The Painful Ear

Last updated 31 May 2026 · ENT

📋 Key Information Summary

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The painful ear is a common presenting complaint in Australian primary care and emergency departments, with otitis media and otitis externa accounting for the majority of cases across all age groups.
A systematic diagnostic approach using history (onset, character, associated symptoms), otoscopy, and pneumatic assessment differentiates acute otitis media (AOM), otitis media with effusion (OME), otitis externa (OE), referred pain, and foreign bodies.
Red flags requiring urgent referral include mastoid tenderness/swelling (mastoiditis), facial nerve palsy, severe headache with ear pain, vertigo with neurological signs, and post-auricular erythema with pinna protrusion.
Children with AOM should receive first-line analgesia (paracetamol ± ibuprofen) for all cases; antibiotics (amoxicillin 45–50 mg/kg/day for 5–7 days) are indicated for children <2 years with bilateral AOM, systemic features, otorrhoea, or Aboriginal and Torres Strait Islander children.
Watchful waiting (48–72 hours with analgesia only) is appropriate for children ≥2 years with unilateral, non-severe AOM who can be safely followed up.
Recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months with ≥1 in the preceding 6 months) warrants specialist ENT referral for consideration of ventilation tubes (grommets) and adenoidectomy.
Foreign bodies in the ear canal are common in paediatric presentations; water-soluble (organic) material should be removed urgently due to swelling risk. Techniques include irrigation, forceps extraction, and Hook/wire-loop methods; alligator forceps for soft objects and irrigation for hard smooth objects.
Acute otitis media in adults is typically managed with amoxicillin 500 mg–1 g TDS for 5–7 days; consider co-amoxiclav if no response after 48–72 hours or if resistant organisms are suspected.
Chronic suppurative otitis media (CSOM) in adults requires aural toilet, topical quinolone ear drops (ciprofloxacin 0.3%), and ENT referral for persistent perforation or cholesteatoma assessment.
Aboriginal and Torres Strait Islander children have among the highest rates of otitis media globally; suppurative OM affects up to 40% of children in remote communities. Culturally safe, early-intervention programmes and routine otoscopic screening are essential.
All ear pain is not ear disease — referred pain from temporomandibular joint dysfunction, dental pathology, pharyngeal malignancy, and cervical spine disorders must be considered, especially in adults with normal otoscopy.
Prevention strategies include pneumococcal and influenza vaccination (NIP schedule), breastfeeding promotion, avoidance of passive smoke exposure, and swimmer's ear prevention advice (keep ears dry, avoid cotton buds).

Introduction & Australian Epidemiology

Ear pain (otalgia) is one of the most frequent presenting complaints in Australian general practice and paediatric emergency departments. It encompasses a broad differential diagnosis ranging from benign self-limiting conditions to life-threatening infections requiring urgent intervention. A structured, age-appropriate diagnostic approach is essential to avoid both over-treatment (particularly inappropriate antibiotic prescribing) and under-recognition of serious pathology.

In Australia, the burden of ear disease is substantial and inequitable. Otitis media is the most common reason for antibiotic prescription in children, accounting for an estimated 2.4 million general practice encounters annually. Aboriginal and Torres Strait Islander children experience some of the highest rates of otitis media in the world, with chronic suppurative otitis media (CSOM) prevalence rates up to 10 times higher than non-Indigenous children in remote communities. The Australian Institute of Health and Welfare (AIHW) reports that ear and hearing problems are among the top five chronic conditions affecting Indigenous Australians.

Otitis externa ("swimmer's ear") affects approximately 1% of the general population annually, with peak incidence during warmer months and in swimmers, surfers, and humid-climate workers. Chronic otitis externa with dermatological overlap (eczema, psoriasis, seborrhoeic dermatitis) is a significant contributor to ongoing ear morbidity in adults.

This guideline provides a comprehensive, evidence-based framework for the diagnosis and management of ear pain across all age groups in the Australian healthcare setting, aligned with Therapeutic Guidelines (eTG), the National Aboriginal Community Controlled Health Organisation (NACCHO) otitis media guidelines, and the Australian Commission on Safety and Quality in Health Care (ACSQHC) standards.

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National Nuisance — antibiotic overprescribing: Ear infections remain the leading indication for antibiotic prescribing in Australian children. The NPS MedicineWise Choosing Wisely initiative emphasises that most uncomplicated AOM resolves spontaneously with analgesia alone, and antibiotic stewardship is critical in this clinical scenario.

Painful Ear Diagnostic Model & Red Flags

A systematic approach to the painful ear begins with distinguishing otogenic pain (arising from the ear itself) from referred otalgia (pain transmitted to the ear from adjacent structures). Approximately 50% of adult cases of ear pain with a normal tympanic membrane are referred from the pharynx, larynx, or temporomandibular joint.

Stepwise Diagnostic Framework

History

Onset (acute vs chronic), character (sharp, dull, throbbing), duration, laterality, associated hearing loss, tinnitus, vertigo, otorrhoea (serous vs purulent), recent swimming or water exposure, upper respiratory tract infection symptoms, trauma, previous ear surgery, and constitutional symptoms (fever, lethargy).

External Inspection

Inspect pinna and post-auricular area for erythema, swelling, tenderness, protrusion of pinna, vesicles (Ramsay Hunt syndrome), cellulitis, or perichondritis. Palpate tragus and pinna (positive tragal tenderness suggests otitis externa).

Otoscopy

Assess external canal (erythema, oedema, debris, foreign body, cerumen), tympanic membrane (colour, position, light reflex, perforation, bulging, retraction, effusion, cholesteatoma). Use pneumatic otoscopy to assess mobility where possible.

Differential Narrowing

Categorise as acute otitis media, otitis media with effusion, otitis externa, foreign body, myringitis, mastoiditis, barotrauma, or referred pain. Consider red flags and need for urgent referral.

Referred Pain Assessment (Adults)

If otoscopy is normal, systematically examine the oropharynx, tongue base, tonsillar fossa, nasopharynx, larynx (indirect or flexible nasendoscopy if available), temporomandibular joint, and cervical spine. Red flags for pharyngeal malignancy include unilateral referred otalgia, dysphagia, odynophagia, neck mass, and weight loss in smokers/drinkers.

Red Flags — Urgent ENT Referral Required

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Mastoiditis: Post-auricular erythema, tenderness, swelling, and forward/inferior protrusion of the pinna — requires emergency ENT assessment and IV antibiotics.
Facial nerve palsy: Lower motor neurone facial weakness (inability to close eye, forehead involvement) in the context of acute or chronic ear infection — suggests temporal bone pathology, cholesteatoma, or intracranial complication.
Intracranial complications: Severe headache, meningism, altered consciousness, focal neurological signs in the context of ear infection — possible epidural abscess, brain abscess, sigmoid sinus thrombosis, or meningitis.
Cholesteatoma: Painless or mildly painful otorrhoea with squamous debris visible on otoscopy, attic retraction pocket, or granulation tissue — progressive bone erosion and potential for serious complications.
Herpes zoster oticus (Ramsay Hunt syndrome): Vesicles on pinna/canal with severe pain, hearing loss, tinnitus, vertigo, and facial nerve palsy.
Necrotising (malignant) otitis externa: Severe, unrelenting otalgia in an immunocompromised or diabetic patient with granulation tissue at the bony-cartilaginous junction, persistent otorrhoea unresponsive to standard treatment, and potential cranial nerve palsies.
Post-auricular abscess: Fluctuant swelling behind the ear with systemic illness — surgical drainage required.
Suspected pharyngeal malignancy: Unilateral referred otalgia with normal ear examination in an older adult with risk factors (smoking, alcohol), particularly with associated dysphagia, neck mass, or voice change.

Differential Diagnosis of the Painful Ear

Diagnosis	Key Features	Otoscopy	Age Group
Acute otitis media (AOM)	Acute onset pain, fever, ± hearing loss, often preceded by URTI	Bulging, erythematous TM; loss of light reflex; ± effusion	Children > adults
Otitis media with effusion (OME)	Painless or mild discomfort, conductive hearing loss, sensation of fullness	Amber/retracted TM; air-fluid level; reduced mobility	Children > adults
Acute otitis externa	Ear pain worsened by tragal/pinna manipulation, ± discharge, pruritus	Erythematous, oedematous canal; debris; TM may be obscured	All ages; swimmers
Chronic suppurative otitis media	Persistent (>6 weeks) otorrhoea through TM perforation; hearing loss	TM perforation (central or attic); mucosal oedema; granulation	Adults; ATSI children
Foreign body	History of insertion; pain, hearing loss, ± discharge if present >24 hrs	Visible object in canal	Children (peak 2–8 yrs)
Myringitis	Pain, ± hearing loss; may be viral or bacterial	Erythematous, bulging TM without middle ear effusion	All ages
Mastoiditis	Post-auricular pain/swelling, pinna protrusion, fever, systemic illness	Often abnormal TM; post-auricular erythema/swelling	Children > adults
Referred pain	Normal ear examination; TMJ dysfunction, dental, pharyngeal pathology	Normal	Adults

Otitis Media in Children (Antibiotics, Recurrent)

Acute otitis media (AOM) is the most common bacterial infection in childhood and the leading cause of antibiotic prescriptions in Australian children. By age three, approximately 80% of children will have experienced at least one episode of AOM. Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis are the predominant pathogens.

Diagnostic Criteria for AOM in Children

Diagnosis requires: (1) acute onset of symptoms (otalgia, fever, irritability, otorrhoea), (2) presence of middle ear effusion (bulging TM, loss of light reflex, reduced mobility on pneumatic otoscopy, air-fluid level), and (3) signs of middle ear inflammation (distinct erythema of the TM or distinct otalgia causing sleep disturbance). All three criteria must be met to diagnose AOM.

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Diagnostic precision matters: Distinguishing AOM from otitis media with effusion (OME) is essential. OME — the presence of non-purulent fluid without acute signs of infection — does NOT require antibiotics and is managed with watchful waiting and audiological follow-up.

Severity Assessment in Paediatric AOM

Mild

Mild AOM

Mild otalgia for <48 hours, temperature <38.5°C, not systemically unwell, eating/drinking, sleeping reasonably.

Setting: Home — watchful waiting with analgesia

Moderate

Moderate AOM

Moderate to severe otalgia ≥48 hours, temperature ≥38.5°C, systemically unwell, bilateral AOM, or age <2 years.

Setting: GP — antibiotics indicated + analgesia

Severe

Severe / Complicated AOM

Systemic toxicity, otorrhoea (spontaneous TM perforation), mastoid tenderness/swelling, facial nerve palsy, intracranial signs.

Setting: Emergency — urgent ENT referral + IV antibiotics

Management Approach

🔍 Watchful Waiting (48–72 hours)

Appropriate for children ≥2 years with unilateral, non-severe AOM who have reliable carers and can return if symptoms worsen. Provide:
• Paracetamol 15 mg/kg PO/PR QDS PRN (max 60 mg/kg/day)
• Ibuprofen 5–10 mg/kg PO TDS PRN (if ≥3 months, no contraindications)
• Safety-net advice: return in 48 hours if not improving or sooner if worsening

💊 Immediate Antibiotics

Indicated for:
• Age <2 years with bilateral AOM
• Systemic features (fever ≥38.5°C, vomiting, lethargy)
• Otorrhoea (spontaneous TM perforation)
• Aboriginal and Torres Strait Islander children (any age)
• Immunocompromised children
• Recurrence within 4 weeks of previous episode

Antibiotic Therapy — Paediatric AOM

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Amoxicillin

Amoxil® · Generic · Penicillin antibiotic

Paediatric dose 45–50 mg/kg/day PO divided TDS (standard dose); 80–90 mg/kg/day PO divided TDS (high-dose for resistant S. pneumoniae, recurrent AOM, recent antibiotics, daycare attendance)

Duration 5 days (age ≥2 years, uncomplicated); 7 days (age <2 years or severe)

Renal adjustment eGFR 10–30: reduce dose by 50% or extend interval; eGFR <10: 250–500 mg Q12H

PBS status ✔ PBS General Benefit

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Amoxicillin–Clavulanate

Augmentin® · Generic · β-lactam/β-lactamase inhibitor

Paediatric dose Dose expressed as amoxicillin component: 45 mg/kg/day PO divided TDS (standard); use formulations providing higher amoxicillin:clavulanate ratio (14:1 preferred over 7:1) to minimise GI side effects from clavulanate

Indication Second-line: amoxicillin failure at 48–72 hrs, recurrent AOM, recent amoxicillin use, β-lactamase producing organisms suspected

Duration 5–7 days

PBS status ✔ PBS General Benefit

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Cefalexin

Keflex® · Generic · First-generation cephalosporin

Paediatric dose 25–50 mg/kg/day PO divided BD-TDS (max 1 g TDS)

Indication Penicillin allergy (non-anaphylactic); check for cross-reactivity risk

Duration 5–7 days

PBS status ✔ PBS General Benefit

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Azithromycin

Zithromax® · Generic · Macrolide antibiotic

Paediatric dose 10 mg/kg/day PO OD for 3 days (or 10 mg/kg day 1 then 5 mg/kg days 2–5)

Indication β-lactam allergy (immediate/hypersensitivity); atypical organisms suspected. Note: increasing pneumococcal macrolide resistance in Australia (15–20%).

PBS status ✔ PBS General Benefit

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Paracetamol (analgesia)

Panadol® · Dymadon® · Panamax® · Analgesic/antipyretic

Paediatric dose 15 mg/kg PO/PR QDS PRN (max 60 mg/kg/day; max 4 g/day in adolescents)

Key role First-line analgesia for ALL cases of AOM — antibiotics do not reduce pain in the first 24 hours; adequate analgesia is the priority

PBS status ✔ PBS General Benefit (Rx for children <12 months)

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Ibuprofen

Nurofen® · Brufen® · NSAID analgesic

Paediatric dose 5–10 mg/kg PO TDS PRN (age ≥3 months; ≥5 kg)

Key role Second-line or adjunctive analgesia; superior to paracetamol for ear pain in some studies. Avoid in renal impairment, dehydration, asthma (aspirin-sensitive), GI bleeding risk.

PBS status ✔ PBS General Benefit

Recurrent Acute Otitis Media

Recurrent AOM is defined as ≥3 episodes in 6 months or ≥4 episodes in 12 months with at least one episode in the preceding 6 months. It affects approximately 15–20% of children and is associated with daycare attendance, family history, first episode before age 12 months, passive tobacco smoke exposure, Indigenous background, and craniofacial abnormalities (cleft palate, Down syndrome).

Prevention Strategies

Pneumococcal conjugate vaccine (PCV13): NIP schedule — 2, 4, and 12 months. Reduces AOM caused by vaccine serotypes by 6–7% overall, up to 25% in high-risk populations.
Influenza vaccine: Annual vaccination for children ≥6 months reduces influenza-associated AOM.
Breastfeeding: Exclusive breastfeeding for ≥4 months reduces AOM risk by approximately 40%.
Reduce passive smoke exposure: Strong association with recurrent AOM and CSOM.
Reduce daycare exposure: If possible; daycare attendance is a strong independent risk factor.
No role for long-term antibiotic prophylaxis in most cases — risk of AMR outweighs marginal benefit.

Surgical Management — ENT Referral Indications

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Ventilation tubes (grommets): Indicated for recurrent AOM meeting diagnostic criteria above, persistent bilateral OME with hearing loss >3 months, or OME with speech/language delay. Grommets reduce the frequency of AOM episodes by approximately 50% while in situ.
Adenoidectomy: Considered in children ≥4 years with recurrent AOM or OME, particularly with nasal obstruction or chronic adenoiditis. Often performed concurrently with grommet insertion.
Tonsillectomy: Not routinely indicated for recurrent AOM alone.

Otitis Media with Effusion (OME) in Children

OME (glue ear) is the most common cause of hearing loss in children. It is characterised by non-purulent fluid in the middle ear without acute signs of infection. Most episodes resolve spontaneously within 3 months. Management:

Observation: Minimum 3 months before considering intervention for bilateral OME.
Audiological assessment: Refer for formal audiometry if hearing loss suspected or OME persists >3 months.
Antibiotics, antihistamines, decongestants, and intranasal steroids are NOT recommended for OME in children — no consistent evidence of benefit.
AUTOINFLATION (Otovent® balloon): May be considered in children who can perform it (>3 years); modest evidence of benefit. Not PBS-listed but available OTC.
Surgical referral: Bilateral OME with documented hearing loss >3 months, speech/language delay, or structural abnormality (cleft palate, Down syndrome).

Foreign Bodies in the Ear

Foreign body insertion into the external auditory canal is a common presentation in paediatric emergency departments and general practice, with peak incidence between ages 2 and 8 years. Common objects include beads, food material (cereal, peas, insects), cotton bud tips, paper, small toy parts, and button batteries. In adults, cotton bud fragments and insects are the most frequent foreign bodies.

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Button batteries — ENT emergency: Button/disc batteries lodged in the ear canal require IMMEDIATE removal. They cause chemical burns and liquefactive necrosis within 1–2 hours of contact with moist mucosa, potentially leading to tympanic membrane perforation, ossicular erosion, and permanent hearing loss. If removal is not immediately possible, irrigate continuously with normal saline to dilute the alkaline contents and refer emergently to ENT.

Classification & Management Approach

Foreign Body Type	Examples	Urgency	Preferred Removal Method
Button/disc battery	Watch batteries, hearing aid batteries	EMERGENCY — immediate	Suction, crocodile forceps; ENT if not easily removable; continuous saline irrigation pending removal
Organic / water-soluble	Peas, beans, cereal, food matter	Urgent (swelling with time)	Micro-hook, wire loop, alligator forceps; avoid irrigation (swelling). Do NOT use water.
Smooth, hard, inorganic	Beads, plastic pieces, stones	Same-day	Irrigation (warm water via syringe) is first-line; crocodile forceps if accessible
Irregular / hooked	Toy parts, paper, cotton bud fragments	Same-day	Alligator forceps, micro-hook, suction; under direct visualisation with otoscope or microscope
Live insects	Cockroaches, moths, flies, spiders	Urgent (patient distress)	Kill insect first: fill canal with lignocaine 1% or olive/mineral oil, then irrigate or extract with forceps

Removal Techniques

Direct Visualisation & Cooperation

Ensure adequate lighting, patient positioning, and (in children) parental assistance for head stabilisation. Sedation may be required for uncooperative children — consult with ED senior or paediatric service. Use an operating microscope if available.

Irrigation

Warm water via 20–50 mL syringe with an 18G angiocatheter or Zalzmann irrigation tip directed along the superior canal wall. Suitable for hard, smooth objects. Contraindicated for organic material, perforated TM, button batteries, and tympanostomy tubes.

Instrument Extraction

Under direct vision with otoscope or headlight: alligator forceps (soft/irregular objects), crocodile forceps (hard objects), micro-hook or wire loop (passed behind object), or Jobson-Horne probe. Avoid pushing the object deeper — maintain visualisation at all times.

Suction

Frazier suction tip or wall suction at low pressure can be used to extract soft or irregular objects. Useful as an adjunct with forceps.

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When to stop and refer to ENT: Refer to ENT specialist if: (1) the foreign body cannot be removed after 2–3 careful attempts, (2) there is significant canal oedema limiting visualisation, (3) TM injury is suspected, (4) the patient is uncooperative/young and sedation is not available, or (5) the object is a button battery or expands with irrigation. Never persist blindly — multiple failed attempts cause oedema and make subsequent removal more difficult.

Post-Removal Care

Re-examine the canal and TM after removal for lacerations, abrasions, or perforation.
If canal abrasion/trauma: Ciprofloxacin 0.3% + hydrocortisone 1% ear drops (Ciproxin HC®) — 3–4 drops BD for 5–7 days.
If TM perforation: ENT referral; avoid water entry; topical quinolone drops only (avoid aminoglycosides if perforation confirmed).
If infection develops post-removal: treat as otitis externa (see below).

Acute & Chronic Otitis Media in Adults

Acute Otitis Media in Adults

While less common than in children, AOM in adults should be taken seriously, as it may indicate underlying pathology (immunocompromise, nasopharyngeal malignancy) and is more likely to be associated with Gram-negative organisms. Pneumococcus, H. influenzae, and M. catarrhalis remain the principal pathogens, but Pseudomonas aeruginosa must be considered in adults with diabetes, immunosuppression, or chronic ear disease.

Management of Uncomplicated Adult AOM

Analgesia: Paracetamol 1 g PO QDS PRN ± ibuprofen 400 mg PO TDS PRN. Adequate pain control is the primary treatment goal.
Antibiotics: Recommended for most adult AOM (adults are less likely to self-resolve than children and more likely to develop complications).
Nasal decongestants: Oxymetazoline 0.05% nasal spray BD for up to 5 days — may improve Eustachian tube function. Avoid prolonged use.

Antibiotic Therapy — Adult AOM

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Amoxicillin

Amoxil® · Generic · Penicillin antibiotic

Adult dose 500 mg PO TDS (or 1 g PO TDS if high-dose therapy indicated for resistant organisms)

Duration 5–7 days

Renal adjustment eGFR 10–30: 500 mg BD-TDS; eGFR <10: 500 mg OD-BD

PBS status ✔ PBS General Benefit

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Amoxicillin–Clavulanate

Augmentin® · Augmentin Duo Forte® · β-lactam/β-lactamase inhibitor

Adult dose 875/125 mg PO BD or 500/125 mg PO TDS (amoxicillin/clavulanate)

Indication Second-line: amoxicillin failure at 48–72 hrs, recent antibiotic use, recurrent episodes, β-lactamase producing organisms suspected

Duration 5–7 days

PBS status ✔ PBS General Benefit

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Cefalexin

Keflex® · Generic · First-generation cephalosporin

Adult dose 500 mg PO TDS (up to 1 g TDS for severe infection)

Indication Penicillin allergy (non-severe/non-anaphylactic)

Duration 5–7 days

PBS status ✔ PBS General Benefit

⚠️

Adult AOM with no response to first-line antibiotics at 48–72 hours: Broaden to amoxicillin–clavulanate, review for complications (mastoiditis), and consider ENT referral if no improvement after a further 48–72 hours. If Pseudomonas is suspected (immunocompromise, chronic ear disease), refer for culture-directed therapy — do NOT prescribe fluoroquinolones empirically for uncomplicated AOM.

Otitis Externa in Adults

Acute otitis externa (AOE) is inflammation of the external auditory canal, most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus. Risk factors include water exposure (swimming, surfing), humid climates, use of cotton buds/earplugs, hearing aids, skin conditions (eczema, psoriasis), and canal stenosis.

💧 Non-Purulent / Mild Otitis Externa

Mild pain, pruritus, minimal discharge. Management:
• Aural toilet (dry mopping, suction)
• Acetic acid 2% ear drops (Vosol®) — 3–4 drops TDS-QDS for 7 days
• Keep ear dry; avoid swimming for 7–10 days
• Consider swimmer's ear preventive measures

🦻 Moderate–Severe / Purulent Otitis Externa

Significant pain, canal oedema, purulent discharge, hearing loss. Management:
• Aural toilet (essential — clear debris for drops to work)
• Ciprofloxacin 0.3% + hydrocortisone 1% ear drops (Ciproxin HC®) — 3–4 drops BD for 7–10 days
• If canal oedema prevents drop entry: Pope wick (expandable sponge wick) + drops
• Analgesia: paracetamol ± ibuprofen; codeine if severe
• Oral antibiotics only if cellulitis extends beyond the canal or systemic features

Topical Therapy — Otitis Externa

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Ciprofloxacin + Hydrocortisone

Ciproxin HC® · Quinolone + steroid combination drops

Adult dose 3–4 drops into affected ear BD for 7–10 days

Key advantage Safe with perforated TM (unlike aminoglycoside drops); anti-inflammatory component reduces oedema. First-line for moderate–severe OE.

PBS status ✔ PBS General Benefit

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Acetic acid 2%

Vosol® · Otic acidifier / antifungal

Adult dose 3–4 drops TDS-QDS for 7 days

Indication Mild otitis externa; prophylaxis in swimmers; antifungal otitis externa (adjunct)

PBS status ✔ PBS General Benefit

Chronic Suppurative Otitis Media (CSOM) in Adults

CSOM is defined as chronic (>6 weeks) drainage from the middle ear through a non-intact tympanic membrane. It is a leading cause of preventable hearing loss worldwide and disproportionately affects Aboriginal and Torres Strait Islander Australians. Complications include permanent conductive hearing loss, cholesteatoma, and (rarely) intracranial spread.

CSOM Subtypes

Feature	Tubotympanic (Safe)	Atticoantral (Unsafe)
Perforation site	Central (pars tensa)	Attic or marginal (pars flaccida)
Discharge	Mucoid; intermittent	Foul-smelling; persistent; may contain cholesteatoma
Hearing loss	Conductive; usually mild–moderate	Mixed; sensorineural component possible
Cholesteatoma risk	Low	High — requires surgical assessment
Complications	Rare; hearing loss main concern	Ossicular erosion, facial nerve palsy, labyrinthitis, intracranial abscess
Management	Aural toilet + topical quinolone; hearing assessment; surgical repair if persistent	ENT referral for surgical assessment (tympanomastoidectomy); cholesteatoma excision

CSOM Treatment Principles

Aural toilet is the cornerstone — dry mopping or microsuction to clear discharge and debris, enabling topical drops to reach the middle ear.
Topical quinolone ear drops (ciprofloxacin 0.3%) — 3–4 drops BD into the affected ear for 14 days. Safe in perforated TM. Avoid aminoglycoside drops (gentamicin, framycetin) when perforation is present due to ototoxicity risk.
Systemic antibiotics are reserved for acute exacerbations with systemic features, spreading cellulitis, or when topical therapy cannot reach the middle ear.
Audiological assessment — all patients with CSOM should have a formal audiogram.
ENT referral for all CSOM — surgical repair (tympanoplasty, tympanomastoidectomy) may be required. Atticoantral disease and suspected cholesteatoma require urgent surgical assessment.
Water precautions: Keep the ear dry; use petroleum jelly–coated cotton wool or custom earplugs when bathing.

Cholesteatoma

Cholesteatoma is a cyst-like collection of squamous epithelium within the middle ear or mastoid that progressively expands and erodes bone. It may arise from an attic retraction pocket, marginal perforation, or (rarely) as a congenital lesion. Symptoms include painless or mildly painful, foul-smelling otorrhoea, progressive conductive hearing loss, and (rarely) facial nerve palsy or vertigo. All suspected cholesteatomas require urgent ENT referral for surgical excision (modified radical mastoidectomy or tympanomastoidectomy).

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Cholesteatoma is not managed conservatively. Delayed treatment leads to irreversible bone erosion, sensorineural hearing loss, facial nerve paralysis, labyrinthitis, and potentially fatal intracranial complications. Refer all suspected cases urgently.

Special Populations

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Paediatrics

• Eustachian tube is shorter, more horizontal, and more collapsible in young children → higher susceptibility to AOM.

• Infants <3 months with ear pain and fever require urgent assessment (serious bacterial infection risk — UTI, meningitis).

• Amoxicillin dosing: use weight-based dosing (45–50 mg/kg/day standard; 80–90 mg/kg/day high-dose).

• Avoid quinolone ear drops in children unless specifically indicated (e.g., CSOM with perforation) — off-label but accepted practice in Australian paediatrics.

• Cleft palate and Down syndrome: high risk for chronic OME and recurrent AOM — early ENT involvement and audiological surveillance recommended.

Key: Weight-based antibiotic dosing; paracetamol 15 mg/kg; ibuprofen 5–10 mg/kg (≥3 months).

🤰

Pregnancy

• Amoxicillin is safe in all trimesters (Category A in Australian TGA classification).

• Avoid ciprofloxacin systemic use (risk of cartilage damage in animal studies); topical ciprofloxacin ear drops are generally considered safe as minimal systemic absorption occurs.

• Avoid ibuprofen in the third trimester (risk of premature closure of ductus arteriosus); paracetamol is preferred.

• Pseudoephedrine nasal decongestant should be avoided (uterine vasoconstriction risk).

• Ear irrigation for foreign body removal is safe.

Safe: amoxicillin, cefalexin, paracetamol, topical ciprofloxacin. Avoid: ibuprofen (>30 weeks), pseudoephedrine.

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Elderly

• Presbycusis (age-related hearing loss) complicates assessment and follow-up.

• Elderly patients with hearing aids are at increased risk of otitis externa due to canal irritation and moisture retention.

• Renal impairment is common — adjust amoxicillin doses; avoid or adjust NSAIDs for analgesia.

• Consider referred pain sources more frequently (pharyngeal malignancy, cervical pathology).

• Immune senescence increases risk of invasive complications from otitis media and otitis externa.

Reduce paracetamol to max 3 g/day if low body weight or hepatic concerns. Review NSAID use for GI/renal/cardiovascular risk.

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Renal Impairment

• Amoxicillin: reduce dose or extend interval for eGFR <30 mL/min.

• Avoid NSAIDs (ibuprofen) in severe renal impairment (eGFR <30) — risk of AKI.

• Aminoglycoside ear drops should be avoided if perforation suspected — cumulative ototoxicity risk.

• Topical ciprofloxacin ear drops have negligible systemic absorption and are safe.

Topical ear drops are generally safe systemically; systemic antibiotics require dose adjustment.

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Hepatic Impairment

• Amoxicillin and cefalexin: no specific dose adjustment required; use with caution in severe hepatic impairment.

• Amoxicillin–clavulanate: avoid or use with extreme caution — risk of cholestatic hepatitis.

• Paracetamol: reduce maximum dose to 2–3 g/day in significant hepatic impairment.

• Avoid or minimise NSAIDs due to increased bleeding risk.

Avoid amoxicillin–clavulanate; reduce paracetamol dose; minimise NSAIDs.

🛡️

Immunocompromised

• Patients with diabetes, HIV/AIDS, chemotherapy, or transplant immunosuppression are at heightened risk of malignant (necrotising) otitis externa, invasive fungal otitis, and complicated AOM.

• Necrotising otitis externa requires systemic anti-pseudomonal therapy (ciprofloxacin 750 mg PO BD or IV piperacillin–tazobactam) + ENT specialist involvement. Duration: 4–6 weeks minimum.

• Aspergillus species cause fungal otitis externa — aural toilet + topical clotrimazole 1% or miconazole 2% ear drops; refer if invasive disease suspected.

• Low threshold for imaging (CT temporal bones, MRI) and biopsy in immunocompromised patients with atypical ear pathology.

Empiric anti-pseudomonal therapy for necrotising OE; specialist infectious diseases co-management recommended.

Investigations

Most ear conditions are diagnosed clinically. Investigations are targeted based on clinical scenario, severity, and suspected complications.

Essential

Pneumatic otoscopy

Assessment of tympanic membrane mobility. Reduced mobility confirms middle ear effusion. Gold standard for AOM diagnosis when combined with visual assessment. Available in all primary care settings.

Available

Audiometry (pure tone + tympanometry)

Formal audiometric assessment for hearing loss, OME, CSOM. Tympanometry (Type B flat = effusion; Type As = stiff TM; Type Ad = hypermobile TM). MBS Item 82220 (audiological assessment). Refer to audiologist.

Available

Ear swab for microscopy, culture & sensitivity

Indicated for: chronic/recurrent otorrhoea, failed first-line therapy, suspected resistant organisms, immunocompromised patients, CSOM. Not routinely indicated for uncomplicated AOM or OE.

Referral

CT temporal bones (± contrast)

Mastoiditis, suspected cholesteatoma, intracranial complications, necrotising otitis externa, bony erosion assessment. MBS Item 56001 (CT head/temporal bones). Request urgent through ED if acute complications suspected.

Referral

MRI brain/internal auditory meatus

Suspected intracranial complications (brain abscess, sigmoid sinus thrombosis, meningitis), cholesteatoma extension, vestibular schwannoma. MBS Item 63001. Arrange via ED or ENT specialist.

Specialist

Otoendoscopy / operative microscopy

Detailed assessment of canal, TM, and middle ear structures. Performed by ENT specialist. Essential for cholesteatoma assessment and surgical planning.

Available

FBC, CRP/ESR, blood cultures

For systemic illness in the context of ear infection — mastoiditis, intracranial complications, immunocompromised patients. Elevated WCC, CRP with ear infection should prompt consideration of complications.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Ear disease is one of the most significant health disparities experienced by Aboriginal and Torres Strait Islander Australians. The burden of otitis media — including acute, chronic suppurative, and otitis media with effusion — is among the highest in the world in Indigenous Australian communities, particularly in remote and very remote areas. The NACCHO/RHDAustralia Otitis Media Clinical Guidelines and the Australian Department of Health EarInfoNet provide culturally specific guidance for management.

⚠️

Key health disparity: Aboriginal and Torres Strait Islander children experience AOM at 2–3 times the rate of non-Indigenous children, and CSOM prevalence in remote communities can reach 40%. The median age of first AOM episode is younger (often <6 months), and suppurative complications (mastoiditis, cholesteatoma, hearing loss) are disproportionately represented. This drives significant downstream effects on speech, language development, education, and social outcomes.

Screening & Early Detection

Implement routine otoscopic screening at all child health checks (including child health checks under the MBS Indigenous health assessment — MBS Item 715). Use video otoscopy where available to allow telehealth review by ENT specialists. Ear assessments should be incorporated into all presentations — well-child checks, immunisation visits, school entry health assessments.

Antibiotic Approach

Treat ALL Aboriginal and Torres Strait Islander children with AOM with antibiotics regardless of age or severity — no watchful waiting. Use high-dose amoxicillin (80–90 mg/kg/day) as first-line. Longer courses (7 days minimum) are recommended. Ensure timely follow-up at 2–4 weeks to document resolution.

Chronic Suppurative Otitis Media

CSOM in Aboriginal and Torres Strait Islander communities requires community-based management models: regular aural toilet by trained primary care staff or Aboriginal health practitioners, topical quinolone drops (ciprofloxacin 0.3%), community education, and access to ENT outreach services. Long-term ear health programmes coordinated through ACCHOs (Aboriginal Community Controlled Health Organisations) are essential.

Access to Specialist Care

Remote communities have limited or no ENT specialist access. Utilise the Australian Government-funded Specialist Outreach programmes, Northern Territory Ear, Nose and Throat Outreach Program, state-based Telehealth ENT services, and Operation Open Ears (surgical outreach). Advocate for timely surgical waitlist access for grommets, tympanoplasty, and cholesteatoma surgery.

Housing & Social Determinants

Overcrowded housing, poor water supply and sanitation, and environmental tobacco smoke exposure are major drivers of ear disease. Address upstream: advocate for improved housing, reduce household crowding, promote smoke-free homes, and ensure clean water access. Ear health programmes must be embedded within broader social determinants of health frameworks.

Culturally Safe Practice

Use culturally appropriate health education materials (ear health resources from NACCHO, Menzies School of Health Research). Employ Aboriginal Health Practitioners and Aboriginal Health Workers as ear health champions. Ensure communication is respectful, unhurried, and where possible conducted with cultural interpreters. Recognise that ear disease management may be secondary to competing health and social priorities.

Vaccination & Prevention

Ensure full pneumococcal conjugate vaccine (PCV13) and influenza vaccine coverage. NIP schedule PCV13 at 2, 4, and 12 months — catch-up programmes available for children who have missed doses. Influenza vaccine annually from 6 months. Promote breastfeeding (protective against OM). Community-based smoking cessation programmes reduce passive smoke exposure.

Impact on Education

Hearing loss from ear disease is a major contributor to the education gap between Indigenous and non-Indigenous children. Conductive hearing loss affects speech and language development, classroom participation, and literacy. Classroom amplification systems, teacher awareness, and speech pathology support should be available for all affected children. Coordinated care between health, education, and community services is essential.

📚 References

1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–e999. doi:10.1542/peds.2012-3488
2. Morris PS, Leach AJ. Acute and chronic otitis media. Pediatr Clin North Am. 2009;56(6):1383–1399.
3. Australian Government Department of Health. Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations. Canberra: Commonwealth of Australia; 2020.
4. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1–S24.
5. Gunasekera H, Morris PS, Daniels J, Couzos S, Craig JC. Otitis media in Aboriginal children: the discordance between burden of illness and access to services in remote Australia. J Paediatr Child Health. 2009;45(7-8):425–430.
6. Australian Institute of Health and Welfare (AIHW). Ear disease in Aboriginal and Torres Strait Islander children. AIHW Cat. No. IHW 223. Canberra: AIHW; 2022.
7. Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013;(1):CD000219. doi:10.1002/14651858.CD000219.pub3
8. National Aboriginal Community Controlled Health Organisation (NACCHO). Otitis Media Clinical Guidelines. Canberra: NACCHO; 2023.
9. PS. Management of foreign bodies of the external auditory canal. Aust Fam Physician. 2018;47(7):458–461.
10. Acuin J. Chronic suppurative otitis media: burden of illness and management options. Geneva: World Health Organization; 2004.
11. Royal Australian College of General Practitioners (RACGP). Ear, nose and throat. In: RACGP Specific Interests Guide. Melbourne: RACGP; 2023.
12. Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).