OBJECTIVES: Necrotizing external otitis is a potentially lethal infection that affects mainly elderly diabetic patients, starts at the external auditory canal (EAC), and extends to the skull base. Pseudomonas aeruginosa is found in 96 to 98% of cases. We report a case and correlate it with the literature. CASE REPORT: An elderly hypertensive and insulin diabetic reported the onset of right otalgia and sudden otorrhea for 45 days without a clinical response to systemic or topical antibiotics. The patient's condition progressed with worsening pain and facial paralysis. Upon examination, grade V right facial palsy (House-Brackmann) was noted. Otoscopy found hyperemia and edema of the shell and conduit, pus, and granulation tissue at the junction of the osteocartilaginous and tympanic membranes. Tests showed leukocytosis, hyperglycemia, and increased ESR and CRP. A CT scan revealed mastoid fabric with a soft tissue density and thickening in the EAC. An ear discharge culture was positive for Pseudomonas aeruginosa and biopsy of the granulation tissue revealed chronic inflammatory infiltrates. Tympanometry noted stapedial areflexia. Bone scintigraphy with technetium captante right. Intravenous and topical antibiotics were initiated, with glycemic control and daily vacuuming of the conduit. After 48 h, there was a regression of granuloma, decreased otorrhea, no pain, and normoglycemia. Antibiotic therapy was maintained for 8 weeks. After this period, gallium scintigraphy was acquired using the VHS standard, and the otoscopy was unchanged and clinically stable. We chose to continue the ciprofloxacin and to acquire new control scintigraphy with gallium. CONCLUSION: A higher index of suspicion should be provoked early and the appropriate therapy instituted to reduce the morbidity and mortality of patients.