A 25-year-old client presents to the emergency department complaining of severe ear pain that began 2 days ago after swimming at a local pool. The client reports that the pain worsens when touching the ear. Which assessment finding would be most characteristic of otitis externa?

Pain when pulling on the auricle (tragus sign) is the most characteristic finding of otitis externa, as it directly indicates inflammation in the external ear canal. Other findings are more typical of otitis media or other conditions.

Clinical Reasoning Analysis

The client's history of recent swimming and severe ear pain that worsens with physical manipulation of the external ear structures points toward an inflammatory process of the ear canal rather than the middle ear. The most characteristic assessment finding for otitis externa is pain elicited by manipulating the auricle or tragus, a clinical indicator often referred to as the tragus sign. This finding directly reflects the pathophysiology of the condition, where the inflamed, edematous skin of the external auditory canal becomes highly sensitive to mechanical deformation ^[1].

Differentiating between otitis externa and acute otitis media is a critical clinical judgment skill for the NCLEX-RN. In otitis externa, the infection and inflammation are localized to the external auditory canal. Because the canal's skin is tightly adherent to the underlying cartilage, any movement of the auricle or pressure on the tragus stretches this inflamed tissue, causing sharp, localized pain. This is a pathognomonic physical examination finding that is consistently highlighted in clinical practice guidelines for diagnosis ^[1]. The absence of this finding, or the presence of a bulging tympanic membrane, would redirect the clinical suspicion toward a middle ear process.

The incorrect options represent findings more consistent with other ear pathologies. Hearing loss without pain on palpation is a nonspecific finding that can occur with cerumen impaction or serous otitis media but lacks the hallmark inflammatory sign of external ear involvement. Purulent drainage suggests a ruptured tympanic membrane from a middle ear infection, where the initial pain often subsides after perforation and is not primarily triggered by auricle manipulation. Fever with a bulging, erythematous tympanic membrane is the classic presentation of acute otitis media, an infection of the middle ear space that is distinct from the external canal inflammation seen in this client ^[1]. The client's history of water exposure from swimming is a well-established predisposing factor for otitis externa, as moisture macerates the protective epithelial lining of the canal, creating an environment conducive to bacterial or fungal overgrowth [1,2].