Bilateral Milian's Ear Sign of Erysipelas

A 76-year-old man presented with fever, and pain in his right ear. Physical examination revealed tender edematous, erythema, and a few vesicles of the right ear, along with facial involvement (Picture 1, 2). Laboratory examination showed neutrophilic leukocytosis. The next day, his left ear and face showed a tender light-colored erythema (Picture 3). After treatment with intravenous ceftriaxone, his symptoms fully resolved. Serum IgM using an enzyme immunoassay for both varicella-zoster virus and herpes simplex virus was negative. Finally, a clinical diagnosis of bilateral ear erysipelas was made. Erysipelas is a common infection involving the upper dermis and lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat (1). Ear involvement is called Milian’s ear sign, and it is a feature distinguishing erysipelas from cellulitis, because the pinna has no deeper dermis and subcutaneous tissue (2). Bilateral ear erysipelas is rare, but it should be considered in the differential diagnosis when encountering patients presenting with red ears.