Acute Ear Pain and Otitis Media / Externa

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Acute Ear Pain and Otitis Media / Externa

< 24 months?

Concerning signs of mastoiditis?

  • NSAID analgesia
  • Amoxicillin-clavulanate 45 mg/kg PO BID (max 875 mg/dose) for 10 days
  • Probiotics

Treat appropriately

Consider other diagnosis or otolaryngology consult

Penicillin allergy?

  • NSAID analgesia
  • Cefdinir PO 7 mg/kg BID x 10 days
  • Probiotics

  • NSAID analgesia
  • Azithromycin 10 mg/kg PO (max 500 mg) once on day one then 5 mg/kg PO daily (maximum 250 mg) for days two through five
  • Probiotics

Received amoxicillin within 30 days?

Bilateral, severe otalgia or fever ≥ 39°C??

Type 1 hypersensitivity PCN allergy?

  • NSAID analgesia
  • Amoxicillin 45 mg/kg PO BID x10 days
  • Probiotics

Features of Otitis Externa

Symptoms: ear pain, pruritus, discharge, and hearing loss

Signs: tenderness with tragal pressure or when the auricle movement, edematous and/or erythematous ear canal

Otomycosis (fungal infection): fine, dark coating or white, sebaceous-like

Severe otalgia, perforation or fever ≥ 39°C?

Features of otomycosis?

Place wick

Avoid if possible given its protective nature and potential for complications


  • Unsafe in patients with tympanic membrane perforation or otorrhea
  • No difference between types used in large study (including just water & saline)
  • Often takes several days to achieve effectiveness


  • Unlikely to be effective for hard impaction
  • Procedure: pull ear upward to straighten canal. Place the tip of syringe in lateral 1/3 of canal directing stream upwards in the canal.

Manual removal

  • Faster and does not expose the ear canal to water
  • Should only be used under direct visualization with cooperative patients
  • Unlikely to be successful if cerumen is in the medial 2/3rds of ear canal or impacted against the tympanic membrane
  • Can have complications of bleeding, laceration, and perforation of the tympanic membrane

Cerumen blocking proper otoscopy?

Severe swelling of the ear canal?

Decongestants and antihistamines

  • These medications are not recommended in the treatment of acute otitis media

Acetaminophen and/or Ibuprofen

Penicillin allergy?

Any of the following circumstances

  • Concurrent conjunctivitis
  • Patient received amoxicillin preceding 30 days

  • Cefdinir PO 7 mg/kg BID x 10 days
  • Probiotics

Bullous myringitis

Bullous myringitis occurs in 5-10% of patients with acute otitis media and may be associated with more pain. Despite earlier reports, the pathogens associated with bullous myringitis are the same as other cases of AOM without bullae, as is the treatment.


Although rare, cholesteatomas are an important finding if identified during otoscopy. They represent an abnormal accumulation of squamous epithelium within the middle ear and mastoid. They are most often identified by observation of a white mass behind the tympanic membrane and should be referred to an otolaryngologist.

< 6 months?

  • NSAID analgesia
  • Observation for 48 hours, with ensured follow up
  • Antibiotic prescription (Amoxicillin 45 mg/kg BID x 10 days) with instructions to start if symptoms worsen or persist in the next 48 hours

  • Tympanic membrane perforation
  • Continued use of oral antibiotics instead of otic drops is recommended
  • Topical analgesia is not recommended

Normal Ear Examination