Otitis externa — branching viva

Branching viva from an eight-year-old swimmer with otalgia, otorrhoea and tragal tenderness, through the canal-versus-middle-ear distinction and the analgesia-led, topical-first stepwise management, with a pivot to a too-swollen canal requiring an ear wick, and a final stem on an immunocompromised child with severe otalgia and a facial palsy testing the recognition of necrotising otitis externa, its inflammatory-marker and imaging work-up, and prolonged systemic antipseudomonal therapy.

branching clinical structured oral2 min readVerification in progress

Prompt

You are the paediatric registrar in the emergency department. The examiner asks you to work through an eight-year-old swimmer with a painful discharging ear and tragal tenderness, then the same child whose canal is too swollen to admit drops, and finally an immunocompromised six-year-old with severe unremitting otalgia and a facial palsy. Information is released in stages.

Opening — the swimmer with a painful discharging ear

Examiner: An eight-year-old girl who swims daily presents with two days of right ear pain, a mucky discharge and itching, crying when the ear is touched. Talk me through your immediate thoughts and your examination. ^[1]

Candidate should cover: the diagnosis of acute diffuse otitis externa (swimmer's ear) from the water-exposure history, otalgia, otorrhoea and pruritus; the two localising signs — tenderness on pressing the tragus and pain on pulling the pinna backwards — that place the disease in the canal rather than the middle ear; and a cleared view of a normal tympanic membrane excluding acute otitis media. ^[3]

References7Show

[1]Rosenfeld RM; Schwartz SR; Cannon CR; et al Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg, 2014.PMID 24491310
[3]Hajioff D; MacKeith S Otitis externa. BMJ Clin Evid, 2015.PMID 26074134
[5]Di Traglia R; Tudor-Green B; Muzaffar J; et al Antibiotics versus non-antibiotic treatments for acute otitis externa: A systematic review and meta-analysis. Clin Otolaryngol, 2023.PMID 37550850
[7]Khokhar ZA; Mills JF; Nguyen SA; et al Pediatric Necrotizing Otitis Externa: A Scoping Review. Ann Otol Rhinol Laryngol, 2024.PMID 39289874
[9]Aljariri AA; Al-Qudimat AR; Hammoud R; et al Mortality of malignant otitis externa: A prevalence meta-analysis. Qatar Med J, 2025.PMID 40765727
[10]Agarwal M, Juliano AF, Hagiwara M, et al. ACR Appropriateness Criteria: Inflammatory Ear Disease. J Am Coll Radiol, 2025.PMID 40409884
[11]Patel S; Owen GS; Vivas EX; et al Otitis Externa and Malignant Otitis Externa-for the Hospitalist/Internist. Med Clin North Am, 2026.PMID 41206199

Otitis externa — branching viva

branching clinical structured oral2 min readVerification in progress

Opening — the swimmer with a painful discharging ear

References7Show

[1]Rosenfeld RM; Schwartz SR; Cannon CR; et al Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg, 2014.PMID 24491310
[3]Hajioff D; MacKeith S Otitis externa. BMJ Clin Evid, 2015.PMID 26074134
[5]Di Traglia R; Tudor-Green B; Muzaffar J; et al Antibiotics versus non-antibiotic treatments for acute otitis externa: A systematic review and meta-analysis. Clin Otolaryngol, 2023.PMID 37550850
[7]Khokhar ZA; Mills JF; Nguyen SA; et al Pediatric Necrotizing Otitis Externa: A Scoping Review. Ann Otol Rhinol Laryngol, 2024.PMID 39289874
[9]Aljariri AA; Al-Qudimat AR; Hammoud R; et al Mortality of malignant otitis externa: A prevalence meta-analysis. Qatar Med J, 2025.PMID 40765727
[10]Agarwal M, Juliano AF, Hagiwara M, et al. ACR Appropriateness Criteria: Inflammatory Ear Disease. J Am Coll Radiol, 2025.PMID 40409884
[11]Patel S; Owen GS; Vivas EX; et al Otitis Externa and Malignant Otitis Externa-for the Hospitalist/Internist. Med Clin North Am, 2026.PMID 41206199