Chapter 50: The painful ear

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

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.

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

Probability diagnosis

The commonest cause of ear pain is acute otitis media. Chronic otitis media and otitis externa are also common. In the tropics, ‘tropical ear’ due to acute bacterial otitis is a particular problem. Temporomandibular joint (TMJ) arthralgia, which may be acute or chronic, is also common and must be considered, especially when otitis media and otitis externa are excluded.

Serious disorders not to be missed

As always, it is important not to overlook malignant diseases, especially the obscure ones, such as cancer of the tongue, palate or tonsils, which cause referred pain.

Locally destructive cholesteatoma associated with chronic otitis media must be searched for. It signifies the ‘unsafe’ ear (see FIG. 50.1) that must be distinguished from the so-called ‘safe’ ear (see FIG. 50.2).

Herpes zoster should be considered, especially if it does not erupt on the pinna and is confined to the ear canal (usually the posterior wall), and especially in the older person.

Pitfalls

The medical aphorism ‘more things are missed by not looking than by not knowing’ applies particularly to the painful ear—good illumination and focusing the auroscope are mandatory. Particular attention should be paid to the external canal—look for hard wax, otitis externa, furuncles and foreign objects such as insects.

It may not be possible to visualise the TMs so it is important to clean the canal to permit this (if possible, on the first visit). Otitis media may coexist with otitis externa. Barotrauma should be considered, especially if pain follows air travel or diving.

General pitfalls

• Failing to visualise the TM before diagnosis and treatment

• Not checking out possible referral sites such as the oropharynx and teeth

• Overlooking common musculoskeletal causes such as TMJ arthralgia and cervical spondylosis

• Failing to recognise the unsafe ear

Seven masquerades checklist

Of the conditions in the checklist, depression and dysfunction of the upper cervical spine have to be considered. Depressive illnesses should be considered in any patient complaining of chronic pain.

Disorders of the upper cervical spine are a commonly overlooked cause of periotic pain. Pain from the C2 and C3 levels is referred to the posterior region of the ear.

Psychogenic considerations

Such factors are unlikely, unless the pain causes discomfort in the periotic region, which is likely to be magnified by a depressive state.

History

In assessing the painful ear the relevant features are:

• site of pain and radiation

• details of the onset of pain

• nature of the pain

• aggravating or relieving factors, especially swimming

• associated features such as deafness, discharge, vertigo, tinnitus and irritation of the external ear, sore throat

Agonising pain may be caused by perichondritis or furunculosis of the external ear and by the rare problem of herpes zoster (Ramsay–Hunt syndrome).³ Movement of the pinna markedly increases the pain of acute otitis externa and perichondritis, and movement of the jaw usually causes an exacerbation of TMJ arthralgia or severe otitis externa.

Key questions (especially children)

• Where is the pain?

• Is it in the ear, behind or below it?

• Is it in one ear or both ears?

• Have you noticed any other symptoms such as sore throat, fever or vomiting?

• Has anyone hit you over the ear?

• Has there been a discharge from the ear?

• Have you noticed any deafness?

• Are you allergic to penicillin?

• Have you been swimming in a spa, and where?

• Have you been in an aeroplane?

Examination

The patient’s general state and behaviour is observed during the history taking. Sudden, jabbing pain may indicate neuralgia, particularly glossopharyngeal neuralgia or a severe infection. The external ear is carefully inspected and the pinna manipulated to determine any tenderness.

Palpate the face and neck and include the parotid glands, regional lymph nodes, the mastoid process and the skin. Inspect the TMJs—tenderness from dysfunction typically lies immediately in front of the external auditory meatus. Palpate the TMJ over the lateral aspect at the joint disc. Ask the patient to open the mouth fully when tenderness is maximal. The TMJ can be palpated posteriorly by inserting the little finger into the external canal.

Inspect both ear canals and TMs with the auroscope, using the largest earpiece that comfortably fits into the canal. Better visualisation of the TM can be achieved by pulling the pinna back and downwards in young children and up and back in older children—see FIGURE 50.3 for normal appearance. Impacted wax may not explain the otalgia. If herpes zoster involves the facial nerve, vesicles may be noted in and around the external auditory meatus (notably the posterior wall).

If the diagnosis is still doubtful look for causes of referred pain; inspect the cervical spine, the nose and postnasal space and the mouth, including the teeth, pharynx and larynx.

Pharyngeal and mandibular causes of periotic pain are summarised in FIGURES 50.4 and 50.5.

Inspect sites supplied by the nerves V2, IX, X, XI, C1, C2 and C3 to exclude other causes of referred pain.

Investigations

Investigations are seldom necessary. Hearing tests are essential, especially for children. Simple tests such as speech discrimination, hair rubbing and tuning fork tests can be used. Otherwise audiometry can be used. Audiometry combined with tympanometry and physical measurement of the volume of the ear canal can be performed in children, irrespective of age.

Swabs from discharge, especially to determine bacterial causes, such as Staphylococcus aureus or Pseudomonas spp. infection, may be necessary. However, swabs are of no value if the TM is intact.

Radiology and CT/MRI scanning may be indicated for special conditions such as a suspected extraotic malignancy.

Important causes of primary otalgia in children include otitis media, otitis externa, external canal furuncle or abscess, chronic eczema with fissuring of the auricle, impacted wax, foreign body, barotrauma, perichondritis, mastoiditis and bullous myringitis. Secondary otalgia includes pharyngeal lesions, dental problems, gingivostomatitis, mumps and postauricular lymphadenopathy. Peritonsillar abscess (quinsy) may cause ear pain.

Foreign bodies

Foreign bodies (FBs) are frequently inserted into the ear canal (see FIG. 50.6). They can usually be syringed out or lifted with thin forceps. Various improvised methods can be used to remove FBs in cooperative children. These include a probe to roll out the FB or a rubber catheter used as a form of suction or otherwise a fine sucker.⁶

Probe method

This requires good vision using a head mirror or head light and a thin probe. The probe is inserted under and just beyond the FB. Lever it in such a way that the tip of the probe ‘rolls’ the foreign body out of the obstructed passage.

Rubber catheter suction method

The only equipment required for this relatively simple and painless method is a straight rubber catheter (large type) and perhaps a suction pump. The end of the catheter is cut at right angles, a thin smear of petroleum jelly is applied to the rim and this end is applied to the FB. Suction is applied either orally or by a pump. Gentle pump suction is preferred but it is advisable to pinch closed the suction catheter until close to the FB as the hissing noise may frighten the child.

Insects in the ear

Live insects should be immobilised by first instilling Aquaear drops or olive oil, and then syringing the ear with warm water.

Dead flies that have originally been attracted to pus are best removed by suction.

Note: If simple methods such as syringing fail to dislodge the FB it is important to refer for examination and removal under microscopic vision. Syringing should not be performed if there is a possibility of the FB perforating the TM.

Otitis media in children

Otitis media is very common in children and is the most common reason a child is brought in for medical attention. Persistent middle ear effusions may follow and affect the language and cognitive development of young children.

Clinical features

• Two peaks of incidence: 6–12 months of age and school entry

• Seasonal incidence coincides with URTIs

• Bacteria cause two-thirds of cases⁵

• The commonest organisms are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis

• Fever, irritability, otalgia and otorrhoea may be present

• The main symptoms in older children are increasing earache and hearing loss

• Pulling at the ears is a common sign in infants

• Removal of wax is necessary in about 30% to visualise the TM

Use the largest ear speculum that will comfortably fit in the child’s ear. A good technique to enable the examination of the ears (also nose and throat) in a reluctant child is where the child is held against the parent’s chest while the parent’s arm embraces the child’s arm and trunk.

Note the following features of the TM: translucency, colour, position and motility.

Treatment

Many children with viral URTIs have mild reddening or dullness of the eardrum and antibiotics are not warranted, particularly in the absence of systemic features (fever and vomiting).⁵ Best practice at this stage is symptomatic relief with analgesics and either watchful waiting, especially in healthy children over 6 months, or antibiotics.⁶ In contrast, where the eardrum is red or yellow and bulging, with loss of anatomical landmarks, antibiotic therapy is indicated.⁷

The debate about the role of antibiotics in acute otitis media is controversial. An Australian study revealed that antibiotics provided only modest benefit: up to 20 children must be treated to prevent one child from experiencing pain by 2–7 days after presentation.^6,8,9 A North American survey concluded: ‘treat children who are very ill (approximately 15%) with antibiotics immediately. Treat all others for pain and pain only and follow up according to age. Treat with antibiotics if more serious symptoms develop, or the fever, pain and other symptoms do not resolve within the time frame’.⁹

The antibiotic of choice for children with systemic features is:⁵

• amoxycillin 15 mg/kg 8-hourly up to 500 mg (o) for 5 days

• or

• amoxycillin 30 mg/kg 12-hourly (o) for 5 days

Amoxycillin is also the preferred choice in the US and UK.¹⁰

If β-lactamase-producing bacteria are suspected or documented, or initial treatment fails, use:

• (if resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate

• or

• cefaclor 12.5 mg/kg/day (max. 750 mg/day) orally in three divided doses for 5–7 days (if penicillin hypersensitive) or cefuroxamine

With appropriate treatment most children with acute otitis media are significantly improved within 48 hours. Parents should be encouraged to contact their doctor if no improvement occurs within 72 hours. This problem is usually due to a resistant organism or suppuration. The patient should be re-evaluated at 10 days.¹⁰

It is of interest that some practitioners refer to the ‘Pollyanna’ phenomenon when treating otitis media; that is, all antibiotics seem to work!

A randomised trial has found that antibiotic eardrops are superior to oral antibiotics for the treatment of acute otorrhoea in children with grommets.¹¹ This method has advocates among specialists who recommend ciprofloxacin drops following aural toilet.

Rest the patient in a warm room with adequate humidity. Use analgesics such as paracetamol (acetaminophen) or ibuprofen in high dosage. Although the use of antihistamines and decongestants has not been verified scientifically, the author has found nasal decongestants (as oxymetazoline nasal drops or sprays) effective in distressed children with an associated URTI. Otherwise, avoid antihistamines and decongestants.

Follow-up: adequate follow-up with hearing assessment is mandatory.

Complications^5,6

• Middle ear effusion. 70% of children will have an effusion present 2 weeks from the time of diagnosis, 40% at 4 weeks, with 10% having persistent effusions for 3 months or more. If the effusion is still present at 6–8 weeks, a second course of antibiotics should be prescribed.² If the effusion persists beyond 3 months, refer for an ENT opinion or earlier if an associated speech delay or educational difficulty (especially a 20 dB hearing loss).

• Acute mastoiditis. This is a major complication that presents with pain, swelling and tenderness developing behind the ear associated with a general deterioration in the condition of the child (see FIG 50.7). Such a complication requires immediate referral.

• Chronic suppurative otitis media. Discharge through a perforation of the TM >6 weeks.

• Rare complications. These include labyrinthitis, petrositis, facial paresis and intracranial abscess.

• Serous otitis media (glue ear). This represents incomplete resolution of suppurative otitis media. Signs include loss of drum mobility, hearing loss and abnormal impedance confirmed by pneumatic otoscopy or tympanometry. Most resolve spontaneously but any necessary treatment includes medications such as bromhexine elixir and Demazin syrup, auto-inflations and Otovent assisted nasal inflation.

If an effusion lasts for >3 months, arrange for a hearing assessment and consider referral to an ENT surgeon for possible tympanostomy tubes (grommets).¹³

Note: a proposed S. pneumoniae and H. influenzae conjugate vaccine may be an effective preventive measure for childhood otitis media.

Recurrent acute otitis media

Antibiotic prevention of acute otitis media is indicated (arguably) if it occurs more often than every other month or for three or more episodes in 6 months or >4 in 12 months:¹⁴

• chemoprophylaxis (for about 4 months)

• amoxycillin twice daily (first choice)

• or

• cefaclor twice daily

Consider Pneumococcus vaccine in children over 18 months of age (if not already given) in combination with the antibiotic. Avoid smoke exposure (cigarettes and wood fires) and group child care.

Consider review by ENT consultant.

Viral infections

Most children with viral URTIs have mild–moderate reddening or dullness of the eardrum and antibiotics are not warranted. If painful bullous otitis media is present, either prick the bulla with a sterile needle for pain relief, or instil dehydrating eardrops such as anhydrous glycerol.

Causes of otalgia that mainly afflict the elderly include herpes zoster (Ramsay–Hunt syndrome), TMJ arthralgia, temporal arteritis and neoplasia. It is especially important to search for evidence of malignancy.

Acute otitis media

Acute otitis media causes deep-seated ear pain, deafness and often systemic illness (see FIG. 50.8). The sequence of symptoms is a blocked ear feeling, pain and fever. Discharge may follow if the TM perforates, with relief of pain and fever.

The commonest organisms are viruses (adenovirus and enterovirus), and the bacteria H. influenzae, S. pneumoniae, Moraxella (previously Neisseria catarrhalis) and β-haemolytic streptococci.

The two cardinal features of diagnosis are inflammation and middle ear effusion.

Appearance of the tympanic membrane (all ages)

Translucency. If the middle ear structures are clearly visible through the drum, otitis media is unlikely.

Colour. The normal TM is a shiny pale-grey to brown: a yellow colour is suggestive of an effusion.

Diagnosis

The main diagnostic feature is the redness of the TM. The inflammatory process usually begins in the upper posterior quadrant and spreads peripherally and down the handle of the malleus (see FIG. 50.9). The TM will be seen to be reddened and inflamed with engorgement of the vessels, particularly along the handle of the malleus. The loss of light reflex follows and anatomical features then become difficult to recognise as the TM becomes oedematous. Bulging of the drum is a late sign. Blisters are often seen on the TM and this is thought to be due to a viral infection in the epidermal layers of the drum.

Treatment of acute otitis media (adults)

• Analgesics to relieve pain

• Adequate rest in a warm room

• Nasal decongestants for nasal congestion

• Antibiotics until resolution of all signs of infection

• Treat associated conditions (e.g. adenoid hypertrophy)

• Follow-up: review and test hearing audiometrically

First choice:

• amoxycillin 750 mg (o) bd for 5 days⁵

• or

• 500 mg (o) tds for 5 days

A longer course (up to 10 days) may be required depending on severity and response to 5-day course.

Alternatives:

• doxycycline 100 mg (o) bd for 5–7 days (daily for milder infections)

• or

• cefaclor 250 mg (o) tds for 5–7 days

• or

• (if resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate 500/125 mg (o) tds for 5 days (the most effective antibiotic)

Consider surgical intervention for failed therapy.

There are two types of chronic suppurative otitis media and they both present with deafness and discharge without pain. The discharge occurs through a perforation in the TM: one is safe (see FIG. 50.10a), the other unsafe (see FIG. 50.10b).

Chronic discharging otitis media (safe)^5,13

If aural discharge persists for >6 weeks after a course of antibiotics, treatment can be with topical steroid and antibiotic combination drops, following ear toilet. The toileting can be done at home by dry mopping with rolled tissue spear. If persistent, referral to exclude cholesteatoma or chronic osteitis is advisable.

Recognising the unsafe ear

Examination of an infected ear should include inspection of the attic region, the small area of drum between the lateral process of the malleus, and the roof of the external auditory canal immediately above it. A perforation here renders the ear ‘unsafe’ (see FIG. 50.1); other perforations, not involving the drum margin (see FIG. 50.2), are regarded as ‘safe’.¹³

Cholesteatoma¹²

Refer CHAPTER 43.

The status of a perforation depends on the presence of accumulated squamous epithelium (termed cholesteatoma) in the middle ear, because this erodes bone. An attic perforation contains such material; safe perforations do not.

Red flags for cholesteatoma include meningitis-type features, cranial nerve deficits, sensorineural hearing loss and persistent deep ear pain.

Cholesteatoma is visible through the hole as white flakes, unless it is obscured by discharge or a persistent overlying scab. Either type of perforation can lead to chronic infective discharge, the nature of which varies with its origin. Mucus admixture is recognised by its stretch and recoil when this discharge is being cleaned from the external auditory canal. The types of discharge are compared in TABLE 50.3.

Management

If an attic perforation is recognised or suspected, specialist referral is essential. Cholesteatoma cannot be eradicated by medical means: surgical removal is necessary to prevent a serious infratemporal or intracranial complication. Adjunct suction with care may be necessary to decompress the mass.

Otitis externa¹³

Otitis externa (see FIG. 50.11), also known as ‘swimmer’s ear’, ‘surfer’s ear’ and ‘tropical ear’, is common in a country whose climate and coastal living leads to extensive water sports. It is more prevalent in hot humid conditions and therefore in the tropics.

Predisposing factors are allergic skin conditions, ear canal trauma, water penetration (swimming, humidity, showering), water and debris retention (wax, dermatitis, exostoses), foreign bodies, contamination from swimming water including spas, and use of Q tips and hearing aids.

Common responsible organisms

• Bacteria:

  • – Pseudomonas sp.

  • – Escherichia coli

  • – S. aureus

  • – Proteus sp.

  • – Klebsiella sp.

• Fungi:

  • – Candida albicans

  • – Aspergillus sp.

Clinical features

• Itching at first

• Otalgia/pain (mild to intense) in 70%

• Fullness in ear canal

• Scant discharge

• Hearing loss

Signs

• Oedema (mild to extensive)

• Tenderness on moving auricle or jaw

• Erythema

• Discharge (offensive if coliform)

• Pale cream ‘wet blotting paper’ debris—C. albicans

• Black spores of Aspergillus nigra

• TM granular or dull red

Obtain culture, especially if resistant Pseudomonas sp. suspected, by using small ear swab.

Note: ‘Malignant’ otitis externa occurs in diabetics due to Pseudomonas infection at base of skull.

Management

Meticulous aural toilet by gentle suction and dry mopping with a wisp of cotton wool on a fine brooch under good lighting is the keystone of management. This enables topical medication to be applied directly to the skin.

This is appropriate in some cases but the canal must be dried meticulously afterwards. For most cases it is not recommended.

Dressings are essential in all but the mildest forms. After cleaning and drying, insert 10–20 cm of 4 mm Nufold gauze impregnated with a steroid and antibiotic cream.

For severe otitis externa, a wick is important and will reduce the oedema and pain in 12–24 hours (see FIG. 50.12). The wick can be soaked in an astringent (e.g. aluminium acetate 4% solution or glycerin and 10% ichthammol). The wick needs replacement daily until the swelling has subsided.

Most effective, especially when the canal is open, is an antibacterial, antifungal and corticosteroid preparation such as Kenacomb or Sofradex drops (2–3 drops tds), Locacorten-Vioform drops (2–3 drops bd) or Ciproxin HC (3 drops bd). Be cautious of ear drops with neomycin (hypersensitivity). The tragus should be pumped for 30 seconds after instillation by pressing on it repeatedly, within the limitation of any pain.

• Strong analgesics are essential

• Antibiotics have a minimal place in treatment unless a spreading cellulitis has developed (refer if in doubt)

• Prevent scratching and entry of water

• Use a wick soaked in combination steroid and antibiotic ointment for more severe cases

Prevention

• Keep the ear dry, especially those involved in water sports

• Protect the ear with various waterproofing methods:

  • – cotton wool coated with petroleum jelly

  • – an antiseptic drying agent (e.g. ethanol) after swimming and showering

  • – tailor-made ear plugs (e.g. EAR foam plugs)

  • – silicone putty or Blu-Tack

  • – a bathing cap pulled well forward allows these plugs to stay in situ

• Avoid poking objects such as hairpins and cotton buds in the ear to clean the canal

• If water enters, shake it out or use Aquaear (acetic acid) drops (spirit drops to help dry the canal)

Necrotising otitis externa

This severe complication, usually due to Pseudomonas aeruginosa, can occur in the immunocompromised, diabetic or elderly patient. It involves cartilage and bone and should be considered with treatment failure, severe persistent pain, fever and visible granulation tissue. Urgent referral is advisable.

Ear exostoses (‘surfer’s ear’)

These periosteal bony overgrowths are usually caused by water retention in the ear. They are often multiple. They tend to trap keratin, wax and water, leading to infection.

Prevention

• Use plugs or Blu-Tack to waterproof ear.

• Dry thoroughly with hair dryer after swimming.

They may require surgical removal.

Acute localised otitis externa (furunculosis)

Furunculosis is a staphylococcal infection of the hair follicle in the outer cartilaginous part of the ear canal. It is usually intensely painful. Fever occurs only when the infection spreads in front of the ear as cellulitis. The pinna is tender on movement—a sign that is not a feature of acute otitis media. The furuncle (boil) may be seen in the external auditory meatus (see FIG. 50.13).

Management

• If pointing, it can be incised after a local anaesthetic or freezing spray

• Warmth (e.g. use hot washcloth, hot water bottle)

• If fever with cellulitis—flu/dicloxacillin or cephalexin

Perichondritis

Perichondritis is infection of the cartilage of the ear characterised by severe pain of the pinna, which is red, swollen and exquisitely tender. It is rare and follows trauma or surgery to the ear. As the organism is frequently P. pyocyaneus, the appropriate antibiotics must be carefully chosen (e.g. ciprofloxacin).

Infected ear lobe

The cause is most likely a contact allergy to nickel in an earring, complicated by a S. aureus infection.

Management

• Discard the earrings

• Clean the site to eliminate residual traces of nickel

• Swab the site and then commence antibiotics (e.g. flucloxacillin or erythromycin)

• Instruct the patient to clean the site daily, and then apply the appropriate ointment

• Use a ‘noble metal’ stud to keep the tract patent

• Advise the use of only gold, silver or platinum studs in future

Eustachian tube dysfunction

This is a common cause of discomfort.¹⁵ Symptoms include fullness in the ear, pain of various levels and impairment of hearing. The most common causes of dysfunction are disorders causing oedema of the tubal lining, such as viral URTI and allergy when the tube is only partially blocked; swallowing and yawning may elicit a crackling or popping sound. Examination reveals retraction of the TM and decreased mobility on pneumatic otoscopy. The problem is usually transient after a viral URTI.

Treatment

• Systemic and intranasal decongestants (e.g. pseudoephedrine or corticosteroids in allergic patients)

• Autoinflation by forced exhalation against closed nostrils (avoid in active intranasal infection)

• Avoid air travel, rapid altitude change and underwater diving

Otic barotrauma

Barotrauma is damage caused by undergoing rapid changes in atmospheric pressure in the presence of an occluded Eustachian tube (see FIG. 50.14). It affects scuba divers and aircraft travellers.

The symptoms include temporary or persistent pain or pressure in both ears, deafness, vertigo, tinnitus and perhaps discharge.

Inspection of the TM may reveal (in order of seriousness): retraction; erythema; haemorrhage (due to extravasation of blood into the layers of the TM); fluid or blood in the middle ear; perforation. Perform conductive hearing loss tests with tuning fork.

Treatment

Most cases are mild and resolve spontaneously in a few days, so treat with analgesics and reassurance. Menthol inhalations are soothing and effective. Refer if any persistent problems for consideration of the Politzer bag inflation or myringotomy.

Prevention

Flying. Perform repeated Valsalva manoeuvres during descent. Use decongestant drops or sprays before boarding the aircraft, and then 2 hours before descent.

Diving. Those with nasal problems, otitis media or chronic tubal dysfunction should not dive.

Penetrating injury to tympanic membrane

A penetrating injury to the TM can occur in children and adults from various causes such as pencils and slivers of wood or glass. Bleeding invariably follows and infection is the danger.

Management

• Remove blood clot by suction toilet or gentle dry mopping

• Ensure no FB is present

• Check hearing

• Prescribe a course of broad-spectrum antibiotics (e.g. cotrimoxazole)

• Prescribe analgesics

• Instruct patient not to let water enter ear

• Review in 2 days and then regularly

• At review in 1 month, the drum should be virtually healed

• Check hearing 2 months after injury

Complete healing can be expected within 8 weeks in 90–95% of such cases.¹⁶

If rheumatoid arthritis is excluded, a set of special exercises, which may include ‘chewing’ a piece of soft wood over the molars, invariably solves this problem (see CHAPTER 52). If an obvious dental malocclusion is present, referral is necessary.

Otitis media

• Incomplete resolution of acute otitis media

• Persistent middle ear effusion for 3 months after an attack of acute otitis media

• Persistent apparent or proved deafness

• Evidence or suspicion of acute mastoiditis or other severe complications

• Frequent recurrences (e.g. four attacks a year)

• Presence of craniofacial abnormalities

Other ear problems

• Attic perforation/cholesteatoma

• FBs in ear not removed by simple measures such as syringing

• No response to treatment after 2 weeks for otitis externa

• Suspicion of carcinoma of the ear canal

• Acute TM perforation that has not healed in 6 weeks

• Chronic TM perforation (involving lower two-thirds of TM)

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Earache in children

• Ear infection (otitis media)

• Ear: otitis externa

• Ear: wax in your ear

National Health and Medical Research Council (NHMRC). Australian Clinical Practice Guidelines. <https://www.clinicalguidelines.gov.au>

National Institute for Health and Care Excellence (NICE). Respiratory tract infection: Antibiotic prescribing. London: NICE, 2008. <https://www.nice.org.uk/guidance/cg69/evidence/full-guideline-196853293>

The Royal Children’s Hospital Melbourne. Australian clinical practice guidelines for managing acute otitis media. Melbourne: RCH, last updated April 2018. <https://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/>