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50 yr female with ear pain, nodule with pus discharge from ear canal

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Diagnosis: Furunculosis of the External Auditory Canal (EAC)

Clinical Correlation

The image shows a nodular swelling with pus discharge at the entrance of the ear canal in a 50-year-old female — a classic presentation of a furuncle (furunculosis) of the EAC.

What is it?

A furuncle is a walled-off, localized collection of pus arising from hair follicles in the lateral (cartilaginous) ear canal. The causative organism is almost invariably Staphylococcus aureus.

Pathophysiology

  • The EAC's lateral third contains hair follicles and sebaceous glands → entry point for S. aureus
  • Infection → folliculitis → abscess formation (furuncle)
  • Progression: nodular erythema → fluctuance → spontaneous rupture with pus drainage

Clinical Features

FeatureDetail
PainSevere, exquisitely tender to pinna manipulation (tragal sign)
SwellingFirm or fluctuant nodule at lateral EAC
DischargePurulent, once the furuncle ruptures
HearingMay have conductive hearing loss if canal is occluded
FeverUsually absent unless cellulitis develops

Reference Image from Cummings Otolaryngology

Furuncle of the ear canal — the small abscess at the canal entrance, pointing and beginning to rupture
Furuncle of the ear canal — localized swelling at the canal entrance, pointing and beginning to rupture (Cummings Otolaryngology)

Management

  1. Warm compresses — promotes pointing and drainage
  2. Topical antibiotic ointment (e.g., mupirocin)
  3. Oral antistaphylococcal antibiotics:
    • First-line: Cloxacillin/Dicloxacillin or Co-amoxiclav
    • If MRSA suspected: Trimethoprim-sulfamethoxazole or Doxycycline
  4. Incision and Drainage (I&D) — indicated for fluctuant lesions, done under local anesthesia
  5. Analgesics for pain control

Points to Consider in this Patient

  • Ear jewellery (visible in the image) and trauma from earrings/manipulation can introduce organisms → risk factor
  • Check for diabetes mellitus — recurrent furunculosis in adults warrants blood glucose screening
  • Rule out malignant/necrotizing otitis externa in diabetic or immunocompromised patients (aggressive S. aureus or Pseudomonas infection with bone involvement — far more serious)
— Cummings Otolaryngology Head and Neck Surgery, Chapter 138

Will icthymol glycerin ear pack useful

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Yes — ichthyol glycerin (Ichthammol glycerin) ear pack is a well-established, useful treatment for EAC furunculosis, particularly in the early/pre-fluctuant stage.

How It Works

Ichthammol (Ammonium bituminosulfonate / "black salve") has the following pharmacological properties:
PropertyMechanism
Anti-inflammatoryInhibits leukotriene B4 lipoxygenase → reduces local inflammation
Hygroscopic (osmotic)Glycerin draws out tissue fluid → reduces oedema in the canal
Mild antisepticSulphur-containing compounds have mild antibacterial activity
Counter-irritantPromotes localisation and "pointing" of the abscess

How the Pack Is Applied

  1. A ribbon gauze/wick soaked in 10% ichthyol in glycerin is gently inserted into the external auditory canal
  2. Left in place for 24–48 hours
  3. Changed every 1–2 days until the furuncle points or resolves
  4. Acts as a vehicle to maintain contact of the drug with the inflamed canal wall
  5. The glycerin base keeps the canal moist and helps the ichthyol penetrate

When It Is Most Useful

  • Pre-fluctuant stage — when the furuncle is firm and painful but not yet pointing; ichthyol glycerin promotes maturation and pointing
  • Helps reduce the intense oedema and canal swelling, which also relieves pain
  • Avoids the need for immediate I&D in many cases

When I&D Takes Over

Once the furuncle is clearly fluctuant, incision and drainage under local anaesthesia is required — the pack alone will not adequately drain a tense abscess.

Practical Note

Ichthyol glycerin pack is a time-tested ENT standard treatment for EAC furunculosis, especially popular in South Asian and ENT practice. It is used alongside:
  • Oral antistaphylococcal antibiotics (e.g., cloxacillin, co-amoxiclav)
  • Analgesics (NSAIDs or paracetamol)
  • Warm fomentations
Bottom line: Yes, it is useful and appropriate for this patient, especially if the furuncle has not yet become fluctuant. If the lesion is already pointing/draining (as visible in the image), proceed to I&D + antibiotics while using the pack for residual inflammation and canal management.
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