What could be the single cause of myalgia, ear congestion, and pruritus?

Acute Otitis Externa (Swimmer's Ear) is the Single Most Likely Diagnosis

The combination of muscle pain (myalgia), stopped-up ear (fullness), and itching strongly suggests acute otitis externa (AOE), which classically presents with ear itching (60% of cases), ear fullness (22%), and regional lymphadenitis or cellulitis that can cause localized muscle pain. 1

Clinical Reasoning

Why Acute Otitis Externa Fits Best

• Itching is a hallmark symptom, occurring in 60% of AOE cases and often preceding other symptoms 1
• Ear fullness/congestion occurs in 22% of AOE cases due to ear canal edema and inflammation 1
• Muscle pain can result from regional lymphadenitis or cellulitis of the pinna and adjacent skin, which are documented complications of AOE 1
• The triad suggests inflammation extending beyond just the ear canal itself 1

Key Diagnostic Features to Confirm

• Tragal tenderness (pain when pushing the tragus) or pinna tenderness (pain when pulling the ear) is the hallmark sign—often intense and disproportionate to visible findings 1
• Otoscopy reveals diffuse ear canal edema, erythema, or both, with or without discharge 1
• Predisposing factors include recent water exposure, humidity, use of ear plugs/hearing aids, or trauma from cleaning the ear 1

Alternative Diagnoses to Consider

Contact Dermatitis of the Ear Canal

• Can present with itching, ear canal inflammation, and regional swelling that might cause muscle discomfort 1, 2
• Distinguished by history of allergen exposure (nickel jewelry, cosmetics, hearing aids) and typically more chronic presentation 1, 2
• Eczematous or maculopapular eruption visible on examination, often involving conchal bowl 2

Auricular Perichondritis

• Presents with painful swelling, warmth, and redness of the auricular cartilage (sparing the earlobe) 2
• Would cause more severe localized pain and visible cartilage inflammation 2
• Less likely to present primarily with itching 2

Immediate Management Algorithm

First-Line Treatment

• Topical antimicrobial ear drops are the initial therapy of choice for uncomplicated AOE 1, 3
• Topical preparations deliver concentrations 100-1000 times higher than systemic therapy 2
• Do NOT prescribe systemic antibiotics as initial therapy for uncomplicated AOE unless there is extension outside the ear canal 1, 3

Pain Management Priority

• Assess and treat pain immediately with analgesics based on severity 1, 3
• Pain relief is essential and should be addressed regardless of antibiotic therapy 3

Enhance Drug Delivery

• If ear canal is obstructed by edema or debris, perform aural toilet (gentle cleaning) or place a wick to facilitate topical medication delivery 1

Critical Red Flags Requiring Urgent Evaluation

• Facial nerve paralysis or paresis suggests herpes zoster oticus (Ramsay Hunt syndrome) requiring immediate antiviral therapy 2
• Severe headache, meningismus, or cranial nerve deficits suggest necrotizing otitis externa or intracranial extension 2
• Vesicles on external ear canal indicate viral infection rather than bacterial AOE 2
• Failure to respond within 48-72 hours requires reassessment to confirm diagnosis and exclude other causes 1

Common Clinical Pitfalls

• Confusing AOE with acute otitis media (AOM): AOE shows normal tympanic membrane mobility on pneumatic otoscopy, while AOM shows limited mobility 1
• Missing contact dermatitis: Nickel allergy affects ~10% of women with pierced ears and can mimic AOE 1, 2
• Delaying treatment of perichondritis: If cartilage involvement is present, systemic fluoroquinolones are required immediately to prevent devastating cartilage necrosis 2
• Prescribing systemic antibiotics for uncomplicated AOE: This is inappropriate when topical therapy is superior 1, 3