What's Your Diagnosis? Otalgia in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Evaluation and Management of Constipation correct.

Case Presentation: Managing Emergency Department Patients With Otalgia

A 70-year-old man with a history of diabetes mellitus presents with persistent severe left-sided otalgia and otorrhea after being diagnosed with acute otitis externa 2 weeks ago…

The patient reports his symptoms are not improving despite ciprofloxacin/dexamethasone otic drops. He is reporting severe otalgia, left-sided headache, as well as facial pain adjacent to his temporomandibular joint.
He is febrile to 38.3°C upon arrival to the ED, but his other vital signs are normal.
On examination, the external auditory canal appears macerated and edematous and there is granulation tissue visible at the osseocartilaginous junction.
You consider whether this patient could have necrotizing otitis externa and start to plan what the next steps should be…

Case Conclusion

On initial assessment, you considered a broad differential, including the possibility of referred otalgia. The otoscopic examination was abnormal, and the finding of granulation tissue at the osseocartilaginous junction in the setting of severe otorrhea was highly suggestive of NOE. The patient’s advanced age, history of diabetes, duration of symptoms, and failure of symptoms to improve with topical therapy also raised your suspicion for NOE. You ordered laboratory tests, including ESR and CRP, and obtained a culture of the ear drainage. In addition, you consulted an otolaryngology specialist and ordered a CT head with IV contrast. The diagnosis was confirmed on imaging, and the patient was admitted for IV antibiotic therapy.