Ear Pain

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.

More About Earache

• Back to disease: Earache: Introduction
• Next Book Extract About Earache: Otalgia (Ear Pain) (In A Page: Pediatric Signs and Symptoms)
• More Book Extracts: All Online Books for Earache

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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: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Otalgia (Ear Pain) (In A Page: Pediatric Signs and Symptoms)

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