<prompt> A 68-year-old diabetic male presents with persistent ear discharge with fever and headache. He complained of pain out of proportion. On examination, granulations and tenderness are observed on the floor of the external auditory canal along with facial nerve palsy. He is not responding to antibiotics. What is the most probable diagnosis?Malignant otitis externaMalignant disease of middle earMalignant disease of nasopharynxChronic otitis externa  <response>: Ans. a. Malignant otitis externa Ref: Dhingra 5th58Presence of a painful lesion in the external ear with the evidence of granulation tissue and associated cranial nerve palsies VII nerve in a diabetic or immunocompromised patient suggest a diagnosis of malignant otitis externa.Severe hearing loss is not the chief presenting complaint malignant otitis externa.Malignant Otitis Externa:Characterized by granulation tissue in external auditory canal at the junction of bone and cartilage.MC organism: Pseudomonas aeruginosaQESR is raised, used for follow up of treatmentMalignant Otitis Externa Necrotizing Otitis Externa Skull Base OsteomyelitisProgressive debilitating and sometimes fatal infection of the external auditory canalQCharacterized by granulation tissue in external auditory canal at the junction of bone and cartilageQ.MC organism: Pseudomonas aeruginosaQPathophysiolology:Characterized by necrotizing vasculitisQThe infection does not spread through the pneumatized air tracts of the temporal bone.The otic capsule appears to be resistant to the disease process.Extensive destruction in the wall of the bony external auditory canal and osteomyelitic destruction of the wall of the fallopian canal in the descending portion of the facial nerve is seen.The infection spreads beneath the otic capsule to erode the wall of the carotid canal and then extended into the central skull base.Predisposing Factors:Diabetes 90 of patients, AIDS, aural irrigationFeatures:Occurs commonly in elderly diabetic 60 years, immunosuppressed patients or patients who have received radiotherapy to skull baseQMore common in malesMC nerve involved: VII FacialQ; Others: IX, X, XI, XIIQSevere, unrelenting, deep-seated otalgia, temporal headaches, purulent otorrhea, possibly dysphagia, hoarseness, andor facial nerve dysfunction.The pain is out of proportion to the physical examination findings.Marked tenderness is present in the soft tissue between the mandible ramus and mastoid tip.Granulation tissue is present at the floor of the osseo-cartiliginous junction. This finding is virtually pathognomonic of malignant external otitis.Otoscopic examination may also reveal exposed bone.The tympanic membrane is usually intact.Spread of the infectionDiagnosis:Investigation: CT scan, gallium and technetium-99 scintigraphyThe leukocyte count is usually normal or mildly elevated. ESR is raised.CT scanning and MRI is both useful for evaluating the anatomic extent of soft tissue inflammation, abscess formation, and intracranial complications.MRI is more sensitive for detecting intracranial complications.Treatment:Correction of immunosuppression when possible, local treatment of the auditory canal, long-term systemic antibiotic therapy, and in selected patients, surgery.In all cases, the external ear canal is cleansed and a biopsy specimen of the granulation tissue sent for culture.IV antibiotics are directed against the offending organism.Extensive surgical debridement once an important part of the treatment is now rarely needed.Prognosis:High mortality rate So termed as malignantDeath due to intracranial complications like sigmoid sinus thrombosis 