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Malignant Otitis Externa Clinical Presentation

  • Author: Brian Nussenbaum, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: May 16, 2016


See the list below:

  • Diabetes (90%) or immunosuppression (illness or treatment related)
  • Severe, unrelenting, deep-seated otalgia
  • Temporal headaches
  • Purulent otorrhea
  • Possibly dysphagia, hoarseness, and/or facial nerve dysfunction


See the list below:

  • Inflammatory changes are observed in the external auditory canal and the periauricular soft tissue.
  • The pain is out of proportion to the physical examination findings.
    • Marked tenderness is present in the soft tissue between the mandible ramus and mastoid tip.
    • Granulation tissue is present at the floor of the osseocartilaginous junction. This finding is virtually pathognomonic of malignant external otitis (MEO). Otoscopic examination may also reveal exposed bone.
  • The cranial nerves (V-XII) should be examined.
  • Mental status examination should be performed. Deterioration of the mental status may indicate intracranial complication.
  • The tympanic membrane is usually intact.
  • Fever is uncommon.


See the list below:

  • Diabetes (90% of patients)
    • Diabetes is the most significant risk factor for developing malignant external otitis (MEO).
    • Small-vessel vasculopathy and immune dysfunction associated with diabetes are primarily responsible for this predisposition.
    • The cerumen of patients with diabetes has a higher pH and reduced concentration of lysozyme, which may impair local antibacterial activity.
    • No difference in predisposition is found between diabetes types I and II.
    • The predisposition is not necessarily related to the severity of glucose intolerance or periods of hyperglycemia.
  • Immunodeficiencies, such as lymphoproliferative disorders or medication-related immunosuppression
  • AIDS
    • Malignant external otitis (MEO) associated with AIDS may have a different pathophysiology than classic malignant external otitis (MEO).
    • Patients present with similar symptoms but are generally younger and do not have diabetes.
    • Granulation tissue may be absent in the external auditory canal.
    • Pseudomonas is not necessarily the dominant causative organism.
    • Patients with AIDS generally have a poorer outcome than patients with diabetes.
  • Aural irrigation: As many as 50% of cases of malignant external otitis (MEO) have been reported to be preceded by traumatic aural irrigation in patients with diabetes.
Contributor Information and Disclosures

Brian Nussenbaum, MD, FACS Christy J and Richard S Hawes III Professor, Vice Chair for Clinical Affairs, Division Chief, Head and Neck Surgery, Patient Safety Officer, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine

Brian Nussenbaum, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society

Disclosure: Nothing to disclose.


Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Jack A Shohet, MD President, Shohet Ear Associates Medical Group, Inc; Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, School of Medicine

Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, California Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Envoy Medical .

  1. Chandler JR. Malignant external otitis. Laryngoscope. 1968 Aug. 78(8):1257-94. [Medline].

  2. Karaman E, Yilmaz M, Ibrahimov M, Haciyev Y, Enver O. Malignant otitis externa. J Craniofac Surg. 2012 Nov. 23(6):1748-51. [Medline].

  3. Chandler JR. Malignant external otitis: further considerations. Ann Otol Rhinol Laryngol. 1977 Jul-Aug. 86(4 Pt 1):417-28. [Medline].

  4. Franco-Vidal V, Blanchet H, Bebear C, Dutronc H, Darrouzet V. Necrotizing external otitis: a report of 46 cases. Otol Neurotol. 2007 Sep. 28(6):771-3. [Medline].

  5. Soudry E, Joshua BZ, Sulkes J, Nageris BI. Characteristics and prognosis of malignant external otitis with facial paralysis. Arch Otolaryngol Head Neck Surg. 2007 Oct. 133(10):1002-4. [Medline].

  6. Mani N, Sudhoff H, Rajagopal S, Moffat D, Axon PR. Cranial nerve involvement in malignant external otitis: implications for clinical outcome. Laryngoscope. 2007 May. 117(5):907-10. [Medline].

  7. Nawas MT, Daruwalla VJ, Spirer D, Micco AG, Nemeth AJ. Complicated necrotizing otitis externa. Am J Otolaryngol. 2013 Nov-Dec. 34(6):706-9. [Medline].

  8. Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and implications for diagnosis and treatment. Otolaryngol Head Neck Surg. 2014 Mar 26. [Medline].

  9. Gruber M, Roitman A, Doweck I, et al. Clinical utility of a polymerase chain reaction assay in culture-negative necrotizing otitis externa. Otol Neurotol. 2015 Apr. 36 (4):733-6. [Medline].

  10. Peleg U, Perez R, Raveh D, Berelowitz D, Cohen D. Stratification for malignant external otitis. Otolaryngol Head Neck Surg. 2007 Aug. 137(2):301-5. [Medline].

  11. Lee JE, Song JJ, Oh SH, Chang SO, Kim CH, Lee JH. Prognostic Value of Extension Patterns on Follow-up Magnetic Resonance Imaging in Patients With Necrotizing Otitis Externa. Arch Otolaryngol Head Neck Surg. 2011 Jul. 137(7):688-93. [Medline].

  12. Levenson MJ, Parisier SC, Dolitsky J, Bindra G. Ciprofloxacin: drug of choice in the treatment of malignant external otitis (MEO). Laryngoscope. 1991 Aug. 101(8):821-4. [Medline].

  13. Benecke JE Jr. Management of osteomyelitis of the skull base. Laryngoscope. 1989 Dec. 99(12):1220-3. [Medline].

  14. Davis JC, Gates GA, Lerner C, Davis MG Jr, Mader JT, Dinesman A. Adjuvant hyperbaric oxygen in malignant external otitis. Arch Otolaryngol Head Neck Surg. 1992 Jan. 118(1):89-93. [Medline].

  15. Ling SS, Sader C. Fungal malignant otitis externa treated with hyperbaric oxygen. Int J Infect Dis. 2008 Sep. 12(5):550-2. [Medline].

  16. Phillips JS, Jones SE. Hyperbaric oxygen as an adjuvant treatment for malignant otitis externa. Cochrane Database Syst Rev. 2013 May 31. 5:CD004617. [Medline].

  17. Berenholz L, Katzenell U, Harell M. Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa. Laryngoscope. 2002 Sep. 112(9):1619-22. [Medline].

  18. Stevens SM, Lambert PR, Baker AB, Meyer TA. Malignant Otitis Externa: A Novel Stratification Protocol for Predicting Treatment Outcomes. Otol Neurotol. 2015 Sep. 36 (9):1492-8. [Medline].

  19. Mion M, Bovo R, Marchese-Ragona R, Martini A. Outcome predictors of treatment effectiveness for fungal malignant external otitis: a systematic review. Acta Otorhinolaryngol Ital. 2015 Oct. 35 (5):307-13. [Medline]. [Full Text].

  20. Foden N, Burgess C, Damato S, et al. Concurrent necrotising otitis externa and adenocarcinoma of the temporal bone: a diagnostic challenge. BMJ Case Rep. 2013 Nov 6. 2013:[Medline].

  21. Chin RY, Nguyen TB. Synchronous malignant otitis externa and squamous cell carcinoma of the external auditory canal. Case Rep Otolaryngol. 2013. 2013:837169. [Medline]. [Full Text].

  22. Bae WK, Lee KS, Park JW, et al. A case of malignant otitis externa caused by Candida glabrata in a patient receiving haemodialysis. Scand J Infect Dis. 2007. 39(4):370-2. [Medline].

  23. Okpala NC, Siraj QH, Nilssen E, Pringle M. Radiological and radionuclide investigation of malignant otitis externa. J Laryngol Otol. 2005 Jan. 119(1):71-5. [Medline].

  24. Rubin Grandis J, Branstetter BF 4th, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis. 2004 Jan. 4(1):34-9. [Medline].

  25. Sudhoff H, Linthicum FH Jr. Malignant external otitis: temporal bone histopathology case of the month. Otol Neurotol. 2003 Mar. 24(2):346-7. [Medline].

Anatomy of the ear.
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