Otalgia, also known as earache, can affect any age group and is a troublesome condition that is a frequent cause of visits to GP surgeries and walk-in centres. There are a variety of causes, the majority of which are benign conditions that can be easily treated; however, there are a few more sinister diagnoses that need to be considered in some cases.
Otalgia is generally classified as either primary, when pain originates in the ear itself and is more common in children, or secondary, occurring as a result of referred pain arising from a problem elsewhere, the latter more frequently seen in adults (Earwood et al, 2018).
Assessment
A thorough history is needed to guide clinicians towards making an accurate diagnosis. A detailed history of the degree and severity of pain, any discharge from the ear (otorrhea), hearing loss, vertigo, tinnitus, or a feeling of fullness in the ear, together with duration of symptoms, is vital as part of the initial assessment. The time frame of symptom onset is important, as, generally, shorter time frames suggest a primary or benign cause and longer time frames may indicate a secondary cause (Harrison and Cronin, 2016). If the history is vague or does not suggest an immediate reason for the patient's symptoms, then more information should be sought to determine an alternative cause. History should then focus on symptoms relating to the other anatomical regions supplied by the same nerves innervating the ear, such as oral and dental problems, tonsillitis, and nasal and sinusitis problems (Harrison and Cronin, 2016). Red flags are shown in Table 1.
Table 1. Red flags in the patient history
| Symptom | Possible cause |
|---|---|
| Dysphagia, dysphonia (hoarse voice) odynophagia (difficulty swallowing), weight loss | May suggest head and neck cancer |
| Hearing loss, either of sudden onset or gradual over 72-hour period | Sudden sensorineural hearing loss. Otalgia is a feature in 50% of cases |
| Immunosuppressed or diabetic patients | Infection can progress more rapidly |
Primary otalgia
The most common causes of primary otalgia are otitis externa and otitis media (Earwood et al, 2018). These two conditions will be discussed here. Other less common causes are shown in Table 2.
Table 2. Less common causes of otalgia
| External ear causes | Middle ear causes |
|---|---|
|
|
Otitis externa
This condition occurs because of inflammation of the ear canal and can be acute, lasting for 3 weeks or less, or chronic, lasting for more than 3 weeks (National Institute for Health and Care Excellence [NICE], 2018a). In most cases the condition is easily treated and resolves quickly.
Acute otitis externa
The main symptoms of otitis externa are pain and itching but there may also be some discharge and hearing loss (Lowth, 2016a). Additional clues to aid the diagnosis are that in otitis externa itching precedes the onset of pain, and any discharge is scant with a white or clear colour (Spinks, 2007).
Treatment and management
Most cases are self-limiting and resolve with analgesia and self help measures such as applying a warm towel or cloth to ease discomfort in the affected ear. Antibiotics are rarely indicated, but may be needed if the infection is severe or there is a high risk of severe infection which may be a concern in patients with the following (NICE, 2018a):
- Systemic signs of infection such as fever
- Co-morbid disease, such as diabetes or being immunocompromised, which increases the risk of severe infection
- Furunculosis (deep infection of the hair follicle) or cellulitis which spreads beyond the ear canal to the neck, face or pinna.
Ear drops or ear sprays containing an antibiotic are usually tried as first-line treatment, as much higher concentrations of antibiotic are achieved with topical treatments (Lowth, 2016a). If oral antibiotics are needed, guidance suggests a 7-day course of flucloxacillin, or clarithromycin or erythromycin if the patient is allergic to penicillin (NICE, 2018a).
Complications of otitis externa
Complications of otitis externa are rare but can occur. A brief description is shown in Table 3.
Table 3. Complication of otitis externa
| Problem | Additional information |
|---|---|
| Abscesses | Painful pus-filled lesions may resolve without treatment but often antibiotics are needed, more rarely drainage may be required |
| Perforated ear drum | Caused by rupture of the tympanic membrane as a result of a build up of pus in the inner ear. Symptoms include hearing loss, tinnitus and discharge from the ear |
| Narrowing of the ear canal | Chronic otitis externa may lead to thickening of the ear canal, which can result in loss of hearing |
| Cellulitis | This is a bacterial infection of the deeper layers of the skin, causing pain, redness and the affected area is hot to the touch. Treated with a 7-day course of antibiotics |
| Necrotising (malignant) otitis externa | Rare but serious, potentially fatal, complication occurring as a result of the spread of the infection to the bone surrounding the ear canal. More common in adults and in particular patients with health problems, eg diabetes or those receiving chemotherapy. Presents with severe pain and headaches and drooping of the face on the affected side. Treatable with antibiotics and sometimes surgery to remove damaged bone |
Chronic otitis externa
Chronic otitis externa has a variety of causes, including dermatitis, fungal or, more rarely, bacterial infections. Treating the condition can be challenging and it may be necessary to try several treatments before a successful outcome is achieved.
Guidance generally advises (NICE, 2018a):
- If the cause is thought to be an irritant or allergic dermatitis, then any aggravating factors should be avoided, and a topical steroid prescribed (eg Betnesol)
- If seborrheic dermatitis is suspected, an antifungal/corticosteroid combination should be prescribed (eg Otomise)
- If fungal infection is suspected a topical antifungal preparation should be prescribed (eg clotrimazole solution)
- If no cause is evident: a 7-day course of a topical preparation containing only a corticosteroid without antibiotic (eg Betnesol) should be prescribed
- If a response to treatment is achieved: continue the corticosteroid, but the potency/frequency should be reduced to the minimum required to maintain control
- If the response is inadequate consider a trial of a topical antifungal treatment
- Referral to a specialist may be needed if treatment is needed for more than 2–3 months.
Otitis media
Otitis media condition can occur at any age but is far more frequently seen in children, with 75% of cases occurring in those below the age of 10 years, with onset frequently occurring after a cold (Lowth, 2016b). Pain and fever are the predominant symptoms and very young children will display pain by pulling at their ears. Examination will show a red bulging tympanic membrane with purulent ear discharge if perforation of the drum occurs (See and Mcmurran, 2016).
Treatment and management
Parents of children affected should be advised that the condition usually resolves without antibiotics within 3 days, but occasionally symptoms last for a week and analgesia alone (paracetamol or ibuprofen) is sufficient until symptoms resolve. In rare cases admission to hospital may be necessary (NICE, 2018b):
- Children under the age of 3 months with a temperature of 38°C or more
- Anyone with severe systemic infection
- Those with suspected complications.
Antibiotics
The use of antibiotics is a difficult area for clinicians, as parents may feel they are needed. Three separate antibiotic prescribing strategies may be helpful according to the age and clinical assessment of the child (See and McMurran, 2016).
- Immediate antibiotic prescription for children under the age of 2 years with bilateral otitis media or those who have ear discharge
- A no antibiotic or a delayed antibiotic strategy can be used for other cases
- Antibiotics should be given if there is no improvement over a 4-day period or symptoms are worsening (a 7-day course of amoxicillin is recommended, or erythromycin or clarithromycin if penicillin allergic) (NICE, 2018b)
- If acute complications are suspected an urgent ear, nose and throat (ENT) referral is recommended.
Recurrent otitis media
Treatment with systemic antibiotics is required when there are recurrent episodes of acute otitis media; however, caution is needed if antibiotic resistance is to be avoided. Treatment prescribed is generally the same as that given at the first presentation but referral should be considered in the following situations (NICE, 2018b):
- Adults with recurrent symptoms
- Episodes are distressing and associated with complications (see below)
- The patient has a craniofacial abnormality such as Downs syndrome or cleft palate.
Complications of otitis media
Complications of otitis media are rare but can include meningitis, mastoiditis, intracranial abscess and facial nerve paralysis (NICE, 2018b).
Secondary otalgia
In the majority of cases, referred otalgia occurs as a result of a benign condition. Dental problems are an extremely common cause of referred otalgia; and are estimated to occur in up to 63% of cases, and include inflammation and infection of dental structures (Harrison and Cronin, 2016). Temporomandibular joint (TMJ) disorders are another important cause of secondary otalgia and some patients will present with additional symptoms such as tinnitus and vertigo. However, referred otalgia may be an early sign of serious underlying pathology; and, therefore, needs careful and thorough evaluation. Ear pain may be the earliest and only symptom of cancer lurking somewhere in the head and neck, and the severity of the symptoms may not always correlate with the gravity of disease (Chen et al, 2009). Tumours in the nose, nasopharynx, oral cavity, oropharynx, hypopharynx, infratemporal fossa, neck, or chest can cause ear pain with the most commonly reported sites being the base of the tongue, tonsillar fossa, and hypopharynx (Ely et al, 2008).
Other less common causes of secondary otalgia are shown in Table 4.
Table 4. Less common causes of secondary otalgia
| Disease | Additional information |
|---|---|
| Temporal arteritis | Temporal arteritis should be considered in patients 50 years or older who have normal ear examination but have associated symptoms of headache, malaise, weight loss, fever or anorexia |
| Sinusitis | Referred pain from the trigeminal nerve may cause sinusitis symptoms |
| Herpes zoster | This can affect cranial nerve V11 |
| Mandibular osteomyelitis | This is an infection in the jawbone, often following dental extraction, or dental abscess |
| Trigeminal neuralgia | Referred pain from the trigeminal nerve (cranial nerve V) may be a cause of secondary otalgia |
Table 5. Factors influencing recurrent otitis media
| Factor influencing recurrence | Supporting evidence |
|---|---|
| Genetics | Otitis media appears to run in families |
| Vaccinations | Both pneumococcal and influenza vaccinations are thought to be beneficial in reducing recurrent episodes |
| Parental smoking | Parental smoking is thought to have an effect on the development of otitis media symptoms |
| Breastfeeding | Breastfeeding reduces the risk of otitis media and the longer the mother continues to breastfeed the greater the degree of protection |
| Adenoidectomy | Adenoidectomy has been shown to be beneficial in reducing recurrence in children |
Risk factors for serious pathology
Certain patients are at a greater risk of having a more sinister cause for their otalgia. Patients who are 50 years or older, have coronary artery disease, diabetes, or are immunocompromised, smokers and those who have a high alcohol consumption all have a higher risk (Earwood et al, 2018). In patients who consume more than 3.5 drinks per day, the risk of head, neck, and oesophageal cancers is two to three times greater when compared with non-drinkers, and those who also smoke have an even greater risk when compared with alcohol consumption alone (Earwood et al, 2018).
Conclusion
Otalgia is a common presentation and will be very familiar to nurses who see patients in minor illness clinics. In the majority of cases, assessment and diagnosis is straightforward but there are rare instances when the symptoms and presentation are more complex. It is hoped this article has given nurses and non-medical prescribers a brief insight into both scenarios so that they will feel more confident when assessing this frequently seen condition.
KEY POINTS:
- Otalgia is often benign but more serious causes can occur
- Primary otalgia is more common in children
- The most common causes of primary otalgia are otitis externa and otitis media
- Secondary otalgia more common in adults
CPD reflective practice
- What particular red flags would you be looking out for in an adult who presented with otalgia?
- What are the common causes of secondary otalgia in older patients?
- How would you approach a consultation with a parent who strongly felt antibiotics were necessary for their child's earache?