Malignant external otitis is a condition primarily affecting children who have chronic illnesses or are immunosuppressed. Clinicians should be on the lookout for signs such as severe and persistent ear pain, ear discharge containing Pseudomonas aeruginosa, a signicantly elevated erythrocyte sedimentation rate, and evidence of bone damage on a computed tomography scan, especially when dealing with these vulnerable populations. The infection typically starts with a skin infection and can progress to involve deeper structures like cartilage, tissue, and bone. As the infec­tion advances, it can lead to complications such as osteomyelitis at the base of the skull, osteomyelitis of the temporomandibular joint, the formation of brain abscesses, and the development of generalized bacterial sepsis. Culture of the exter­nal ear canal in otorrhea is rarely helpful, as Pseudomonas species are commonly identied with or without local infection. It is also quite difcult to obtain samples from the middle ear that are not contaminated by external canal ora. In addition, culture rarely changes management decisions in children with otorrhea.

Patients with malignant external otitis classically present with otorrhea and exquisite otalgia which are not responsive to topical measures used to treat simple external otitis. The pain is generally more severe than that found in simple external otitis, although the two may be difcult to distinguish in their early stages. The pain in malignant external otitis tends to extend into the temporomandibular joint, result­ing in pain with chewing [11].