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Table E1The painful ear: diagnostic strategy model

Key features

Key history Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or relieving factors and associated features such as vertigo, tinnitus, sore throat and irritation of the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.

Key examination

  • The external ear with manipulation of the ear

  • Check helix for chondrodermatitis nodularis helicis.

  • Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ).

  • Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece.

  • Look for causes of referred pain: cervical spine, nose, postnasal space and mouth including teeth.

Key investigations

Seldom necessary.

  • Consider hearing tests, audiometry

  • Any ear discharge for MC but swabs of no value if the TM is intact

Red flags for painful ear

  • Offensive discharge >9 days

  • Downward displacement of pinna

  • Swelling behind ear

  • Neurological symptoms (e.g. headache)

  • In older person, unexplained intractable pain

  • Persistent fever

Otitis media in children


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

  • Seasonal incidence coincides with URTIs.

  • The commonest organisms are viruses (adenovirus and enterovirus) and the bacteria S. pneumoniae, H. 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.

  • Viral cause indicated by reddening and dullness of tympanic membrane (without mucopus) associated with URTI.

  • Antibiotics not warranted for viral causes, most improve within 48 hrs.

  • Bacterial OM is suggested by acute onset of ear pain/tugging, hearing loss, irritability and fever. Suppurative OM has progressive erythema and bulging of OM with loss of landmarks ± vomiting. Treat with ABs that are most beneficial in children <2 yrs with bilateral OM, for devt. of more serious symptoms or if the fever, pain and other symptoms do not resolve within 2–3 d (see box below).

Possible clinical indications for antibiotics in children with painful otitis media

Consider immediate treatment:


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