Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. This infection usually occurs in older, poorly controlled diabetics and is almost always caused by P aeruginosa. It can invade contiguous structures including facial nerve or temporal bone and can even progress to meningitis. Streptococcus pneumoniae, H influenzae, and M catarrhalis frequently cause otitis media, but not external otitis. Candida albicans almost never affects the external ear.