Synopsis
Recognise invasive external ear infection early, investigate its extent and organise sustained multidisciplinary antimicrobial treatment with active surveillance for complications.
- Necrotising otitis externa is an invasive infection that can progress into temporal bone and the central skull base.
- The historical term malignant otitis externa describes aggressive infection rather than a cancer diagnosis.
- Suspect it when pain, especially at night, exceeds expectations for an apparently limited canal infection.
Key red flags
Deep nocturnal pain continuing despite appropriate local treatment, particularly with diabetes or immunosuppression, should prompt urgent assessment for invasive disease.
Investigation priorities
Identify pathogens while investigating an important malignant mimic.
Management branches
Persistent deep pain or granulation raises concern for invasion.
- Arrange same-day ENT discussion and emergency admission for neurological signs, systemic instability or pain that cannot be safely managed.
- Assess airway, breathing, circulation and neurological state while giving appropriate analgesia and correcting clinically important physiological problems.
Key medicines
Ciprofloxacin for selected adult necrotising infectionThe February 2026 NHS Lothian specialist pathway considers 750 mg orally every 12 hours for uncomplicated disease with suitable renal function. Total treatment is at least six weeks in that pathway, with agent changes and stopping decided by ENT and infection specialists.
Piperacillin/tazobactam for complicated adult diseaseThe current NHS Lothian initial regimen is 4.5 g intravenously every six hours for complicated infection, adjusted for renal impairment. This is specialist use for this indication; review cultures and IV need regularly within a prolonged total course, rather than prescribing a fixed six-week IV course.