Reasoning GP · Algorithm · 1-page summary
Otalgia (ear pain)
For: adults and children with ear pain in primary care. Not for: hearing loss without pain (hearing loss algorithm) or facial and jaw pain without ear symptoms (facial pain algorithm). Children's antibiotic decisions follow NICE NG91.
Core rule: otoscopy first. A normal ear prompts a search for referred causes — it proves nothing. Examine the mouth, throat, tongue base, neck, teeth and TMJ; unilateral unexplained head-and-neck pain >4 weeks with otalgia and normal otoscopy → urgent suspected cancer pathway.
0Stop — call 999 now
- Meningism, severe headache, drowsiness or a neurological deficit with ear disease (intracranial complication) → 999
- Sepsis or airway compromise — cannot swallow or manage secretions → 999
- Vertigo with new neurological signs (possible posterior circulation stroke) → 999. Do not delay transfer for audiometry or imaging.
1Triage by otoscopy — is the drum visible and intact?
| Finding | Think → next |
|---|---|
| Bulging, opaque drum | AOM (redness alone is not enough) → block 5 |
| Tender tragus, swollen canal | Otitis externa (OE); may coexist with AOM → block 5 |
| Dull, retracted drum | OME → watchful waiting (children); adult → ENT (block 2) |
| Attic pocket, white debris | Cholesteatoma (offensive discharge) → Urgent ENT ≤2 weeks |
| Normal ear | Referred pain: dental, TMJ, pharynx/larynx, salivary, neck, neuralgia — and cancer |
2Screen — one row is enough
- Post-auricular swelling + fever, lost sulcus, protruding pinna (mastoiditis) → Same-day hospital/ENT; do not wait for imaging.
- Diabetes, immunosuppression or frailty + disproportionate (often night) pain, persistent discharge, canal granulation, cranial nerve palsy or failed drops (necrotising OE) → Same-day ENT
- Facial palsy with ear pain (Ramsay Hunt, cholesteatoma, parotid) → Same-day ENT; antiviral if vesicles; protect the eye. Vesicles, no palsy → antiviral + Urgent ENT
- Sudden hearing loss (≤3 days, within 30 days) → ENT/ED ≤24 h; later, or progressive over 4–90 days → ENT ≤2 weeks
- Head and neck: core-rule criterion (local pathway), sooner with dysphagia, weight loss, neck mass or oral lesion → Suspected cancer. NG12: consider for unexplained oral ulcer >3 weeks, persistent unexplained neck lump, or persistent unexplained hoarseness at 45+.
- Adult persistent or unexplained middle-ear effusion, especially unilateral or Chinese/South-East Asian origin → Urgent ENT (NG98)
3Assess
☐ Pinna and canal (vesicles), tragus, mastoid ☐ Both ears: document if the drum is visible and intact ☐ Facial nerve and eye closure ☐ Normal ear in an adult: teeth, tonsils, tongue base, floor of mouth (palpate), neck, parotid, TMJ ☐ Whisper, Rinne, Weber
Not routinely: FBC, CRP, EBV, OPG, imaging. Swab only if treatment fails, recurrent, immunocompromised, fungal or necrotising OE.
4Classify — only if the screen is negative
- AOM — after a cold, fever, bulging drum ± discharge → analgesia; antibiotic by block 5.
- OE — swimming, itch, discharge, tragal pain; check for eczema, fungal debris → topical treatment.
- TMJ — pre-auricular pain on chewing, clicking, bruxism, normal ear → soft diet, jaw rest, heat/ice, analgesia.
- Dental — lower molar, abscess, wisdom tooth, dry socket → dentist; abscess, spreading swelling or trismus → urgent dental (NHS 111).
- Uncertain — normal ear, no cause: say so, reassess, and refer by block 2 timing.
5Treat today — doses: NICE/SPC, BNF, local formulary
- OE: analgesia + acetic acid 2% spray, or antibiotic/steroid drops if indicated; wick if the canal is shut. Drum perforated, grommet or not seen → non-ototoxic quinolone; no aminoglycoside, polymyxin or acidic drops. Oral antibiotics only if spreading or unwell.
- AOM, children (NG91): regular paracetamol or ibuprofen; no or back-up antibiotic for most. Consider more strongly with otorrhoea or bilateral under 2; immediate if systemically unwell or high risk.
- AOM, adults: analgesia; no or back-up antibiotic for most. Consider immediate if unwell, high risk or ~4 days without improvement (amoxicillin per local guidance guideline).
- Ramsay Hunt: aciclovir 800 mg 5× daily for 7 days, ideally ≤72 h; check renal function. Steroids only per local pathway; eye protection; driving advice.
6Refer routinely
- ENT: persistent hearing loss or otorrhoea; recurrent AOM (≥3 in 6 months or ≥4 in 12); OE failing 2 courses; perforation at 6 weeks.
- Audiometry 4–6 weeks after AOM if hearing not recovered. Glue ear in children: hearing assessment if persistent (NG233).
- TMJ: dentist if persistent (splints); maxillofacial for severe trismus or no response after 6–8 weeks.
7Never reassure by
- A normal-looking ear — it starts the search for referred causes.
- A red drum alone — it is not AOM.
- Repeat ear drops for persistent pain or failed OE without re-examining.
- "Simple OE" in a diabetic patient with pain out of proportion.
- Bloods or imaging in primary care instead of a cancer referral.
- Waiting for audiometry in sudden hearing loss.
8Safety-net — say it, then document it
999 “Call 999 for a fit, severe headache with a stiff neck, being very drowsy, trouble breathing or swallowing saliva, or new arm or leg weakness or slurred speech.” Same day “Swelling or redness behind the ear or the ear sticking out, fever or feeling worse, severe or night-time pain, sudden hearing loss, facial weakness, ear blisters, severe dizziness or not being able to open your mouth — contact us or NHS 111 today.” ≤1 week “A new neck lump, trouble swallowing, weight loss or one-sided throat or ear pain that persists — see your GP.”
Review: OE not improving in 48–72 h or not settled by ~7 days; AOM not starting to improve by ~3 days → re-examine before changing antibiotic.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Drum seen and intact, or treated as not intact
Normal ear: mouth, throat, neck, TMJ examined
Hearing and facial nerve checked
Treatment, review date and safety-net given
Summary of the full Reasoning GP otalgia algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG12 (updated April 2026), NG91, NG98, NG233; local antimicrobial guideline and local formulary; ENT UK; British Society of Otology; UKHSA Green Book. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.