Ear pain is a common presentation — but the anatomy determines the diagnosis and the treatment. Otitis media is a middle ear infection treated with oral antibiotics. Otitis externa is an external canal infection treated with topical drops. A single bedside maneuver — tragus tenderness and pinna traction — distinguishes them.
CLINICAL PRINTABLE
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A one-page Otitis Media / Otitis Externa clinical reference is on the way.
1 · Recognition
- Acute otitis media (AOM): middle ear infection. Ear pain, fever, irritability in children. Otoscopy: bulging tympanic membrane (TM), loss of light reflex, erythema, air-fluid level, or TM perforation with purulent discharge. Immobile TM on pneumatic otoscopy.
- Otitis media with effusion (OME, 'glue ear'): fluid in the middle ear without signs of acute infection. Dull, retracted TM with decreased mobility. No fever or acute pain. Common after AOM. Watchful waiting for 3 months before intervention.
- Otitis externa (OE, 'swimmer's ear'): infection of the external auditory canal. Ear pain, pruritus, discharge, tragus tenderness, and pain with pinna traction. Canal edema and erythema on otoscopy. TM is normal (if visible). Caused by Pseudomonas aeruginosa and Staphylococcus aureus.
- Bedside distinction: tragus tenderness and pain with pinna traction = otitis externa. Bulging TM without canal tenderness = otitis media. This distinction determines treatment.
- Malignant (necrotizing) otitis externa: severe OE with osteomyelitis of the skull base. Occurs in diabetics and immunocompromised patients. Severe pain, granulation tissue at the bony-cartilaginous junction, cranial nerve involvement (CN VII most common). Medical emergency.
2 · Differential / Mimics
Referred ear pain
Ear pain without otoscopic findings. Sources: temporomandibular joint (TMJ) dysfunction, dental pathology, cervical spine disease, pharyngeal/tonsillar pathology. Examine the oropharynx and TMJ.
Mastoiditis
Complication of AOM. Postauricular erythema, tenderness, swelling, and protrusion of the auricle. CT temporal bones. IV antibiotics and ENT consultation — may require mastoidectomy.
Cholesteatoma
Abnormal skin growth in the middle ear. Painless, foul-smelling discharge, hearing loss. Retraction pocket or pearly white mass on otoscopy. ENT referral — surgical treatment required.
Herpes zoster oticus (Ramsay Hunt syndrome)
Vesicular eruption in the ear canal or pinna, facial nerve palsy, ear pain, and hearing loss. Treat with antivirals (valacyclovir) and corticosteroids. ENT referral.
3 · Treatment Pathway
AOM — watchful waiting (observation option)
Children ≥2 years with mild symptoms (mild pain, fever <39°C) and non-severe AOM: watchful waiting for 48–72 hours is appropriate. Provide a backup prescription with instructions to fill if no improvement. Analgesics for pain.
AOM — immediate antibiotic treatment
Treat immediately: age <6 months, bilateral AOM in children <2 years, AOM with otorrhea, severe symptoms (severe pain, fever ≥39°C), or immunocompromised. Amoxicillin 80–90 mg/kg/day divided twice daily for 10 days (5–7 days for children ≥2 years with mild-moderate disease).
AOM — antibiotic failure
No improvement after 48–72 hours of amoxicillin: amoxicillin-clavulanate (covers beta-lactamase-producing H. influenzae and M. catarrhalis). Ceftriaxone IM for vomiting or treatment failure. Tympanocentesis for culture in refractory cases.
Otitis externa — topical treatment
Topical fluoroquinolone (ciprofloxacin-dexamethasone or ofloxacin) or acetic acid drops. Acidify the canal. Keep ear dry — no swimming, minimize water exposure. Wick placement if canal is severely edematous to allow drop penetration. Oral antibiotics are NOT indicated for uncomplicated OE.
Malignant otitis externa
Hospitalization, IV antipseudomonal antibiotics (ciprofloxacin or piperacillin-tazobactam). CT temporal bones and skull base. ENT and infectious disease consultation. Prolonged treatment (6–8 weeks). Optimize diabetes control.
4 · Expected Response
- AOM with antibiotics: fever and pain should improve within 48–72 hours. If no improvement, reassess and consider antibiotic failure (switch to amoxicillin-clavulanate).
- Otitis externa: pain and discharge should improve within 48–72 hours of topical treatment. Canal edema may take 1–2 weeks to fully resolve. Instruct patients to keep the ear dry during treatment.
- OME: most cases resolve spontaneously within 3 months. Persistent OME >3 months with hearing loss warrants ENT referral for tympanostomy tube consideration.
5 · Escalation
- Mastoiditis: postauricular swelling, erythema, and protrusion of the auricle — CT temporal bones, IV antibiotics, ENT consultation. May require mastoidectomy.
- Malignant otitis externa: diabetic or immunocompromised patient with severe OE, granulation tissue, or cranial nerve involvement — hospitalization, IV antipseudomonal antibiotics, CT skull base, ENT and ID consultation.
- Intracranial complications of AOM (meningitis, brain abscess, lateral sinus thrombosis): severe headache, meningismus, altered mental status, focal neurological deficits — CT/MRI, neurosurgery and ID consultation.
- Recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months) or persistent OME with hearing loss: ENT referral for tympanostomy tube evaluation.
Apply It · Change One Detail
APPLY IT
A 45-year-old swimmer presents with 2 days of right ear pain and discharge. Pulling the right pinna causes significant pain. The ear canal is erythematous and edematous with white discharge. The TM is not visible due to canal edema. This is otitis externa. Topical ciprofloxacin-dexamethasone drops, keep the ear dry, and a wick if the canal is severely edematous. Oral antibiotics are not indicated.
CHANGE ONE DETAIL
Change one detail — the same patient has ear pain but no tragus tenderness, no pain with pinna traction, and otoscopy shows a bulging, erythematous TM with loss of the light reflex. This is acute otitis media. The treatment is completely different: oral amoxicillin, not topical drops. The bedside distinction — tragus tenderness vs TM findings — determines the entire treatment approach.
Bottom Line
Tragus tenderness and pain with pinna traction = otitis externa. Bulging TM without canal tenderness = otitis media. This distinction determines treatment — topical drops vs oral antibiotics.
EVIDENCE & REFERENCES
- Lieberthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-999. doi:10.1542/peds.2012-3488
- Rosenfeld RM, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-24. doi:10.1177/0194599813517083