Ear Pain (Case 9)

Chapter 37 Ear Pain (Case 9)



Jacquelyn M. Aveta, MD, FAAP




Case


A 22-month-old with ear pain




Differential Diagnosis











Otitis media Foreign body
Traumatic ear injury Otitis externa


Speaking Intelligently


When asked to evaluate a child with ear pain, I first obtain the history. If there has been trauma or a foreign body inserted in the canal, I will check the tympanic membrane (TM) for perforation. For an embedded ear piercing, it is critical to determine presence of infection and cartilaginous involvement. Facts such as recent congestion, previous otitis media, or day care attendance followed by onset of fever suggest acute otitis media (AOM), or possibly acute pharyngitis with referred ear pain. Physical examination and history are key to distinguishing AOM from otitis media with effusion (OME), or fluid in the middle ear space that is not acutely infected.



Patient Care



Clinical Thinking



• Ear pain is usually not an emergency; but pain control is a high priority.

• When evaluating the middle ear, distinguish AOM from otitis media with effusion.


History



• Are there preexisting symptoms such as rhinorrhea, sore throat, or cough; or was there abrupt onset of ear pain?

• Is the child playful or fussy or somnolent?

• Any fever?

• Any ear drainage? Specify if purulent or sanguinous or clear.

• Any history of objects in the ear or nose?

• Has the child been swimming?

• Are there ear piercings? Any associated swelling or redness?

• Has there been recent otitis media? What was the treatment? Was there a follow-up examination after treatment?

• Are there craniofacial anomalies, immunodeficiencies, or cochlear implants to increase risk for otitis media or mastoiditis?

• Any dental problems, such as unfilled caries or abscess?


Physical Examination



• Note general appearance. Most with ear pain will be calm or perhaps crying, but should not be lethargic.

• Check vital signs, and note presence of fever. Tachycardia occurs with pain and/or fever.

• Are the ears symmetric, or is one pushed forward as in mastoiditis?

• Is there pain on tugging the tragus?

• Is there drainage in the canal to suggest AOM with TM perforation?

• Using an otoscope, evaluate the canal for erythema, drainage, and foreign body.

• Use pneumatic otoscopy to identify middle ear effusion (MEE). Distinguish effusion from acute infection by the additional presence of erythema and pus in acute infection (see Chapter 38, Teaching Visual: Examination of the Middle Ear).

• Complete the oral examination using a tongue blade and otoscope with appropriate support to position the child to maximize your examination and minimize discomfort.

• Assess the neck for any lumps, swelling, or tenderness.


Tests for Consideration



• Culture of ear drainage: Indicated if chronic and unresponsive to therapy $152

• If suspect group A streptococcus:
• Rapid streptococcal antigen test $148

• Throat culture $148

• Tympanometry: Indicated to confirm presence of MEE $125


Imaging Considerations


→ Computed tomography (CT) scan for mastoiditis $1965


→ Magnetic Resonance Imaging (MRI) for mastoiditis $2308




Clinical Entities: Medical Knowledge
















Otitis Media
Pϕ An antecedent viral upper respiratory infection (URI) may be followed by fever. The eustachian tube, which normally allows ventilation between the nasal airway and middle ear, becomes blocked, creating negative pressure leading to accumulation of serous fluid. The fluid subsequently becomes infected with either a virus or bacteria. Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis are the most common bacteria. Rapid growth of the infectious agent and the resultant inflammatory reaction leads to pain and pressure on the TM, which may perforate. Since introduction of the heptavalent pneumococcal conjugate vaccine in 2000, there has been an overall decrease in S. pneumoniae, with emergence of some nonvaccine strains and an increase in nontypable H. influenzae. The 13-valent pneumococcal conjugate vaccine was approved in 2010, and ongoing alteration in causative bacteria may continue to emerge.2
TP Infants may only have URI symptoms, or there may be fever, irritability, poor oral intake, and/or sleep disruption. Toddlers may tug the ear or seem less balanced when walking. Older children will usually verbalize ear pain and may perceive decreased hearing.
Dx The diagnosis is made using pneumatic otoscopy. The American Academy of Pediatrics 2004 diagnostic criteria for AOM are:

1 Abrupt onset of signs and symptoms
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Ear Pain (Case 9)

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