What should be assessed and included in a SOAP (Subjective, Objective, Assessment, Plan) note for a patient presenting with ear pain?

SOAP Note for Ear Pain Assessment

Subjective

Start by distinguishing primary from secondary otalgia—this fundamentally determines your diagnostic pathway. 1

Chief Complaint & Pain Characteristics

• Onset and duration: Rapid onset suggests acute otitis externa (AOE) or acute otitis media (AOM); gradual onset may indicate referred pain 1
• Pain severity: Use a standardized pain scale (0-10 numeric or faces scale for children) 1
• Pain quality: Sharp, throbbing pain suggests primary ear pathology; dull, aching pain suggests referred etiology 2, 3
• Aggravating factors: Pain with tragus pressure or pinna traction is pathognomonic for AOE 1
• Pain with chewing: Suggests temporomandibular joint (TMJ) syndrome or AOE 1

Associated Otologic Symptoms

• Hearing loss: Fluctuating hearing suggests Ménière's disease; stable conductive loss suggests middle ear effusion 1
• Otorrhea: Presence indicates AOE, AOM with perforation, or chronic suppurative otitis media 1
• Tinnitus and aural fullness: Common with Ménière's disease or sudden sensorineural hearing loss 1
• Vertigo: True spinning sensation suggests inner ear pathology (Ménière's, labyrinthitis); vague dizziness suggests other causes 1
• Pruritus: Suggests AOE or allergic contact dermatitis 1

Predisposing Factors & Red Flags

• Water exposure: Swimming, bathing, or humid environments predispose to AOE 1
• Trauma history: Cotton swabs, hearing aids, or foreign body insertion 1
• Recent upper respiratory infection: Precedes AOM in most cases 1
• High-risk features requiring urgent evaluation: 2, 3
  • Age >50 years with new-onset ear pain
  • Tobacco use or alcohol consumption (malignancy risk)
  • Diabetes mellitus (necrotizing otitis externa risk)
  • Immunocompromised state
  • Constitutional symptoms (fever, weight loss, night sweats)
  • Focal neurologic findings

Systems Review for Referred Pain

• Dental symptoms: Recent dental work, tooth pain, or jaw clicking (TMJ syndrome) 1, 2
• Pharyngeal symptoms: Sore throat, dysphagia, or odynophagia 1, 4
• Headache patterns: Temporal headaches suggest temporal arteritis in elderly 5, 3
• Neck pain: Cervical spine arthritis can refer to ear 2, 3

Objective

Vital Signs

• Temperature: Fever suggests AOM, mastoiditis, or systemic infection 1
• Blood pressure: Elevated in severe pain; assess cardiovascular status before NSAID use 6

Otoscopic Examination (Critical for Primary vs. Secondary Otalgia)

A normal otoscopic exam with ear pain indicates secondary (referred) otalgia until proven otherwise. 1, 2, 3

External Ear & Canal Assessment

• Tragus tenderness: Push tragus—exquisite tenderness confirms AOE 1
• Pinna traction test: Pull pinna upward/backward—pain confirms AOE 1
• Canal inspection: 1
  • Edema and erythema indicate AOE
  • Debris or purulent material suggests infection
  • Cerumen impaction can cause conductive hearing loss
  • Foreign body presence (especially in children <6 years)
  • Vesicles suggest herpes zoster oticus (Ramsay Hunt syndrome) 1

Tympanic Membrane Evaluation

• Color: Normal is pearly gray; erythema alone is nonspecific 1, 7
• Position: 1, 7
  • Bulging indicates middle ear effusion/AOM
  • Retraction suggests negative middle ear pressure or chronic disease
• Translucency: Opaque or cloudy suggests middle ear fluid 1
• Perforation: Note size, location, and drainage 1
• Mobility: 1
  • Pneumatic otoscopy is essential: Perform by creating hermetic seal and applying positive/negative pressure
  • Normal: Brisk movement with pressure changes
  • AOM: Absent or severely limited mobility
  • AOE: Normal mobility (distinguishes from AOM)

Tuning Fork Tests (Weber & Rinne)

Perform these to differentiate conductive from sensorineural hearing loss—this changes management completely. 1

• Weber test (512 Hz fork on forehead): 1
  • Lateralizes to affected ear = conductive hearing loss
  • Lateralizes to unaffected ear = sensorineural hearing loss
• Rinne test (mastoid then ear canal): 1
  • Air conduction > bone conduction = normal or sensorineural loss
  • Bone conduction > air conduction = conductive hearing loss

Head & Neck Examination (for Secondary Otalgia)

• TMJ palpation: Tenderness, crepitus, or clicking with jaw movement 1, 2
• Dental examination: Caries, periodontal disease, or malocclusion 1, 2
• Oropharynx: Tonsillar erythema, exudates, or asymmetry (peritonsillar abscess) 1, 4
• Neck palpation: Lymphadenopathy or masses 1, 5
• Cranial nerve examination: Facial nerve function (especially with vesicles suggesting Ramsay Hunt) 1
• Cervical spine: Range of motion and tenderness 2, 3

Tympanometry (if available)

• Type A (peaked) curve: Normal middle ear function—consistent with AOE or secondary otalgia 1
• Type B (flat) curve: Middle ear effusion—consistent with AOM or OME 1
• Type C (negative pressure) curve: Eustachian tube dysfunction 1

Assessment

Primary Otalgia (Abnormal Ear Exam)

1. Acute Otitis Externa: Tragus/pinna tenderness + canal edema/erythema + normal TM mobility 1
2. Acute Otitis Media: Bulging TM + decreased/absent mobility + middle ear effusion 1, 7
3. Cerumen Impaction: Visualized cerumen occluding canal + conductive hearing loss 1, 7
4. TM Perforation: Visible perforation ± otorrhea 1
5. Herpes Zoster Oticus: Vesicles + severe otalgia ± facial paralysis 1

Secondary Otalgia (Normal Ear Exam)

1. TMJ Syndrome: TMJ tenderness + jaw clicking + pain with chewing 1, 2
2. Pharyngitis with Referred Pain: Tonsillar inflammation + normal otoscopy 1, 4
3. Dental Disease: Dental pathology + normal otoscopy 1, 2
4. Cervical Spine Arthritis: Neck pain/limited ROM + normal otoscopy 2, 3
5. Malignancy (red flag): Age >50 + tobacco/alcohol use + persistent pain + normal otoscopy 2, 3

Modifying Factors Requiring Special Consideration

• Diabetes or immunocompromised state: Risk for necrotizing otitis externa 1
• Nonintact TM or tympanostomy tube: Requires non-ototoxic topical therapy 1
• Prior radiotherapy: Alters tissue healing and infection risk 1

Plan

Immediate Pain Management

Pain assessment and treatment is a strong recommendation—do not undertreat. 1, 6

• First-line: Acetaminophen 650-1000 mg PO every 6 hours (safer profile, especially in elderly) 6, 4
• Second-line: Ibuprofen 400-600 mg PO every 6-8 hours (superior for inflammatory pain but GI/renal/CV risks) 6, 4
• Combination therapy: NSAIDs + acetaminophen for moderate-severe pain provides enhanced analgesia 6, 4
• Dosing strategy: Fixed-interval dosing (not PRN) provides more consistent relief 6, 4
• Avoid: Opioids as initial therapy unless severe pain unresponsive to above 6

Treatment Based on Diagnosis

For Acute Otitis Externa

• Topical antibiotics are first-line therapy (strong recommendation against systemic antibiotics for uncomplicated AOE) 1
• Ofloxacin 0.3% otic solution: 8
  • Age ≥13 years: 10 drops once daily × 7 days
  • Age 6 months-12 years: 5 drops once daily × 7 days
  • Patient should lie with affected ear up × 5 minutes after instillation
  • Gently pull pinna upward/backward to enhance delivery
• If canal obstructed: Perform aural toilet (gentle suction/irrigation) or place wick to enhance drug delivery 1
• If TM perforation or tube present: Use non-ototoxic preparation (fluoroquinolones like ofloxacin are safe) 1, 8
• Systemic antibiotics only if: Extension beyond canal, cellulitis, or high-risk host factors 1

For Acute Otitis Media

• Analgesics are the primary intervention—antibiotics do NOT provide symptomatic relief in first 24 hours 4
• Antibiotic decision based on age, severity, and laterality (not detailed here but per AOM guidelines) 1
• Reassess in 48-72 hours if no improvement 1

For Cerumen Impaction

• Must remove cerumen before establishing diagnosis of hearing loss 1
• Options: Cerumenolytics, irrigation, or manual extraction 7

For Secondary Otalgia

• TMJ syndrome: NSAIDs, soft diet, jaw rest, warm compresses; refer to dentistry if persistent 2, 3
• Pharyngitis: Analgesics as above; antibiotics only if streptococcal (does not relieve ear pain acutely) 4
• Dental disease: Urgent dental referral 2, 3

When Diagnosis Unclear or High-Risk Features Present

Do not attribute persistent ear pain to idiopathic causes—assume you've missed the diagnosis. 5

• Trial of symptomatic treatment: 48-72 hours with close follow-up 1, 2
• Imaging indications: 2, 5, 3
  • Age >50 years with persistent pain
  • Tobacco/alcohol use
  • Diabetes mellitus
  • Constitutional symptoms
  • Focal neurologic findings
  • Failed symptomatic treatment
• Imaging modality: MRI preferred over CT for soft tissue evaluation; consider temporal bone CT if mastoiditis suspected 2, 3
• Laboratory tests: ESR/CRP if temporal arteritis suspected (age >50 + temporal headache) 5, 3
• ENT referral: Persistent symptoms >2 weeks, high-risk features, or diagnostic uncertainty warrant fiberoptic nasolaryngoscopy 2, 3

Patient Education & Follow-Up

• Proper drop administration: Demonstrate technique; emphasize lying on side × 5 minutes after instillation 1, 8
• Complete full course: Even if symptoms improve (prevents recurrence) 1, 8
• Return precautions: Worsening pain, fever, facial swelling, hearing loss, or neurologic symptoms 1
• Scheduled reassessment: 48-72 hours if no improvement 1

Common Pitfalls to Avoid

• Do not prescribe systemic antibiotics for uncomplicated AOE—topical therapy is superior 1
• Do not prescribe antibiotics solely for ear pain with pharyngitis—it's referred pain, not ear infection 4
• Do not use ototoxic drops (aminoglycosides) if TM perforation or tube present 1
• Do not underestimate pain severity—clinicians consistently undertreat otalgia 6
• Do not miss red flags in patients >50, smokers, diabetics—these require aggressive workup 2, 3