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Clinical Challenge
July 2018

Unilateral Otorrhea and Mastoid Erosion

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, College of Medicine, Pennsylvania State University, Hershey
JAMA Otolaryngol Head Neck Surg. 2018;144(7):641-642. doi:10.1001/jamaoto.2018.1096

An 87-year-old man with type 2 diabetes presented with a 4-month history of persistent otorrhea in the right ear and pain overlying the mastoid. A culture of his right ear performed at an outside facility approximately 3 months prior was positive for Pseudomonas species, and he had been treated with Ciprodex (ciprofloxacin, 0.3%, and dexamethasone, 0.1%) ear drops. He presented to the emergency department with progressive otalgia and drainage. His hemoglobin A1c was 9.4% (to convert to proportion of total hemoglobin, multiply by 0.01), white blood cell count was 11 950/μL (to convert to billions per liter, multiply by 0.001), erythrocyte sedimentation rate obtained was normal at 34 mm/h, and serum C-reactive protein level was 1.20 mg/L (to convert to nanomoles per liter, multiply by 9.524). Examination revealed tenderness to palpation overlying the mastoid and an edematous external auditory canal (EAC) with keratinaceous debris and pale fleshy growth along the posterior canal wall. No tenderness of the auricle or canal was elicited. Computed tomography showed soft-tissue density of the right EAC and partial opacification of mastoid air cells with cortical erosion of the mastoid posterior to the EAC (Figure, A). An Oto-Wick was placed in the right ear, and the patient was prescribed Ciprodex ear drops and parenteral antibiotics. Cultures of the EAC obtained prior to antibiotic therapy revealed normal skin flora. Owing to the patient’s atypical presentation, a biopsy of the right posterior ear canal was obtained (Figure, B).