Otitis Externa: The Daily PANCE Blueprint
A 19-year-old competitive swimmer presents with 3 days of right ear pain, itching, and a sense of fullness. He has no fever and no recent cold, and the only hearing change is mild muffling on the right. He is otherwise healthy and does not have diabetes. Which of the following findings would you most expect on examination?
A. A bulging, red tympanic membrane with decreased mobility
B. Tenderness and swelling behind the ear with a protruding auricle
C. Pain with traction on the pinna or pressure on the tragus
D. Vesicles on the outer ear with weakness of the same side of the face
E. A retracted tympanic membrane with an air-fluid level
Answer and topic summary
The answer is C. Pain with traction on the pinna or pressure on the tragus
This is acute otitis externa (“swimmer’s ear”), an infection of the ear canal skin, most often from Pseudomonas aeruginosa or Staphylococcus aureus. Water and trauma strip the protective cerumen layer. The signature exam finding is pain with traction on the pinna or pressure on the tragus, with an edematous, red canal and debris; the tympanic membrane may be hard to see but is normal. Treatment is topical antibiotic drops, often with a steroid (for example ciprofloxacin-dexamethasone), plus a wick if the canal is swollen shut. Severe pain with granulation tissue in the canal in an older adult with diabetes suggests necrotizing (malignant) otitis externa, which needs IV antipseudomonal therapy and imaging. A bulging red tympanic membrane is acute otitis media, a retracted membrane with fluid is otitis media with effusion, postauricular swelling is mastoiditis, and vesicles with facial weakness are Ramsay Hunt syndrome.
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