Diagnosis of Earache
Earache Diagnosis: Book Excerpts
Diagnostic Tests for Earache: Online Medical Books
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EARACHE:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there abnormalities on the ear examination? The ear examination may reveal severe otitis externa, an epithelioma of the pinna, a foreign body, or impacted wax. It may also show inflammation and bulging of the eardrum. A vesicular rash of the drum and external auditory canal may indicate herpes zoster.
- Is there pain on moving the pinna? Pain on moving the ear suggests otitis externa, foreign body, impacted wax, or keratosis obturans.
- Is there hearing loss? Hearing loss with an abnormal drum would suggest serous or bacterial otitis media. It may also suggest a cholesteatoma. Hearing loss with a normal ear exam suggests aero-otitis.
- Could the pain be a referred pain? Dental caries, dental abscesses, impacted teeth, tonsillitis, and temporomandibular joint syndrome may refer pain to the ear.
DIAGNOSTIC WORKUP
It should go without saying that diagnosis begins with an adequate otoscopic examination. If the drum is obscured by wax, gentle lavage after using Cerumenex will usually clear the canal. If there is an exudate, a culture and sensitivity should be ordered. Perhaps a throat culture should be done also. X-rays of the mastoids and petrous bones should be done if the exudate is believed to be from a deeper source. Perhaps a CT scan is also needed. If there is hearing loss, an audiogram needs to be done and a tympanogram will be useful in diagnosing serous otitis media. A trial of carbamazepine (Tegretol®) or phenytoin (Dilantin®) may be useful in diagnosing glossopharyngeal neuralgia or tic douloureux. If the discharge is thought to be cerebrospinal fluid, a CT scan and RISA study should be done.
Referral to an ear, nose, and throat specialist or neurologist should be considered before ordering expensive diagnostic tests.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Otorrhea:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Otitis externa (swimmer's ear)
–Most common source of otorrhea
–Usually associated with water contamination or cotton swab abuse
–Pain with movement of pinna
–Usually secondary to Pseudomonas or
Staphylococcus infection
- Malignant otitis externa
–Also known as necrotizing external otitis and skull base osteomyelitis
–Suspect in patients with diabetes or immunosuppression who present with persistent otorrhea, ear pain, and granulation tissue in the ear canal
–Usually secondary to Pseudomonas
-
Foreign body
–Frequently a retained cotton swab
–Often occurs in toddlers
-
Otitis media (acute or chronic) with perforated tympanic membrane
- Cholesteatoma
–A skin-lined cyst of the middle ear or mastoid that occurs secondary to chronic otitis media
–In most cases there is fullness, bulging, or a white mass of the tympanic membrane (may easily be confused with ear wax)
- Mastoiditis
–Tenderness or bogginess over mastoid
- Cerebrospinal fluid otorrhea
–Clear, colorless discharge through a tympanic membrane perforation or tympanostomy tube
–Patients usually have a history of trauma or surgery, but CSF otorrhea may occasionally be spontaneous
Workup and Diagnosis
- History should focus on onset, duration, appearance of discharge, associated symptoms, activity history (e.g., swimming), and past history (e.g., frequent otitis, tympanostomy tubes, diabetes)
- A thorough cleaning of the ear canal under direct visualization (with magnification is ideal) with a curette or suction is necessary to determine the source of discharge
–The presence or absence of tympanic membrane pathology must be determined
–The absence of tympanic membrane pathology usually signifies that the source of otorrhea is limited to the external ear canal
–Unless the ear canal is cleaned with suction, many pathologies will not be identified
–Ear lavage should be avoided in the presence of otorrhea
-
Ear cultures from the canal may be helpful in persistent cases; however, contamination by normal ear canal flora usually decreases their value
-
If CSF otorrhea is suspected, an assay for β2 transferrin will identify CSF from other fluids
-
CT of the temporal bones is helpful in evaluation of patients with suspected cholesteatoma, mastoiditis, and CSF otorrhea
-
Gallium and technetium scans may be helpful in patients with malignant external otitis
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Source: In a Page: Signs and Symptoms, 2004
Ear Pain:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- 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
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Source: In a Page: Signs and Symptoms, 2004
Otalgia (Ear Pain):
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
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)
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Source: In A Page: Pediatric Signs and Symptoms, 2007
Otorrhea (Ear Discharge):
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Cerumen
–Often brownish color
–Rarely associated with otalgia or pruritis
- Otitis externa
–Bacterial (frequently Pseudomonas and Staphylococcus aureus) vs fungal (especially after prolonged treatment with antibiotic drops)
–Concern: Necrotizing (malignant) otitis externa (i.e., temporal bone osteomyelitis) in immunosuppressed patients, including brittle diabetics
-
Acute otitis media with tympanic membrane (TM) perforation
–Acute perforation may already have closed by the time the patient is examined
-
Chronic perforation drainage
–From water contamination (swimming, bathing) if patient is not maintaining dry ear precautions (ear plugs, occlusive head bands, shower caps, etc.)
-
Tympanostomy tube drainage
–If bloody, suspect granulation tissue surrounding the tube
–Increased incidence when not maintaining dry ear precautions is debated (as small tube lumen diameter has considerable surface tension)
-
Chronic suppurative otitis media
–Chronic middle ear and/or mastoid infection with perforated TM
-
Cholesteatoma
–“Skin cyst” (keratinizing stratified squamous epithelium) in the middle ear/mastoid
–Benign, but often very aggressively locally
erosive (mechanical and enzymatic)
–Surgical, not medical, condition
-
Perichondritis
–Spares the lobule (as there is no cartilage there)
-
Myringitis
–TM granulation or de-epithelialization
-
Foreign body
-
CSF leak
–Watery drainage
–Traumatic or congenital
–With or without perilymphatic fistula
-
Primary dermatologic condition
–Eczema, psoriasis
Workup and Diagnosis
- History
–Quality of otorrhea: Malodorous and purulent (infectious) vs bloody (traumatic, granulation tissue) vs clear and watery (CSF)
–Associated symptoms: Pain and tenderness in acute otitis externa, aural pruritus in chronic or fungal otitis externa
–Past medical/surgical history: Prior tympanostomy tubes, middle ear surgery (cholesteatoma), trauma or neurosurgery (CSF leak); dermatologic disease
- Physical exam
–Must suction and debride the ear canal of debris to examine tympanic membrane
–If canal is too narrow from swelling to see the tympanic membrane, place hydrocellulose wick to draw ototopical medication to affected areas; reexamine in several days
–Visualize after suctioning (through otoscope) if source is external or middle ear
-
Labs
–Gram stain and culture specimen of otorrhea if diagnosis is in question, if patient is initially systemically symptomatic (febrile or other complications), or if patient fails initial treatment
-
Imaging studies
–CT scan of temporal bone (noncontrast, 1-mm slice thickness) if cholesteatoma or trauma is suspected
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Source: In A Page: Pediatric Signs and Symptoms, 2007
EARACHE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis requires ear, nose, and throat examination, culture of any discharge, x-ray film of the mastoids, petrous bone, temporomandibular (TM) joints, and, in some cases, the sinuses and teeth. A careful neurologic examination is necessary in unexplained otalgia. Referral to an otolaryngologist or neurologist is probably best for the busy physician who is unable to find the cause on a routine examination.
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Source: Differential Diagnosis in Primary Care, 2007
AURAL DISCHARGE (OTORRHEA):
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.
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Source: Differential Diagnosis in Primary Care, 2007
Otorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin your evaluation by asking the patient when otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.
Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.
Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.
Focus the physical examination on the patient’s external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first as not to cross-contaminate.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.
Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn’t read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform Weber’s and the Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 316.)
Complete your assessment by palpating the patient’s neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Earache:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of ear pain? Does he have pain in other areas such as the jaw? Does he experience any associated hearing loss?
Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noise in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?
Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.
Find out if the patient has flown, been to a high-altitude location, or been scuba diving.
Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.)
Perform the watch tick, whispered voice, Rinne, and Weber's tests to assess for hearing loss.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Otorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin your evaluation by asking the patient when the otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.
Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.
Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.
Focus the physical examination on the patient’s external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first as not to cross-contaminate.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.
Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn’t read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform the Weber and Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 397.)
Complete your assessment by palpating the patient’s neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Earache [Otalgia]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of the pain? Does he have pain in any other areas, such as the jaw?
Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noises in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?
Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.
Finally, find out if the patient has recently flown, been to a high-altitude location, or been scuba diving.
Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit any tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.) Perform the watch tick, whispered voice, Rinne, and Weber’s tests to assess for hearing loss.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Ear Pain/Discharge:
Differential Overview
(Field Guide to Bedside Diagnosis)
Ear Pain
❑ Acute otitis media
❑ Acute otitis externa
❑ Eustachian dysfunction
❑ Temporomandibular joint arthritis
❑ Traumatic tympanic membrane rupture
❑ Foreign body, external auditory canal
❑ Erysipelas
❑ Herpes zoster oticus
❑ Dental abscess
❑ Frostbite
❑ Relapsing polychondritis
❑ Malignant otitis externa
❑ Acute mastoiditis
❑ Nasopharyngeal cancer
Ear Discharge
❑ Otitis externa
❑ Eczematoid dermatitis
❑ Low-viscosity cerumen
❑ Otitis media with perforation
❑ Foreign body
❑ Psoriasis
❑ Herpes zoster oticus
Diagnostic Approach
If ear pain is present without ear findings, consider referred pain from the tonsils, teeth, trachea, or temporomandibular joint. Ear pain may be an early sign of nasopharyngeal carcinoma. Lesions of the anterior portion of the tongue refer pain in front of the ear whereas the posterior one-third of the tongue refers pain to within the ear.
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Source: Field Guide to Bedside Diagnosis, 2007
Otorrhea:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin your evaluation by asking the patient when the otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.
Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.
Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Earache:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to characterize the earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he pinpoint the site of the ear pain? Does he have pain in any other areas such as the jaw?
Also ask the patient about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noises in his ears? Ask about dizziness or vertigo. Do these symptoms worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?
Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves. Also find out if the patient has recently flown, been to a high altitude location, or been scuba diving.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Earache:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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. >
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Otorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin your evaluation by asking the patient when otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.
Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.
Next, check the patient's medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he's an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.
Focus the physical examination on the patient's external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first to avoid cross-contamination.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.
Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn't read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform Weber's and the Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 304.)
Complete your assessment by palpating the patient's neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Earache [Otalgia]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of ear pain? Does he have pain in other areas such as the jaw? Does he experience any associated hearing loss?
Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noise in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?
Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.
Find out if the patient has flown, been to a high-altitude location, or been scuba diving.
Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.) Perform the watch tick, whispered voice, Rinne, and Weber's tests to assess for hearing loss.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
AURAL DISCHARGE (OTORRHEA):
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of an aural discharge is similar to the
approach for discharges from any body orifice. After careful examination for
a foreign body or obstruction, the discharge is cultured and appropriate
therapy begun. A gram stain of the material often aids in the determination
of the most appropriate antibiotic. If the discharge is chronic, x-rays of
the mastoids and petrous bones may be necessary, as well as tomography.
Obviously, referral to an otolaryngologist is wise at this point.
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Source: Differential Diagnosis in Primary Care, 2007
EARACHE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis requires ear, nose, and throat
examination; culture of any discharge; and x-ray film of the mastoids,
petrous bone, TMJs; and, in some cases, the sinuses and teeth. A careful
neurologic examination is necessary in unexplained otalgia. Referral to an
otolaryngologist or neurologist is probably best for the busy physician who
is unable to find the cause on a routine examination.
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Source: Differential Diagnosis in Primary Care, 2007
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