One-liner#

Distinguish primary ear pathology (otitis externa, otitis media) from referred pain (TMJ, dental, pharyngeal), and identify serious causes requiring urgent evaluation (malignant otitis externa, mastoiditis).

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Severe pain with diabetes or immunocompromise (malignant otitis externa)
• Postauricular swelling, erythema, or tenderness with fever (mastoiditis)
• Cranial nerve palsies (facial weakness, diplopia)
• Meningeal signs (neck stiffness, photophobia)
• Vertigo with hearing loss and ear pain (labyrinthitis, cholesteatoma complication)
• Rapidly progressive symptoms in immunocompromised patient
• Signs of intracranial extension: severe headache, altered mental status

Key history#

Pain characteristics:

• Location: deep ear, outer ear, around ear, radiating
• Quality: sharp, dull, pressure, throbbing
• Duration: acute (<2 weeks) vs chronic
• Timing: constant vs intermittent; worse at night (AOM)
• Aggravating factors: chewing (TMJ), swallowing (referred), touching ear (OE)

Associated ear symptoms (suggests primary ear pathology):

• Discharge (otorrhea): purulent, bloody, clear
• Hearing loss
• Tinnitus
• Vertigo
• Itching (otitis externa, eczema)
• Fullness or pressure

Associated symptoms suggesting referred pain:

• Sore throat, odynophagia (pharyngeal source)
• Jaw pain, clicking, teeth grinding (TMJ)
• Dental pain, recent dental work (dental source)
• Neck pain, cervical radiculopathy
• Headache (tension, migraine)

Exposures and risk factors:

• Water exposure: swimming, showering (otitis externa)
• Recent URI (otitis media)
• Q-tip or foreign body use
• Hearing aid or earbud use
• Diabetes or immunocompromise (malignant OE risk)
• Smoking, alcohol (head/neck cancer risk)
• Prior ear surgery or tubes

Relevant history:

• Recurrent ear infections
• History of cholesteatoma
• Prior radiation to head/neck
• Immunocompromised status

Focused exam#

• Vitals: Temperature (fever suggests infection)
• External ear: Erythema, swelling, tenderness of pinna or tragus (OE); postauricular swelling (mastoiditis)
• Otoscopy:
  • Canal: edema, debris, discharge, foreign body
  • TM: erythema, bulging, perforation, effusion, retraction, cholesteatoma
• Pneumatic otoscopy: TM mobility (decreased in AOM and OME)
• Hearing: Whisper test, Weber/Rinne if tuning fork available
• TMJ: Tenderness, clicking, limited ROM, pain with jaw movement
• Oropharynx: Tonsillar pathology, pharyngeal lesions
• Teeth: Percussion tenderness, dental caries
• Neck: Lymphadenopathy, masses
• Cranial nerves: Facial nerve function (CN VII), especially in diabetics with OE

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Clinical diagnosis—imaging NOT routinely indicated:

• AOM and OE are clinical diagnoses
• Otoscopy is the key diagnostic tool

When to order imaging:

• CT temporal bone: suspected mastoiditis, malignant OE, cholesteatoma, or intracranial complication
• MRI: suspected acoustic neuroma (unilateral hearing loss + tinnitus), intracranial extension

When to order labs:

• Not routinely indicated
• Consider glucose/A1c if malignant OE suspected (undiagnosed diabetes)
• ESR/CRP may be elevated in malignant OE (can track treatment response)

When to order audiometry:

• Hearing loss that persists after treatment
• Suspected cholesteatoma
• Unilateral hearing loss (rule out acoustic neuroma)
• Chronic OME (>3 months)

When NOT to test:

• Uncomplicated AOM or OE
• Clear referred pain with identifiable source
• Cerumen impaction

Initial management#

Otitis externa:

• Topical antibiotic drops (fluoroquinolone preferred)
• Keep ear dry; use ear plugs for showering
• Wick placement if canal too swollen for drops to penetrate
• Pain control with NSAIDs or acetaminophen

Acute otitis media:

• Pain control is priority (acetaminophen, ibuprofen)
• Antibiotics if: age <2, bilateral, severe symptoms, otorrhea, or not improving after 48-72h observation
• Watchful waiting appropriate for mild-moderate unilateral AOM in children ≥2 years

Referred pain:

• Treat underlying cause (TMJ, dental, pharyngeal)
• Normal ear exam is reassuring

Management by diagnosis#

Otitis externa#

Education:

• Infection of the ear canal, often from water exposure
• Keep ear completely dry during treatment (ear plugs for showering, no swimming)
• Drops work best if the ear canal is clear—may need wick if very swollen
• Should improve within 2-3 days; complete full course

Treatment:

Wick placement: If canal too edematous for drops to penetrate, place wick (Pope wick or ribbon gauze); drops applied to wick; remove in 2-3 days.

Severe OE (cellulitis extending beyond canal): Add oral antibiotics—ciprofloxacin 500 mg BID x 7-10 days or amoxicillin-clavulanate 875/125 mg BID if Pseudomonas coverage not critical.

Otomycosis (fungal OE): Suspect if: not responding to antibacterial drops, visible fungal hyphae or spores (white/black debris), immunocompromised, prolonged antibiotic drop use. Treatment: thorough cleaning + clotrimazole 1% solution 3-4 drops BID x 7-14 days or acetic acid drops. ENT referral if refractory.

Follow-up: 7-10 days if not improving. Sooner if worsening, fever, or facial weakness develops.

Acute otitis media (AOM)#

Education:

• Middle ear infection, usually following a cold
• Pain is often worst at night; pain control is important
• Antibiotics help but many cases resolve without them
• Ear may drain if eardrum ruptures—this often relieves pain and heals on its own

Treatment:

Watchful waiting criteria (can defer antibiotics 48-72h):

• Age ≥2 years
• Unilateral AOM
• Mild symptoms (mild otalgia <48h, temp <39°C)
• Reliable follow-up available
• Provide “safety net” prescription to fill if not improving

Duration: 10 days for age <2 or severe; 5-7 days for age ≥2 with mild-moderate symptoms.

Follow-up: If not improving after 48-72 hours of antibiotics, reassess. Persistent effusion at 3 months warrants audiology and ENT referral.

Otitis media with effusion (OME)#

Education:

• Fluid in the middle ear without infection
• Common after ear infections or colds
• Usually resolves on its own over weeks to months
• Antibiotics do NOT help
• Main concern is hearing—important to monitor in children

Treatment:

• Watchful waiting is first-line
• No proven benefit from: antibiotics, decongestants, antihistamines, intranasal steroids
• Autoinflation (Valsalva, Otovent balloon) may help in older children/adults

Follow-up: Recheck in 3 months. If persistent OME >3 months with hearing loss, refer to ENT for consideration of tympanostomy tubes.

TMJ dysfunction#

Education:

• Pain from the jaw joint that often refers to the ear
• Common causes: teeth grinding, stress, jaw clenching, arthritis
• Usually improves with conservative treatment
• Avoid hard or chewy foods; don’t open mouth wide (no big bites, no yawning wide)

Treatment:

Non-pharmacologic: Soft diet, moist heat, jaw exercises, stress reduction, avoid gum chewing. Night guard if bruxism (dental referral).

Follow-up: 2-4 weeks. If not improving, refer to dentist or oral surgery for occlusal evaluation and possible night guard.

Malignant (necrotizing) otitis externa#

Recognition: Severe otalgia in diabetic or immunocompromised patient; granulation tissue at bone-cartilage junction; cranial nerve involvement; not responding to topical treatment.

PCP role:

• Recognize and refer urgently
• Check glucose (may be undiagnosed diabetes)
• Do NOT delay for imaging if clinical suspicion high

Referral: Urgent ENT same day. May need CT temporal bone, IV antibiotics (anti-pseudomonal), and possible surgical debridement.

Herpes zoster oticus (Ramsay Hunt syndrome)#

Recognition: Vesicles on pinna or ear canal + facial palsy ± hearing loss ± vertigo.

Treatment (start within 72 hours for best outcomes):

Follow-up: ENT referral for facial nerve monitoring. Ophthalmology if eye involvement. Prognosis for facial recovery worse than Bell’s palsy (~50% full recovery).

Follow-up#

• Otitis externa: 7-10 days if not improving; sooner if worsening or facial weakness
• AOM: 48-72 hours if on watchful waiting; otherwise no routine follow-up unless not improving
• OME: 3 months; ENT referral if persistent with hearing loss
• TMJ: 2-4 weeks; dental referral if not improving
• Recurrent AOM (≥3 in 6 months or ≥4 in 12 months): ENT referral for tube consideration

Tympanostomy tube criteria:

• Recurrent AOM: ≥3 episodes in 6 months OR ≥4 episodes in 12 months (with ≥1 in past 6 months)
• Chronic OME: bilateral effusion ≥3 months with hearing loss OR unilateral effusion ≥6 months
• At-risk children: developmental delays, craniofacial abnormalities, Down syndrome

Return precautions (all patients):

• Swelling or redness behind the ear
• Facial weakness or drooping
• Severe headache, stiff neck, or confusion
• Fever not responding to treatment
• Symptoms worsening despite treatment
• Dizziness or vertigo

Patient instructions#

• If you have an ear infection, take pain medicine (acetaminophen or ibuprofen) regularly—don’t wait until the pain is severe.
• For swimmer’s ear: Keep your ear completely dry. Use ear plugs when showering. No swimming until cleared.
• Use ear drops as directed: warm the bottle in your hands, lie on your side, pull the ear up and back, put in drops, stay lying down for 5 minutes.
• Do NOT put anything in your ear (Q-tips, fingers, bobby pins)—this can make infections worse.
• If you were prescribed antibiotics, complete the full course even if you feel better.
• Call or return immediately if you develop swelling behind your ear, facial weakness, severe headache, or high fever.

Smartphrase snippets#

Otitis externa: Ear pain with tragal tenderness and canal edema/erythema consistent with otitis externa. TM visualized and normal. Started ofloxacin otic drops 5 drops BID x 7 days. Discussed keeping ear dry. Return precautions given for worsening pain, fever, or facial weakness.

Acute otitis media: Ear pain following URI. Otoscopy shows bulging, erythematous TM with decreased mobility consistent with AOM. Started amoxicillin [dose] x [duration]. Pain control with ibuprofen. Return if not improving in 48-72 hours.

AOM watchful waiting: Mild unilateral ear pain x 1 day in [age] patient. Otoscopy shows mildly bulging TM. Meets criteria for watchful waiting. Provided safety-net antibiotic prescription (amoxicillin) to fill if not improving in 48-72 hours. Pain control with ibuprofen. Return precautions discussed.

Referred otalgia (TMJ): Ear pain with normal otoscopy. TMJ tenderness and clicking on exam. Consistent with TMJ dysfunction with referred otalgia. Started ibuprofen, soft diet, and jaw exercises. Dental referral for night guard evaluation if not improving.

Coding/billing notes#

• Document otoscopic findings in detail (TM appearance, mobility, canal)
• For AOM, document criteria met for antibiotic treatment or watchful waiting
• If prescribing antibiotics, document severity and rationale for duration
• For referred pain, document normal ear exam and identified source
• Document red flag assessment (no postauricular swelling, no facial weakness, etc.)