Welcome!
Welcome to the wonderful world of earache! This tutorial should take you 30 minutes to complete
(but don’t worry, you can do it as many times as you like)
Learning Objectives:
By the end of this tutorial you will be able to:
1) Identify the commonest causes of earache in primary care
2) Know how to approach the patient with earache and diagnose through history and
examination
3) Manage the main causes of earache
To navigate:
Click on the
and
buttons to the right or the headings in the left-hand column.
Have fun!
(All otoscopic photos reproduced with the kind permission of The Hawke Library –
www.hawkelibrary.com1-11)
Causes of Earache
Causes of earache can be local to the ear itself or referred from other structures.
Local:


Middle ear – acute otitis media
Outer ear – otitis externa
Note that there will always be clinical signs in the ear.
Referred:
Cause
Nerve root12
Dental abscess
Tempero mandibular joint
pain
Problems in the Tonsil or base
of tongue (eg. infection or
tumour)
Auriculo-temporal branch of the trigeminal nerve
Direct contact with ear (the back wall of the joint
is the front wall of the ear canal)
Glossopharyngeal nerve
Problems in the pharynx or
larynx (eg. infection or
tumour)
Auricular branch of the vagus nerve
Acute otitis media and otitis externa are the most common causes of earache seen in primary care
so we will look at both of these by working our way through 2 case studies.
The ear will usually look normal.
Case 1
A mother, Mrs Morris, comes to your GP surgery with her 18 month old son, Oscar.
She tells you he has been up in the night, has felt hot to touch and has been rubbing his ear. He’s
been quite grouchy today and ‘not his usual self’. He is clinging to his mother but appears alert.
What is your top differential at this point?
Go to the next page to find out more…
Acute Otitis Media
Unsurprisingly, we’re going to start with otitis media. The terminology of middle ear infections can
be a bit confusing so here’s a quick breakdown:
Term
Acute otitis media
Glue ear*
Chronic suppurative otitis
media
Acute infection and
inflammation
Non-infected effusion in
middle ear. Also known as
secretory otitis media or
otitis media with effusion
Perforation and discharge
lasting ~>1 month
Pus behind the ear drum.
If left untreated, the ear
drum will burst and pus
will come out of the ear.
This is normally painful,
and patients will have a
fever.
Mucus behind the ear
drum.
Patients will have a mild
earache and no fever.
A perforation and ear
discharge
Patients will have a mild
earache and no fever.
Definition
Photo1,2,3
This
essentially
shows:
This tutorial is on earache so we will look at the one that causes pain, acute otitis media.
It is caused by infection and inflammation of the middle ear. The infection may be:



Bacterial – e.g. Strep. pneumoniae (25%), Haemophilus influenzae (25%), Moraxella
catarrhalis (15%)
Viral
Both may be present
Epidemiology
Though otitis media may occur at any age it is most common in children:
 75% of cases seen in primary care are under the age of 10 ** REFERENCE NICE GUIDE
 The peak incidence is 6-15 months of age13
The reason why it is mostly seen in children is thought to be due to Eustachian tube dysfunction
The main functions of the Eustachian tube are to:
 Drain middle ear secretions into the nasopharynx
 Ventilate middle ear
 Protect middle ear from nasopharyngeal secretions
Infants have shorter, wider and more horizontal tubes with incomplete musculature which doesn’t
effectively open and close the tube. However, children have large adenoids in the naso pharynx
which can physically obstruct the eustachian tubes and harbour respiratory bacteria.
It’s thought that an upper respiratory tract infection causes obstruction of the tube, preventing
drainage of the middle ear secretions leading to effusion. If micro pathogens are present they may
multiply and cause infection and inflammation.
Case 1 b
You start by taking a full history.
What risk factors for otitis media will you ask Mrs Morris about?
Go to the next page to find out…
Risk Factors
Factors proven to increase the risk of otitis media include:14,15
Host factors
Environmental factors
Age
Male
Family history
Prematurity
Passive smoking
Nursery/day care attendance
Use of a dummy
Craniofacial syndromes (cleft palate or Down’s
syndrome)
As with any condition, asking about risk factors serves a dual purpose:
1) To add weight to a diagnosis
2) To identify modifiable risk factors which can then be addressed
In this case, it is particularly important to ask about parental smoking and to encourage quitting.
The increased risk from passive smoking may be used in antenatal care (alongside other tactics) to
encourage mothers to quit smoking. Also, breastfeeding has been shown to be protective against
acute otitis media which is one of the reasons why it is encouraged. 16
Case 1 c
Mrs Morris confirms that Oscar’s father had numerous ear infections when he was a child, Oscar
attends nursery and she is a smoker, though she is ‘cutting down’. Oscar has no other medical
history of note.
You clearly explain that smoking not only affects her health but that of her son and you recommend
she makes use of the NHS smoking cessation services.
You then go on to examine Oscar.
What findings would suggest otitis media?
Go on to the next page to find out…
Presentation
The signs and symptoms of otitis media are due to:



Earache (note that the pinna will not be tender)
Fever
Redness of the tympanic membrane. The ear drum may have perforated (giving ear
discharge)
The following are signs of acute otitis media:
Bulging tympanic
membrane1
Effusion4
Otorrhoea6
The following show ears that are not acutely inflamed and show signs of glue ear.
Effusion4
Bubbles in themiddle
ear4
Bear in mind that most patients will be young children and may not be able to tell you that their ear
is hurting. Therefore signs may be non-specific, such as tugging at an ear, fever (often very high),
crying and poor feeding.
Examination is a useful tool and it is good practice in all children presenting with fever to examine
both their ears and throat.
Case 1 d
You examine Oscar and see that his left ear has a red tympanic membrane with a bulging red
tympanic membrane. The right ear is normal.
He has a temperature of 37.8°C
What are the treatment options and which do you feel is most appropriate for Oscar?
Mrs Morris asks you about antibiotics. She says she is aware that it’s not always best to give them
but she doesn’t understand why.
How would you describe the pros and cons of giving antibiotics?
Go to the next page to find out more…
Management
Investigations
Investigations are rarely required for the clinical diagnosis of acute otitis media. Culture of discharge
may be of help in recurrent/chronic cases.
Treatment
Once you have expertly diagnosed acute otitis media there are 2 main steps to consider for
treatment:
1) Treat the pain – paracetamol/ibuprofen
2) Consider whether to give antibiotics
Antibiotics
This is all about weighing benefits against risks. You must be able to decide whether to prescribe
antibiotics and be able to justify your choice to the patient. The pros and cons of antibiotics are
summed up in the table below:
Pros
Cons
May shorten symptom duration
Decreased risk of complications
Side effects (vomiting, diarrhoea, rash)
Risk of allergy
Risk of antibiotic resistance
Cost
Complications

Mastoiditis – where the infection extends out of the back of the middle ear into the mastoid
bone. This in turn can lead to a mastoid abscess behind the ear. Theimage below shows how
the ear is pushed downwards and outwards.

Intra-cranial infection – the middle ear sits just below the middle fossa. Infection in the
meiddle ear can lead, rarely, to intracranial abscesses or meningitis. The risk of this
happening is about 0.04% but is easily prevented by using antibiotics.
Facial nerve weakness – the facial nerve has no bony covering within the middle ear in up to
10% of the population. This is why you should always examine the ears if someone presents
with a facial nerve palsy.

80% of cases of acute otitis media resolve spontaneously within 3 days of onset. In these cases the
disadvantages of antibiotics are therefore thought to outweigh the benefits.
Of course, when you first see a patient you don’t know whether they will be in this 80%. Therefore
antibiotics are recommended for patients if symptoms persist for 4 or more days.
The treatment of choice is:
amoxicillin (or erythromycin) for 5 days
There are 2 ways to arrange delaying treatment:
1) Ask the patient to return if they are no better after 3 days
2) Give them a delayed prescription which they can use in 3 days if they need it.
Delayed prescribing has been shown to lead to decreased antibiotic use.17 Also, the patient feels
empowered and able to manage themselves reducing repeat visits.18
Case 1 e
You decide that considering Oscar has only been symptomatic for 1 day you will prescribe analgesia
and ask Mrs Morris to return if he does not improve after 3 days.
Mrs Morris returns 4 days later and Oscar has still not improved. She asks whether he should have
been given immediate antibiotics.
What clinical features would make you think about giving immediate antibiotics?
Go to the next page to find out…
Management 2
In some circumstances a patient should be offered immediate antibiotics, even at the first visit.
These include:12





Systemically very unwell (e.g. temp ~>38.5°C, vomiting)
High risk of serious complications due to other health problems (e.g. cystic fibrosis,
immunosuppression, significant heart/lung /renal disease)
Already had symptoms for 4 days without improvement
~< 2 years old with bilateral symptoms
Perforation/otorrhoea
An important aspect of primary care is to know when to refer.
Admission/referral may be indicated if:12





~<6 months old with a high fever
Suspected
(e.g. meningitis, mastoiditis, cholesteatoma)
Recurrent AOM (≥3 episodes in 6 months)
Repeated AOM in adults (especially elderly) – risk of nasopharyngeal carcinoma
This may seem like a fairly long list but try and think of it in terms of:
 High risk or recurrent = admit/refer
 Moderate risk = immediate antibiotics
Treatment Flowchart
Here is the same information displayed in a flowchart algorithm for those whose minds are that way
inclined:
Case 1 f
You explain that though it is unfortunate that Oscar’s symptoms have not yet resolved, at the time
of their first appointment there was nothing to suggest the need for immediate antibiotics. You then
affirm that she has done the right thing to bring him back and it would now be appropriate to give
him antibiotics. You first take a brief history to see if anything has changed (and check for allergies to
antibiotics) and you exam Oscar again. You prescribe a 5 day course of amoxicillin.
Mrs Morris asks how long symptoms are likely to last and whether she should use anything else,
such as over the counter decongestants.
What advice would you give her?
Go to the next page to find out more…
Other Treatments and Prognosis
Other Treatments
There is no evidence for the benefit of antihistamines, mucolytics, decongestants or inhaled steroids
in otitis media19
Prognosis
The prognosis for acute otitis media is very good. Most symptoms resolve within a number of days
though the effusion(glue ear plus mild hearing loss) may persist for a number of weeks.
If antibiotics have been given remind patients to complete the full course, even if symptoms resolve
before this.
Case 1 g
Oscar’s symptoms improve with the antibiotics and he is back to his cherubic self within the next few
days. You sleep comfortably at night knowing that you treated him in a safe and evidence-based
manner.
Case 2
A Mr Oliver Edwards, a 50 year old accountant, attends your surgery complaining of earache. He
says the problem has lasted for about 3 days. It is his right ear and it feels tender to touch.
What is your top differential at this point?
Go to the next page to find out more…
Otitis Externa
We’re onto otitis externa now.
Otitis externa is caused by inflammation of the skin lining the external auditory canal.
Acute Otitis Externa7
Causes & Epidemiology
Causes
The causes of otitis externa can be:

Infective:
o Bacterial (90%) – e.g. Staphylococcus, Pseudomonas
o Fungal (10%) – e.g. Candida, Aspergillus20
Epidemiology
Unlike otitis media, otitis externa is most common in adults.
Case 2 b
Having decided from his presenting complaint and his age that otitis externa is the most likely cause,
you take a full history.
What risk factors for otitis externa will you ask about?
Go to the next page to find out…
Risk Factors
Risk factors for otitis externa include:




Foreign objects in the ear canal (e.g. cotton buds or
hearing aids) r
Swimming, particularly warm swimming pools. 20
Chronic skin diseases (e.g. eczema, psoriasis)
Swimmers ear – where the ear canal is narrowed by
bony nodules called exostoses. It is caused by
swimming in cold water over many years – it is very
common in UK surfers.
Case 2 c
You are interested to hear that Mr Edwards is a keen swimmer, and that following a dip he likes to
clean his ears out with a cotton bud.
You politely inform him that, although cotton buds are very well designed for pushing wax further
into ears and perforating ear drums, he would perhaps do better without them.
You continue with the history and examination.
What symptoms will you ask about and what will you look for on examination?
Go to the next page to find out more…
Signs and Symptoms
There are important similarities and differences with the signs and symptoms of acute otitis media.
Symptoms:
 Itching (this is the most common symptom)
 Pain - which can be very severe
 Otorrhoea (watery compared to the mucous discharge in otitis media)
 Mild hearing loss may occur
Signs:




Tenderness at the meatus and tragus (especially on movement of the pinna)
Erythema (at meatus and lining canal)
Swelling of the ear canal skin – you often can’t see the ear drum because of swelling
Skin debris in the ear canal
Canal swelling and erthythema8
Swimmer’s ear9
Case 2 d
Mr Edwards confirms that his ear is very itchy and he has noticed a small amount of watery
discharge. On examination the ear is tender, the canal is erythematous and the tympanic membrane
looks normal. He is apyrexial. This all confirms your diagnosis of otitis externa.
How will you go on to manage Mr Edwards?
Go to the next page to find out more…
Management
Investigations
Like otitis media, in most cases no investigations are needed. If the initial treatment fails, a swab
should be taken of any discharge for culture.
Treatment
1) Address risk factors:
 Stop using cotton buds
 Remove any potential allergens
2) Analgesia
3) Topical ear preparation for 7 days:
 Antibiotic (e.g. aminoglycoside - gentamicin) & corticosteroid
or
 Antibiotic only drops
Antibiotic use is restricted to 7 days to reduce the risk of fungal infection.
Gentamicin is contraindicated if the tympanic membrane is perforated because of the risk
ototoxicity. However, in usual clinical practice, gentamicin drops are frequently used.
Case 2 e
You prescribe regular ibuprofen and gentamicin & hydrocortisone drops for 7 days.
You advise Mr Edwards to avoid swimming for a few weeks and to stop using cotton buds.
He asks how long it is likely to be before he feels better.
What will you tell him?
Go to the next page to find out more…
Prognosis
In most cases symptoms resolve completely within a few days of starting treatment.
A rare complication is malignant otitis externa. This is where infection extends into the underlying
bone causing an osteomyelitis. It usually affects patients with diabetes or the immunocompromised
and may cause facial nerve palsy. If suspected an urgent ENT referral should be made.
Malignant otitis externa10
Case 2 f
Mr Edwards takes the complete course of antibiotics and recovers fully by the end of the week.
A few weeks later he goes on to win his local swimming gala, in part thanks to your good medical
practice.
Go to the next page for a few words on history and examination…
History and Examination
History
Remember that the majority of diagnoses come from the history so it’s important to practice.
The information in this tutorial should slot nicely into the history taking structure that you already
have.
Take a moment to consider what you would ask in each section.






Presenting complaint
History of presenting complaint
Past medical history
Drug history
Family history
Social history
Go to the next page for a brief reminder of the important bits…
History and Examination 2
Presenting Complaint
 Earache
History of Presenting Complaint
 Duration – important for whether to give antibiotics
 Risk factors – important to aid diagnosis and if they are modifiable
 Indications for immediate antibiotics or referral/admission
Past Medical History
 Craniofacial syndromes, eczema, psoriasis
Drug History & Allergies
 Allergy to penicillins important
Family History
Social History
 Parental smoking (if not already asked)
And remember the Calgary-Cambridge framework:
A reminder of the Calgary-Cambridge framework21
Forward planning and safety netting is very important in the treatment of both acute otitis media
and otitis externa.
For example:
 Make sure that the patient knows to come back if their condition worsens or if there is no
improvement
 Tell them of specific symptoms to look for, such as facial nerve palsy for malignant otitis
externa (you can reassure them that the complication is unlikely)
 Always review if unable to see drum in otitis media due to suppuration
Examination
This ear examination e-tutorial demonstrates the correct equipment required for each examination,
how to conduct an examination of the ear and the special tests involved in testing hearing.
It also shows how to recognise the landmarks and common pathologies associated with the outer
ear and tympanic membrane.
Summary
To summarise everything we’ve covered, earache is a common presentation in primary care which
can usually be resolved promptly provided the correct diagnosis and treatment is given.
Some important differences that we have looked at between the 2 main causes are shown in the
table below:
Pain
Fever
Tenderness of the
pinna
Erythema
Fluid behind the
ear drum
Discharge
Age
Antibiotics
Otitis Media
Otitis Externa
Deep
Common
No
Superficial
Unusual
Yes
Tympanic membrane
Yes
External auditory canal
No
Mucous (if perforated)
Children
Oral amoxicillin (if
necessary)
Scant, watery
Adults
Topical antibiotic (with
steroid)
References
The Hawke Library (www.hawkelibrary.com)
1
http://otitismedia.hawkelibrary.com/aom/1_11?full=1
2
http://me.hawkelibrary.com/album03/Air_Fluid_Level_3?full=1
3
http://me.hawkelibrary.com/Chronic-Suppurative-Otitis-Media/CSOM_Mucopus_2_001?full=1
4
http://otitismedia.hawkelibrary.com/aom/1_12?full=1
5
http://otitismedia.hawkelibrary.com/som/5_4?full=1
6
http://otitismedia.hawkelibrary.com/aom/1_20?full=1
7
http://eac.hawkelibrary.com/aoe/50_G?full=1
8
http://eac.hawkelibrary.com/chronicoe/55_G?full=1
9
http://eac.hawkelibrary.com/aoe/51_G?full=1
10
http://eac.hawkelibrary.com/malignantoe/82_Left?full=1
11
http://otitismedia.hawkelibrary.com/aom/3_2_CSOM_Otorrhea?full=1
12
COMP 2 Primary Heath Care Study Guide, Chapter 7m Earache (Dr S Goodson). University of Bristol
http://www.patient.co.uk/doctor/Acute-Otitis-Media.htm
14
Niemela M, Uhari M, Mottonen M; A pacifier increases the risk of recurrent acute otitis media in
children in day care centers. Pediatrics. 1995 Nov;96(5 Pt 1):884-8.
15
Strachan DP, Cook DG; Health effects of passive smoking. 4. Parental smoking, middle ear disease
and adenotonsillectomy in children. Thorax. 1998 Jan;53(1):50-6
16
Duncan B et al. Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media.
Pediatrics Vol. 91 No. 5 May 1, 1993 (pp. 867 -872)
17
Arroll B et al. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A
systematic review. Br J Gen Pract. 2003 November; 53(496): 871–877.
18
Little P et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood
acute otitis media. BMJ. 2001 Feb 10;322(7282):336-42.
19
Diagnosis and management of childhood otitis media in primary care. SIGN (2003)
20
http://www.patient.co.uk/doctor/Otitis-Externa-and-Painful-Discharging-Ears.htm
21
http://www.gp-training.net/training/communication_skills/calgary/framwork/framework.htm
22
http://www.entusa.com/Ear_Photos/serous-otitis_08052002.jpg
13