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EARACHE
Rabia A. Malik, M.D.
Department of Family & Community Medicine
History:
When did it start?
Does one ear hurt or both?
Describe the Pain?
Any Hearing Loss, Discharge, Ringing (tinnitus), Vertigo?
Any fevers, nasal congestion, sinus problems, headaches?
Any facial pain/swelling, trouble swallowing/chewing, hoarseness?
Do you have Seasonal Allergies?
History of Trauma? Hearing Aids?
History of Swimming?
Sick contacts?
Skin diseases?
PMHx?
Medications?
Dental History?
Family history of cancer?
DDX: Otitis Externa, Otitis Media (w or w/out perforation) Auricular Infections, Foreign Body,
Cerumen Impaction, Mastoiditis, TMJ, Dental disorders, Eustachian Tube Dysfunction, Herpes,
Trigeminal Neuralgia, Parotiditis, Tonsillitis, Adenoiditis, Pharyngitis, Laryngitis, Esophagitis, Bell’s
Palsy, Lymphadeopathy, Temporal Arteritis, Meneire’s disease, Aerodigestive Tract Tumors, Idiopathic,
Acoustic Neuroma.
Red Flags: Fever > 104 with lethargy, 3 Infx/6 mo OR 4 infx/12 mo, Persistant Otalgia with Normal Ear
Exam, Necrotizing Otitis Externa, Mastoiditis, Meningitis, Temporal Arteritis, Oropharyngeal
Cancers/Tumors, Cholesteatomas, Diabetes
Physical Exam: Pay attention to VS (temp>104) and appearance of patient (lethargy)
Otologic:
Ext. ear- redness, swelling, discharge, lesions
Palpation: pain on traction of pinna/pressure on tragus, parotid gland, feel mastoid and assess for LN pre and post
auricular, cervical and submandibular; Palpate TMJ.
Ext. canal: for narrowing, skin breakdown, granulation tissue, cerumen, mucus, blood, fluffy white discharge,
odor, purulent discharge, lesions, masses
TM: Inflammation, Redness, bulging, Decreased Mobility on insufflation, Loss of Landmarks, Air Fluid Levels,
Perforation, Growths
Neuro Otologic: consider Rinne and Weber’s if hearing loss a concern
Orophayrnx: redness, swelling, exudates, consider Indirect Laryngoscopy for masses or lesions.
Rhinoscopy: Septum deviation, Obstructive Polyps, Mucosa – allergic (pale) vs. infection (red), turbinates –
enlarged/inflamed, Discharge, Sinus tenderness.
Diagnostic Exams: If indicated,
Rarely, Ear Swab for C&S if discharge present. WBC, ESR, CT scan if suspecting more serious etiology.
Patient Education:
Children's Eustachian tubes are shorter and more narrow than those of adults.
More than 3 out of 4 children will have at least 1 ear infection by their third birthday.
Children around people who smoke are at higher risk.
© 2009 The University of Texas Southwestern Medical Center at Dallas
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The University of Texas Southwestern Medical Center at Dallas
Bottle Fed infants are at higher risk compared to Breast Fed Infants.
Ear Infections often recur if treated partially, so take the full course as prescribed.
Careful drying of the ear after bathing, swimming.
May use cotton wick in ear during shower.
Cleaning with a cotton-tipped swab is unnecessary and potentially harmful.
Avoid paperclips, keys, fingernails.
Treatment:
Otitis Media – Tylenol or Motrin and may consider observation for 24-48h
Amoxicillin or Augmentin x7-10 d ; Decongestant my be helpful.
Add ceftriaxone IM, if abx failure on day 3 and/or abx in prior month.
(If allergic to amoxicillin, consider arithromycin, clarithromycin, clindaymycin or cefpodoxime)
Otitis Externa: Bacterial: ABX drops and sometime steroid drops. (VoSol, VoSol HC, Floxin Otic, Cipro
HC Otic) Warm compress may assist with pain or consider topical benzocaine drops.
If Fungal: Ear drying/suctioning and acidifying drops 4x/d x5days
Seborrheic Dermatitis – medicated shampoo externally
Acne – Benzoyl peroxide solution externally
Eustachian Tube Dysfunction: Protection from cold winds and reassurance.
Sterile Effusions – course of Decongestants and reassurance that it may take 2 mos to clear.
Herpes/Shingles – Antivirals (Acyclovir 500mg po 5x/day for 7-10 days)
Cerumen Impaction- Debrox Drops/Ear Lavage
Idiopathic: a Brief course of NSAIDS
Mastoiditis: If Acute, admit, broad coverage IV abx, ENT consult for myringotomy/tympanostomy
Foreign Body: Soft tip suction, syringe with angiocatheter or magnet (if metallic)
Follow-up:
- 2 weeks (with appropriate consultation if needed: dentist, ENT, Neuro)
ICD-9 Codes:
Otitis Externa, Infective 380.1 Eczemoid/Reactive 380.22 Mycotic 380.15
Otitis Media, NOS 382.90 Purulent 382.40 Serous 381.01
Eustachian Tube Dysfunction 381.81
Sterile Effusions 381.4
Herpes Simplex 054.73 Zoster 054.71
Cerumen Impaction 380.40
Mastoiditis 383.00
TMJ disorder 524.60
Foreign Body in Ear 931
Resources:
Acute Otitis Media in Children Encounter Form:
http://www.aafp.org/fpm/20040600/aomencounterform.pdf
Rabia A. Malik, M.D.
Assistant Professor, Family & Community Medicine
Last Reviewed: 2008
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