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Malignant otitis externa

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Malignant otitis externa is otitis externa which has spread to cause osteomyelitis of the skull base

  • all tissues (soft tissue, cartilage, and bone) area affected as osteomyelitis spreads along the skull base

It is due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue in the external canal

  • P aeruginosa is isolated from exudate in the ear canal in more than 90% of cases (1)

  • a facial nerve palsy occurs in 50% of patients with this condition, and nerves IX to XII may also be involved
    • 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 (1)

  • affects immunocompromised patients, especially elderly diabetics
    • lavage of the ear canal for cerumen impaction in elderly or diabetic patients has been implicated as a contributing factor in malignant otitis externa (1)

  • may be life threatening

  • clinical diagnosis of necrotizing otitis externa can be confirmed with a raised CRP plus an abnormal computed tomography or magnetic resonance imaging

  • treatment includes surgical debridement and systemic antibiotics adequate to cover pseudomonal and staphylococcal infection, including methicillin-
    resistant S aureus

  • biopsy may be necessary to detect neoplasia if the diagnosis of malignant otitis externa is uncertain or response to therapy is incomplete (1)

  • 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 (2)


  • Rosenfeld RM, Schwartz SR, Cannon CR, etal. Clinical practice guideline: acute otitis externa.Otolaryngol Head Neck Surg2014;150(Suppl):S1-24.doi: 10.1177/0194599813517083 pmid: 24491310
  • Barry V et al. 10-Minute Consultation - Otitis externa. BMJ2021;372:n714

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