At the Bedside

  • Typical otitis externa: severe otalgia, pain with tragal/pinna manipulation, canal edema/erythema, otorrhea, conductive hearing symptoms, often after water exposure or instrumentation.
  • Red flags for malignant otitis externa (MOE):
  • Older adult, diabetes, immunocompromised state
  • Severe, deep, nocturnal otalgia out of proportion
  • Persistent otorrhea despite drops
  • Granulation tissue in external auditory canal
  • Cranial nerve deficits: facial weakness, dysphagia, hoarseness, tongue deviation
  • Fever may be absent
  • Exam: inspect canal and tympanic membrane if possible; assess mastoid tenderness, auricle/pinna tenderness, periauricular cellulitis, cranial nerves, mastication pain, trismus.
  • Testing:
  • Routine OE usually clinical; no labs needed.
  • If MOE suspected: CBC, BMP, glucose, ESR/CRP often elevated; consider blood cultures if febrile/toxic.
  • CT temporal bone with contrast if concern for bony erosion, deep space extension, or to define anatomy; MRI better for skull base/soft tissue/intracranial extension if neurologic findings.
  • Culture canal drainage if available before antibiotics, but don’t delay treatment.
  • Initial management:
  • Routine OE: topical antibiotic drops ± steroid, pain control, keep ear dry, no ear instrumentation, consider ear wick if canal swollen shut.
  • Avoid ototoxic drops if TM perforation is possible; use non-ototoxic agents when uncertain.
  • MOE: admit, start anti-pseudomonal systemic therapy; ENT consult, often ID consult. Evaluate for diabetes control and cranial nerve involvement.
  • Disposition:
  • Routine OE with reliable follow-up: discharge with drops and return precautions.
  • MOE, immunocompromised, severe pain, cranial nerve deficits, inability to take PO, or concern for extension: admit.
A Classic Presentation
A 72-year-old man with poorly controlled diabetes presents with 3 weeks of worsening left ear pain and foul drainage. He says the pain wakes him up at night and feels “deep” behind the ear; topical drops from urgent care did not help. Exam shows marked tenderness with tragal manipulation, swollen canal with granulation tissue, and mild left facial weakness. CT temporal bone shows soft tissue thickening with concern for bony erosion. He is admitted for IV antipseudomonal antibiotics and ENT evaluation for malignant otitis externa.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 72-year-old man with diabetes presenting with 3 weeks of progressively worse unilateral otalgia and otorrhea. My main concern is malignant otitis externa rather than routine swimmer’s ear because the pain is severe, persistent, and wakes him from sleep, and he now has a subtle facial nerve deficit. On exam he has canal edema, granulation tissue, and marked tenderness with tragal manipulation, but no mastoid fluctuance or toxic appearance. I’m less worried about simple otitis media because the canal findings are the dominant source of pain, and there’s no bulging TM or URI prodrome driving this. CT temporal bone is concerning for early bony involvement, so I think this is skull-base osteomyelitis until proven otherwise. I’ve started antipseudomonal coverage and consulted ENT, and he should be admitted for IV therapy and further imaging/follow-up planning.

Study Directive

  • Draw a quick differential for ear pain: otitis externa vs otitis media vs mastoiditis vs MOE.
  • From memory, list 3 features that make you admit for possible MOE.
  • Review which otic drops are safe when TM perforation is uncertain.
  • Practice a 20-second otoscopy-based presentation with one key red flag and one disposition sentence.
  • Read your local pathway for when CT temporal bone vs MRI is preferred.

Recent Literature