Earache

Any person, 4 weeks to 15 years, presenting with unilateral or bilateral earache.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Assess the external ear and post auricle surface for signs of inflammation Redness, swelling or pain over the mastoid process may indicate acute mastoiditis Escalate care, if indicated

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses

Glucose

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete an ear focused assessment.

Precautions and notes

• Do not accept acute otitis media as the sole diagnosis of a sick febrile young child. Look for other causes.
• Explain to the caregiver that in most cases acute otitis media (AOM) is a self-limiting condition, and usually resolves spontaneously in 2–3 days.

Interventions and diagnostics

Specific treatment

• Give regular pain relief.
• If discharge is evident, clean the external ear with tissue or gauze.
• Otitis externa is a painful condition requiring regular analgesia.

High-risk groups

The following high-risk groups require senior medical review and antibiotic therapy:

• Aboriginal or Torres Strait Islander
• infants less than 6 months old
• systemically unwell patients
• patient at high risk of complications, including the immunocompromised.

Foreign body

• Removing an object from the ear can be uncomfortable and distressing for the patient. Seek an experienced clinician to attempt removal, as the second attempt may require sedation and specialist services.

Live insect in the ear

• Do not undertake if the patient has grommets, or a suspected ruptured tympanic membrane.
• Direct the patient to lie on their side with the affected ear facing upwards.
• Gently instil olive oil into the affected ear.
• Continue to lay still for 15–20 minutes, as this will provide analgesia and drown the insect.
• Do not attempt to syringe the ear or attempt to remove the insect.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)

Consider non-pharmacological pain relief (appendix).

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au