Diagnosis and Management of Ear Pain to Rule Out Infection
Diagnostic Approach
To diagnose acute otitis media (AOM), you must confirm three elements: acute onset of signs/symptoms, presence of middle ear effusion, and signs of middle ear inflammation. 1
Diagnostic criteria for AOM include:
- Recent, usually abrupt onset of signs and symptoms of middle ear inflammation 1
- Presence of middle ear effusion indicated by: bulging tympanic membrane, limited/absent mobility of tympanic membrane, air-fluid level behind tympanic membrane, or otorrhea 1
- Signs of middle ear inflammation shown by distinct erythema of the tympanic membrane or distinct otalgia 1
Pneumatic otoscopy is the primary diagnostic tool, which can be supplemented by tympanometry and/or acoustic reflectometry to visualize the tympanic membrane 1
Key otoscopic findings that predict AOM include fullness or bulging of the tympanic membrane combined with changes in color and reduced mobility 1
Differential Diagnosis
Otitis media with effusion (OME) - middle ear effusion without acute symptoms, often mistaken for AOM leading to unnecessary antibiotic use 1, 2
Acute otitis externa (AOE) - inflammation of the external ear canal, often with pain, itching, and sometimes discharge 1
Furunculosis (localized otitis externa) - infected hair follicle in the outer third of the ear canal 1
Non-ear causes of referred otalgia - TMJ syndrome, dental pathology, tonsillitis, peritonsillar abscess 1
Initial Management
For confirmed AOM, high-dose amoxicillin (80-90 mg/kg/day in divided doses) is the first-line treatment for most patients with ear pain due to infection. 1, 3, 4, 2
Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1, 5
For patients aged 2 years or older with mild symptoms and uncertain diagnosis, observation without antibiotics for 48-72 hours is an appropriate option 1, 6
If observation is chosen, provide a "safety-net" antibiotic prescription to be filled only if symptoms worsen or don't improve after 48 hours 6
Treatment Algorithm Based on Diagnosis
For Acute Otitis Media (AOM):
First-line therapy: Amoxicillin 80-90 mg/kg/day divided in two doses 1, 3, 2
For patients with penicillin allergy (non-type I): Alternative options include cefdinir, cefuroxime, or cefpodoxime 3
For treatment failure after 48-72 hours: Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 3, 2
Duration of therapy: Continue treatment for a minimum of 48-72 hours beyond symptom resolution 4
For Acute Otitis Externa (AOE):
Primary treatment: Topical antibiotic drops rather than oral antibiotics 1
Common pathogens include Pseudomonas aeruginosa and Staphylococcus aureus 1
For auricular perichondritis (painful swelling, warmth, redness of auricle): Fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) 1
Special Considerations
Distinguish between AOM and otitis media with effusion (OME), as antibiotics are indicated for AOM but not for OME in the absence of acute symptoms 3, 2
For patients with tympanostomy tubes who develop ear infection with drainage, topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) are more effective than systemic antibiotics 1, 7
For recurrent AOM, consider referral for tympanostomy tube placement, especially in children with documented language delay or significant medical complications 8
Common pitfall: Mistaking cerumen impaction for infection - ensure adequate visualization of the tympanic membrane by clearing the external auditory canal of cerumen 1
Bacterial resistance is increasingly influencing treatment success, particularly with S. pneumoniae, H. influenzae, and M. catarrhalis, which are the most common pathogens in AOM 3, 2