Malignant external otitis (MEO) is a rare inflammatory and infectious condition, typically caused by
Pseudomonas aeruginosa, that mainly affects diabetic or immunocompromised elderly patients. It begins in the external auditory canal and progresses through the skull base, causing osteomyelitis and eventually cranial neuropathy, especially of the facial nerve.  

A 65-year old diabetic man, presented with an 8-month progressing left otitis externa and evolved with ipsilateral proptosis, ophthalmoplegia, blindness, facial palsy, hearing loss and contralateral evolvement of the temporal bone with hearing impairment. The cranial and brain images showed erosion of the anterior wall of the left external ear conduct, osteomyelitis through the skull base and tissue occupying the left superior orbital fissure intraconal fat, with invasion of the left orbit. Cavernous sinus thrombosis was excluded and the diagnosis of a rare presentation of multiple cranial nerve palsies associated with MEO was made. He was initially treated with oral ciprofloxacin, which was switched to meropenem and vancomycin and underwent left canal wall-up mastoidectomy with good recovery of right ear hearing capacity, but no improvements of neurological deficits nor left hearing function. Microbiological tests were negative as a possible consequence of the early use of antibiotics. Unfortunately, the patient was infected by Sars-CoV-2 during hospitalization and passed away after ten days of COVID-19 intensive care unit internment.