Diseases » Earache

Earache

Earache: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics

Can be causedby external or middle ear pathology or by referred pain from another source.

According to Potsic (1997), 85% ofchildren with ear pain have infection; 7%, referred pain; 5%,middle ear effusion; and 3%, miscellaneous causes.

Principal Causes of Earache

1. Externalear including external auditory canal
   1. Infection/inflammation
      1. Otitisexterna
      2. Cellulitis
      3. Furuncle or abscess
      4. Perichondritis of the pinna
   2. Cerumen impaction
   3. Trauma
   4. Foreign body
   5. Neoplasm
2. Middle ear, eustachian tube, and mastoiddisorders
   1. Infection/inflammation
      1. Acuteand chronic otitis media
      2. Otitis media with effusion
      3. Mastoiditis
   2. Trauma
   3. Neoplasm
3. Referred ear pain from cranial nerves(V, VII, IX, X) or cervical nerves (C2, C3)
   1. Cranialnerve V
   2. Cranial nerve VII
   3. Cranial nerve IX
   4. Cranial nerve X
   5. Cervical nerves (C2 and C3)
4. Psychogenic

Clinical Features and Diagnosis

External Ear Including External Auditory Canal

Pain-sensitive structures of external earare skin and perichondrium of auricle and skin of external auditorycanal.

Infection/Inflammation

Otitis Externa

Producesinflamed, painful external auditory canal ± discharge.

Predisposingfactors include swimming, chronic otitis media with otorrhea, excessive cleaning,hearing aid use, and skin disorders (e.g., eczema).

Common pathogens include S. aureus,P. aeruginosa, and other gram-negative enteric bacteria. Fungalinfections with Aspergillus and Candida species are also common.

Culture of discharge is diagnostic.

Rare severe form is called invasive,necrotizing, or malignant otitis externa.

Usual pathogens are gram-negative entericbacteria, most commonly P. aeruginosa.

Has been reported in children withcancer, neutropenia, malnutrition, and immunosuppression.

Usual findings include ear pain, fever,otorrhea, and swelling of pinna. Tympanic membrane necrosis, ossiculardestruction, and involvement of temporal bone can occur.

CT shows extent of soft tissue andbone involvement.

Cellulitis

Inflammation of pinna or skin around earcan lead to cellulitis. Usual pathogens are S. aureus and groupA Streptococcus.

Furuncle or Abscess

S. aureusis pathogen most commonly responsible for furuncle or abscess, whichcan involve pinna, external auditory canal, or skin around ear.

Mass is tender, warm, and sometimesfluctuant.

Incision and drainage of abscess followedby Gram stain and culture are diagnostic.

Perichondritis of Pinna

Common causesof ear cartilage inflammation are trauma, burns, frostbite, or extensionof otitis externa.

Pinna is exquisitely tender and swollen.

Fluctuance may occur with bacterialperichondritis. Common pathogens are S. aureus and Pseudomonas species.Aspirate with Gram stain and culture may be diagnostic.

Cerumen Impaction

May causemild earache.

Impaction is readily visible by otoscopy,and earache resolves after its removal.

Trauma

Any traumato external ear may cause pain, swelling, and tenderness.

Hematoma of pinna may appear as purplish,boggy mass.

History and physical exam are diagnostic.

Foreign Body

Childrensometimes place beads, paper, erasers, cotton balls, and other smallobjects in external canal.

Ear pain, bleeding, and foul-smellingear discharge are frequent findings.

Otoscopy is diagnostic.

Neoplasm

Tumors ofexternal canal are usually visible, but extension can occur intomiddle ear, temporal bone, and temporomandibular joint.

Ear pain, otorrhea, and conductivehearing loss are common findings.

See Bellet et al. (1992) for discussionof tumors of external auditory canal.

Middle Ear, Eustachian Tube, and Mastoid Disorders

Infection/Inflammation

Acute and Chronic Otitis Media

Acute otitismedia is most common cause of ear pain in childhood.

Most common pathogens are S. pneumoniae,nontypeable H. influenzae, and M. catarrhalis. In infants <6wks of age, pathogens include S. aureus, group B Streptococcus,and gram-negative enteric bacteria (e.g., E. coli and P. aeruginosa).In some cases, respiratory syncytial virus, parainfluenza viruses, influenzaviruses, and enteroviruses can be cultured from middle ear fluid.

P. aeruginosa is most common causeof chronic otitis media, which involves nonintact tympanic membranewith either perforation or placement of tympanostomy tube.

Typically, child presents with upperrespiratory infection for 1–2 days and then develops ear pain.Nonspecific symptoms of acute otitis media in infancy include excessivecrying, irritability, vomiting, and diarrhea. Fever is variablefinding.

Visualization of tympanic membraneconfirms diagnosis. There is loss of or distortion of normal architectureof tympanic membrane, which appears opaque or bright red in color.Tympanic membrane loses its normal mobility with pus in middle earspace. With perforation of tympanic membrane, pus is seen in externalcanal. Large bulla or bullae (bullous myringitis) involving tympanicmembrane also signifies acute otitis media.

Acute otitis media is usually due tobacterial infection and requires antibiotic treatment. If resolutionof infection fails to occur after 2 or 3 courses of treatment withdifferent antibiotics, fluid should be drained and cultured.

Other indications for tympanocentesisor myringotomy and culture of middle ear fluid are critically illchild with otitis media, immunologically compromised child, or presenceof complication (e.g., facial paralysis or brain abscess).

Otitis Media with Effusion

Pathogenesisof persistent middle ear effusion is related to eustachian tubedysfunction. Predisposing factors include recurrent otitis media,enlarged adenoids and/or tonsils, allergic rhinitis, and,less commonly, nasopharyngeal tumors.

Sensation of ear discomfort or fullness,ear tugging, and irritability are frequent findings.

Otoscopic exam including pneumaticotoscopy usually confirms diagnosis. Retraction of tympanic membrane,air-fluid level, or bubbles in middle ear may be seen. Pneumaticotoscopy reveals decreased or absent mobility of tympanic membrane.If uncertainty exists about presence of effusion, tympanometry maybe diagnostic. This technique is more reliable in children who are≥6 mos of age.

Mastoiditis

Acute mastoiditisis usually complication of acute otitis media.

Same pathogens that cause acute otitismedia also cause mastoiditis. S. pneumoniae and nontypeable H. influenzaeare most common.

Usual findings include ear pain, postauricularswelling, tenderness over mastoid bone, and fever.

Radiographs of mastoid bone show evidenceof osteitis with destruction of bony trabeculae.

Chronic mastoiditis is usually complicationof chronic otitis media. S. aureus and gram-negative enteric bacteria(E. coli, P. aeruginosa, and Proteus species) are frequent pathogens.

Trauma

Acute headinjury may result in basilar skull fracture with hemotympanum. Ecchymosisbehind ear and in periorbital area may be seen.

Acute head injury or explosive blastalso can cause rupture of tympanic membrane and acute ear pain.

Injuries severe enough to rupture tympanicmembrane also can damage ossicular chain.

CT should be performed to determineextent of injury.

Barotrauma with sudden changes in middleear pressure sometimes occurs with flying in airplane or scuba diving.

In airplane,individuals experience positive middle ear pressure on ascent andnegative middle ear pressure on descent. Opposite happens in scubadiving.

If eustachian tube fails to open andequilibration of pressure fails to occur, negative pressure in middleear causes transudation of fluid, resulting in ear pain, conductivehearing loss, and sometimes bleeding.

Tympanic membrane also can rupture.Swallowing helps relieve pain by keeping eustachian tube open andenhancing pressure equilibration.

Neoplasm

Tumors arisingin middle ear or temporal bone are rare in pediatric population.

Conductive hearing loss, tinnitus,ear fullness, or facial nerve palsy may signal presence of middleear mass, which may or may not be visible by otoscopy.

Extension of tumor into external auditorycanal may produce otorrhea, whereas sensorineural hearing loss,tinnitus and vertigo may occur with inner ear involvement.

Temporal bone tumors may produce sensorineuralhearing loss, tinnitus, vertigo, and facial nerve palsy.

CT is initial imaging exam for massesin middle ear and temporal bone.

See Bellet et al. (1992) for discussionof tumors that arise in middle ear and temporal bone.

Referred Ear Pain from Cranial Nerves (V, VII, IX, X) orCervical Nerves (C2, C3)

Cranial Nerve V

Auriculotemporalbranch of mandibular division of trigeminal nerve (CN V) supplies tragus,anterior portion of auricle, anterior and superior auditory canalwalls, and anterior portion of tympanic membrane.

Pain from structures innervated bymaxillary and ophthalmic divisions of trigeminal nerve also canbe referred to those areas supplied by mandibular branch. Sinusitis,sialadenitis, parotitis, and tumors involving any of these areascan cause earache. Tooth (erupting teeth, impacted third molars,caries, dental abscess), gingival (gingivitis, stomatitis, aphthousulcers), jaw, and temporomandibular joint pain also can cause earpain.

Cranial Nerve VII

Sensoryportion of facial nerve (CN VII) supplies part of posterior wallof external auditory canal and posterior portion of tympanic membrane.

Herpes zoster can cause neuritis offacial nerve, with severe earache and vesicular eruption of auricle,external auditory canal, and occasionally tympanic membrane. Tumorsinvolving facial nerve during its intracranial or temporal bonecourse also can cause ear pain.

Cranial Nerve IX

Glossopharyngealnerve (CN IX) supplies pharynx, tonsils, nasopharynx, posterior one-thirdof tongue, and eustachian tube. Branch of this nerve supplies posteriorportion of external auditory canal and surface of tympanic membrane.

Ear pain can be due to lesions of oropharynx(pharyngitis, tonsillitis, foreign body, tumor, peritonsillar abscess,retropharyngeal abscess) and nasopharynx (nasopharyngitis, foreignbody, enlarged adenoids, tumor).

Cranial Nerve X

Sensoryfibers of vagus nerve (CN X) supply portion of posterior externalauditory canal and tympanic membrane. This nerve also supplies sensationto larynx, esophagus, trachea, and thyroid gland.

Although uncommonly seen in childhood,earache mediated by vagus nerve can be associated with lesions oflarynx (trauma, foreign body), esophagus (foreign body, causticburn), trachea (tracheitis), and thyroid gland (thyroiditis).

Cervical Nerves (C2 and C3)

Upper cervicalnerves, especially great auricular nerve, supply skin and musclesof neck as well as external ear and posterior auricular area.

Cervical lymphadenitis is common causeof ear pain. Unusual causes are infected branchial cyst and disordersof cervical spine (dislocation/subluxation, osteomyelitis,tumor).

Psychogenic

Ear painmay be psychogenic if otologic exam is normal and no lesion canbe found responsible for pain, including referred pain from cranialor cervical nerves.

Often these individuals have anxietyor depression.

Psychosocial history provides cluesto this diagnosis.

Diagnostic Approach

Most commoncauses of ear pain are acute and chronic otitis media, otitis externa, cerumenimpaction, foreign body, and trauma.

History and careful exam of externalear, external auditory canal, and middle ear are diagnostic. Ifexam of these structures is normal, possibility of referred earpain must be considered. Head, face, nose, mouth, pharynx, and neckshould be carefully examined.

Radiographs of temporal bone and mastoidregion, CT, and MRI are helpful in diagnosis of suspected neoplasmof external auditory canal, middle ear, mastoid, or temporal bone.

References

1. Arnett AM. Pain—earache. In:Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine,4th ed. Philadelphia: Lippincott Williams & Wilkins, 2000,453–458.
2. Bellet PS, et al. The evaluation of ear canal, middleear, temporal bone, and cerebellopontine angle masses in infants,children, and adolescents. Adv Pediatr 1992;39:167–205.
3. Benton C Jr, Bellet PS. The ear and temporal bone.In: Ball WS Jr, ed. Pediatric neuroradiology. Philadelphia: Lippincott-Raven,1997:607–669.
4. Bluestone CD, Klein JO. Otitis media in infants andchildren, 3rd ed. Philadelphia: WB Saunders, 2001.
5. Bluestone CD, et al., eds. Pediatric otolaryngology,3rd ed. Philadelphia: WB Saunders, 1996.
6. Cotton RT, Myer CM III, eds. Practical pediatric otolaryngology.Philadelphia: Lippincott-Raven, 1999.
7. Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
8. Heikkinen T, et al. Prevalence of various respiratoryviruses in the middle ear during acute otitis media. N Engl J Med1999;340:260–264.
9. Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
10. Pelton SI. Otoscopy for the diagnosis of otitis media.Pediatr Infect Dis J 1998;17:540–543.
11. Potsic WP. Earache. In: Schwartz MW, ed. Pediatricprimary care: a problem-oriented approach, 3rd ed. St. Louis: Mosby-YearBook, 1997:246–249.
12. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
13. Sarkkinen H, et al. Identification of respiratory virusantigens in middle ear fluids of children with acute otitis media.J Infect Dis 1985;151:444–448.
14. Tetzlaff TR, et al. Otitis media in children less than12 weeks of age. Pediatrics 1977;59:827–832.

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Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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