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 39.1.1
Table 39.1Causes of ear pain ||Download (.pdf) Table 39.1 Causes of ear pain
2 Periotic cause
Dental disorders, e.g. dental abscess; malocclusion
Upper cervical spinal dysfunction
Lymph node inflammation
Other referred causes
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.
Approximately 1 in 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; 1 in 7 children will have had more than 6 episodes by this age. Peak prevalence is 9–15 months.2
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.3 Consider herpes zoster.
The role of antibiotics (usually amoxicillin) is limited.
Otitis externa can be distinguished from otitis media by pain on movement of the pinna.
The five self-posed questions can be answered using the diagnostic strategy model (see TABLE 39.2).
Table 39.2The painful ear: diagnostic strategy model ||Download (.pdf) Table 39.2 The painful ear: diagnostic strategy model
Otitis media (viral or bacterial)
Otitis externa (fungal, viral or ...