Earache

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

OMOE Boils TraumaThroat Problems
DischargePossibleYesPossiblePossibleNo
Pain on Pulling Pinna and Pressing TragusNoYesYesPossibleNo
Red, Bulging EardrumYesNoNoNoNo
DeafnessYesPossibleNoPossibleNo
Pain on SwallowingNoNoNoNoYes

Possible Investigations

Likely:None.

Possible:Ear swab.

Small Print:X-rays of TMJ, teeth and mastoid bone, FBC, Paul–Bunnell test.

  • Swab of ear canal useful if discharge present, after failure of empirical first-line treatment.
  • X-ray of mastoid bone excludes mastoiditis if mastoid clear – usually arranged by specialist. X-rays of TMJ and teeth are the remit of the dentist or oral surgeon.
  • FBC and Paul–Bunnell test useful if glandular fever suspected. The diagnosis provides a label and guides further advice, though no specific treatment exists.
  • Further specialist investigations may include CT/MRI as the only way adequately (noninvasively) to investigate the inner ear and temporal bone anatomy

Top Tips

  • Persistent debris in the ear canal will prevent resolution of OE and mask possible underlying causes. Aural toilet is essential.
  • If inserting the aural speculum causes pain, the diagnosis is likely to be otitis externa or a furuncle.
  • Don’t forget to ask about trauma – especially the use of a cotton bud. Excavating earwax with a bud tends to produce an inflamed canal and drum, mimicking infection.
  • Earache can be excruciating: Don’t underestimate the need for adequate analgesia while you establish and treat the cause.

Red Flags

  • Consider mastoiditis if foul-smelling discharge is present for more than 10 days. Look for swelling behind the ear and downward displacement of the pinna.
  • Consider necrotising (or malignant) otitis externa in elderly diabetics or the immunocompromised with otalgia apparently out of proportion to their otitis externa. They may have a high fever and a facial palsy too. Refer urgently.
  • Don’t be too ready to diagnose otitis media in children – URTIs and crying inevitably result in some redness of the drum. Indiscriminate prescribing may lead to iatrogenic problems or the masking of the true diagnosis.
  • Beware the elderly patient with intractable, unexplained earache – refer to exclude a nasopharyngeal carcinoma.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter. Pulse Reference is designed to help GPs make sense of patient presentations. It analyses a multitude of symptoms commonly seen in primary care and for each presents differentials, distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Pulse Reference is based on the best-selling book Symptom Sorter. The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse. This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.