What is the appropriate evaluation and management for a patient with three days of otalgia without otorrhea?

Evaluation and Management of Ear Pain Without Discharge

For a patient with 3 days of ear pain without discharge, perform otoscopy with pneumatic assessment to distinguish between acute otitis media (middle ear infection) and acute otitis externa (ear canal infection), as this distinction determines whether systemic antibiotics, topical therapy, or observation is appropriate.

Initial Diagnostic Approach

The absence of otorrhea (discharge) narrows the differential but does not exclude either otitis media or otitis externa 1. Your physical examination should focus on:

Key Distinguishing Features

For Acute Otitis Externa (AOE):

• Tragal tenderness test: Push the tragus or pull the pinna—intense, disproportionate tenderness strongly suggests AOE 1
• Ear canal findings: Look for edema, erythema, or debris in the external auditory canal 1
• Tympanic membrane mobility: Will show normal mobility on pneumatic otoscopy if AOE alone 1

For Acute Otitis Media (AOM):

• Bulging tympanic membrane with limited or absent mobility on pneumatic otoscopy 1
• Middle ear effusion signs: Air-fluid level behind the tympanic membrane 1
• Distinct erythema of the tympanic membrane with acute onset of symptoms 1
• Minimal or no tragal tenderness (helps differentiate from AOE) 1

Critical Pitfall to Avoid

AOE can mimic AOM because erythema may involve the tympanic membrane 1. Always perform pneumatic otoscopy: normal tympanic membrane mobility indicates AOE, while absent/limited mobility with effusion confirms AOM 1. Tympanometry can supplement this—showing a normal peaked curve (type A) with AOE versus a flat tracing (type B) with AOM 1.

Management Based on Diagnosis

If Acute Otitis Externa is Diagnosed

Topical antibiotic drops are first-line therapy 1:

• Use fluoroquinolone drops (e.g., ciprofloxacin-dexamethasone) or aminoglycoside with corticosteroid 1
• Ensure proper drop administration—if the ear canal is obstructed by debris, perform aural toilet or place a wick 1
• Imaging is NOT indicated for uncomplicated otitis externa 1
• Reassess at 48-72 hours if no improvement 1

If Acute Otitis Media is Diagnosed

Your management depends on age, severity, and diagnostic certainty 1:

Immediate Antibiotics Required For:

• All children <6 months 2
• Children 6-23 months with severe symptoms (moderate-to-severe otalgia OR fever ≥39°C) 2
• Children 6-23 months with bilateral AOM (even if non-severe) 2
• Adults with severe symptoms 2

Observation Without Immediate Antibiotics Appropriate For:

• Children 6-23 months with non-severe unilateral AOM and certain diagnosis 1, 2
• Children ≥24 months with non-severe AOM 1, 2

Requirements for observation strategy: You must ensure reliable follow-up within 48-72 hours and have a mechanism to start antibiotics immediately if symptoms worsen or fail to improve 1, 2.

First-Line Antibiotic Selection (When Indicated):

High-dose amoxicillin 80-90 mg/kg/day in 2 divided doses (maximum 2 grams per dose) 1, 2:

• Achieves adequate middle ear concentrations against resistant S. pneumoniae, H. influenzae, and M. catarrhalis 2, 3

Use amoxicillin-clavulanate instead if 1, 2:

• Patient received amoxicillin in previous 30 days
• Concurrent purulent conjunctivitis present
• High local prevalence of beta-lactamase-producing organisms

Treatment duration 2:

• 10 days for children <2 years (regardless of severity)
• 7 days for children 2-5 years with mild-moderate symptoms
• 5-7 days for children ≥6 years with mild-moderate symptoms

Pain Management (Essential for ALL Patients)

Address pain immediately regardless of antibiotic decision 1, 2:

• Acetaminophen or ibuprofen dosed appropriately for age/weight 2
• Continue throughout the acute phase—antibiotics provide no symptomatic relief in the first 24 hours 2
• Even after 3-7 days of antibiotics, 30% of children <2 years still have pain or fever 2

When to Reassess or Escalate

Reassess at 48-72 hours if 1, 2:

• Symptoms worsen at any time
• No improvement within 48-72 hours
• New symptoms develop (posterior auricular swelling, neurological changes, severe headache)

For treatment failure after initial antibiotics 2:

• Switch to amoxicillin-clavulanate if started on amoxicillin
• Consider intramuscular ceftriaxone 50 mg/kg daily for 1-3 days for persistent failure 2
• Tympanocentesis with culture should be considered after multiple failures 2

Special Considerations

Post-treatment middle ear effusion is expected and normal 2:

• 60-70% have effusion at 2 weeks
• 40% at 1 month
• 10-25% at 3 months
• This does NOT require antibiotics unless it persists >3 months with hearing loss 2

Imaging is NOT indicated for uncomplicated AOM 1. Consider CT temporal bone only if complications develop (mastoiditis, intracranial extension, persistent symptoms despite appropriate therapy) 1.