Ear Ache (Otalgia)

Ear ache often triggers a visit to the GP; for children it is the most common cause for an out-of-hours call. The common causes seen in general practice are otitis media (middle ear infection) and otitis externa (infection of the outer ear canal). Otitis media with effusion (‘glue ear’) can cause niggly, short-lived ear pain. Remember that, particularly in adults, ear ache can come from outside the ear – referred from, for example, tonsils, dental abscess or trigeminal neuralgia.

History

• Assess the usual features of pain, including how severe it is, when it came on and if anything makes it better or worse.
  
• Ask about discharge: this may be thick and scanty in otitis externa or copious and mucoid through perforation from acute middle ear infections.
  
• Deafness can accompany both otitis media and externa, and pain on swallowing might suggest referred pain from the pharynx or tonsils.
  
• Ask whether the patient uses cotton buds – ‘cleaning’ the ear canal can traumatise the canal and introduce infection triggering otitis externa. A history of recent swimming or diving could indicate otitis externa, and pain during a flight points towards barotrauma.

Examination

See Table 52.1.

Management

Ear ache can be excruciating so adequate analgesia is the focus for treatment. Management then depends on the cause (see Table 52.1).

Otitis media is usually a self-limiting condition, so most patients do not need antibiotics. GPs sometimes offer a delayed prescription (only start antibiotics if needed after 24–48 hours). The evidence suggests that the following may benefit from antibiotics:

• Child under 3 months (or under 2 years of age with bilateral acute otitis media)
  
• Systemically very unwell, including high temperature (above 38.5°C) or vomiting
  
• Those at risk of complications (e.g. heart disease or immunocompromised)
  
• Acute otitis media (AOM) symptoms already lasted 4 days or more

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