Intended for healthcare professionals

Endgames Case Review

Acute otalgia and otorrhoea in primary care

BMJ 2016; 352 doi: (Published 18 February 2016) Cite this as: BMJ 2016;352:i844
  1. Leigh N Sanyaolu, general practitioner registrar1,
  2. Sarah E J Farmer, consultant otolaryngologist1
  1. 1Department of Otolaryngology, Royal Gwent Hospital, Newport NP20 2UB, UK
  1. Correspondence to: L N Sanyaolu lnsanyaolu{at}

A 26 year old otherwise well man with no medical history of note attended his general practice with a five day history of severe right ear pain and scanty ear discharge. He had returned from holiday one week earlier, where he had been swimming. He had no headache, fever, or systemic upset.

Clinical examination identified oedema and discharge at the right external auditory meatus but an otherwise normal pinna. Palpation of the right tragus caused sudden onset intense pain, and otoscopy showed oedema of the external auditory canal, with a small amount of discharge obstructing visualisation of the tympanic membrane. He had no post-auricular swelling, erythema, tenderness suggestive of mastoiditis, or signs of meningism. His observations were within normal limits.


  1. What is the most likely diagnosis?

  2. How would you manage this patient?

  3. When would you refer him to secondary care?

  4. What advice would you give him?


1. What is the most likely diagnosis?

Short answer

Acute otitis externa.


The diagnosis is acute right otitis externa, an acute inflammatory condition of the skin of the external auditory canal, generally secondary to bacterial infection.1 This condition is often seen in primary care, with a reported prevalence of 1% within a 12 month period.1 2 Common symptoms associated with this condition include otalgia, otorrhoea, pruritus, and hearing loss.1-3 In uncomplicated disease, clinical examination often shows oedema of the external auditory canal, with or without erythema and discharge, and a normal and intact tympanic membrane.1 3 A key clinical sign is tenderness over the …

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