Ear PainAPPROACH

ENT, EYE, DENTAL · 19 SECTIONS

⚲

595 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Dysphagia And Odynophagia Throat Pain Ear Pain Foreign Body In Ear Or Nose Vision Loss Complaint Flashes And Floaters Atraumatic Eye Pain Red Eye Dental Abscess Concern Post Extraction Pain And Complications

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx77

HPI

›Ear pain history

›Laterality

›Unilateral

›Bilateral

›Onset context

›After viral URI

›After swimming or water exposure

›Prior episodes

›Recurrent acute otitis media

›Recurrent otitis externa

Onset

›Onset details

›Sudden

›Gradual

›Duration

›Hours

›Days

Provocation/Palliation

›Triggers and relief

›Worse with auricle movement

›Tragus pressure

›Pinna manipulation

›Worse with pressure changes

›Flying

›Diving

›Relief with analgesics

›Acetaminophen

›Ibuprofen

Quality

›Pain characteristics

›Sharp

›Throbbing

›Itchy predominant

›Otitis externa pattern

›Dermatitis pattern

Region/Radiation

›Location and radiation

›External ear

›Deep ear

›Referred pain sites

›Jaw or TMJ

›Teeth

Severity

›Severity and function

›Pain score trend

›Improving

›Worsening

›Sleep disruption

›None

›Present

Timing

›Temporal pattern

›Constant

›Intermittent

›Diurnal variation

›Worse at night

›No pattern

Associated symptoms

›Associated features

›Otorrhea

›Purulent

›Bloody

›Hearing change

›Muffled

›Sudden loss

›Vestibular symptoms

›Vertigo

›Imbalance

›Infection symptoms

›Fever

›URI symptoms

›Neuro symptoms

›Facial weakness

›Severe headache

Exposures and procedures

›Exposures and instrumentation

›Q tip or ear canal trauma

›Recent

›None

›Piercing

›Cartilage piercing

›Lobule piercing

›Foreign body risk

›Child history

›Known insertion

02Alarm Features/alarm40

Immediate threats

›Otalgia red flags

›Toxic appearance

›Lethargy

›Poor perfusion

›Mastoid concern

›Post auricular swelling

›Ear protrusion

›Intracranial extension concern

›Neck stiffness

›Altered mental status

›Cranial neuropathy

›Facial weakness

›Dysphagia or hoarseness

High risk populations

›High risk context

›Diabetes mellitus

›Malignant otitis externa risk

›Poor glycemic control

›Immunocompromised state

›Neutropenia

›Transplant medications

›Older adult with new otalgia

›Temporal arteritis risk

›Head and neck malignancy risk

Vital sign danger thresholds

›Vital danger signs

›Hypotension

›Shock physiology

›Sepsis pathway activation

›High fever with toxicity

›Bacteremia concern

›Meningitis concern

Escalation triggers

›Escalation logic

›If airway compromise signs, immediate resuscitation bay

›Stridor

›Drooling

›If mastoiditis suspected, urgent ENT

›CT temporal bone if available

›IV antibiotics per local protocol dependent

›If malignant otitis externa suspected, urgent admission

›Severe otalgia out of proportion

›Granulation tissue in canal

03Medications/meds27

Current and recent therapies

›Medication review

›Recent antibiotics

›Amoxicillin or amoxicillin clavulanate

›Cephalosporins

›Otic drops use

›Antibiotic steroid combination

›Acidifying drops

›Analgesics

›Acetaminophen

›NSAIDs

High risk medication considerations

›Medication risks

›Anticoagulants

›Bleeding risk with trauma

›Hemotympanum differential

›Immunosuppressants

›Severe infection risk

›Atypical pathogens

›Ototoxic exposure

›Aminoglycosides

›Loop diuretics

Contraindications and interactions

›Therapy constraints

›Tympanic membrane perforation concern

›Avoid aminoglycoside ear drops

›Prefer non ototoxic drops per local formulary

›NSAID cautions

›CKD risk

›GI bleed risk

04Diet/diet14

Intake and hydration

›Intake pattern

›Reduced oral intake

›Pain limited intake

›Nausea

›Hydration indicators

›Normal urine output

›Decreased urine output

Relevant exposures

›Exposure factors

›Bottle feeding position in infants

›Supine feeding

›Upright feeding

›Caffeine and stimulants

›Increased use

›None

05Review of Systems/ros33

ENT and infectious

›ENT and infection ROS

›Sore throat

›Present

›Absent

›Nasal congestion

›Present

›Absent

›Sinus pressure

›Present

›Absent

›Fever or chills

›Present

›Absent

Neurologic and vestibular

›Neuro vestibular ROS

›Vertigo

›Present

›Absent

›Headache

›Mild

›Severe

›Focal deficits

›Facial weakness

›Limb weakness

Dental and jaw

›Orofacial ROS

›Dental pain

›Present

›Absent

›Jaw pain

›Chewing pain

›Clicking

›Neck mass symptoms

›Dysphagia

›Weight loss

06Collateral History and Family History/chafh14

Collateral sources

›Collateral

›Parent or caregiver report

›Reliable

›Limited

›School or daycare exposure

›Sick contacts

›None

Family history

›Family history factors

›Atopy

›Allergic rhinitis

›Eczema

›Immunodeficiency

›Primary immunodeficiency history

›Recurrent severe infections in family

07Risk Factors/rf27

Infection and anatomy risks

›Predisposing factors

›Young age

›Under 2 years

›Daycare attendance

›Tobacco smoke exposure

›Household smoking

›None

›Craniofacial anomalies

›Cleft palate history

›Down syndrome

Otitis externa risks

›Canal infection risks

›Swimming

›Frequent

›Recent single exposure

›Ear canal trauma

›Q tip use

›Hearing aids or earbuds

›Dermatologic disease

›Psoriasis

›Eczema

Severe infection risks

›Invasive risk

›Diabetes mellitus

›Malignant otitis externa risk

›Poor control risk

›Immunocompromised state

›Steroids

›Chemotherapy

08Differential Diagnosis/ddx52

Life threatening

›Life threatening causes

›Acute mastoiditis (H70.0)

›Post auricular erythema swelling

›Ear protrusion

›Malignant otitis externa (H60.20)

›Diabetes or immunocompromise

›Severe otalgia out of proportion

›Meningitis (G00.9)

›Neck stiffness

›Altered mental status

›Temporal arteritis (M31.6)

›Age over 50

›Jaw claudication

Common

›Common causes

›Acute otitis media (H66.90)

›Bulging tympanic membrane

›Middle ear effusion

›Otitis externa (H60.90)

›Tragus tenderness

›Edematous canal

›Cerumen impaction (H61.20)

›Occlusive wax

›Conductive hearing loss

›Eustachian tube dysfunction (H69.90)

›Aural fullness

›Recent URI

Less common

›Less common causes

›Tympanic membrane perforation (H72.90)

›Sudden pain then relief

›Otorrhea

›Barotrauma (T70.0)

›Flying or diving trigger

›Hemotympanum

›Herpes zoster oticus Ramsay Hunt (B02.21)

›Vesicular rash on ear

›Facial palsy

›Dental infection

›Caries

›Gingival swelling

Referred otalgia

›Referred pain sources

›TMJ disorder (M26.60)

›Pain with chewing

›Joint clicking

›Pharyngitis or tonsillitis (J02.9)

›Sore throat

›Tonsillar exudate

›Peritonsillar abscess (J36)

›Trismus

›Muffled voice

›Cervical spine pathology

›Neck pain

›Radicular symptoms

09Past Medical History/pmh17

Relevant conditions

›Comorbidities

›Recurrent otitis media

›Tympanostomy tubes history

›Prior complications

›Diabetes mellitus

›Most recent glycemic control

›Prior severe infections

›Immunodeficiency or immunosuppression

›HIV

›Chronic steroids

Procedures and devices

›Otologic history

›Tympanostomy tubes

›Current

›Past

›Ear surgery history

›Mastoidectomy

›Tympanoplasty

10Physical Exam/exam49

General and vitals

›General assessment

›Vitals pattern

›Fever

›Tachycardia

›Toxic appearance

›Ill appearing

›Well appearing

Otologic exam

›Ear exam elements

›External ear and pinna

›Cellulitis

›Perichondritis signs

›Ear canal

›Edema

›Debris

›Tragus and pinna tenderness

›Present

›Absent

›Otoscopy tympanic membrane

›Bulging

›Erythema

›Perforation

›Tube in place

Mastoid and surrounding structures

›Post auricular assessment

›Mastoid tenderness

›Present

›Absent

›Post auricular swelling

›Present

›Absent

Head and neck

›Adjacent sources

›Oropharynx

›Tonsillar exudate

›Uvular deviation

›Dentition and gingiva

›Caries

›Abscess

›TMJ

›Tenderness

›Crepitus

›Neck

›Cervical lymphadenopathy

›Meningismus

Neurologic

›Neuro screen

›Cranial nerves

›Facial nerve weakness

›Hearing asymmetry

›Cerebellar signs

›Gait instability

›Nystagmus

11Lab Studies/labs17

Targeted labs by severity

›Lab strategy

›Uncomplicated otitis externa or otitis media

›No routine labs

›Reassessment if worsening

›Toxic or systemic illness

›CBC

›CRP

›Blood cultures if sepsis pathway

›Before antibiotics if feasible

›Local protocol dependent

Special populations labs

›Risk based testing

›Diabetes mellitus with severe otalgia

›Serum glucose

›Electrolytes and creatinine

›Suspected temporal arteritis

›ESR

›CRP

12Imaging/img28

Scoring Systems

›Imaging decision aids

›No validated universal scoring tool for otalgia

›Imaging driven by red flags

›Specialty input for high risk cases

›Suspected temporal arteritis pathways

›Local protocol dependent

›Tie to ESR CRP and symptoms

MRI

›MRI considerations

›Intracranial complication concern

›Dural sinus thrombosis concern

›Brain abscess concern

›Skull base osteomyelitis concern

›Malignant otitis externa

›Persistent pain with cranial neuropathy

›CT considerations

›CT temporal bone

›Suspected mastoiditis

›Suspected complications of otitis media

›CT neck with contrast

›Suspected deep neck infection

›Peritonsillar or retropharyngeal abscess concern

Ultrasound

›Ultrasound applications

›Cervical lymphadenitis assessment

›Abscess versus phlegmon

›Guidance for drainage planning

›Temporal artery ultrasound

›Giant cell arteritis pathway

›Local protocol dependent

13Special Tests/spec17

Bedside otologic tests

›Bedside tests

›Pneumatic otoscopy

›Middle ear effusion assessment

›Reduced mobility

›Tympanometry if available

›Type B pattern with effusion

›Limitations in acute pain

›Tuning fork tests

›Weber lateralization

›Rinne air versus bone

Microbiology and culture

›Culture strategy

›Otitis externa refractory or severe

›Culture canal discharge

›Consider resistant organisms

›Tympanostomy tube otorrhea

›Culture if recurrent

›Guide targeted therapy

14ECG/ecg7

Indications for ECG in otalgia

›ECG triggers

›Adult with risk factors and atypical symptoms

›Jaw or ear pain with exertion

›Diaphoresis or dyspnea

›Syncope or presyncope with pain

›Arrhythmia screen

›QT prolongation risk if antiemetics used

15Assessment/ax28

Problem representation

›Clinical summary anchors

›Otalgia laterality and duration

›Unilateral

›Bilateral

›Primary suspected source category

›External canal

›Middle ear

›Referred

Working diagnoses

›Working diagnosis options

›Otitis externa (H60.90)

›Tragus tenderness

›Canal edema debris

›Acute otitis media (H66.90)

›Bulging tympanic membrane

›Middle ear effusion

›Referred otalgia

›Normal otoscopy

›Dental or TMJ findings

Complications to exclude

›Cannot miss complications

›Mastoiditis

›Post auricular swelling

›Ear protrusion

›Malignant otitis externa

›Diabetes or immunocompromise

›Granulation tissue

›Ramsay Hunt syndrome

›Vesicles

›Facial palsy

16Plan/plan77

First 5 minutes

›Immediate priorities

›Analgesia early

›Acetaminophen

›Ibuprofen if safe

›Fever or toxicity pathway

›Sepsis screen if indicated

›IV access if unstable

›Airway red flags

›Drooling

›Stridor

Analgesia

›Pain control options

›Acetaminophen PO

›Adult 1000 mg every 6 hours

›Pediatric 15 mg per kg every 6 hours

›Ibuprofen PO

›Adult 400 mg every 6 hours

›Pediatric 10 mg per kg every 6 hours

›Topical anesthetic drops

›Avoid if tympanic membrane perforation suspected

›Local protocol dependent formulary

Otitis externa treatment

›Otitis externa pathway

›Canal toilet if feasible

›Gentle suction or wick placement if swollen

›Avoid irrigation if perforation risk

›Topical antibiotic drops

›Ciprofloxacin otic typical option

›Ofloxacin otic typical option

›Systemic antibiotics

›Only if cellulitis beyond canal

›Only if immunocompromised with severe disease

Acute otitis media treatment

›Acute otitis media pathway

›Antibiotic indications

›Severe otalgia

›Fever

›Under 2 years with bilateral disease

›First line antibiotic

›Amoxicillin PO adult 875 mg every 12 hours

›Amoxicillin PO pediatric 45 mg per kg per dose every 12 hours

›Amoxicillin clavulanate triggers

›Purulent conjunctivitis

›Recent amoxicillin within 30 days

›Observation option

›Mild symptoms with reliable follow up

›Shared decision making

Tympanic membrane perforation and otorrhea

›Perforation or tube otorrhea pathway

›Otic quinolone drops preferred

›Ofloxacin otic typical option

›Ciprofloxacin otic typical option

›Avoid ototoxic drops

›Aminoglycoside containing preparations

›Alcohol containing solutions if painful

Foreign body and cerumen

›Obstruction management

›Cerumen impaction

›Cerumenolytic drops if intact tympanic membrane

›Manual removal if cooperative and safe

›Foreign body

›Immediate removal if button battery

›Avoid irrigation for organic material that swells

Mastoiditis and complicated infection

›Complicated infection pathway

›Suspected mastoiditis

›CT temporal bone

›IV antibiotics per local protocol dependent

›ENT urgent consult

›Suspected malignant otitis externa

›ESR or CRP supportive

›CT or MRI skull base per local protocol dependent

›Admission for IV therapy and ENT

Reassessment loop

›Reassessment schedule

›Pain response

›Recheck at 30 to 60 minutes after analgesia

›Escalate if persistent severe pain

›Fever trajectory

›Repeat vitals after antipyretic

›Sepsis screen if worsening

›Neuro and mastoid changes

›Repeat cranial nerve exam if severe disease

›Repeat mastoid exam if swelling suspected

17Disposition/dispo30

Discharge criteria

›Discharge suitability

›Hemodynamically stable

›Normal perfusion

›No hypotension

›No red flags

›No mastoid swelling

›No cranial neuropathy

›Pain controlled

›Acceptable at rest

›Oral intake adequate

›Follow up reliable

›Primary care in 24 to 72 hours if not improving

›Earlier if worsening

Observation or admission

›Higher level of care triggers

›Suspected mastoiditis

›Admit or transfer with ENT

›Imaging obtained or arranged

›Suspected malignant otitis externa

›Admit for IV therapy

›Diabetes or immunocompromise

›Systemic toxicity

›Sepsis concern

›Inability to tolerate PO

Transfer criteria

›Transfer needs

›No ENT coverage with suspected complication

›Mastoiditis

›Deep neck infection

›Imaging unavailable with high risk features

›Cranial neuropathy

›Altered mental status

18Discharge Instructions/di25

Copy discharge instructions

›Ear pain

›Likely cause based on exam and tests

›Outer ear canal infection

›Middle ear infection

›Pain medicine

›Use acetaminophen as directed

›Use ibuprofen as directed if safe

›Ear drops

›Use exactly as prescribed

›Keep ear dry during treatment

›Antibiotics by mouth

›Take exactly as prescribed

›Do not stop early unless instructed

›Return to emergency care now if

›Worsening pain despite medicine

›Fever with appearing very sick

›Swelling or redness behind the ear

›Ear sticking out more than usual

›New facial weakness

›Severe headache

›Neck stiffness

›Confusion

›Follow up

›Primary care in 2 to 3 days if not improving

›ENT follow up if recurrent infections or complications

19References/r16

Guidelines and key references

›Reference set

›American Academy of Pediatrics

›The Diagnosis and Management of Acute Otitis Media

›2013

›American Academy of Otolaryngology Head and Neck Surgery Foundation

›Clinical Practice Guideline Acute Otitis Externa

›2014

›National Institute for Health and Care Excellence

›Otitis media acute antimicrobial prescribing

›2018

›Infectious Diseases Society of America

›Acute bacterial rhinosinusitis guideline

›2012

›Centers for Disease Control and Prevention

›Antibiotic stewardship outpatient respiratory infections

›Most recent version local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Ear PainAPPROACH

ENT, EYE, DENTAL · 19 SECTIONS

⚲

595 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx77

HPI

›Ear pain history

›Laterality

›Unilateral

›Bilateral

›Onset context

›After viral URI

›After swimming or water exposure

›Prior episodes

›Recurrent acute otitis media

›Recurrent otitis externa

Onset

›Onset details

›Sudden

›Gradual

›Duration

›Hours

›Days

Provocation/Palliation

›Triggers and relief

›Worse with auricle movement

›Tragus pressure

›Pinna manipulation

›Worse with pressure changes

›Flying

›Diving

›Relief with analgesics

›Acetaminophen

›Ibuprofen

Quality

›Pain characteristics

›Sharp

›Throbbing

›Itchy predominant

›Otitis externa pattern

›Dermatitis pattern

Region/Radiation

›Location and radiation

›External ear

›Deep ear

›Referred pain sites

›Jaw or TMJ

›Teeth

Severity

›Severity and function

›Pain score trend

›Improving

›Worsening

›Sleep disruption

›None

›Present

Timing

›Temporal pattern

›Constant

›Intermittent

›Diurnal variation

›Worse at night

›No pattern

Associated symptoms

›Associated features

›Otorrhea

›Purulent

›Bloody

›Hearing change

›Muffled

›Sudden loss

›Vestibular symptoms

›Vertigo

›Imbalance

›Infection symptoms

›Fever

›URI symptoms

›Neuro symptoms

›Facial weakness

›Severe headache

Exposures and procedures

›Exposures and instrumentation

›Q tip or ear canal trauma

›Recent

›None

›Piercing

›Cartilage piercing

›Lobule piercing

›Foreign body risk

›Child history

›Known insertion

02Alarm Features/alarm40

Immediate threats

›Otalgia red flags

›Toxic appearance

›Lethargy

›Poor perfusion

›Mastoid concern

›Post auricular swelling

›Ear protrusion

›Intracranial extension concern

›Neck stiffness

›Altered mental status

›Cranial neuropathy

›Facial weakness

›Dysphagia or hoarseness

High risk populations

›High risk context

›Diabetes mellitus

›Malignant otitis externa risk

›Poor glycemic control

›Immunocompromised state

›Neutropenia

›Transplant medications

›Older adult with new otalgia

›Temporal arteritis risk

›Head and neck malignancy risk

Vital sign danger thresholds

›Vital danger signs

›Hypotension

›Shock physiology

›Sepsis pathway activation

›High fever with toxicity

›Bacteremia concern

›Meningitis concern

Escalation triggers

›Escalation logic

›If airway compromise signs, immediate resuscitation bay

›Stridor

›Drooling

›If mastoiditis suspected, urgent ENT

›CT temporal bone if available

›IV antibiotics per local protocol dependent

›If malignant otitis externa suspected, urgent admission

›Severe otalgia out of proportion

›Granulation tissue in canal

03Medications/meds27

Current and recent therapies

›Medication review

›Recent antibiotics

›Amoxicillin or amoxicillin clavulanate

›Cephalosporins

›Otic drops use

›Antibiotic steroid combination

›Acidifying drops

›Analgesics

›Acetaminophen

›NSAIDs

High risk medication considerations

›Medication risks

›Anticoagulants

›Bleeding risk with trauma

›Hemotympanum differential

›Immunosuppressants

›Severe infection risk

›Atypical pathogens

›Ototoxic exposure

›Aminoglycosides

›Loop diuretics

Contraindications and interactions

›Therapy constraints

›Tympanic membrane perforation concern

›Avoid aminoglycoside ear drops

›Prefer non ototoxic drops per local formulary

›NSAID cautions

›CKD risk

›GI bleed risk

04Diet/diet14

Intake and hydration

›Intake pattern

›Reduced oral intake

›Pain limited intake

›Nausea

›Hydration indicators

›Normal urine output

›Decreased urine output

Relevant exposures

›Exposure factors

›Bottle feeding position in infants

›Supine feeding

›Upright feeding

›Caffeine and stimulants

›Increased use

›None

05Review of Systems/ros33

ENT and infectious

›ENT and infection ROS

›Sore throat

›Present

›Absent

›Nasal congestion

›Present

›Absent

›Sinus pressure

›Present

›Absent

›Fever or chills

›Present

›Absent

Neurologic and vestibular

›Neuro vestibular ROS

›Vertigo

›Present

›Absent

›Headache

›Mild

›Severe

›Focal deficits

›Facial weakness

›Limb weakness

Dental and jaw

›Orofacial ROS

›Dental pain

›Present

›Absent

›Jaw pain

›Chewing pain

›Clicking

›Neck mass symptoms

›Dysphagia

›Weight loss

06Collateral History and Family History/chafh14

Collateral sources

›Collateral

›Parent or caregiver report

›Reliable

›Limited

›School or daycare exposure

›Sick contacts

›None

Family history

›Family history factors

›Atopy

›Allergic rhinitis

›Eczema

›Immunodeficiency

›Primary immunodeficiency history

›Recurrent severe infections in family

07Risk Factors/rf27

Infection and anatomy risks

›Predisposing factors

›Young age

›Under 2 years

›Daycare attendance

›Tobacco smoke exposure

›Household smoking

›None

›Craniofacial anomalies

›Cleft palate history

›Down syndrome

Otitis externa risks

›Canal infection risks

›Swimming

›Frequent

›Recent single exposure

›Ear canal trauma

›Q tip use

›Hearing aids or earbuds

›Dermatologic disease

›Psoriasis

›Eczema

Severe infection risks

›Invasive risk

›Diabetes mellitus

›Malignant otitis externa risk

›Poor control risk

›Immunocompromised state

›Steroids

›Chemotherapy

08Differential Diagnosis/ddx52

Life threatening

›Life threatening causes

›Acute mastoiditis (H70.0)

›Post auricular erythema swelling

›Ear protrusion

›Malignant otitis externa (H60.20)

›Diabetes or immunocompromise

›Severe otalgia out of proportion

›Meningitis (G00.9)

›Neck stiffness

›Altered mental status

›Temporal arteritis (M31.6)

›Age over 50

›Jaw claudication

Common

›Common causes

›Acute otitis media (H66.90)

›Bulging tympanic membrane

›Middle ear effusion

›Otitis externa (H60.90)

›Tragus tenderness

›Edematous canal

›Cerumen impaction (H61.20)

›Occlusive wax

›Conductive hearing loss

›Eustachian tube dysfunction (H69.90)

›Aural fullness

›Recent URI

Less common

›Less common causes

›Tympanic membrane perforation (H72.90)

›Sudden pain then relief

›Otorrhea

›Barotrauma (T70.0)

›Flying or diving trigger

›Hemotympanum

›Herpes zoster oticus Ramsay Hunt (B02.21)

›Vesicular rash on ear

›Facial palsy

›Dental infection

›Caries

›Gingival swelling

Referred otalgia

›Referred pain sources

›TMJ disorder (M26.60)

›Pain with chewing

›Joint clicking

›Pharyngitis or tonsillitis (J02.9)

›Sore throat

›Tonsillar exudate

›Peritonsillar abscess (J36)

›Trismus

›Muffled voice

›Cervical spine pathology

›Neck pain

›Radicular symptoms

09Past Medical History/pmh17

Relevant conditions

›Comorbidities

›Recurrent otitis media

›Tympanostomy tubes history

›Prior complications

›Diabetes mellitus

›Most recent glycemic control

›Prior severe infections

›Immunodeficiency or immunosuppression

›HIV

›Chronic steroids

Procedures and devices

›Otologic history

›Tympanostomy tubes

›Current

›Past

›Ear surgery history

›Mastoidectomy

›Tympanoplasty

10Physical Exam/exam49

General and vitals

›General assessment

›Vitals pattern

›Fever

›Tachycardia

›Toxic appearance

›Ill appearing

›Well appearing

Otologic exam

›Ear exam elements

›External ear and pinna

›Cellulitis

›Perichondritis signs

›Ear canal

›Edema

›Debris

›Tragus and pinna tenderness

›Present

›Absent

›Otoscopy tympanic membrane

›Bulging

›Erythema

›Perforation

›Tube in place

Mastoid and surrounding structures

›Post auricular assessment

›Mastoid tenderness

›Present

›Absent

›Post auricular swelling

›Present

›Absent

Head and neck

›Adjacent sources

›Oropharynx

›Tonsillar exudate

›Uvular deviation

›Dentition and gingiva

›Caries

›Abscess

›TMJ

›Tenderness

›Crepitus

›Neck

›Cervical lymphadenopathy

›Meningismus

Neurologic

›Neuro screen

›Cranial nerves

›Facial nerve weakness

›Hearing asymmetry

›Cerebellar signs

›Gait instability

›Nystagmus

11Lab Studies/labs17

Targeted labs by severity

›Lab strategy

›Uncomplicated otitis externa or otitis media

›No routine labs

›Reassessment if worsening

›Toxic or systemic illness

›CBC

›CRP

›Blood cultures if sepsis pathway

›Before antibiotics if feasible

›Local protocol dependent

Special populations labs

›Risk based testing

›Diabetes mellitus with severe otalgia

›Serum glucose

›Electrolytes and creatinine

›Suspected temporal arteritis

›ESR

›CRP

12Imaging/img28

Scoring Systems

›Imaging decision aids

›No validated universal scoring tool for otalgia

›Imaging driven by red flags

›Specialty input for high risk cases

›Suspected temporal arteritis pathways

›Local protocol dependent

›Tie to ESR CRP and symptoms

MRI

›MRI considerations

›Intracranial complication concern

›Dural sinus thrombosis concern

›Brain abscess concern

›Skull base osteomyelitis concern

›Malignant otitis externa

›Persistent pain with cranial neuropathy

›CT considerations

›CT temporal bone

›Suspected mastoiditis

›Suspected complications of otitis media

›CT neck with contrast

›Suspected deep neck infection

›Peritonsillar or retropharyngeal abscess concern

Ultrasound

›Ultrasound applications

›Cervical lymphadenitis assessment

›Abscess versus phlegmon

›Guidance for drainage planning

›Temporal artery ultrasound

›Giant cell arteritis pathway

›Local protocol dependent

13Special Tests/spec17

Bedside otologic tests

›Bedside tests

›Pneumatic otoscopy

›Middle ear effusion assessment

›Reduced mobility

›Tympanometry if available

›Type B pattern with effusion

›Limitations in acute pain

›Tuning fork tests

›Weber lateralization

›Rinne air versus bone

Microbiology and culture

›Culture strategy

›Otitis externa refractory or severe

›Culture canal discharge

›Consider resistant organisms

›Tympanostomy tube otorrhea

›Culture if recurrent

›Guide targeted therapy

14ECG/ecg7

Indications for ECG in otalgia

›ECG triggers

›Adult with risk factors and atypical symptoms

›Jaw or ear pain with exertion

›Diaphoresis or dyspnea

›Syncope or presyncope with pain

›Arrhythmia screen

›QT prolongation risk if antiemetics used

15Assessment/ax28

Problem representation

›Clinical summary anchors

›Otalgia laterality and duration

›Unilateral

›Bilateral

›Primary suspected source category

›External canal

›Middle ear

›Referred

Working diagnoses

›Working diagnosis options

›Otitis externa (H60.90)

›Tragus tenderness

›Canal edema debris

›Acute otitis media (H66.90)

›Bulging tympanic membrane

›Middle ear effusion

›Referred otalgia

›Normal otoscopy

›Dental or TMJ findings

Complications to exclude

›Cannot miss complications

›Mastoiditis

›Post auricular swelling

›Ear protrusion

›Malignant otitis externa

›Diabetes or immunocompromise

›Granulation tissue

›Ramsay Hunt syndrome

›Vesicles

›Facial palsy

16Plan/plan77

First 5 minutes

›Immediate priorities

›Analgesia early

›Acetaminophen

›Ibuprofen if safe

›Fever or toxicity pathway

›Sepsis screen if indicated

›IV access if unstable

›Airway red flags

›Drooling

›Stridor

Analgesia

›Pain control options

›Acetaminophen PO

›Adult 1000 mg every 6 hours

›Pediatric 15 mg per kg every 6 hours

›Ibuprofen PO

›Adult 400 mg every 6 hours

›Pediatric 10 mg per kg every 6 hours

›Topical anesthetic drops

›Avoid if tympanic membrane perforation suspected

›Local protocol dependent formulary

Otitis externa treatment

›Otitis externa pathway

›Canal toilet if feasible

›Gentle suction or wick placement if swollen

›Avoid irrigation if perforation risk

›Topical antibiotic drops

›Ciprofloxacin otic typical option

›Ofloxacin otic typical option

›Systemic antibiotics

›Only if cellulitis beyond canal

›Only if immunocompromised with severe disease

Acute otitis media treatment

›Acute otitis media pathway

›Antibiotic indications

›Severe otalgia

›Fever

›Under 2 years with bilateral disease

›First line antibiotic

›Amoxicillin PO adult 875 mg every 12 hours

›Amoxicillin PO pediatric 45 mg per kg per dose every 12 hours

›Amoxicillin clavulanate triggers

›Purulent conjunctivitis

›Recent amoxicillin within 30 days

›Observation option

›Mild symptoms with reliable follow up

›Shared decision making

Tympanic membrane perforation and otorrhea

›Perforation or tube otorrhea pathway

›Otic quinolone drops preferred

›Ofloxacin otic typical option

›Ciprofloxacin otic typical option

›Avoid ototoxic drops

›Aminoglycoside containing preparations

›Alcohol containing solutions if painful

Foreign body and cerumen

›Obstruction management

›Cerumen impaction

›Cerumenolytic drops if intact tympanic membrane

›Manual removal if cooperative and safe

›Foreign body

›Immediate removal if button battery

›Avoid irrigation for organic material that swells

Mastoiditis and complicated infection

›Complicated infection pathway

›Suspected mastoiditis

›CT temporal bone

›IV antibiotics per local protocol dependent

›ENT urgent consult

›Suspected malignant otitis externa

›ESR or CRP supportive

›CT or MRI skull base per local protocol dependent

›Admission for IV therapy and ENT

Reassessment loop

›Reassessment schedule

›Pain response

›Recheck at 30 to 60 minutes after analgesia

›Escalate if persistent severe pain

›Fever trajectory

›Repeat vitals after antipyretic

›Sepsis screen if worsening

›Neuro and mastoid changes

›Repeat cranial nerve exam if severe disease

›Repeat mastoid exam if swelling suspected

17Disposition/dispo30

Discharge criteria

›Discharge suitability

›Hemodynamically stable

›Normal perfusion

›No hypotension

›No red flags

›No mastoid swelling

›No cranial neuropathy

›Pain controlled

›Acceptable at rest

›Oral intake adequate

›Follow up reliable

›Primary care in 24 to 72 hours if not improving

›Earlier if worsening

Observation or admission

›Higher level of care triggers

›Suspected mastoiditis

›Admit or transfer with ENT

›Imaging obtained or arranged

›Suspected malignant otitis externa

›Admit for IV therapy

›Diabetes or immunocompromise

›Systemic toxicity

›Sepsis concern

›Inability to tolerate PO

Transfer criteria

›Transfer needs

›No ENT coverage with suspected complication

›Mastoiditis

›Deep neck infection

›Imaging unavailable with high risk features

›Cranial neuropathy

›Altered mental status

18Discharge Instructions/di25

Copy discharge instructions

›Ear pain

›Likely cause based on exam and tests

›Outer ear canal infection

›Middle ear infection

›Pain medicine

›Use acetaminophen as directed

›Use ibuprofen as directed if safe

›Ear drops

›Use exactly as prescribed

›Keep ear dry during treatment

›Antibiotics by mouth

›Take exactly as prescribed

›Do not stop early unless instructed

›Return to emergency care now if

›Worsening pain despite medicine

›Fever with appearing very sick

›Swelling or redness behind the ear

›Ear sticking out more than usual

›New facial weakness

›Severe headache

›Neck stiffness

›Confusion

›Follow up

›Primary care in 2 to 3 days if not improving

›ENT follow up if recurrent infections or complications

19References/r16

Guidelines and key references

›Reference set

›American Academy of Pediatrics

›The Diagnosis and Management of Acute Otitis Media

›2013

›American Academy of Otolaryngology Head and Neck Surgery Foundation

›Clinical Practice Guideline Acute Otitis Externa

›2014

›National Institute for Health and Care Excellence

›Otitis media acute antimicrobial prescribing

›2018

›Infectious Diseases Society of America

›Acute bacterial rhinosinusitis guideline

›2012

›Centers for Disease Control and Prevention

›Antibiotic stewardship outpatient respiratory infections

›Most recent version local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.