Family medicine
Ear Pain
Ear pain (otalgia) is discomfort in or around the ear that may arise from primary ear pathology or be referred from adjacent structures such as the temporomandibular joint, pharynx, or cervical spine.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute otitis media (AOM) | Preceded by URTI; deep ear pain; bulging red TM on otoscopy; fever in children [1][2] | 「之前有冇傷風？入面痛定外面痛？」 |
| Otitis externa (OE) | Pain on tragal pressure / pinna traction; ear canal oedema/discharge; normal TM [1][2] | 「我撳你耳仔前面呢粒會唔會痛？」(tragal tenderness) | |
| Impacted cerumen | Fullness, reduced hearing; wax seen on otoscopy | 「覺得隻耳塞住咗？」 | |
| Serious Not To Miss | Mastoiditis | Post-auricular swelling/erythema/tenderness; displaced pinna; fever; follows AOM [1] | 「耳仔後面有冇腫痛？」; examine post-auricular area |
| Malignant (necrotizing) otitis externa | Elderly + DM; severe pain; granulation tissue in EAC floor; CN palsy [1] | 「你有冇糖尿病？痛得好犀利？」 | |
| Cholesteatoma | Chronic foul-smelling discharge; marginal TM perforation; hearing loss [1] | 「耳仔流嘢有冇臭味？流咗幾耐？」 | |
| NPC (referred otalgia) | Unilateral ear blockage + epistaxis + neck mass; Southern Chinese; EBV [4] | 「有冇鼻水帶血？條頸有冇摸到粒嘢？」 | |
| Pitfalls | TMJ dysfunction | Pain on chewing/yawning; jaw clicking; tenderness over TMJ | 「開口或者食嘢嗰陣痛唔痛？」 |
| Referred pain from dental pathology | Toothache; recent extraction; tender tooth on percussion | 「近排有冇牙痛？」 | |
| Ramsay Hunt syndrome | Vesicles on auricle/EAC + facial nerve palsy + otalgia (VZV CN VII) [1][3] | 「耳仔附近有冇起水泡？塊面郁唔郁到？」 | |
| Foreign body in ear canal | History of insertion; children; visible on otoscopy | 「有冇塞咗嘢入耳仔？」(children) | |
| Masquerades | Cervical spine / neurological (C2-3 referred) | Neck pain/stiffness; worse with neck movement | 「條頸有冇痛或者僵硬？」 |
| Drugs (ototoxicity) | Hearing loss + tinnitus after aminoglycosides/cisplatin [5] | 「最近有冇打抗生素針或者化療？」 | |
| Trying to Tell Me Something? | Health anxiety (cancer worry), work/exam stress, relationship issue | Hidden agenda: fear of NPC, disability | 「你最擔心嘅係咩？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, intro, set agenda | 「你好，我係X醫生。今日想同你傾吓你耳仔嘅問題，大概傾六分鐘左右，可以嗎？」("Hi, I'm Dr X. I'd like to chat about your ear problem for about 6 min, OK?") | Rapport, consent, signposting → interpersonal marks |
| 0:30–2:30 | HPI: SOCRATES + associated Sx | 「隻耳仔邊度痛？痛咗幾耐？乜嘢情況會痛啲？有冇嘢流出嚟？聽嘢有冇差咗？有冇耳鳴？有冇發燒？有冇頭暈？」 | Systematic symptom analysis; covers AOM, otitis externa (OE), referred pain |
| 2:30–3:30 | Red flags + targeted review | 「有冇面部郁唔到嘅情況？有冇起水泡喺耳仔附近？頭痛嚴重唔嚴重？條頸硬唔硬？有冇嘢出咗喺耳仔入面？」 | Screens mastoiditis, Ramsay Hunt, cholesteatoma, NPC, malignant OE |
| 3:30–4:30 | PMHx, DHx, allergy, FHx, social Hx | 「之前有冇耳仔嘅問題？有冇糖尿病？食緊咩藥？有冇藥物敏感？屋企人有冇鼻咽癌？你食唔食煙？做咩工？」 | DM → malignant OE; FHx NPC; occupation noise |
| 4:30–5:15 | ICE + hidden agenda | 「你自己覺得耳仔痛會唔會係咩嚟㗎？最擔心邊方面？你今日最想我幫到你啲咩？」 | Captures ICE; uncovers hidden agenda (e.g. worry about cancer/hearing loss/work) |
| 5:15–5:45 | Summarise + check understanding | 「等我總結返：你隻右耳痛咗三日，有啲流膿，冇發燒。我想幫你檢查吓隻耳仔，你覺得啱唔啱？」 | Shows active listening, accuracy |
| 5:45–6:00 | Safety-net + close | 「如果之後痛得好犀利、發高燒、面部郁唔到、或者聽嘢差咗好多，要即刻返嚟睇。」 | Safety-net scores marks; professional close |
Uncovering the hidden agenda: Ask 「其實你今日點解決定嚟睇醫生？」 — the patient may have come not for the pain itself but because of worry about hearing loss, cancer (NPC), or a work/exam impact. This separates the "main reason for consultation" from the chief complaint.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Which ear? Both? | 「邊隻耳仔痛？定兩隻都痛？」 | Laterality; bilateral → viral/systemic | Bilateral → viral parotitis, referred |
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始痛？突然定慢慢嚟？」 | Acute → AOM/OE; chronic → CSOM/cholesteatoma | |
| Character | What kind of pain? Deep or on the outside? | 「點痛法？入面痛定外面痛？」 | Deep → AOM/referred; superficial → OE | |
| Severity | Pain score 0–10? Affects sleep? | 「痛嘅程度，十分滿分幾多分？瞓唔瞓到覺？」 | Severity guides analgesia | |
| Ear discharge | Any fluid/pus from the ear? Colour? Smell? | 「有冇嘢流出嚟？咩色？臭唔臭？」 | Purulent → AOM perforation/OE/CSOM; foul-smelling → cholesteatoma [1] | CSOM, cholesteatoma |
| Hearing loss | Hearing worse? Which ear? | 「聽嘢有冇差咗？邊隻耳？」 | Conductive HL → AOM/CSOM/cholesteatoma; sensorineural HL → inner ear/acoustic neuroma [2] | |
| Tinnitus | Ringing in the ear? | 「有冇耳鳴？」 | Ménière's, acoustic neuroma, NPC | |
| Vertigo | Dizziness/spinning? | 「有冇頭暈？周圍嘅嘢有冇轉？」 | Complication of middle/inner ear disease | Labyrinthitis, Ménière's, cholesteatoma erosion |
| Tragal tenderness / pain on pinna traction | Does it hurt when you pull the ear? | 「我拉吓你隻耳仔會唔會痛？」 | Positive → otitis externa (key discriminator from AOM) [1][2] | OE |
| URTI symptoms | Runny nose, sore throat, cough before this? | 「之前有冇傷風、喉嚨痛、咳？」 | Preceding URTI → AOM via Eustachian tube dysfunction | AOM |
| Fever | Any fever? | 「有冇發燒？」 | Infection; high fever → mastoiditis/abscess | |
| Facial weakness | Face drooping? Mouth/eye affected? | 「塊面有冇郁唔到？嘴角有冇歪？」 | Facial nerve palsy → Ramsay Hunt, cholesteatoma, malignant OE [3] | |
| Vesicles | Blisters around the ear? | 「耳仔附近有冇起水泡？」 | Vesicles on auricle + facial palsy + otalgia = Ramsay Hunt syndrome [1] | |
| Postnasal drip / epistaxis | Blood in nose/throat? Blocked nose? | 「有冇鼻塞？有冇鼻血或者鼻水帶血？」 | Referred ear pain may be first sign of NPC [4] | NPC |
| TMJ | Jaw pain? Clicking? Worse on chewing? | 「開口咀嚼嗰陣痛唔痛？有冇格格聲？」 | TMJ dysfunction = common referred cause of ear pain | TMJ dysfunction |
| Dental | Recent toothache or dental work? | 「近排有冇牙痛？有冇睇過牙醫？」 | Referred pain from dental pathology | Dental abscess/impacted wisdom tooth |
| Swimming / water exposure | Do you swim? Water entering the ear? | 「你有冇游水？耳仔有冇入過水？」 | Swimmer's ear = OE risk | OE |
| Foreign body / cotton bud | Use cotton buds? Anything stuck? | 「有冇用棉花棒撩耳仔？有冇嘢塞住？」 | Trauma → OE; impacted cerumen; FB | |
| PMHx | DM? Immunosuppression? Eczema? | 「有冇糖尿病？有冇濕疹？免疫力有冇差？」 | DM/immunosuppressed → malignant (necrotizing) otitis externa [1] | Malignant OE |
| DHx | Current medications? Ear drops? | 「食緊咩藥？有冇用耳藥水？」 | Ototoxic drugs (aminoglycosides); anticoagulants | |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safe prescribing | |
| FHx | Family history of NPC? Hearing loss? | 「屋企人有冇鼻咽癌？有冇耳聾？」 | NPC endemic in southern Chinese | NPC |
| Social/Occupation | Job? Noise exposure? Stress? | 「做咩工？工作環境嘈唔嘈？最近壓力大唔大？」 | Noise → hearing loss; stress → hidden agenda | |
| Functional impact | Affecting work/school/sleep? | 「影唔影響返工/返學/瞓覺？」 | Biopsychosocial problem |
Case Report Form Answer Builder
- CC: "Ear pain × [duration]" — state side, onset, character
- HPI high-yield points: SOCRATES of ear pain; presence/absence of discharge (character, smell), hearing change, tinnitus, vertigo, fever, preceding URTI, facial weakness, vesicles, nasal symptoms, water exposure, cotton bud use, PMHx (DM/eczema)
- The RFC is often NOT "ear pain" alone. Examples:
- "Worried ear pain might be something serious (cancer)"
- "Ear pain affecting sleep/work"
- "Concerned about hearing loss"
- "Ear discharge not settling despite self-treatment"
- Phrase it as the patient's own concern driving the visit.
| Likely Examples | Exact Wording to Write | |
|---|---|---|
| Ideas | "I think it might be an ear infection" / "I'm worried it could be cancer" | "Patient thinks the ear pain may be due to an ear infection." |
| Concerns | "I'm worried about losing my hearing" / "Could it be NPC?" | "Patient is worried about permanent hearing loss." |
| Expectations | "I want ear drops" / "I want a referral to ENT" / "I want a hearing test" | "Patient expects antibiotics/ear drops and reassurance." |
- In an adult with acute ear pain + preceding URTI + fever + no tragal tenderness → Acute Otitis Media (AOM)
- In an adult with ear canal pain + tragal tenderness + discharge + history of water exposure/cotton buds → Otitis Externa (OE)
- Minimum supporting evidence: History features + one physical sign (see Q6)
| DDx | Key Discriminator |
|---|---|
| 1. Otitis externa (if AOM is main Dx) or AOM (if OE is main Dx) | Tragal tenderness (OE) vs deep pain + bulging TM (AOM) |
| 2. Referred pain from TMJ dysfunction | Pain on chewing/yawning; no ear discharge; normal otoscopy |
| 3. Cholesteatoma / CSOM | Chronic foul-smelling discharge; marginal perforation on otoscopy |
(Adjust if stem suggests NPC, Ramsay Hunt, or mastoiditis)
| Domain | Example |
|---|---|
| Biological | Acute ear infection causing pain and possible conductive hearing loss |
| Psychological | Anxiety about hearing loss or underlying cancer (e.g. NPC) |
| Social/Functional | Sleep disturbance; inability to attend work/school; difficulty communicating |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| AOM | Bulging, erythematous tympanic membrane (TM) ± effusion on otoscopy [1][2] | Otoscopic examination of TM | Bulging red TM with loss of light reflex = middle ear inflammation/effusion |
| Otitis externa | Tenderness on tragal pressure or pinna traction [1][2] | Press tragus; gently pull pinna posterosuperiorly | Pain reproduced → inflamed ear canal (OE); NOT present in isolated AOM |
| Mastoiditis | Post-auricular swelling, erythema, tenderness; pinna pushed forward | Inspect & palpate behind the ear | Swelling over mastoid process = spread of infection from middle ear |
| Ramsay Hunt | Vesicles on auricle/EAC + ipsilateral LMN facial palsy [1][3] | Inspect pinna/EAC for vesicles; test facial nerve branches | Triad of otalgia + vesicles + facial palsy = VZV of CN VII |
| Cholesteatoma | Marginal/attic TM perforation with keratin debris on otoscopy [1] | Otoscopy with suction clearance if needed | Foul debris + marginal perforation = cholesteatoma until proven otherwise |
| NPC (referred) | Neck mass (Level II lymph node) + normal otoscopy; flexible nasopharyngoscopy needed [4] | Palpate bilateral cervical lymph nodes; nasopharyngoscopy for definitive | Painless upper neck mass in Southern Chinese + unilateral otalgia → NPC referral |
| TMJ dysfunction | Tenderness over TMJ; click/crepitus on jaw opening | Palpate TMJ while patient opens/closes mouth | Reproduces pain without ear canal pathology |
Must-Not-Miss Red Flags → Urgent Referral
- Post-auricular swelling/tenderness (mastoiditis) → urgent ENT
- Facial nerve palsy with ear symptoms → Ramsay Hunt (aciclovir within 72h) or malignant OE → urgent ENT
- Granulation tissue in EAC floor + DM → malignant (necrotizing) otitis externa → urgent ENT + IV antibiotics
- Unilateral serous otitis media in adult (especially Southern Chinese) → must exclude NPC by nasopharyngoscopy [4]
- Bloody post-nasal drip + unilateral ear blockage + neck mass → NPC until proven otherwise
Top traps that lose marks:
- Forgetting referred otalgia — up to 50% of adult ear pain is referred (TMJ, dental, cervical spine, NPC, pharyngeal pathology). Always ask about jaw, teeth, neck, nose.
- Not asking about DM in an elderly patient with severe OE → misses malignant OE.
- Confusing OE and AOM — the key discriminator is tragal tenderness / pain on pinna traction (OE) vs deep pain + bulging TM (AOM) [1][2].
- Missing Ramsay Hunt — vesicles may be subtle or inside EAC; always inspect and ask about facial weakness.
- Not screening for NPC in a Southern Chinese patient with unilateral otalgia + nasal symptoms.
- Forgetting ICE — the question "你最擔心係咩？" must be asked; it's a separate marks section.
- Leaving no safety-net — always give return criteria (worsening pain, facial weakness, high fever, hearing deterioration).
Shortest safe management/safety-net close: 「如果你之後發高燒、耳仔後面腫起嚟、塊面郁唔到、或者突然聽唔到嘢，要即刻返嚟急症室。」
High Yield Summary
What to ASK: SOCRATES of ear pain; discharge (character/smell); hearing/tinnitus/vertigo; preceding URTI; facial weakness; vesicles; nasal bleeding/obstruction; jaw/dental pain; DM; water/cotton bud exposure; FHx NPC; ICE + hidden agenda.
What to WRITE: CC with duration/side → HPI covering above → RFC as patient's real concern → ICE verbatim → Most likely Dx (AOM or OE) with supporting sign (bulging TM or tragal tenderness) → 3 DDx (the other of AOM/OE, TMJ dysfunction, cholesteatoma/NPC) → Biopsychosocial problems → Safety-net plan.
What NOT to MISS: Mastoiditis (post-auricular signs), malignant OE (DM + severe pain + granulation), Ramsay Hunt (vesicles + facial palsy), NPC referred otalgia (unilateral, Southern Chinese, nasal symptoms), cholesteatoma (chronic foul discharge).
Active Recall - Family Medicine Clinical Test
[1] GC 214. Common ear diseases and hearing loss.pdf [2] MBBS IV Clinical Skills Session Ear and Nose 2025 (1).pdf [3] GC 217. Facial nerve palsy and salivary gland diseases.pdf [4] GC 215. Common nasal conditions and nasopharyngeal carcinoma.pdf [5] Block A - Drugs and the Kidney.pdf (aminoglycoside ototoxicity)
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