This the commonest reason for an out-of-hours call for a child. Parental distress is often as great as the child’s, and appropriate advice can do much to relieve this – even over the telephone. Causes in adults are far more varied than for children and can originate in the pinna, ear canal, middle ear and from neighbouring structures (referred pain).
- Infective Otitis Media (OM): Bacterial/Viral
- Infective Otitis Externa (OE): Bacterial/Fungal/Viral
- Boils and Furuncles of the Canal and Pinna
- Trauma (Especially Cotton Buds) and Foreign Bodies (Including Earwax)
- Throat Problems: Tonsillitis/Pharyngitis/Quinsy
- Temporomandibular Joint (TMJ) Dysfunction
- Dental Abscess
- Impacted Molar
- Trigeminal Neuralgia
- Ear canal Eczema/Seborrhoeic Dermatitis
- Chondrodermatitis Nodularis Helicis Externa
- Necrotising (or Malignant) Otitis Externa
- Cervical Spondylosis
- Malignant Disease
Key distinguishing features of the most common diagnoses
|Pain on Pulling Pinna and Pressing Tragus||No||Yes||Yes||Possible||No|
|Red, Bulging Eardrum||Yes||No||No||No||No|
|Pain on Swallowing||No||No||No||No||Yes|
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
- 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.
- 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.