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Ear Pain

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Ear Pain: Excerpt from In a Page: Signs and Symptoms

Ear pain is an extremely common presenting complaint in both primary care and otolaryngology practices. The description of the onset, character, and location of pain, along with a careful physical examination, identify most common causes of ear pain. Otitis media (infection/inflammation of the inner ear) and otitis externa (infection/inflammation of the ear canal) cause most ear pain. The vast majority of otitis media cases are caused by viruses; thus, deciding when to use antibiotics is a common medical issue.

Differential Diagnosis

  • Otitis media
    –Most cases are of viral origin
    –Red tympanic membrane with decreased mobility
    –Male > female; peak incidence 6–18 months
    –Risk factors include day care, supine bottle feeding, smoking in household, siblings with otitis media, anatomic abnormalities (e.g., Down's syndrome)
  • Eustachian tube dysfunction
    –Common in young children
  • Otitis externa
    –Pain upon movement of tragus
  • Malignant (necrotizing) otitis externa
    –Usually due to Pseudomonas –Mostly seen in diabetics
  • Referred pain
    –TMJ: May result in ear pain, jaw pain, neck pain, and/or headache
    –Dental infection, trauma, or orthodontic intervention (e.g., tightening of braces)
    –Pharyngitis or tonsillitis
    –Post-tonsillectomy/adenoidectomy
    –Retropharyngeal abscess and other ENT deep-space infections
    –Cervical adenitis
    –Sinusitis/rhinitis
    –Laryngitis
    –Trigeminal neuralgia
    –Esophagitis
    –Cervical spine arthritis
    –Parotiditis/sialoadenitis (including mumps)
    –Angina/acute coronary syndrome
  • Foreign body in ear canal (including impacted cerumen)
  • Reaction to topical agents
  • Trauma: Laceration, abrasion, barotrauma (e.g., deep sea diving, airplane)
  • Cellulitis
  • Tympanostomy tube obstruction
  • Myringitis bullosa
  • Furunculosis (localized abscess)
  • Varicella or herpes simplex/zoster infection in the ear canal
  • Mastoiditis
    –Ear protrudes anteriorly
  • Tumor
  • Eczema/psoriasis
  • Mumps

Workup and Diagnosis

  • History and physical examination, including otoscopic exam with pneumatic otoscopy and complete head and neck examination
    –Pain upon traction of pinna suggests otitis externa (hyperemic external canal)
    –Bulging, red, immobile tympanic membrane is consistent with acute otitis media (with or without otorrhea secondary to perforation)
    –Retracted, immobile tympanic membrane may be seen in serous otitis media
    –Mass lesion behind tympanic membrane suggests cholesteotoma or tumor
    –Tonsillar asymmetry or uvular deviation suggests peritonsillar abscess or mass
  • Tympanometry may reveal otitis media with effusion, eustachian tube dysfunction, or tympanostomy tube obstruction
  • Audiometry to evaluate for hearing loss
  • Consider culture of otorrhea if perforation (not canal) or complicated (e.g., recurrent infection, spread of infection such as meningitis or mastoiditis)
  • Lateral neck X-ray will diagnose retropharyngeal mass or abscess
  • Head CT is indicated if intracranial lesion or basilar skull fracture is suspected
  • Consider CBC and ESR if suspect malignant necrotizing otitis media
  • Check glucose in recurrent severe otitis externa

Treatment

  • If patient is in distress, immediately stabilize airway, breathing, and circulation
  • Pain control with acetaminophen, NSAIDs, warm compress, and topical benzocaine solution
    • Otitis media: Most patients with risk factors (e.g., persistent fever, immunocompromise) should be treated with appropriate antibiotics
      • –Serous otitis media that persists for >3 months may require a course of corticosteroids or myringotomy
    • Otitis externa: 8% aluminum acetate ±2% acetic acid (especially eczematous otitis externa), antibiotics, steroid drops
    • Malignant otitis externa: IV antipseudomonal or antistaphylococcal antibiotics
    • Cerumen and foreign bodies: Remove with a curette
    • Pharyngitis/tonsillitis: Appropriate antibiotics
    • Barotrauma: Pinch nose, then exhale with mouth closed to equalize pressure; decongestants
    • TMJ: NSAIDs, physical therapy, dental bite adjustment

Book Source Details

  • Book Title: In a Page: Signs and Symptoms
  • Author(s): Scott Kahan, Ellen G. Smith
  • Year of Publication: 2004
  • Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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  • ARM PAIN
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  • EYE PAIN
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  • HIP PAIN
  • "Differential Diagnosis in Primary Care" (2007)
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  • Arm pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Back pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Chest pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Eye pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Flank pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Jaw pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Leg pain
  • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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  • Neck pain
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  • Back Pain
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  • Chest Pain
  • "A Pocket Manual of Differential Diagnosis" (1999)
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  • Arm pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Back pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Chest pain
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  • Facial pain
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  • Flank pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Jaw pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Leg Pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Neck pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Rectal pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Throat pain
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Gum swelling
  • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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  • Arthralgia
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Chest Pain, Atypical
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Low Back Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Abdominal Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Calf Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Chronic Pelvic Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Hip Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Knee Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
  • [ read ]
  • Neck Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
  • [ read ]
  • Pleuritic Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
  • [ read ]
  • Shoulder Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Scrotal Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Eye Pain
  • "Field Guide to Bedside Diagnosis" (2007)
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  • Abdominal pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Back pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Chest pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Eye pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Flank pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Jaw pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Neck pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Scrotal swelling
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Arm pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Back pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Breast pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Chest pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Eye pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Facial pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Flank pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Jaw pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Leg pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Neck pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Rectal pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Throat pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Abdominal Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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  • Back Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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  • Chest Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
  • [ read ]
  • Arm pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Back pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Chest pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Flank pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Jaw pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Leg pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Neck pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • ARM PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
  • EYE PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
  • HIP PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
 

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.



More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X

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