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Ear Infections for PLAB 2: Otitis Externa vs Otitis Media vs Malignant Otitis Externa


Understand the Location

  • Otitis Externa → External ear canal

  • Acute Otitis Media → Middle ear

  • Malignant Otitis Externa → External ear → spreads to skull base 🚨


1. Otitis Externa (OE)


What is it?

Infection of the external auditory canal


Presentation

  • Ear pain (worse on touching ear)

  • Itching

  • Ear discharge

  • Mild hearing loss


Examination findings

  • Tragus tenderness (classic)

  • Swollen, erythematous canal

  • Debris/discharge

  • Tympanic membrane usually normal (if visible)


Risk factors / triggers

  • Swimming

  • Cotton bud use

  • Ear trauma

  • Hearing aids


Red flags

  • Not improving with treatment

  • Severe pain → think malignant OE


Treatment

  • Topical antibiotic ± steroid drops

  • Analgesia

  • Keep ear dry


Urgency & referral

  • Routine GP management

  • Refer if:

    • Not improving

    • Immunocompromised


  1. Malignant Otitis Externa


What is it?

A serious, invasive infection of the ear canal that spreads to the skull base


Presentation (VERY HIGH-YIELD)

  • Severe deep ear pain

  • Worse at night 🌙

  • Persistent discharge

  • Not improving with drops


Examination findings

  • Granulation tissue (hallmark)

  • Swollen canal

  • Debris, discharge

  • Cranial nerve deficits (late)


Risk factors

  • Diabetes (most important)

  • Elderly

  • Immunocompromised


Red flags (MUST NOT MISS)

  • Pain out of proportion

  • Night pain

  • Facial weakness (CN VII)

  • Dysphagia / hoarseness

  • Persistent symptoms


Complications

  • Skull base osteomyelitis

  • Cranial nerve palsies

  • Intracranial spread


Treatment (UK practice)

  • URGENT ADMISSION

  • IV anti-pseudomonal antibiotics:

    • Ceftazidime / Piperacillin-tazobactam

  • Long course (6–8 weeks)

  • Glycaemic control

  • Imaging (CT/MRI)


Urgency & referral

🚨 MEDICAL EMERGENCY — SAME DAY ENT REFERRAL

3. Acute Otitis Media


What is it?

Infection of the middle ear


Presentation

  • Ear pain (deep, not touch-related)

  • Fever

  • Reduced hearing

  • Children: irritability, pulling ear


Examination findings

  • Bulging, red tympanic membrane

  • Reduced mobility

  • Possible perforation → discharge


Risk factors

  • Children

  • URTI

  • Bottle feeding

  • Daycare exposure


Red flags

  • Mastoid swelling

  • Persistent high fever

  • Neurological symptoms


Treatment (UK NICE approach)

  • Often self-limiting

  • Analgesia (paracetamol/ibuprofen)

  • Delayed antibiotics (e.g. amoxicillin) if needed


Urgency & referral

  • Routine

  • Urgent if:

    • Complications suspected

    • <3 months old



Quick Comparison

Feature

Otitis Externa

Otitis Media

Malignant OE

Pain

On touching ear

Deep

Severe, deep, night pain

Tragus tenderness

✅

❌

±

Tympanic membrane

Normal

Bulging

Often not visible

Discharge

Yes

±

Persistent

Patient

Swimmer

Child

Diabetic elderly

Severity

Mild

Moderate

🚨 Severe

Treatment

Drops

Analgesia ± Abx

🚨 IV antibiotics


References

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