A 68-year-old woman with a poorly controlled history of type 2 diabetes mellitus, hypertension, and morbid obesity presents to the emergency department with severe, unremitting right ear pain for the past five days, describing it as a throbbing 10/10 that is worse at night. She also reports progressive ipsilateral facial weakness that began yesterday. Her current medications include insulin glargine, metformin, lisinopril, and rosuvastatin. On examination, her temperature is 38.50C, blood pressure is 165/95 mmHg, pulse is 98/min, respirations are 18/min, and oxygen saturation is 97% on room air. Inspection of the right external auditory canal reveals significant purulent discharge, granulation tissue at the bony-cartilaginous junction, and exquisite tenderness to palpation of the tragus and pinna. There is also evidence of right facial nerve palsy (House-Brackmann Grade III) affecting eyebrow elevation and oral commissure depression. Which of the following represents the most appropriate initial management strategy and the most concerning potential complication in this patient?

A 68-year-old woman with a history of type 2 diabetes mellitus presents to an outpatient clinic with a four-day history of progressively worsening left ear pain. She reports the pain is constant, throbbing, and exquisitely tender to touch. She recalls a minor scratch to her earlobe a week prior. She denies fever or chills but notes significant swelling and warmth of the entire external ear. Her medications include metformin and lisinopril. On examination, her temperature is 37.5°C, blood pressure is 138/82 mmHg, pulse is 88/min, and respirations are 16/min. Physical examination of the left auricle reveals marked erythema, edema, and exquisite tenderness to palpation, particularly over the cartilaginous portion. The ear canal appears clear, and the tympanic membrane is intact. There is no evidence of frank fluctuance or discharge. What is the most likely diagnosis and the most appropriate initial management strategy for this patient?

A 65-year-old female with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department reporting severe, throbbing pain in her left ear that has worsened over the past month. She initially experienced some discharge, which has since ceased, but now notices difficulty closing her left eye and a drooping corner of her mouth for the past several days. She admits to inconsistent adherence to her antidiabetic medications. On examination, her vital signs are: temperature 38.3 °C, blood pressure 138/88 mmHg, pulse 92/min, and respirations 16/min. Otoscopic examination of the left ear reveals an edematous external auditory canal with purulent exudate and friable granulation tissue present at the bony-cartilaginous junction. There is clear evidence of left facial nerve palsy. Given this presentation, which of the following represents the most appropriate initial diagnostic step and subsequent management?

A 28-year-old female presents to her primary care provider complaining of worsening right ear pain, itching, and a feeling of fullness for the past 3 days. She recently returned from a tropical vacation where she spent significant time swimming. She frequently uses in-ear headphones for extended periods. She reports a mild low-grade fever of 37.8 A and has noticed intermittent, scant serous discharge. The pain is exacerbated by chewing or jaw movement. Her past medical history is unremarkable, and she takes no regular medications. On examination, she is mildly febrile at 37.8 A C. Her right ear is exquisitely tender to palpation of the tragus and manipulation of the pinna. Otoscopy reveals a moderately swollen and erythematous external auditory canal, with a partial obscuration due to yellowish debris. The tympanic membrane is visualized and appears intact, though slightly dull. The left ear examination is normal. Considering these findings, what is the most likely diagnosis and the initial cornerstone of her management?

A 45-year-old woman, known to have well-controlled type 2 diabetes, presents to a primary care clinic with a 4-day history of escalating left ear pain. She reports recent swimming activity. On examination, the external auditory canal is markedly erythematous and edematous, with a seropurulent discharge. Palpation of the tragus elicits severe pain, and the ear canal is so constricted that it obstructs complete otoscopic visualization of the tympanic membrane. Her temperature is 37.50C (99.50F). What is the most likely diagnosis and the most appropriate initial management strategy?

A 72-year-old male presents to an outpatient clinic complaining of severe, unremitting right ear pain radiating to the jaw, accompanied by persistent low-grade fevers and progressive difficulty swallowing over the past week. He has a long-standing history of type 2 diabetes mellitus, poorly controlled, and chronic kidney disease. He reports frequent use of cotton swabs for ear cleaning. On examination, the patient appears unwell but oriented. His temperature is 38.80C, heart rate 105/min, blood pressure 160/95 mmHg, and respiratory rate 16/min. Otoscopic examination of the right ear reveals significant edema of the external auditory canal, purulent discharge, and friable granulation tissue in the inferior wall, near the bony cartilaginous junction. Tenderness is noted with manipulation of the pinna. Neurological examination reveals mild right facial droop and slight deviation of the uvula to the left. The patient's neck is supple without meningismus. Considering the clinical presentation and physical findings, what is the most likely diagnosis and the immediate definitive treatment strategy?

A 72-year-old woman with a history of poorly controlled type 2 diabetes mellitus (HbA1c 9.2%) and hypertension presents to an outpatient clinic with a progressively worsening right ear pain for the past month. She describes the pain as deep and throbbing, radiating to her jaw, and particularly severe at night. She has experienced intermittent fevers and chills, and recently noted a foul-smelling, greenish discharge from her ear, staining her pillowcase. She also reports a new onset of right-sided facial weakness, making it difficult to close her eye and smile. On examination, she appears fatigued but alert. Vitals include a temperature of 38.50C, blood pressure of 128/85 mmHg, pulse of 98/min, and respirations of 16/min. Palpation around the right external auditory canal and mastoid process elicits significant tenderness. Otoscopic examination reveals marked edema and erythema of the external auditory canal with copious purulent discharge and friable granulation tissue noted at the bony-cartilaginous junction. There is also evidence of right facial nerve palsy (House-Brackmann Grade III), characterized by incomplete eye closure and noticeable facial asymmetry. The tympanic membrane is obscured by the canal swelling and discharge. Given her chronic course, immunocompromised status, and new neurological deficits, what is the most likely diagnosis and the critical initial management strategy to prevent further complications?

A 35-year-old woman presents to an outpatient medical office complaining of persistent right-sided ear discomfort and a feeling of fullness for the past 4 days, which began after a weekend of frequent swimming. She reports mild itching followed by increasing pain, especially when touching her ear. On physical examination, there is noticeable tenderness upon manipulation of the right auricle and palpation of the tragus. The external auditory canal is edematous, showing partial occlusion and a thin, whitish discharge. Mild excoriations are also noted along the canal walls. The tympanic membrane, visualized after careful suctioning of superficial debris, appears intact and non-inflamed. The left ear examination is unremarkable. The patient denies fever, chills, or any changes in hearing. What is the most likely diagnosis and the most appropriate initial management strategy?

A 12-year-old girl presents to the clinic with her guardian complaining of persistent left ear discharge. Her guardian states that the patient has a long-standing history of recurrent ear infections, with several instances requiring tympanostomy tube placement in the past, though the tubes are no longer present. For the past two weeks, she has experienced a feeling of fullness in her left ear, followed by intermittent, foul-smelling otorrhea for the last two days. Her guardian admits to attempting to clear the ear canal with a cotton-tipped applicator before the discharge became more noticeable. The patient's vital signs are stable: temperature 36.80C, blood pressure 108/60 mmHg, pulse 85/min, and respirations 18/min with an oxygen saturation of 98% on room air. Physical examination of the left ear reveals an irregular, pearly-white mass protruding through a retraction pocket in the superior-posterior aspect of the tympanic membrane, partially obscured by purulent discharge (refer to Figure A for visual representation of a similar finding). Pneumatic otoscopy demonstrates that this mass does not move with changes in pressure. Lab results indicate a slightly elevated white blood cell count and C-reactive protein. Given these findings, what is the most appropriate initial management strategy for this patient, and what potential long-term complication should be carefully monitored?

A 72-year-old woman with a long-standing history of type 2 diabetes mellitus and chronic kidney disease presents to a primary care clinic reporting persistent, severe right ear pain and headache over the past ten days. She describes the pain as deep-seated, throbbing, and significantly exacerbated by jaw movement and at night, often disrupting her sleep. She also notes a foul-smelling, greenish discharge from the ear canal and a subjective sense of fever and chills. Her vital signs reveal a temperature of 38.8°C, blood pressure of 165/98 mm Hg, and pulse of 92/min. Physical examination of the right ear reveals a severely edematous external auditory canal with purulent exudate and friable granulation tissue visualized at the bony-cartilaginous junction. The tympanic membrane is obscured by swelling. The patient exhibits mild facial asymmetry upon smiling. Given this clinical presentation, what is the most appropriate diagnostic approach and initial empiric therapeutic intervention?

A 28-year-old man presents to an outpatient clinic with a 3-day history of increasing left ear pain and a feeling of fullness. He recently returned from a swimming trip. On physical examination, the external auditory canal is significantly edematous, erythematous, and filled with purulent discharge and desquamated epithelial cells, making visualization of the tympanic membrane difficult. There is marked tenderness upon palpation of the tragus and gentle manipulation of the auricle. His temperature is 37.8°C (100.0°F), and he denies significant systemic symptoms. What is the most likely diagnosis and the appropriate initial management strategy?

A 55-year-old male presents to the clinic with progressive left-sided facial weakness that began approximately two weeks ago, worsening over time. He reports difficulty closing his left eye and an inability to fully smile on the left side. For the past six months, he has experienced persistent, foul-smelling discharge from his left ear, which has not responded to multiple courses of oral antibiotics prescribed by his primary care physician. His medical history includes several episodes of ear infections during his youth, along with chronic, mild hearing loss in the left ear. On examination, his temperature is 37.5°C, blood pressure is 128/78 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination confirms a left peripheral facial nerve palsy, with incomplete eye closure and sagging of the left corner of the mouth. Otoscopic examination of the left ear reveals a significant amount of whitish, cheesy debris in the middle ear space, accompanied by a large posterior-superior tympanic membrane perforation. Audiometric evaluation further confirms a severe conductive hearing loss on the left. What is the most likely diagnosis and the appropriate initial management strategy for this patient's condition, considering potential long-term complications?