Ear Pain / Earache 👂
On-call guide to ear pain and earache: rule out red flags first, then assess otitis externa, otitis media, referred otalgia, and when to escalate to ENT. Based on HSE AMRIC ear infection guidance.
🧭 Clinical workflow
- 1. Red flags first (airway, sepsis, necrotising OE, mastoiditis, facial palsy, sudden hearing loss, meningitis). Escalate before treating as simple infection.
- 2. Localise: canal (OE), middle ear (AOM), or referred pain with normal ear exam.
- 3. Examine pinna, canal, TM, mastoid, CN VII, throat, teeth, TMJ, neck nodes.
- 4. Treat cause after red flags clear. Analgesia for all. Antibiotics only if indicated.
- 5. Safety-net and document escalation plan if pain, discharge, or neurology worsens.
🚨 Red flags — escalate urgently
- Sepsis or meningitis features (fever, neck stiffness, photophobia, altered consciousness): ABC + sepsis pathway.
- Necrotising (malignant) OE → urgent ENT/hospital (HSE): foul/purulent discharge, canal granulation, pain out of proportion or to neck/jaw, CN palsy (esp. VII). Risk: elderly, diabetes, immunosuppressed.
- Mastoiditis → same-day ENT: post-auricular swelling/erythema/tenderness/bogginess, protruding pinna, fever after AOM.
- Facial weakness + ear pain or canal/pinna vesicles: Ramsay Hunt until proven otherwise. Not Bell’s without ear exam. See Shingles.
- Sudden sensorineural hearing loss (usually unilateral, hours–days): urgent ENT. Document onset.
- Spreading facial cellulitis, perichondritis with systemic upset, or rapidly worsening OE: senior/ENT.
- Deep neck infection or airway threat (trismus, drooling, neck swelling, stridor): emergency airway + ENT.
- Persistent unilateral otalgia, normal ear exam, plus dysphagia, hoarseness, weight loss, oral/oropharyngeal lesion, or neck lump → urgent head-and-neck pathway (referred otalgia can be malignant).
- Immunocompromised + ongoing otalgia/otorrhoea not responding to treatment: low threshold for urgent ENT.
📞 When called
- Onset, side, severity; nocturnal or waking pain?
- Discharge, hearing change, tinnitus, vertigo, jaw/throat/dental pain.
- Fever, diabetes, immunosuppression, swimming, ear trauma, cotton buds, hearing aids, grommets, prior ENT surgery.
- Recent antibiotics or drops; any improvement then relapse?
- Current vitals; repeat obs if not recent.
🩺 Assessment
- Vitals ± sepsis screen if febrile/unwell.
- Pinna and post-auricular skin. Tragal/pinna tenderness supports OE (HSE).
- Otoscopy: canal oedema/erythema/debris vs bulging/erythematous/perforated TM. Note granulation or exposed bone.
- Mastoid: swelling, erythema, tenderness, pinna displacement.
- CN VII. Bedside hearing (whisper/finger rub) ± tuning fork.
- Normal ear exam → oropharynx, teeth, TMJ, cervical nodes, thyroid (referred otalgia: teeth, tonsils, TMJ, pharynx/larynx).
- Vesicles (Ramsay Hunt). Foreign body in children or confused adults.
🔬 Investigations
- Well patient with simple OE/AOM: usually no bloods.
- Unwell, complicated infection, or suspected necrotising OE: FBC, U&E, CRP, glucose/HbA1c if diabetes unknown; blood cultures if septic.
- Ear swab if no improvement at 48–72 h, recurrent disease, or suspected resistant/fungal infection (HSE OE).
- Imaging not routine overnight. Discuss CT temporal bone/neck with senior/ENT if necrotising OE, mastoiditis, or deep neck infection suspected.
🔍 Differentials
Otitis externa
- Clues
- Rapid canal pain, tragal tenderness, canal swelling/discharge, swimming or ear trauma
- First action after red-flag screen
- Analgesia + topical therapy (HSE OE, below)
Acute otitis media
- Clues
- Recent URTI, earache, bulging TM ± fever; otorrhoea if perforated
- First action after red-flag screen
- Analgesia first; antibiotics only if indicated (HSE AOM children)
Necrotising OE
- Clues
- Severe pain, granulation, CN palsy; elderly / diabetic / immunosuppressed
- First action after red-flag screen
- Urgent ENT/admission; not simple OE
Mastoiditis
- Clues
- Post-auricular swelling, protruding pinna after AOM
- First action after red-flag screen
- Same-day ENT
Ramsay Hunt
- Clues
- Ear pain + vesicles ± facial palsy, hearing loss, vertigo
- First action after red-flag screen
- Urgent senior/ENT; antivirals per shingles
Referred otalgia
- Clues
- Normal otoscopy; dental, tonsil, TMJ, or throat symptoms
- First action after red-flag screen
- Treat source; urgent H&N if cancer flags
Trauma / FB / wax
- Clues
- Instrumentation, hearing aid, visible FB or impacted wax
- First action after red-flag screen
- No irrigation if perforation possible; ENT if stuck FB
| Cause | Clues | First action after red-flag screen |
|---|---|---|
| Otitis externa | Rapid canal pain, tragal tenderness, canal swelling/discharge, swimming or ear trauma | Analgesia + topical therapy (HSE OE, below) |
| Acute otitis media | Recent URTI, earache, bulging TM ± fever; otorrhoea if perforated | Analgesia first; antibiotics only if indicated (HSE AOM children) |
| Necrotising OE | Severe pain, granulation, CN palsy; elderly / diabetic / immunosuppressed | Urgent ENT/admission; not simple OE |
| Mastoiditis | Post-auricular swelling, protruding pinna after AOM | Same-day ENT |
| Ramsay Hunt | Ear pain + vesicles ± facial palsy, hearing loss, vertigo | Urgent senior/ENT; antivirals per shingles |
| Referred otalgia | Normal otoscopy; dental, tonsil, TMJ, or throat symptoms | Treat source; urgent H&N if cancer flags |
| Trauma / FB / wax | Instrumentation, hearing aid, visible FB or impacted wax | No irrigation if perforation possible; ENT if stuck FB |
💊 Otitis externa (after excluding necrotising OE)
- Analgesia: paracetamol ± ibuprofen if appropriate.
- Keep ear dry (no soap/shampoo/water). No swimming 7–10 days. No cotton buds.
- Topical therapy first-line for acute bacterial OE (usually Pseudomonas or S. aureus). Confirm local formulary.
- Inflammation only, no pus: acetic acid 2% spray (unlicensed in Ireland; max 7 days) per HSE.
- Intact TM: topical antibiotic ± steroid ~7 days (e.g. gentamicin–hydrocortisone). Avoid aminoglycoside drops if perforation suspected; contraindicated with grommets.
- Perforation or grommets: ciprofloxacin drops (Ciloxan); low threshold for ENT (HSE).
- Drop technique: lie affected ear up, fill canal, wait 5 min. Poor technique → treatment failure.
- Escalate if no improvement 48–72 h, pain to neck/jaw, or facial weakness.
- Oral antibiotics rarely needed in uncomplicated OE. Senior/micro if spreading cellulitis or systemically unwell.
💊 Acute otitis media
- Usually viral/self-limiting. Priority: regular paracetamol or ibuprofen at correct dose.
- Children (HSE): no antibiotic or back-up script for most ≥2 y, and for <2 y with unilateral infection and no otorrhoea.
- Immediate antibiotics more often if <2 y bilateral, or otorrhoea from perforated drum (no antibiotic / back-up still an option by judgement).
- If antibiotic indicated (children): amoxicillin 5 days first-line (longer if severe/recurrent per local tables). Clarithromycin if penicillin allergy. Co-amoxiclav if worse after 2–3 days on first-line. Weight-based dosing: antibioticprescribing.ie.
- Adults, uncomplicated and well: analgesia + safety-net usually enough. If considering antibiotics, use local antimicrobial guidance; ask senior overnight if unsure.
- Decongestants, antihistamines, and corticosteroids not effective (HSE).
- Escalate immediately: mastoiditis, facial palsy, meningitis features, or very unwell.
📝 Safety-netting & documentation
- Document red-flag screen (CN VII, mastoid), otoscopy, diagnosis, and treatment.
- Return if worse pain, new discharge, hearing loss, dizziness, facial weakness, high fever, or neck swelling.
- OE: review if not improving 48–72 h or unresolved after topical course.
- AOM: most better in 3 days; can last up to 1 week. Return sooner if rapidly worse.
- Day-team plan if ENT, swab, or imaging deferred.
Based on
Related NICE guidance
NICENICE NG91 — Otitis media (acute): antimicrobial prescribingNICENICE NG98 — Hearing loss in adults: assessment and management
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 06 / 10 / 2026 — 01:54 ATRP re: ear pain / earache Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [diabetes, immunosuppression, ENT history, grommets] 🧾 Hx: • Onset, side, severity, nocturnal pain? • Discharge, hearing change, tinnitus, vertigo, jaw/throat/dental pain • Swimming, cotton buds, hearing aids, recent URTI • Recent antibiotics / ear drops? 🩺 Exam: • Vitals: HR __ BP __ RR __ SpO₂ __ Temp __ • Tragal / pinna tenderness: [Y/N] • Otoscopy: canal __ TM __ discharge __ granulation __ • Mastoid: swelling / erythema / tenderness / protruding pinna: [Y/N] • CN VII intact: [Y/N] Vesicles: [Y/N] • If normal ear exam: oropharynx / teeth / TMJ / neck nodes reviewed 🚨 Red flags excluded / present: • Necrotising OE / mastoiditis / facial palsy / sudden SNHL / sepsis / referred cancer flags: [none / list] 📋 Impression: [otitis externa / AOM / referred otalgia / other] 📌 Plan: • Analgesia: [paracetamol ± ibuprofen] • Topical / oral Rx: [as indicated / none] • Keep ear dry / safety-net advice given • Escalate ENT / senior: [not required / called — reason] 👤 [Your Name], [Role] IMC: _______
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