When to refer and red flags

Most patients who attend a pharmacy with ear pain or AOM will be unwell and have pain but are not severely ill. A few may attend who have symptoms suggesting more severe illness or who are at risk of severe disease. 

The most important requirement for pharmacists is to recognise severely ill patients and make sure they get urgent care. The PGDs may list rare or unusual causes of symptoms. Severe complications with AOM are rare. 

The following should be referred urgently (see also the clinical pathway and PGDs).

Call 999 or go straight to A&E

• Anyone identified with symptoms of severe/life-threatening infection or systemic sepsis
• Individuals with suspected meningitis (neck stiffness, photophobia, mottled skin)
• Individuals with suspected intracranial (brain) abscess (severe headache, confusion or irritability, muscle weakness) 
• Individuals with suspected sinus thrombosis (headache behind or around the eye(s))
• Individuals with suspected mastoiditis (pain, soreness, swelling, tenderness behind the affected ear(s))
• Individuals with facial nerve paralysis (drooping of the face). 

The PGDs also list the following (urgency will be determined by the person’s clinical condition). The list is not exhaustive:

• Systemically very unwell
• Signs of a more serious illness
• Individual at high risk of complications due to a pre-existing comorbidity (for example: children with significant heart, lung, kidney, liver or neuromuscular disease; severe immunosuppression or immunosuppression; cystic fibrosis; and young children born prematurely) 
• Otitis media with visible effusion (glue ear)
• Individuals with temperature over 39°C
• Individuals with cholesteatoma (this is a collection of epidermal and connective tissues within the middle ear; it can be locally invasive and destructive)
• Possible cancer: bloody/blood-stained discharge from ear(s)
• Known chronic kidney disease stages 4 or 5.