Although uncommon, necrotising (previously malignant) otitis externa (nOE) can be very aggressive, particularly if not managed appropriately. In this study the authors perform a retrospective review of 25 patients admitted with nOE over a four year period at a tertiary referral centre. They have also described a treatment algorithm for the management of nOE, having identified a lack of consistency in management within their department. Only 92% of patients had CT scanning, so two patients had no form of imaging. Almost 60% of cases were associated with pseudomonas aeruginosa, and the authors postulate that the increased use of quinolones in managing otitis externa has led to the increased finding of nOE associated with other bacterial strains. The issue of whether to biopsy these patients is a controversial one, and in this paper just over half of patients had a biopsy of granulation tissue. In 28% of cases, the biopsy sample aided the isolation of the causative organism in cases where canal swabs were negative, thus the authors recommend biopsy in resistant cases. In cases of resistant disease repeat CT was also suggested. However no mention is made of MRI scanning, which is suggested in other departments for evaluation of the extent of soft tissue involvement. In line with most UK departments, the authors’ department organises for patients to have extended course of intravenous antibiotics in the community, but the authors recognise that this can be fraught with difficulties in terms of organisation. This paper provides a useful initial management protocol for nOE but some departments may have existing protocols agreed with their local microbiology service.