Otalgia (Ear Pain)

Otalgia (Ear Pain): Excerpt from In A Page: Pediatric Signs and Symptoms

Not all ear pain is otologic; the ears have rich sensory innervation from multiple nerves, and secondary pain is common. Most otologic ear pain has some associated physical findings; if none is present, a complete head and neck examination, including imaging, may be required to search for a source of referred otalgia.

Differential Diagnosis

External ear

• Otitis externa
  –Pinnae and especially tragus, are exquisitely tender
• Impacted cerumen
  –Hearing loss and aural fullness
• Foreign body
  –Items such as beads, toys, and even extruded tympanostomy tubes
• Trauma
  –Any object inserted into the ear canal may cause trauma, including Q-tips
• Perichondritis
  –Inflammation or infection of the cartilage of the pinna and canal, sparing the lobule (since there is no cartilage there)
• Myringitis
  –Tympanic membrane granulation or de-epithelialization

Middle ear/mastoid
• Acute otitis media
  –Otalgia may precede middle ear effusion
• Otitis media with effusion
  –May occur in the absence or presence of an active infection
• Eustachian tube dysfunction
  –Negative intratympanic pressure
• Barotrauma
  –Pretreatment with topical nasal decongestants may be effective prophylaxis
• Mastoiditis
  –Associated with postauricular pain and normal tympanic membrane/middle ear

Non-otologic (secondary)
• Cranial nerve referred pain
  –III: Dental infection, temporal-mandibular joint (TMJ) syndrome
  –VII: Herpes zoster oticus (Ramsay Hunt syndrome)
  –IX: Tonsillitis, pharyngitis
  –X: Laryngitis, GERD, thyroiditis
• Cervical nerve referred pain
  –Neck infections, lymph nodes, cysts
  –Cervical spine disorders
• Paranasal sinusitis
• Migraines
• Neuralgias

Workup and Diagnosis

• History
  –Onset, duration, and specific quality of pain
  –Ability to localize (may distinguish otologic from nonotologic)
  –Associated otologic symptoms: Otorrhea, hearing loss, imbalance, prior ear surgery, antecedent events
  –Pain associated with mastication, swallowing, voice change, purulent rhinorrhea
• Otologic exam
  –Inspection and palpation of pinna, tragus, and preauricular area, and mastoid bone
  –Direct otoscopy for signs of external- or middle-ear infection or inflammation
  –Obstructing cerumen or foreign bodies must be removed to evaluate deeper structures
• Complete head and neck exam
  –Nose and nasal cavities, oral cavity, and pharynx (particularly teeth and tonsils), TMJ
  –Examination of nasopharynx and larynx may require fiberoptic endoscopy
• Tympanometry, if middle ear status (fluid, retraction, perforation) is not evident from otoscopy
• CT or MRI
  –Useful to delineate extent of cholesteatoma, mastoiditis, petrous apicitis, tumor
  –May be necessary to evaluate either otologic disease or an ill child with nonotologic source (rule out abscess or tumor)

Treatment

• Establish appropriate specific diagnosis as promptly as possible

• If infectious process, initiate antimicrobial therapy
  –Topical (intraotic) antibiotic drops for otitis externa or otitis media with either a perforation or patent tympanostomy tube
  –Systemic (oral) for otitis media, nonviral pharyngitis, sinusitis
  –Parenteral antibiotics for abscess, mastoiditis

• If odontogenic, dental referral
• Adequate follow-up to ensure resolution of otalgia

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Ear infection

• Back to disease: Ear infection: Introduction
• Next Book Extract About Ear infection: Hearing Loss – Acquired (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Hearing Loss – Acquired (In A Page: Pediatric Signs and Symptoms)

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• Hearing Loss – Acquired (In A Page: Pediatric Signs and Symptoms)
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