He has pain when the auricle is pulled or the tragus is pushed

A 15-year-old boy has a 1-day history of pain in the right ear. He swims every morning. The right ear canal is red and swollen. He has pain when the auricle is pulled or the tragus is pushed. Which of the following is the most likely diagnosis?

1.Acute otitis media
2.Bullous myringitis
3.Chronic otitis media
4.External otitis


Ear pain worsened on manipulation, with inflammation of the canal (i.e. external ear) is most consistent with external otitis, colloquially known as “swimmer’s ear.”

Acute otitis media (1) is an infection of the middle ear that usually presents with earache unaffected by external manipulation, with a red, bulging tympanic membrane on exam. Patients are often febrile to 102 degrees F (38.9 degrees C) or more. Children under 7 are more susceptible to this condition due to their shorter, more horizontal pharyngotympanic (aka auditory or Eustachian) tubes.
Bullous myringitis (2) is an infection of the tympanic membrane ™ itself, in which bubbles filled with blood form on the TM surface.
Chronic otitis media (3) is incorrect both because of symptoms inconsistent with otitis media (see above), and the 1-day time course of the complaint is more suggestive of an acute process.
Mastoiditis (5) typically manifests with pain, tenderness, and/or swelling of the mastoid process. Further, such a short history of pain is inconsistent with mastoiditis, as it is usually a sequela of otitis media. Accordingly, children (not adolescents) are most frequently affected.