BACKGROUND AND PURPOSE: Necrotizing external otitis is a serious complication of external otitis with different spreading patterns. A persistent foramen of Huschke is a dehiscence located antero-inferior in the osseous external ear canal and posterior-medial to the temporomandibular joint. This dehiscence can facilitate extension of infection in an anterior pattern next to classic spread along the fissures of Santorini. The aim of this study was to define the prevalence and size of a persistent foramen of Huschke in patients with necrotizing external otitis. MATERIALS AND METHODS: We retrospectively examined 78 CT temporal bone studies (39 patients with necrotizing external otitis, 39 control subjects). The side and presence of the foramen were noted, and its prevalence was calculated. The maximal width of the foramen of Huschke was measured in the axial plane and classified as subtle, mild, moderate, or extensive. RESULTS: A persistent foramen of Huschke was present in 21 patients (26 ears) and 7 control subjects (9 ears). Prevalence was 50% (20/40) and 11.5% (9/78) in affected ears of patients with necrotizing external otitis and control subjects, respectively. Almost all affected ears showed an anterior distribution pattern of necrotizing external otitis. The extensive dehiscence was most common in affected ears. CONCLUSIONS: An anterior necrotizing external otitis spreading pattern is associated with the presence and increased size of a persistent foramen of Huschke. These findings facilitate the theory that a persistent foramen of Huschke is an additional risk factor the development of necrotizing external otitis.