Approach the painful ear

Murtagh's Diagnostic strategy model

** one of every 25 patients in general practice will present with an earache**

** Pneumatic otoscopy greatly assists diagnosis since the most valuable sign of otitis media is absent or diminished motility of the TM**

Probability diagnosis

• Otitis media (viral or bacterial) **Indigenous health**
• Otitis externa 
• TMJ arthralgia 
• Eustachian tube dysfunction 

Serious disorders not to be missed

• Neoplasia of external ear
• Cancer of other sites e.g. tongue, throat
• Herpes zoster (Ramsay-Hunt syndrome)
• Acute mastoiditis
• Cholesteatoma
• Necrotising otitis externa

Pitfalls (often missed)

• Foreign bodies in ear
• Hard ear wax
• Barotrauma 
• Dental causes
• Referred pain: neck, throat
• Unerupted wisdom tooth and the dental causes
• Facial neuralgias esp. glossopharyngeal
• Post tonsillectomy:
• - from the wound 
• - from TMJ due to mouth gag

Red flags

• Offensive discharge > 9 days
• Downward displacement of pinna 
• Swelling behind ear
• Neurological symptoms (e.g. headaches, drowsiness)
• Older person: unexplained, intractable ear pain 
• Persistent fever