Ear Pain

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Chapter 12 Ear Pain

Joan E. Shook, MD, MBA

1 What is the most common cause of ear pain in the young child?

Ear pain (otalgia) is a common symptom in the pediatric emergency department (ED). While the differential diagnosis for otalgia is lengthy, the most common cause of ear pain is acute otitis media (AOM). AOM is caused by an acute bacterial (or occasionally viral) infection resulting in inflammation of the middle ear that is usually associated with pain and fever. The peak age for AOM is 3–16 months of life, but it may occur at any time.

Arnett AM: Pain—earache. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

Elden LM, Potsic W: Otolaryngologic emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1663–1678.

2 What three elements must be in place to make a diagnosis of otitis media?

image Recent, usually abrupt onset of signs and symptoms of middle ear infection (such as pain, irritability, fever, otorrhea)

image Presence of middle ear effusion

image Signs of middle ear inflammation

American Academy of Family Physicians: Practice Guidelines: AAP, AAFP Release Guideline on Diagnosis and Management of Acute Otitis Media. www.aafp.org/afp/20040601/practice.html

3 What findings confirm the presence of a middle ear effusion?

Bulging of the tympanic membrane (TM) or limited or absent mobility of the TM with pneumatic otoscopy or air-fluid level behind the TM or otorrhea.

American Academy of Pediatrics, Subcommittee on Otitis Media with Effusion: Otitis media with effusion. Pediatrics 113:1412–1429, 2004.

American Academy of Family Physicians. www.aafp.org

American Academy of Pediatrics: Diagnosis and Management of Acute Otitis Media.

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1451

4 What signs or symptoms suggest middle ear inflammation?

Erythema of the TM or distinct otalgia that results in change in normal activity or sleep.

Dolitsky JN: Otalgia. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, vol. I, 3rd ed. Philadelphia, W.B. Saunders, 1996, pp 235–241.

5 What are the most common bacterial pathogens that cause otitis media?

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial organisms that cause otitis media. While these pathogens predominate at all ages, in infants younger than 1 month of age, Staphylococcus aureus and gram-negative enteric bacilli account for 15–20% of the infections. The majority of H. influenzae organisms are nontypeable, although type B may be seen.

6 How would you treat bacterial otitis media?

Uncomplicated otitis media in the child over 1 month of age should be treated with oral antibiotics on an outpatient basis. Amoxicillin (80 mg/kg per day in two or three divided doses) is the drug of choice. Alternatives to amoxicillin include amoxicillin–clavulanic acid in a 7:1 formulation (amoxicillin, 45 mg/kg per day, in two divided doses), cefuroxime axetil, cefdinir, and cefpodoxime, or azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole in the penicillin-allergic patient. If the patient is vomiting or is nonadherent with medications, a single dose of ceftriaxone (50 mg/kg) is also effective. Infants younger than 4 weeks old are usually treated with IV medications (ampicillin and gentamicin).

Elden LM, Potsic W: Otolaryngologic emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, 1663–1678.

Klein JO, Bluestone CD: Otitis media. In Feigin RD, Cherry JD (eds): Textbook of Pediatric Infectious Diseases, 5th ed. Philadelphia, W.B. Saunders Co., pp 215–235, 2004.

American Academy of Pediatrics Online Learning in Otitis Media: www.aap.org/otitismedia

Klein JO: Epidemiology, pathogenesis, diagnosis and complications of acute otitis media:

www.uptodateonline.com

Pelton SI: Otitis media: Re-evaluation of diagnosis and treatment in the era of antimicrobial resistance pneumococcal conjugate vaccine, and evolving morbidity. Pediatr Clin North Am 52:711–728, 2005.

7 What analgesics are recommended for treatment of ear pain resulting from acute otitis media?

Acetaminophen and ibuprofen are generally effective in relieving pain from otitis media. Topical therapy with Auralgan otic solution is used for children with severe pain or irritable infants. A few drops placed in the ear canal until it is filled often relieves pain promptly. Auralgan contains antipyrine, benzocaine, and glycerin.

Arnett AM: Pain-earache. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

8 What is bullous myringitis? How is the diagnosis made?

Bullous myringitis is an infection of the TM with intensely painful bulla formation on the surface. The diagnosis is made easily by otoscopy. S. pneumoniae and H. influenzae are the most common pathogens, although Mycoplasma sp. has also been implicated. Antibiotic choices for this entity include azithromycin or erythromycin–sulfisoxazole (Pediazole).

Elden LM, Potsic W: Otolaryngologic emergencies. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, 1663–1678.

McCormick DP, Saeed KA, Pittman C, et al: Bullous myringitis: A case-control study. Pediatrics 112:982–986, 2003.

9 You are evaluating a patient who presents with ear pain. On taking the history, you learn that the illness began with itchiness of the ear canal, which has become increasingly severe and evolved into pain. What is the most likely diagnosis in this child?

This presentation is classic for otitis externa, which is also known as swimmer’s ear. Otitis externa is an inflammatory process affecting the external auditory canal. It is most commonly seen during the summer because of increased swimming. Other predisposing factors include moisture retention due to a tortuous narrow canal or obstructive cerumen, loss of acidic environment due to inadequate cerumen lavage, exposure to alkaline substance, or interruption of the epithelial lining of the canal because of trauma or dermatitis.

Physical examination of these patients is significant for the pain that can be elicited by pushing on the tragus or by traction of the pinna or moving the jaw side to side. Frequently, debris or exudates line the external canal and possibly cover the TM. The most common causative organism is Pseudomonas sp. Staphylococcus, Streptococcus, or Proteus spp. may also be seen in association with Pseudomonas.

Dolitsky JN: Otalgia. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, vol. I, 3rd ed. Philadelphia, W.B. Saunders Co., 1996, pp 235–241.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North A 36:1137–1151, 2003.

10 How is otitis externa treated?

Treatment of otitis externa involves a thorough, gentle cleaning of the ear canal and instillation of an acidic solution (e.g., otic Domeboro or Vosol), a combination antibiotic–corticosteroid preparation (e.g., Cortisporin), or antibiotic drops alone (e.g., ofloxacin otic solution 0.3%, a good choice because it covers Pseudomonas sp. well). When severe edema of the canal does not allow instillation of the medications, a wick may be placed to facilitate medication delivery. If a wick is used, it should be removed every 24–48 hours and the external canal inspected and cleaned. Oral antibiotics are added for patients who are improving slowly with local treatment, have a concurrent middle ear infection, or are immunocompromised.

Dolitsky JN: Otalgia. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, Vol. I, 3rd ed. Philadelphia, W.B. Saunders, 1996, pp 235–241.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

11 What is malignant otitis externa?

It is a severe form of otitis externa that is not responsive to conventional therapy. It is caused by P. aeruginosa and involves the bone and marrow of the skull base and may also result in chondritis and facial nerve paralysis. Complications may include stenosis of the canal and permanent hearing loss. It is rare in children but is seen in patients with diabetes mellitus or those who are immunocompromised.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

12 A toddler presents with bruising to the internal surface of the pinna. According to the mother, he is a very active child and falls frequently. What diagnosis should you consider?

Bruising to the internal surface of the pinna may result from “boxing” the ear. You therefore must consider the possibility of child abuse. The unexplained presence of hemotympanum and the perforation of the TM may also suggest child abuse because they can result from a direct blow to the ear.

Licameli GR: Diagnosis and management of otalgia in the pediatric patient. Pediatr Ann 28:364–368, 1999.

Monteleone JA, Brodeur AE: Identifying, interpreting and reporting injuries. In Monteleone JA, Brodeur AE (eds): Child Maltreatment. St. Louis, GW Medical Publishing, 1994, pp 10–11.

13 Infections at the site of ear piercing are often extremely painful and cause some concern. What organisms should you consider covering when you choose an antibiotic?

Infections of the pinna are usually caused by S. aureus or Pseudomonas sp. Infection of the cartilage is of particular concern and should be treated aggressively with IV antibiotics.

Arnett AM: Pain-earache. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

14 You are examining a child who came to the ED because of fever and ear pain. You notice that his ear is red and swollen and seems to be protruding from the side of his head. What diagnosis should you be entertaining?

This child likely has mastoiditis, a relatively uncommon complication of otitis media. On physical examination the posterior auricular area is erythematous and very tender. It is important to visualize the TM because severe otitis externa also can present with postauricular erythema, swelling, and protrusion of the pinna. In mastoiditis, the TM is erythematous and bulging, while with otitis externa, the TM is usually normal. Computed tomography can help differentiate between mastoiditis and severe otitis externa when a complete physical examination is not possible.

Elden LM, Potsic W: Otolaryngologic emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1663–1678.

Klein JO, Bluestone CD: Otitis media. In Feigin RD, Cherry JD (eds): Textbook of Pediatric Infectious Diseases, 5th ed. Philadelphia, W.B. Saunders Co., 2004, pp 215–235.

Klein JO: Epidemiology, pathogenesis, diagnosis and complications of acute otitis media:

www.uptodateonline.com

15 How is mastoiditis treated?

Children with mastoiditis must be evaluated by an otolaryngologist and admitted to the hospital for IV antibiotics. Since the most common organisms in acute mastoiditis are Staphylococcus spp., Streptococcus spp., and H. influenzae, the patient should be treated with clindamycin or vancomycin and cefotaxime. Operative intervention may be required in children with complicated infection or evidence of abscess formation.

Klein JO, Bluestone CD: Otitis media. In Feigin RD, Cherry JD (eds): Textbook of Pediatric Infectious Diseases, 5th ed. Philadelphia, W.B. Saunders Co., 2004, pp 215–235.

16 What are the potential complications of mastoiditis?

Complications of mastoiditis can be intratemporal or intracranial. Intratemporal complications include facial paralysis, labyrinthitis, and Gradenigo syndrome (retro-orbital pain, otorrhea, and diplopia). Intracranial complications include meningitis; lateral sinus thrombosis; and epidural, subdural, or brain abscesses. Children with intracranial complications usually appear toxic in addition to exhibiting local findings.

Elden LM, Potsic W: Otolaryngologic emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1663–1678.

Klein JO, Bluestone CD: Otitis media. In Feigin RD, Cherry JD (eds): Textbook of Pediatric Infectious Diseases, 5th ed. Philadelphia, W.B. Saunders, 2004, pp 215–235.

17 The presence of a foreign body in the external auditory canal can cause severe pain. What is the best method for removing the foreign body?

Occasionally a child places a foreign body in the external canal and presents with symptoms such as hearing loss or a sensation of fullness, as well as ear pain. Symptoms at presentation vary depending on the nature of the foreign material and the length of time that it has been present. Objects can be removed by using alligator forceps, curettes, right-angle hooks, Baron suction devices, or irrigation with warm water. If the foreign body is a bean or other vegetable material, do not irrigate with water because the foreign body may swell. A foreign object that is lodged tightly in the canal may require removal under sedation or even general anesthesia using an operating microscope. Canal wall lacerations are present 50% of the time after a foreign-body removal, so it is recommended that after the object is recovered, the patient be treated with topical antibiotic or steroid drops to prevent the development of otitis externa.

Bressler K, Shelton C: Ear foreign-body removal: A review of 98 consecutive cases. Laryngoscope 103:367–370, 1993.

18 You have just examined a child who has a hearing aid battery in her external auditory canal. You have not been successful in your attempts to remove it with forceps. What should your next step be?

Hearing aid batteries can cause extensive caustic skin and bony damage in a short period of time. Removal of this foreign object is an otologic emergency and should be performed as soon as possible after detection. If you are unable to remove the battery, an otolaryngologist should be called for removal in the operating room.

Bressler K, Shelton C: Ear foreign-body removal: A review of 98 consecutive cases. Laryngoscope 103:367–370, 1993.

Key Points: Ear Pain

1 Ear pain in the child is most commonly due to acute otitis media.

2 To diagnose acute otitis media, one must demonstrate the presence of fluid in the middle ear by pneumatic otoscopy.

3 If the examination of the ear is normal, consider secondary (referred) causes of otalgia, including temporomandibular joint syndrome, dental pathology, and gastroesophageal reflux.

4 Hemotympanum is a rare finding that can result from a basilar skull fracture, barotrauma from scuba diving, a turbulent airplane flight, or a direct blow to the ear. In the absence of a history, child abuse should be entertained as an etiology.

19 A child presents with severe ear pain of sudden onset. You determine there is a live insect, most likely a roach, moving in the ear canal. How should you manage this patient to relieve pain quickly?

Before attempting to remove the insect, immediately place mineral oil or viscous lidocaine in the ear canal. This will “paralyze” the insect and relieve pain promptly. The foreign body can then be removed with an ear curette or by flushing the canal with water.

Leffler S, Cheney P, Tandberg D: Chemical immobilization and killing of intra-aural roaches: An in vitro comparative study. Ann Emerg Med 22:1795–1798, 1993.

Su E: External auditory canal foreign bodies. In Dieckmann RA, Fiser DH, Selbst SM (eds): Illustrated Textbook of Pediatric Emergency and Critical Care Procedures. St. Louis, Mosby, 1997, pp 712–713.

20 Explain how swimming in the ocean can result in a ruptured TM and subsequent ear pain.

A direct blow to the side of the face by a wave or a hand may result in rupture of the TM and severe otalgia.

Vernick DM: Ear barotrauma: www.uptodateonline.com

21 Barotrauma as a result of flying or scuba diving may result in acute, severe otalgia with possible hearing loss and tinnitus. What findings on otoscopic evaluation are most consistent with barotrauma?

Otoscopy usually reveals a thickened, hemorrhagic TM and a middle ear effusion. Treatment for this condition is supportive with analgesics.

Vernick DM: Ear barotrauma: www.uptodateonline.com

22 As your patient leaves the examination room, his mother asks you whether it is safe for him to fly in an airplane even though he recently had pressure equalization tubes placed. How do you answer her?

Children with pressure equalization tubes can fly safely because the pressure equalization in the middle ear takes place without relying on the function of the eustachian tube.

Vernick DM: Ear barotrauma: www.uptodateonline.com

23 You are confronted with a patient who reports ear pain and yet has a normal examination of the ear. How can this phenomenon be explained?

Otalgia can be the result of referred pain from distant sites secondary to inflammatory processes, tumors, or mechanical disturbances. Nonotogenic otalgia is most often of dental origin; however, pain that is perceived in either the external or the middle ear can be referred via cranial nerves V, VI, IX, and X and upper cervical nerves. These nerves supply the nasal sinus area, oral cavity and teeth, oropharynx, hypopharynx, larynx, and upper esophagus. Remember to search for distant sites of origin when examination of the ear is unrevealing.

Arnett AM: Pain-earache. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

24 Name some nonotogenic etiologies of pain in the ear. Name the nerve that carries the sensation.

image Cranial nerve V: Disturbances in the oral cavity, including stomatitis, gingivitis, trauma, and infections of the tongue; dental conditions, including eruption, impaction, trauma, caries, and abscess

image Cranial nerve VI: Bell’s palsy, herpes zoster, tumors

image Cranial nerve IX: Tonsillitis and retropharyngeal abscess or nasopharynx, including foreign body or infection

image Cranial nerve X: Lesions at the base of the tongue, trachea, larynx, and esophagus; otalgia can be a manifestation of gastroesophageal reflux in infants and children

image Upper cervical nerves: Lymphadenitis, infected cysts, c-spine injuries

Arnett AM: Pain-earache. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

25 What is Ramsay-Hunt syndrome?

This is the eponym applied to herpes zoster otitis. Vesicles on the pinna, external auditory canal, and TM characterize the syndrome, and it is exquisitely painful. It can be complicated by hearing loss, nausea, vomiting, dizziness, facial nerve involvement, and ataxia. Treatment is with acyclovir and analgesics.

Arnett AM: Pain-earache. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 505–518.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

26 Temporomandibular joint (TMJ) dysfunction is one of the most common causes of referred otalgia. How can I confirm this as a source of ear pain?

To confirm the diagnosis of TMJ dysfunction, carefully palpate the TMJ externally by placing the fingers just anterior to the tragus and having the patient open and close the mouth. The patient will report otalgia during attempted occlusion. The pain may be caused by nerve irritation, muscle spasm, or degenerative change in the joint. TMJ dysfunction can occur in children who have bruxism, frequently clench their teeth, indulge in frequent gum chewing, or have malocclusion. Tympanometry in these patients is normal. Treatment is directed at reducing the inflammation and pain with heat therapy, soft diet, and analgesia.

Kramer II, Kramer CM: The phantom earache. Temporomandibular joint dysfunction in children. Am J Dis Child 139:943–945, 1985.

Shah RK, Blevins N: Otalgia. Otolaryngol Clin North Am 36:1137–1151, 2003.

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