Mr. Robinson is a 46-year-old man presenting with a four-day history of right ear pain. He described the pain as a constant, dull, burning pain radiating to the neck and face, associated with a feeling of congestion. The patient also stated that the right side of his face had felt numb for about one day. Three days earlier, Mr. Robinson was seen by PCP, who told him that his ear looked normal and free of infection. The day before his current presentation, however, he noticed what he described as an "acne-like" rash on his ear lobe. Shortly before coming to the ED, the patient also developed numbness over his right upper lip, which he likened to the effects of procaine during a dental visit. He reported drooling from the right side of his mouth while drinking water and difficulty blinking his right eye.

He denied any tinnitus, fever, headache, or change in hearing. A review of symptoms was positive only for mild dizziness during the previous two to three days.

The patient was a well-appearing white man. He was alert and oriented to identity, time, and place. His skin was warm, dry, and intact. The examiner noticed a small area of erythematous rash with vesicles on the man's right ear lobe. The external auditory canals appeared within normal limits, with no erythema or edema, and were nontender bilaterally. The tympanic membranes were normal bilaterally, without bulging or discernible fluid levels.

The ocular exam was normal with no visual acuity changes and no fluorescein uptake; external ocular movements were intact. A slight droop was noted in the right eyelid, but there was no droop on the contralateral side of his face. When asked to puff up his cheeks, the patient found it difficult to do so on the right side of his mouth without releasing air from...

Muscle strength was 5/5 in all extremities and equal bilaterally. The man's gait was within normal limits, and the remaining findings in the physical exam were normal.
Differential Diagnosis and Rationale

1. Sinusitis (Blahd, 2015):

a swelling of the sinuses that blocks the sinuses from draining normally. It is often caused by a bacterial, viral, or fungal infection. Sometimes sinusitis is caused by allergies or a blockage in the nose. Sinusitis can cause a stuffy nose, bad breath, cough, fatigue, fever, and headache. You have chronic sinusitis when your symptoms last longer than 12 weeks. If the problem lies in the blood vessels then it could be related to Vasculitis, which may also be referred to as angiitis and arteritis refers to a large group of diseases involving inflammation of the blood vessels. The specific blood vessels affected include arteries, veins and capillaries (tiny veins). The plural of vasculitis is vasculitides. Vasculitis causes alterations in the walls of blood vessels, which may include scarring, weakening, narrowing and thickening (Nordqvist, 2016).

2. Localized otitis externa (Kucherov, 2016):

Otitis externa, "a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum" often caused by a bacterial infection (sometimes allergies, irritation or fungal infection), when localized can cause pimple in ear canal. Localized otitis externa happens when a hair follicle in the ear canal gets infected and will be characterized by a number of symptoms that include pain as well as "A small red pimple located in the ear canal. This pimple may eventually become white,…