consider a diagnosis of malignant otitis externa with features such as (1,2):
fever
disproportionate pain
or a poor response to first line treatment, particularly in people with diabetes or immunocompromise
maintain a high index of suspicion in patients with risk factors, in particular diabetes, who have otitis externa that is not responding to initial treatment
associated vertigo and hearing loss may indicate malignant otitis externa (3)
lavage of the ear canal for cerumen impaction in elderly or diabetic patients, however, has been implicated as a contributing factor in malignant otitis externa (3)
irrigation of the ear canal with tap water is a potential iatrogenic factor
P aeruginosa is isolated from exudate in the ear canal in more than 90% of cases
initial clinical features are those of the initiating acute otitis externa, but untreated disease develops into a skull base osteomyelitis that can invade soft tissue, the middle ear, inner ear, or brain
facial nerve paralysis may be an early sign, with the glossopharyngeal and spinal accessory nerves less frequently involved
granulation tissue or exposed bone in the floor of the osseocartilaginous junction may occur
pathognomonic of malignant otitis externa
if you suspect malignant otitis externa arrange an urgent (same day) ear, nose, and throat (ENT) review. A computed tomography imaging scan is typically required to confirm the diagnosis
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