Earache

Earache: Excerpt from The 5-Minute Pediatric Consult

Laura N. Sinai, MD, MSCE

Earache - BASICS

Earache - description

• Primary otalgia refers to pain originating from the ear structures.
• Secondary otalgia is the sensation of ear pain as a result of referred pain from other areas of the head and neck. Secondary pain is referred through cranial and cervical nerves that share distributions with the ear.

Earache - etiology

• Primary otalgia:
  • Infectious: Acute otitis media, otitis externa, varicella virus, herpes simplex virus, cellulitis; furunculosis (localized abscess of cartilaginous portion of ear canal [outer 1/3]), mastoiditis, myringitis (inflammation and blisters on the tympanic membrane), perichondritis (inflammation of auricle without ear lobe involvement)
  • Trauma: Foreign body; lacerations, abrasions; blunt trauma; barotrauma (injury to middle ear arising from abrupt changes in pressure [e.g., from air travel, scuba diving]); thermal injury to auricle; caustic burns from hearing aid batteries
  • Tumor: Rare in pediatric patients but may involve any of the ear structures, including skin, bone, vascular, and neural components— rhabdomyosarcoma; lymphoma; pheochromocytoma
  • Allergic/inflammatory: Otitis media with effusion, eczema, psoriasis, allergic reaction to topical antibiotic and ceruminolytic agents
  • Functional: Eustachian tube dysfunction
  • Miscellaneous: Impacted cerumen, eosinophilic granuloma, Wegener granulomatosis, aural neuralgia (brief, sharp pain localized deep in ear without radiation; unknown cause)
• Secondary otalgia:
  • Infectious: Dental abscess, gingivitis, stomatitis such as herpes simplex or coxsackie virus, tonsillitis, peritonsillar abscess, retropharyngeal abscess, mumps, sinusitis, cervical adenitis, laryngitis, sialadenitis, Ramsay Hunt syndrome (viral neuritis of facial nerve secondary to herpes zoster)
  • Trauma: Dental trauma; penetrating injuries to the oropharynx; lacerations; post-tonsillectomy/ adenoidectomy; burn (caustic, thermal, or electrical); injuries to the neck and cervical spine, including fractures and muscle tension
  • Tumor: Oropharyngeal/laryngeal tumors, intracranial tumors (rarely will present with ear pain)
  • Allergic/inflammatory: Allergic rhinitis, cervical spine arthritis
  • Miscellaneous: Aphthous ulcers (canker sores), foreign body lodged in piriform sinus or esophagus, esophagitis, temporomandibular joint (TMJ) disease, migraine, thyroid inflammation, psychogenic (rarely), “pillow otalgia” (owing to sleep position)

Earache - DIAGNOSIS

Earache - signs & symptoms

Approach to the patient: General goals:

• The primary determination is whether the child needs acute/emergent treatment for life-threatening disease:
  • Ear pain may arise from disease involving almost any part of the head and neck; therefore, history taking and physical exam should be directed toward assessing symptoms from the entire region, not just the ear.
  • Preceding symptoms and a history of events leading up to the onset of pain are of particular importance, as there are classic historic features of many diseases of the ear (e.g., upper respiratory infection symptoms with acute otitis media, wrestling history with auricular disease, swimming history with otitis externa).
• Phase 1: Each encounter should begin with a careful history and physical exam. If ear exam does not reveal the cause of pain, thoroughly examine the entire head and neck region.
• Phase 2: An abnormal audiogram or tympanogram may help determine whether ear pathology is present when physical exam is normal.
• Phase 3: Referral to an otorhinolaryngologist (ORL) and/or dentist is indicated in cases of persistent ear pain without identifiable cause.

Earache - history

• Duration of symptoms:
  • Acute onset suggests recent trauma or infection.
• Severe pain is usually otogenic.
• Precipitating factors:
  • Pain increased with auricle movement is seen with otitis externa, furunculosis, perichondritis, and cellulitis.
  • Pain increased with jaw movement suggests TMJ disease or furunculosis.
• Associated symptoms that point to primary otalgia include aural discharge, deafness, tinnitus, and vertigo.
• Hoarseness suggests oropharyngeal or laryngeal pathology including infections, foreign body, and gastroesophageal reflux (GER).
• Choking/Coughing: Consider foreign body, mass, or GER.
• Location of additional pain or symptoms: If referred pain, patient will likely have symptoms at primary site as well.
• Fever suggests infectious cause.
• Trauma and barotrauma: Ask about recent ear cleaning, falls, accidents, air travel, diving.
• History of recurrent otitis media: Consider otitis media with effusion, cholesteatoma.

Earache - physical exam

• Intense pain elicited by traction on pinna suggests otitis externa or furunculosis.
• Areas of trauma: There may be an isolated abrasion or laceration; however, inspect carefully for hemotympanum, associated injuries, and evidence of a basilar skull fracture.
• Foreign bodies: May be isolated or associated with otitis externa; there are several case reports of foreign bodies found behind the intact tympanic membrane.
• Bulging, red, immobile tympanic membrane is consistent with acute otitis media.
• Retracted, immobile tympanic membrane suggests otitis media with effusion and eustachian tube dysfunction.
• Redness, swelling, or tenderness of auricle: With lobe involvement, may be seen with cellulitis; without lobe involvement, may be seen with perichondritis
• Laterally displaced auricle: Highly suggestive finding of mastoiditis
• Normal ear exam suggests secondary otalgia. Be sure to examine head and neck carefully (see subsequent findings).
• Dental caries: Multiple dental caries should raise suspicion of a possible dental abscess.
• Unilateral facial swelling is seen with dental abscess and parotitis.
• Vesicles on the auricle or in the ear canal suggest chickenpox and herpes simplex virus.
• Tonsillar asymmetry or uvular deviation from midline may represent peritonsillar cellulitis/abscess or mass.
• Assess facial nerve and other cranial nerve function: Bell palsy may be a complication of acute otitis media. Other cranial nerve dysfunction suggests possible intracranial lesion.
• Ear protrudes anteriorly: Present in mastoiditis, a complication of acute otitis media

Earache - tests

History and physical exam are usually sufficient to make the diagnosis:

• Audiometry: Assess for hearing loss suggestive of primary otalgia.
• Tympanometry: Useful in assessment of otitis media with effusion, eustachian tube dysfunction, and tympanostomy tube obstruction

Earache - lab

• Culture of aural discharge: Indicated when otitis externa or acute otitis media with perforation of the tympanic membrane does not resolve as expected with routine antibiotic usage
• Blood tests: Not routinely useful

Earache - imaging

• CT scan(s): Important if symptoms suggest retropharyngeal mass/abscess (neck), to rule out sinusitis in complicated cases (sinus study), or to further evaluate for mastoiditis (mastoid)
• MRI or CT scan of head: Rarely needed unless intracranial lesion suspected

Earache - TREATMENT

Earache - initial stabilization

• Disorders with potential to cause airway compromise (e.g., mass lesions, foreign bodies, abscess, penetrating injuries, posttonsillectomy complications):
  • Establish airway, breathing, and circulation (ABCs) as indicated.
  • Consult ORL.
  • Hospitalize.
• Trauma resulting in hearing loss, significant bleeding, or fractures:
  • Establish ABCs as indicated.
  • Promptly consult ORL.
  • Do not attempt to remove debris from ear if basilar skull fracture is suspected (may introduce bacteria).
  • Hospitalize as indicated.
• Infectious causes that cause toxic-appearing or “septic” child:
  • Establish ABCs as indicated.
  • Hospitalize and administer intravenous antibiotics.

Earache - general measures

Therapy is directed at the identified underlying cause.

Earache - medication

Pain medication, such as topical benzocaine for acute otitis media and acetaminophen or ibuprofen, is always important, as many of the infectious causes are exquisitely painful.

Earache - first line

Observation without antibiotic therapy is indicated in certain groups of children with acute otitis media.

Earache - FOLLOW UP

Varies depending on the underlying diagnosis

Earache - disposition

Earache - issues for referral

Alerts to make a referral to ORL when otalgia is primary in origin:

• Pain with unexplained hearing loss, vertigo, tinnitus
• Unexplained or persistent otorrhea
• Suspected neoplasm
• History suggestive of severe barotrauma
• Acute otitis media with complications
• Foreign bodies that cannot be removed easily from the ear
• Potential for auricle destruction (e.g., perichondritis may lead to permanent deformation, cauliflower ear)
• Persistent ear pain without an identifiable source should prompt ORL referral.

Earache - bibliography

1. Janvrin S. Middle ear pain and trauma during air travel. Clin Evid. 2002;7:466–468.
2. LeLiever WC. Nonotologic otalgia. JAMA. 1990;264:2302.
3. Leung AK, Fong JH, Leong AG. Otalgia in children. J Natl Med Assoc. 2000;92:254–260.
4. Licameli GR. Diagnosis and management of otalgia in the pediatric patient. Pediatr Ann. 1999;28:364–368.
5. Yellon R. The spectrum of reflux-associated otolaryngologic problems in infants and children. Am J Med. 1997;103:125S–129S.
6. Zenian J. Pillow otalgia. Arch Otolaryngol Head Neck Surg. 2001;127:1288.

Earache - CODES

Earache - icd9

• 388.70 Ear ache
• 388.71 Otogenic
• 388.72 Referred

Earache - FAQ

• Q: Which nerves are involved in referred pain to the ear?
• A: Sensory innervation of the ear arises from branches of cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and X (vagus) as well as cranial nerves II and III.
• Q: What is the most common source of referred ear pain?
• A: Dental disease
• Q: What are the most common organisms in otitis externa?
• A: Pseudomonas aeruginosa, Staphylococcus aureus,Staphylococcus epidermidis, Strep tococci, Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, Candida, Aspergillus
• Q: What are the most common organisms in acute otitis media?
• A: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, viral agents

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Earache

• Back to disease: Earache: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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