Hot Ear: Diagnostic Approach and Management
If your ear feels hot with pain, swelling, and redness that spares the earlobe, you likely have auricular perichondritis requiring immediate fluoroquinolone antibiotics to prevent permanent cartilage deformity. 1, 2
Immediate Red Flags Requiring Urgent Evaluation
- Painful swelling with warmth and redness that spares the earlobe indicates perichondritis, a cartilage infection most commonly caused by Pseudomonas aeruginosa (69% of cases), Staphylococcus aureus, or Streptococcus pyogenes 1, 2
- Acute tenderness when pressing on the ear cartilage distinguishes deeper perichondrial infection from superficial skin infections and mandates systemic antibiotics 1, 2
- Facial nerve weakness or paralysis with a hot ear suggests herpes zoster oticus (Ramsay Hunt syndrome), requiring immediate antiviral therapy and steroids 1
- Vesicles on the ear canal or posterior auricle indicate viral infection rather than bacterial perichondritis 1
Most Likely Diagnoses Based on Presentation
If Hot Ear WITH Pain/Swelling/Redness:
- Auricular perichondritis presents with the classic triad of painful swelling, warmth, and erythema that characteristically spares the earlobe 1, 2
- Otitis externa (ear canal infection) causes pain, warmth, and discharge but typically involves the entire ear including the lobe 3
- Contact dermatitis from nickel jewelry (affects 10% of women with pierced ears) presents with erythema, edema, and scaling on the conchal bowl and ear canal 1
If Hot Ear WITHOUT Pain (Isolated Warmth):
- Positional/mechanical causes: Lying on one side causes the "pillow ear" to measure 0.7°C warmer on average due to local heat retention 4
- Erythromelalgia of the ears (rare variant) causes episodic burning, erythematous, warm ears exacerbated by heat and relieved by cold 5
- Referred pain/sensation from temporomandibular joint syndrome, dental disease, or cervical spine arthritis can cause secondary ear symptoms even with normal ear examination 6, 7
Treatment Algorithm
For Suspected Perichondritis (Hot + Painful + Swollen Ear):
- Start fluoroquinolone antibiotics immediately (ciprofloxacin or levofloxacin) to cover Pseudomonas aeruginosa and Staphylococcus aureus 1, 2
- Re-examine within 48-72 hours to ensure response to antibiotics and absence of abscess formation requiring surgical drainage 2
- Never delay treatment—perichondritis leads to devastating focal cartilage necrosis and permanent "cauliflower ear" deformities if untreated 1
For Suspected Contact Dermatitis:
- Remove the sensitizing agent (jewelry, topical medications, cosmetics) immediately 1
- Apply topical corticosteroid or calcineurin inhibitor (tacrolimus 0.1% ointment or pimecrolimus 1% cream) 1
For Isolated Warmth Without Other Symptoms:
- Observe and reassess—most benign causes resolve spontaneously 4
- Consider erythromelalgia if episodic burning warmth triggered by heat; trial of amitriptyline may be effective 5
Critical Pitfalls to Avoid
- Do not confuse perichondritis with simple otitis externa—this results in inadequate antibiotic coverage for Pseudomonas and treatment failure 1
- Do not use topical therapy alone for perichondritis—systemic antibiotics are mandatory 1
- Do not use antibiotics that don't cover Pseudomonas for suspected cartilage infections, as this leads to permanent deformity 8
- Never use local anesthesia with epinephrine on the ear if surgical intervention is needed, as this compromises the already tenuous blood supply to auricular cartilage 2
When to Escalate Care
- Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk for serious occult causes requiring further evaluation with imaging or otolaryngology consultation 6, 7
- Symptoms persisting after symptomatic treatment warrant magnetic resonance imaging, fiberoptic nasolaryngoscopy, or erythrocyte sedimentation rate measurement 6, 7
- Severe headache, neck stiffness, or cranial nerve deficits suggest necrotizing otitis externa or intracranial extension requiring immediate specialist evaluation 1