinician to make it a principal diagnosis. In a non-diabetic patient, the clinical presentation of mucormycosis bears a solid resemblance to attico-antral disease but with ear pain as a chief complaint. Mucormycosis of the middle ear in non-diabetic patients appears to be non-invasive and is not fatal. The non-invasive variety may occur as indolent infection producing symptoms similar to chronic suppurative otitis media (CSOM), as seen in a case study by Hazarika et al. [5]. Gaining access into the middle ear increases the risks of conductive hearing loss in patients. The extensive angioinvasion caused by mucormycetes can result in vessel thrombosis and tissue necrosis, leading to cholesteatoma in the middle ear [5].

There might have been COVID-19 patients with symptoms of hearing loss or reduced hearing sensitivity in reported cases of black fungus, yet not much noticeable due to various other complications caused by it. Not responding to conventional line of treatment for the ear infection also lines up in the queue with other problems. A long-standing middle-ear infection could lead to further involvement of the inner ear. Negligence of hearing loss could become problematic while the patient battles with other effects of mucormycosis. Thus, there is a need to rule out middle ear involvement and related hearing loss by otorhinolaryngologists and audiologists. A detailed otological evaluation and audiological tests are essential before the discharge from the hospital. Thus, we highlight that Otorhinolaryngologists and audiologists also play a crucial role in the early assessment and rehabilitation of COVID-19 patients with black fungus.