In the light of current concerns regarding ciprofloxacin resistance and the changing face of malignant otitis externa, we reviewed cases of malignant otitis externa treated in our centre, in order both to evaluate the current epidemiology of the condition and to assess the status of drug resistance in our patient population.

Retrospective case review of all malignant otitis externa cases managed in a tertiary referral centre in the north-east of England between 2000 and 2009.

Forty-one patients were identified, but the required data were available for only 37 cases. Patients' ages ranged from 51 to 101 years (median, 81 years). Diabetes was present in 51 per cent of patients (19/37), facial nerve palsy in 40 per cent (15/37) and multiple cranial nerve palsy in 24 per cent (9/37). Pseudomonas aeruginosa was the most commonly isolated organism (54 per cent), sensitive to ciprofloxacin in all cases.

The incidence of cranial nerve palsy in our study was higher than in previous reports. The incidence of diabetes and Pseudomonas aeruginosa in our cohort was much lower than previously reported. The Pseudomonas aeruginosa strains isolated were all sensitive to ciprofloxacin, despite recent reports on emerging resistance.

Malignant otitis externa is a life-threatening infection of the skull base. Its presentation is not always typical.

We report three cases of malignant otitis externa which illustrate the diversity of its clinical manifestations and the difficulties in its diagnosis.

The perception of malignant otitis externa as an infection caused by Pseudomonas aeruginosa in diabetic patients is not always correct. The adoption of diagnostic criteria could be helpful in identifying atypical cases.