Educational revision — for learning, not live patient decisions. Guideline-linked. Always work with your seniors and local guidelines.
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● Urgent care clinic · 30-minute consult

Earache: otitis media & externa

Mostly no antibiotics — but spot mastoiditis and malignant otitis externa.

Typical consult⏱ 10–15 min
Investigations🔬 None
Usual outcome💊 Analgesia ± drops/antibiotic
0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document
1Rule out first — red flags
If you find……then
Swelling, redness or tenderness behind the ear, ear pushed forwardMastoiditis — ENT same day
Severe pain, diabetic or immunosuppressed, granulation tissue in the canalMalignant otitis externa — ENT same day
Facial weakness, vertigo, sudden hearing lossENT same day
Headache, neck stiffness, drowsinessMeningitis / intracranial complication
2Focused history
3Focused examination
4Decide — investigate only if it changes the plan

Media or externa?

  • Otitis media: bulging/red drum, often after URTI, no tragal tenderness
  • Otitis externa: canal inflamed, debris, tragal/pinna tenderness

Otitis media: most no antibiotic or back-up (NICE NG91). Otitis externa: topical treatment, not oral antibiotics.

InvestigationOnly if…
NoneEar swab only if recurrent or not responding
5Treat & send home

Management & advice

  • Otitis media: analgesia; settles in ~3 days, can last a week; consider back-up antibiotic
  • Otitis externa: keep ear dry (cotton wool with Vaseline when showering), no cotton buds, avoid swimming 7–10 days
  • Ear wick / microsuction if canal very swollen (ENT / aural care)

Refer / follow-up

  • Mastoiditis, malignant otitis externa, facial palsy → ENT same day
  • Very swollen canal → ENT / aural care for wick
℞
Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.
DrugDoseDuration / notes
Paracetamol1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk)As needed
Ibuprofen400 mg three times a day with food3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy
Otitis media (if indicated): amoxicillin500 mg three times a day (adults)5–7 days; children per BNFc
Penicillin allergy: clarithromycin250–500 mg twice a day (adults)5–7 days
Otitis externa: acetic acid 2% ear spray1 spray three times a day (mild)7 days
Otitis externa (moderate): topical antibiotic + steroid, e.g. Otomize spray1 spray three times a dayUntil 2 days after symptoms settle (max 14 days); avoid aminoglycosides if perforated drum
6Safety-net
Say it like this

This is an ear infection, most likely caused by a virus. It usually settles in about 3 days without antibiotics. Use regular painkillers. Here’s a back-up prescription: only collect it if you’re not better in 3 days or you’re getting worse. Come back straight away if you get swelling behind the ear, a severe headache, a stiff neck or weakness of your face.

Come back / call 111 — or 999 if severe — if:

  • Swelling, redness or pain behind the ear
  • Severe headache, stiff neck, drowsiness
  • Weakness of the face, dizziness
  • Not improving after 3 days, or worse
7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Ear infectionsnhs.uk/conditions/ear-infections
Antibiotics — when you need themnhs.uk/conditions/antibiotics
8Document

Earache: otitis media & externa — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — EARACHE: OTITIS MEDIA & EXTERNA PRESENTING COMPLAINT: HISTORY Pain, discharge, hearing loss, itch: Swimming, cotton bud use, hearing aids: Fever, URTI symptoms: Diabetes, immunosuppression: Previous ear surgery / known perforation: RED FLAGS (record present / absent) [ ] Swelling, redness or tenderness behind the ear, ear pushed forward [ ] Severe pain, diabetic or immunosuppressed, granulation tissue in the canal [ ] Facial weakness, vertigo, sudden hearing loss [ ] Headache, neck stiffness, drowsiness PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Pinna, tragal tenderness (externa), behind the ear: Otoscopy: canal (swelling, debris) and drum (bulging, red, perforation): Facial nerve function: DECISION RULE — Media or externa?: result ______ INVESTIGATIONS: none required / None — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Ear infections, Antibiotics — when you need them Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Swelling, redness or pain behind the ear - Severe headache, stiff neck, drowsiness - Weakness of the face, dizziness - Not improving after 3 days, or worse Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:
✓Guidelines

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

More ear, nose, throat & eyes

Sore throat & tonsillitisFeverPAIN decides — and don’t miss the quinsy or epiglottitis.SinusitisViral until day 10 — and don’t miss the orbit.Nosebleed (epistaxis)Proper first aid, cautery if you can see it, and who needs ENT.Red eye & conjunctivitisConjunctivitis is a diagnosis of exclusion — check acuity and pain first.