| Acute mastoiditis | Fever or chills, pain, swelling, and erythema at mastoid process; typically an extension of acute otitis media; normal canal and findings of concurrent otitis media | ENT consultation, admission, IV antibiotics, possible necessity for surgical intervention; Cefotaxime, 1 g IV q 24 h, or ceftriaxone, 1–2 g IV q 24 h | Relatively rare; usually S. pneumoniae, S pyogenes, S. aureus; if it develops after resolved otitis media: acute coalescent mastoiditis |
| Bullous myringitis | Severe ear pain, TM bullae on TM surface, with surrounding erythema; middle ear space not affected | Erythromycin (EES, adult: 400 mg q.i.d.; child: 10 mg/kg q.i.d.), doxycycline, azithromycin | Mycoplasma (or viral) |
| Chondritis, perichondritis | Pain or swelling to the external (cartilaginous) ear; recent ear trauma; warm, erythematous, tender auricle, pinna skin; evidence of recent trauma or piercing; if ear is deformed, suspect chondritis (cartilage infection) | Remove foreign bodies, irrigate wounds; warm soaks and oral cephalexin; outpatient ENT follow-up; if evidence of cartilage involvement, ENT consultation, admission, IV antibiotics | |
| Foreign body | Usually young child, witnessed insertion; foreign body in canal | Removal is typically uncomfortable; tailor method to the characteristics of the foreign body (Frazier suction, alligator forceps, curette); prep with topical anesthetic; children may require restraint or sedation | If canal trauma is present, treat as for otitis externa, outpatient follow-up |
| Infected sebaceous cyst | Pain in canal; no discharge; erythematous, cystic canal surface; pain with pinna traction | Incise and drain cysts; cephalexin or dicloxacillin; outpatient ENT follow-up | May prevent recurrence with selenium sulfide (Selsun) or ketoconazole/steroid shampoo |
| Insect in canal | Buzzing or movement sensation; insect in canal or on TM catheter; flush out when patient is calm | Immobilization will relieve the discomfort; instill mineral oil in the canal with a syringe and flexible tip | Alternatively, may remove a large insect with narrow alligator forceps through the otoscope |
| Otitis externa (swimmer's ear) | Common in regular swimmers; ear pain, itching. Purulent discharge, erythematous canal, pain with pinna traction; canal may be occluded by wall edema; normal hearing unless canal is occluded | Place a cotton wick through an obstructed or near-obstructed canal; treat with topical steroid and antibiotic preparations: hydrocortisone-polymyxin neomycin (Cortisporin Otic), 4 drops q.i.d., or hydrocortisone-ciprofloxacin (Cipro HC Otic), 3 drops b.i.d. | Typically Pseudomonas; outpatient follow-up within 3 days; reduce recurrence risk with drying rubbing alcohol drops following water exposure; consider malignant variant in diabetic, immunocompromised, or elderly patients |
| Otitis externa (malignant) | Elderly, immunocompromised, or diabetic patient with findings of otitis externa; physical findings as above | ENT consultation, admission, IV antibiotics ... |