Earache
Media is a bulging drum after a cold; externa is a painful, swollen canal. Most otitis media needs no antibiotic; externa needs drops and a dry ear.
A 3-year-old girl has had ear pain and fever of 38.6 °C for 2 days after a cold. She is pulling at her right ear. The right eardrum is red and bulging. She is drinking well and playful between doses of paracetamol.
A 45-year-old man has had a smelly discharge from his left ear on and off for years, with worsening hearing.
A 62-year-old smoker has right ear pain for 6 weeks; the ear looks normal.
Antibiotics for the child? What worries you about the two adults?
- Swelling behind the ear, ear pushed forwardMastoiditis: admit, IV antibiotics, ENT.
- Facial weakness, severe headache, neck stiffness, confusionComplications: ENT and senior now.
- Acute otitis mediaMost settle within 3 days. Analgesia first.
- Antibiotics ifUnder 2 with both ears, discharge, very unwell, high risk, or not better at 3 days.
- Otitis externaClean, drops, keep the ear dry.
- Foul discharge for years with hearing lossThink cholesteatoma: ENT.
- Normal ear but painReferred pain: teeth, throat, jaw joint, neck, cancer.
- Swelling or redness behind the ear
- Facial weakness
- Severe headache, neck stiffness or confusion
- Diabetic or immunosuppressed with severe otitis externa
- Vertigo with vomiting and hearing loss
- Mastoiditis
- Cholesteatoma
- Malignant (necrotising) otitis externa in diabetics
- Referred pain from throat or laryngeal cancer
- Meningitis or brain abscess
- Foreign body in the ear
| Amoxicillin (child) | 40–90 mg/kg/day in 2–3 doses per local guidance, 5–7 days |
| Amoxicillin (adult) | 500 mg 3 times daily for 5–7 days |
| Penicillin allergy | Clarithromycin |
| Otitis externa drops | Antibiotic with or without steroid, 7 days |
| Watchful waiting | Most acute otitis media resolves within 3 days |
| Referred otalgia | Normal ear in an adult smoker: examine throat, larynx and neck |
Check every dose against a current drug reference and your hospital protocol.
On this page
Which ear problem?
Acute otitis media
Otitis externa
Chronic suppurative otitis media
Cholesteatoma
Referred pain: teeth, throat, jaw, neck
| Condition | Features | Treatment |
|---|---|---|
| Acute otitis media | Fever, pain, red bulging drum, after a cold, young children | Analgesia; antibiotics if criteria |
| Otitis media with effusion | Dull drum, hearing loss, no pain | Watch; ENT if persistent |
| Otitis externa | Pain on pulling the ear, swollen canal, discharge | Clean, drops, keep dry |
| Chronic suppurative otitis media | Painless discharge through a perforation | Clean, drops, ENT |
| Cholesteatoma | Foul discharge, attic retraction, hearing loss | ENT surgery |
| Malignant otitis externa | Diabetic or elderly, severe pain, granulation tissue | Admit, IV antibiotics, ENT |
| Referred pain | Normal ear | Find the source |
Acute otitis media in children
- AnalgesiaParacetamol or ibuprofen regularly for 2–3 days.
- Antibiotic now ifUnder 2 with both ears affected, discharge (perforation), very unwell, high risk (immunosuppressed, cochlear implant).
- OtherwiseWatchful waiting or a delayed prescription to start if not better in 3 days.
- Safety-netReturn with swelling behind the ear, very unwell, drowsiness, stiff neck, or not better in 3 days.
Mastoiditis
- Infection spreading from the middle ear into the mastoid bone.
- Swelling, redness and tenderness behind the ear, ear pushed forward and down, fever, unwell child.
- Admit, IV antibiotics (for example ceftriaxone), ENT review; CT if complications suspected.
Otitis externa
- Common in hot, humid weather, swimmers, and people who clean their ears with cotton buds or other objects.
- Clean the canal (dry mopping or suction), antibiotic or antibiotic-steroid drops for 7 days, keep the ear dry.
- A wick if the canal is very swollen.
- Diabetic or elderly with severe pain: think malignant (necrotising) otitis externa: admit.
Chronic discharge and cholesteatoma
- Chronic suppurative otitis media: painless discharge through a perforation, common in Pakistan. Dry mopping, antibiotic drops (ofloxacin), keep water out, ENT.
- Cholesteatoma: skin growing into the middle ear. Foul-smelling discharge, hearing loss, sometimes dizziness or facial weakness. It erodes bone and can cause meningitis or brain abscess. ENT surgery.
Referred ear pain
A normal ear with pain means the pain is coming from elsewhere: teeth, tonsils, jaw joint, neck, or cancer of the throat, tongue base or larynx, especially in older smokers and tobacco chewers with hoarseness or difficulty swallowing. Examine the throat and neck and refer if no cause is found.
Treatment
Common mistakes
- Antibiotics for every red eardrum.
- Missing mastoiditis in an unwell child.
- Syringing an ear with a perforation or a battery.
- Calling foul discharge "just otitis externa" for years.
- Missing malignant otitis externa in a diabetic.
- Not examining the throat in an adult with a normal ear and ear pain.
Frequently asked questions
Does every ear infection need antibiotics?
No. Most acute otitis media gets better within 3 days. Antibiotics are for children under 2 with both ears affected, discharge, very unwell or high-risk children, or those not improving.
What is a cholesteatoma?
A growth of skin in the middle ear causing foul discharge and hearing loss. It erodes bone and needs ENT surgery.
How is otitis externa treated?
Cleaning the ear canal, antibiotic or antibiotic-steroid drops for 7 days, and keeping the ear dry.
Why might an ear hurt if it looks normal?
The pain may be referred from the teeth, throat, jaw joint, neck or a throat cancer. Examine these, especially in older smokers.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A child has acute otitis media in one ear, is drinking well and not very unwell. What is the first approach?
Answer: Analgesia and watchful waiting. Most AOM settles within 3 days; antibiotics for specific criteria.
- Steroids: No.
- Grommets: No.
- Immediate IV antibiotics: Not needed.
- Ear drops: Not for AOM with an intact drum.
2. A child with otitis media has a swelling behind the ear pushing the ear forward. What is the diagnosis?
Answer: Mastoiditis. Mastoiditis needs admission and IV antibiotics.
- Cholesteatoma: Chronic.
- Mumps: No.
- Otitis externa: No.
- Lymph node: Possible, but ear pushed forward suggests mastoiditis.
3. A 45-year-old has years of foul-smelling ear discharge and hearing loss. What should be suspected?
Answer: Cholesteatoma. Cholesteatoma needs ENT; it erodes bone and can cause complications.
- Otitis externa only: Less likely.
- Wax: No discharge.
- Presbycusis: No discharge.
- Acute otitis media: Not chronic.
4. A 25-year-old has intermittent, profuse, mucoid, non-smelly ear discharge for years, worse after colds or swimming. Otoscopy shows a large central perforation of the pars tensa with healthy margins. What type of disease is this?
Answer: Mucosal CSOM. CSOM: persistent perforation with recurrent/chronic discharge. Mucosal ("safe", tubotympanic): central perforation of pars tensa (rim of drum remains), intermittent profuse mucoid odourless discharge, conductive loss; complications rare. Squamosal ("unsafe", atticoantral): attic or posterosuperior marginal perforation/retraction pocket with cholesteatoma — scanty, foul-smelling, continuous discharge, granulations, bone erosion, risk of intracranial and facial nerve complications → surgery. Management of mucosal disease: aural toilet, topical antibiotic drops (fluoroquinolones avoid ototoxicity), keep water out (cotton wool with Vaseline), treat nasal/sinus sources; surgical repair (myringoplasty/tympanoplasty) once dry to close the perforation and improve hearing. CSOM is common in Pakistan and a major cause of hearing loss.
- Squamosal CSOM: Squamosal disease has a foul discharge with attic retraction or cholesteatoma.
- Otitis externa: Otitis externa does not perforate the drum.
- Otitis media with effusion: In OME the drum is intact.
5. A 30-year-old has painless, persistent ear discharge not responding to repeated antibiotic drops, with rapidly worsening hearing. The drum shows multiple perforations with pale granulation tissue. He has had a chronic cough. What should be suspected?
Answer: Tuberculous otitis media. Tuberculous otitis media is uncommon but important in high-TB-burden countries like Pakistan: usually secondary to pulmonary TB (via Eustachian tube, haematogenous), also primary in infants. Clues: painless, persistent, often thin discharge unresponsive to standard therapy; multiple perforations (coalescing into a large one); pale/abundant granulations; early disproportionate hearing loss (conductive or mixed — cochlear involvement); facial nerve palsy; bone necrosis/sequestra; postauricular fistula; preauricular/cervical lymphadenopathy. Diagnosis: AFB staining, GeneXpert MTB/RIF, culture, histology of granulations (caseating granulomas), CXR, IGRA. Treatment: standard anti-tuberculous therapy (6 months; longer if bone involvement); surgery for complications (sequestrum, abscess, facial palsy).
- Allergic otitis externa: Allergic otitis externa does not cause perforations.
- Cholesteatoma: Cholesteatoma gives foul discharge with keratin, not multiple perforations.
- Otosclerosis: Otosclerosis has an intact drum.
6. On otoscopy of a normal right tympanic membrane, where is the cone of light seen?
Answer: Anteroinferior quadrant. The tympanic membrane is oval, pearly grey, set obliquely, and concave laterally, with the umbo at the tip of the malleus handle. The light reflex (cone of light) extends anteroinferiorly from the umbo. The small pars flaccida (above the lateral process of the malleus, between the malleolar folds) is the site of attic retraction pockets and cholesteatoma; the larger pars tensa forms the rest. The posterosuperior quadrant is related to the long process of the incus and chorda tympani, and myringotomy is done in the anteroinferior or posteroinferior quadrant to avoid ossicles.
- Posterosuperior quadrant: Ossicles lie behind this area.
- Pars flaccida: Site of attic cholesteatoma.
- Posteroinferior quadrant: Not where the light reflex lies.
- Over the umbo: The cone starts at the umbo but points anteroinferiorly.
7. A child with chronic suppurative otitis media develops fever, headache and confusion. CT shows a temporal lobe abscess. Through which part of the middle ear did infection most likely spread?
Answer: Tegmen tympani (roof). Walls of the middle ear: roof—tegmen tympani, a thin bony plate separating it from the middle cranial fossa and temporal lobe (spread causes extradural abscess, meningitis or temporal lobe abscess); floor—jugular bulb (lateral sinus thrombosis); anterior wall—carotid canal and Eustachian tube opening; posterior wall—aditus to the mastoid antrum (mastoiditis, then cerebellar abscess via the sigmoid sinus plate); medial wall—promontory (basal turn of cochlea), oval and round windows, and the facial nerve canal (facial palsy); lateral wall—tympanic membrane.
- Floor over the jugular bulb: Leads to jugular bulb or sinus thrombosis.
- Anterior wall, carotid canal: Carotid canal; rarely involved.
- Lateral wall (drum): The drum; spread outward.
- Eustachian tube: Connects to nasopharynx.
References and dose sources
- NICE NG91 — Otitis media (acute): antimicrobial prescribing
- NICE CKS — Otitis externa
- Amoxicillin dosing: Drugs.com: Amoxicillin dosage (see also our amoxicillin dose page)
- Clarithromycin dosing: Drugs.com: Clarithromycin dosage (see also our clarithromycin dose page)
- Ofloxacin dosing: Drugs.com: Ofloxacin dosage (see also our ofloxacin dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.