A 61 yo female with a history of DM presents with 3 days of severe R ear pain. She denies fever, but reports fullness, swelling and decreased hearing. Exam reveals significant swelling and tenderess of the R pinna and EAC without drainage. A CT is obtained. What's the diagnosis? (scroll down for answer) 

Answer: Malignant Otitis Externa

• infection of the external auditory canal and skull base
• begins as otitis externa and progresses into osteomyelitis of temporal bone
• most commonly due to Pseudomonas aeruginosa, less likely fungal secondary to aspergillosis
• typically seen in elderly patients with DM or immunocompromised patients
• presenting symptoms include: severe otalgia, otorrhea, sense of fullness, and hearing loss
• exam findings include a swollen, tender external auditory canal, purulent otorrhea, and cranial nerve palsy (in more advanced infection)
• CT temporal bones can be used to evaluate extent of infection
• treatment includes a fluoroquinolone or an antipseudomonal cephalosporin