Earache/otitis stewardship workflow

Workflow for earache visits using analgesia-first care, complication screening, and age-aware escalation thresholds.

Medium-risk workflowLast reviewed September 4, 2026

AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Scope

Use for

Earache triage, with treatment thresholds for uncomplicated acute otitis media in children aged 6 months or older.

Not for

Mastoiditis concern, toxic appearance, or severe systemic instability.
Infants under 6 months, recurrent AOM, tympanostomy tubes, craniofacial abnormalities or immunocompromise need individualized care.

Examine the tympanic membrane and canal: AOM needs middle-ear effusion with acute inflammation, usually a bulging membrane; redness alone is insufficient.
Distinguish otitis externa and referred pain. Confirm age, pain severity, fever, duration, perforation and follow-up access.

Treat these as urgent. Escalate early if concern persists or follow-up is unreliable.

Arrange emergency assessment for mastoid swelling/tenderness, toxic appearance or neurologic signs.
Children under 6 months, immunocompromised patients, craniofacial abnormalities, tympanostomy tubes or recurrent AOM require a separate individualized pathway.

Provide analgesia with weight-appropriate dosing when treating children.
For uncomplicated AOM at 6 months or older, offer observation or a delayed prescription for mild illness when reassessment is reliable.
Treat promptly for perforation with purulent discharge, fever of 39 C or higher, moderate or severe systemic illness, severe otalgia or significant symptoms for at least 48 hours.
Amoxicillin is first line when indicated; check allergy and recent treatment. Purulent conjunctivitis or amoxicillin within 30 days may favour amoxicillin-clavulanate.
Usual duration is 5 days at age 2 years or older with uncomplicated disease; use 10 days under age 2, with perforation or initial treatment failure.

Reassess untreated AOM that fails to improve within 24-48 hours or worsens; start antibiotics when criteria are met.
Reassess antibiotic nonresponse after 48-72 hours; persistent effusion alone is not treatment failure.
Refer recurrent disease or ongoing hearing/developmental concerns.

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

Point to the red flags above that apply to this patient.
Confirm follow-up timing and where to go after hours.
Attach a relevant handout to reinforce the plan.
Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

Clinical owner: Family Medicine Editorial Team
Risk tier: Medium
Review cadence: Every 6 months
Last reviewed: September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.
Review status: Evidence current. Next review due March 4, 2027.