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The ears should be kept perfectly clean; but it must never be done in company. It should never be done with a pin, and still less with the fingers, but always with an ear picker.

St Jean Baptiste de la Salle (1651–1719)

Pain in the ear (otalgia) is a common symptom in general practice. It affects all ages, but is most prevalent in children, where otitis media is the commonest cause. Ear pain may be caused by disorders of the ear or may arise from other structures, and in many instances the precise diagnosis is difficult to make. Important causes of ear pain are summarised in Table 50.1.1

Table 50.1

Causes of ear pain

A patient with a painful ear often requests urgent attention, and calls in the middle of the night from anxious parents of a screaming child are commonplace. Infants may present with nothing except malaise, vomiting or screaming attacks.

Key facts and checkpoints

  • Of patients presenting with earache, 77% can be expected to have acute otitis media and 12% otitis externa.2

  • Approximately one of every 25 patients in general practice will present with an earache.

  • Two-thirds of children will sustain at least one episode of otitis media by their second birthday; one in seven children will have had more than six episodes by this age.3

  • Otitis media is unlikely to be present if the tympanic membrane (TM) is mobile. Pneumatic otoscopy greatly assists diagnosis since the most valuable sign of otitis media is absent or diminished motility of the TM.

  • Bullous myringitis, which causes haemorrhagic blistering of the eardrum or external ear canal, is an uncommon cause of severe pain. It is caused by a virus, probably influenza.4

  • The antibiotic of first choice for acute otitis media (children and adults) is amoxycillin.

  • Otitis externa can be distinguished from otitis media by pain on movement of the pinna.

A diagnostic approach

The five self-posed questions can be answered using the diagnostic strategy model (see Table 50.2).

Table 50.2

The painful ear: diagnostic strategy model

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