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.

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