SynopsisCodesLook ForDiagnostic PearlsDifferential Diagnosis & PitfallsBest TestsManagement PearlsTherapyReferences

View all Images (3)

Emergency: requires immediate attention
Malignant otitis externa
Other Resources UpToDate PubMed
Emergency: requires immediate attention

Malignant otitis externa

Contributors: Kaushal B. Shah MD, James H. Willig MD, MSPH
Other Resources UpToDate PubMed


Malignant otitis externa (MOE), or "necrotizing external otitis," is a rare, yet potentially fatal granulomatous infection of the external auditory canal that extends from the squamous epithelium to the adjacent soft tissue, blood vessels, cartilage, and bone.

Predisposing Factors:
Diabetes is the most significant risk factor for MOE. MOE is commonly seen in patients with immunocompromised conditions, including AIDS, chemotherapy, and malnutrition. A recent history of ear irrigation, ear surgery, or hearing aid irritation is often associated with this condition.

Infection originates in the external ear canal accessing the skull base through the fissures of Santorini (perforations in the cartilaginous portion of the external ear canal). The most common causative organism is Pseudomonas aeruginosa, but MOE has rarely been associated with Aspergillus spp., Candida parapsilosis, Staphylococcus spp., and Klebsiella spp. Those with underlying microvascular abnormalities (as may occur in elderly, diabetic, or immunocompromised hosts) are most susceptible, as organisms gain access and cause vasculitis with thrombosis and coagulative necrosis of the surrounding tissue, including bone, causing osteomyelitis.

MOE is more common in warmer climates. Males are more affected than females. Elderly patients are more commonly affected. It is rarely seen in children. Immunosuppressive conditions predispose patients to MOE; in the elderly, diabetes is a common risk factor, while in younger populations, HIV/AIDS increases risk.

MOE typically presents as severe ear pain, otorrhea, and temporal headache around the involved ear. Hearing loss and/or facial weakness may also occur. Fevers are uncommon.

Granulation tissue and edema is a virtually pathognomonic sign that can be seen on examination. Yellowish foul-smelling and persistent drainage can also be seen. Marked tenderness is present between the mandible ramus and mastoid tip.

Potential Complications:
  • Temporal and skull base osteomyelitis
  • Cranial nerve palsies (most commonly facial)
  • Temporomandibular joint arthritis
  • Rarely – meningitis, brain abscess; if left untreated, mortality is up to 50%


H60.20 – Malignant otitis externa, unspecified ear

94146005 – Malignant otitis externa

Look For

Subscription Required

Diagnostic Pearls

Subscription Required

Differential Diagnosis & Pitfalls

  • Acute diffuse otitis externa – Otoscopic examination will not show granulation tissue at the floor of the osseocartilaginous junction. Bone scan will also help distinguish this from MOE. Unlike MOE, topical antibiotics can be effective against acute diffuse otitis externa.
  • Temporal bone cancer – Usually secondary to squamous cell carcinoma. Typically, temporal bone cancer will not have purulent discharge or severe tenderness. Cultures may be negative. Symptoms will not resolve with antibiotics.

Best Tests

Subscription Required

Management Pearls

Subscription Required


Subscription Required


Subscription Required

Last Reviewed:03/16/2017
Last Updated:06/09/2016
Copyright © 2022 VisualDx®. All rights reserved.
Emergency: requires immediate attention
Malignant otitis externa
A medical illustration showing key findings of Malignant otitis externa : Headache, External auditory meatus of ear, Hearing loss, Otalgia, Otorrhea, Ear itch
Clinical image of Malignant otitis externa - imageId=6109639. Click to open in gallery.  caption: 'Dull yellow-greenish discharge at the external auditory meatus, secondary to pseudomonal infection.'
Dull yellow-greenish discharge at the external auditory meatus, secondary to pseudomonal infection.
Copyright © 2022 VisualDx®. All rights reserved.