Ear symptoms

A 35 year old man presents with itch and discharge in his left ear. He also reports decreased hearing in that ear. He is otherwise well and takes no regular medication. He has recently been on holiday to Tenerife.

Ear pain and itch are common symptoms in primary care and are usually straightforward to diagnose and treat. Hearing loss, unless caused by infection or wax which resolves with treatment, should be referred to ENT or audiology. Deafness and tinnitus are covered in ENT.

Contents

Common causes of ear pain or itch

Otitis media – This is one of the most common infectious diseases in childhood. It usually presents under the age of five with a peak at 18 months. It is often associated with a viral URTI and the infection spreads along the eustachian tubes towards the middle ear. Secondary infection may occur.
Acute otitis externa – This can be bacterial or fungal and can be linked to swimming
Chronic otitis externa – Causes discomfort, itch and discharge and it is related to eczema.
Ear wax – Blockage of the ear by wax can cause pain and itch with some discharge.
Pain – Can also be referred from illnesses of the throat such as pharyngitis or tonsillitis.

Assessment

With a good history and examination a diagnosis can usually be confidently made. The examination should include:

Temperature
Pulse
Cervical, auricular lymph nodes
Throat
Ear canal
Tympanic membrane (TM) via otoscope

Otoscopy: In otitis media the ear canal is usually normal, but the TM can be red and bulging with a decreased light reflex. The ear drum can perforate which can be seen on otoscopy. In otitis externa the ear drum is normal, but the canal is red and inflamed with debris seen. The ear canal may be blocked with wax.

Management

Otitis media – pain and fever should be treated with simple analgesia such as paracetamol. Unilateral OM in an otherwise well patient does not require antibiotics. Bilateral OM in the under twos can be treated with antibiotics. If the ear drum is perforated the patient should be advised to avoid getting the ear wet for the next six weeks.

Otitis externa – treatment depends on if the TM is perforated and suitable guidance can be found on the Lothian joint formulary. If chronic may need referred to ENT for regular ear toilet.

Wax – treat with almond oil (if no nut allergy) or sodium bicarbonate drops. Some GP practices will offer syringing of the ears, which is done by the practice nurse. Ask the patient to return if their hearing has not improved after removal of wax.

The patient was diagnosed with otitis externa and treated with a combined steroid and antibacterial ear drop. He was also advised to avoid getting his ears wet for the next six weeks and not to use cotton buds to clean his ears.