Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Earache

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Earache - Key Features

1. Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).

2. Include pain referred from other sources in the differential diagnosis of an earache (eg. Tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.).

3. Consider serious causes in the differential diagnosis of an earache (eg. tumors, temporal arteritis, mastoiditis).

4. In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (e.g., through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (e.g., reassessment in 48 hours).

5. Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)

6. In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).

7. In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).*

8. Test children with recurrent ear infections for hearing loss.
Note: *See the key features on Fever.

1. Diagnosis
- must meet all of the below criteria for certain diagnosis:

i). abrupt onset of symptoms
ii). Presence of middle ear effusion (MEE) indicated by any of
a). bulging TM
b). limited/absent mobility of TM
c). air fluid level behind TM
d). otorrhea
iii). Signs of symptoms of middle ear inflammation as indicated by either
a). erythema of TM
b). distinct otalgia clearly referable to the ear (tugging at ear)

- A red TM is common but is not reliable for diagnosis without MEE (erythema alone has a PPV of 15% for AOM)
- MEE with no inflammation is otitis media with effusion (OME)

** if febrile, any other cause for fever should be considered before concluding AOM

2. Risks
- bottle feeding, day care, passive smoking, craniofacial abnormalities, Aboriginal ethnicity.

3. Etiology (in order of frequency)
Viral, S. pneumoniae, H. influenza, M. catarrhalis

4. Differential Diagnosis
- the main DDx is between AOM and OME in children
- other causes of ear pain are otitis externa, malignant OE, foreign body, TMJ disorders, pharyngitis, cerumen impaction, tooth abscess, trigeminal neuralgia.

5. Serious causes of earache
- in general tumors, temporal arteritis, mastoiditis and malignant OE must be excluded based on history and physical.

6. Treatment
- Observation: oral analgesia with acetaminophen and ibuprofen with follow up in 48-72 hours to reassess

Criteria for Antibacterial treatment

Age Certain Diagnosis Uncertain Diagnosis
<6 mo Antibiotics Antibiotics
6mo-2yr Antibiotics Severe – antibiotics

Nonsevere – observe

≥2yr Severe – antibiotics

Nonsevere - observe

Severe – observe

Nonsevere – observe

*Severe disease: fever ≥ 39 oC or moderate/severe otalgia

Nonsevere – Amoxicillin 80-90mg/kg/day BID → 1st line

Penicillin allergy: cefuroxime, azithromycin, clarithromycin

Severe – Amoxicillin/Clavulinic acid → 1st line

Penicillin allergy: ceftriaxone 1 or 3 days

Treatment failure – increase coverage to Amox/Clav or ceftriaxone; clindamycin if those fail.

7. Recurrent AOM or OME
- Refer if

a). hearing threshold < 20dB
b). MEE >3 months
c). 3 episodes in 6 months or 4 in 12 months

Study Guide



American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media: Clinical practice guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 (5): 1451 -1465, 2004.

Tallia A. F, Scherger E.J, Dickey N. W. Swanson’s Family Medicine Review: a problem oriented approach, 6th edition. Philadelphia, PA : Mosby/Elsevier, c2009.